超声筛查乳腺癌模式在基层医院应用的研究

背景与目的：乳腺癌是影响成年女性的主要慢性疾病之一,我国乳腺癌的发病率正以每年3%~4%的速率增长,严重危害女性的身体健康和生命安全。本研究旨在分析超声筛查乳腺癌模式在基层医院推广应用的可行性,探讨应用超声检查早期发现和诊断乳腺癌的价值。方法：采用基于超声筛查乳腺癌的模式,选择35~60岁哈密地区户籍的各民族妇女进行群体乳腺癌筛查,全部妇女先行乳腺超声检查,对乳腺影像报告与数据系统（Breast Imagine Reporting and Data System,BI-RADS）分级为4级和5级的行活检,0级和3级的补充乳腺X线检查,1级和2级的随访。结果：2012年1月—2017年10月全地区在本院累计完成乳腺癌检查184 680人,其中149例确诊为乳腺癌,乳腺癌检测率80.68/10万,建议行乳腺X线检查3 203人次,实际乳腺X线检查2 675人次;建议活检582人次,实际活检582人次;早期乳腺癌比例：0期36.24%,Ⅰ期51.00%,Ⅱ期10.07%,Ⅲ期2.68%,0+Ⅰ+Ⅱ期97.31%,0+Ⅰ期87.24%。灵敏度和特异度：乳腺超声筛查出122例乳腺癌（81.88%）,X线检查出27例（18.12%）。35~39岁组乳腺癌检出率为8.56/10万,40~50岁组检出率为29.20/10万,51~60岁组检出率为42.71/10万。回族妇女乳腺癌检出率显著高于其他民族（P<0.05）,其次为维吾尔族妇女。结论：超声筛查乳腺癌模式在基层医院易于推广,实际操作过程中筛查对象的依从性较好,易于普及,在乳腺癌的检出、早期诊断等方面效果明显。     

Cost-Effectiveness Analysis of Breast Cancer Screening in Rural Iran

Background: Although breast cancer is the most common cancer in women, economic evaluation of breast cancer screening is not fully addressed in developing countries. The main objective of the present study was to analyze the cost-effectiveness of breast cancer screening using mammography in 35-69 year old women in an Iranian setting. Materials and Methods: This was an economic evaluation study assessing the cost-effectiveness of a population-based screening program in 35-69 year old women residing in rural areas of South east Iran. The study was conducted from the perspective of policy-makers of insurance. The study population consisted of 35- to 69-year old women in rural areas of Kerman with a population of about 19,651 in 2013. The decision tree modeling and economic evaluation software were used for cost-effectiveness and sensitivity analyses of the interventions. Results: The total cost of the screening program was 7,067.69 US$ and the total effectiveness for screening and no-screening interventions was 0.06171 and 0.00864 disability adjusted life years averted, respectively. The average cost-effectiveness ratio DALY averted US$ for screening intervention was 7,7082.5 US$ per DALY averted and 589,027 US $ for no-screening intervention. The incremental cost-effectiveness ratio DALY averted was 6,264 US$ per DALY averted for screening intervention compared with no-screening intervention. Conclusions: Although the screening intervention is more cost effective than the alternative (noscreening) strategy, it seems that including breast cancer screening program in health insurance package may not be recommended as long as the target group has a low participation rate.     

中国妇女乳腺X线钼靶摄影普查成本效益分析

目的:分析中国妇女乳腺X线钼靶摄影普查的成本效益.方法:结合中国妇女的人群年龄结构以及乳腺癌相关数据,利用Markov模型模拟乳腺癌发展过程,结合每一种状态的成本消耗和健康收益,通过10个周期(每个周期为1年)的循环运算,分析乳腺X线钼靶摄影普查的成本效益.结果:35～59岁人群的普查增量成本效益比(incremental cost-effectiveness ratio,ICER)为216 656.00元/质量调整生命年(quality adjusted life year,Q ALY),普查可降低乳腺癌死亡率14.66％; 35～69岁人群的普查ICER为248727.50元/QALY,普查可降低乳腺癌死亡率14.79％.ICER与乳腺癌发病率、X线钼靶摄影检查的敏感度和特异度以及检查费用等密切相关.结论:中国女性采用乳腺癌普查可降低乳腺癌死亡率约15％.根据当前中国女性乳腺癌发病率、普查平均效能(敏感度和特异度)以及检查成本,全国乳腺癌普查暂不具成本效益.鉴于普查的成本效益与发病率、普查效能以及普查中的检查价格密切相关,因此随着乳腺癌发病率的提高、普查中检查价格的降低以及普查敏感度或特异度的提高,中国妇女的乳腺癌普查将具有成本效益甚至极具成本效益.     

佛山市城市妇女乳腺癌筛查结果分析

目的了解佛山市城市妇女乳腺癌的发病情况。方法佛山市2008年中央财政转移支付乳腺癌筛查项目组采用临床乳腺检查初筛、选择性乳腺X线摄片和彩色超声检查,对佛山市10371名35～69岁妇女进行了乳腺癌筛查。乳腺癌及乳腺异常检出率的比较采用Fisher's精确概率法或χ2检验。结果 10371名妇女共检出乳腺癌18例,检出率为173.56/10万(18/10371),其中0期导管内癌2例,Ⅰ期9例,Ⅱ期4例,Ⅲ期1例,Ⅳ期2例。不同年龄段妇女乳腺癌检出率的差异有统计学意义(P=0.026),其中45～69岁乳腺癌检出率高于35～44岁(χ2=8.332,P=0.004)。乳腺临床检查中发现乳腺腺体条索状或局限性、结节性增厚5383例、乳腺肿块642例、病理性乳头溢液210例,总共占筛查人群的60.12%(6235/10371);各年龄段乳腺异常情况分布的差异有统计学意义(χ2=507.982,P0.001,并且35～44岁年龄段乳腺异常检出率最高,占该年龄段的68.96%(3213/4659)。结论佛山市城市妇女乳腺癌检出率较高,尤其45岁以上妇女的乳腺癌检出率明显提高;开展乳腺癌筛查对乳腺癌的早期发现有重要意义。     

Breast cancer screening, outside the population-screening program, of women from breast cancer families without proven BRCA1/BRCA2 mutations: a simulation study.

PURPOSE: We assessed the cost-effectiveness of mammography screening for women under the age of 50, from breast cancer families without proven BRCA1/BRCA2 mutations, because current criteria for screening healthy women from breast cancer families are not evidence-based. METHODS: We did simulation studies with mathematical models on the cost-effectiveness of mammography screening of women under the age of 50 with breast cancer family histories. Breast cancer screening was simulated with varying screening intervals (6, 12, 18, and 24 months) and screening cohorts (starting at ages 30, 35, 40, and 45, and continuing to age 50). Incremental costs of screening were compared with those of women ages 50 to 52 years, the youngest age group currently routinely screened in the nationwide screening program of the Netherlands, to determine cost-effectiveness. Sensitivity analyses were done to explore the effects of model assumptions. The cost-effectiveness of breast cancer screening for women over the age of 50 was not debated. RESULTS: The most effective screening interval was found to be 12 months, which, however, seems only to be cost-effective in a small group of women under the age of 50 with at least two affected relatives, including at least one affected in the first degree diagnosed under the age of 50. Significantly, early breast cancer screening never seemed to be cost-effective in women with only one affected first-degree or second-degree relative. CONCLUSION: Annual breast cancer screening with mammography for women under the age of 50 seems to be cost-effective in women with strong family histories of breast cancer, even when no BRCA1/BRCA2 mutation was found in affected family members.     

中国城市女性乳腺癌筛查卫生经济学评价

  目的  探讨适合中国国情的乳腺癌筛查策略的成本效果。  方法  收集2008年2月至2011年12月基于中国前期多项全国女性乳腺癌筛查项目中的乳腺癌分期、筛查方法的准确性等临床和成本信息,及同期乳腺癌患者临床就诊信息。采用Markov模型系统评价132种乳腺癌筛查策略相对于不筛查的增量成本效果比。  结果  2010年与不筛查相比,40~64岁女性采用1次/2年的乳腺触诊与乳腺超声检查并联筛查策略,符合成本效果评价标准且效果最大。每10万女性采用该筛查策略进行筛查,累计可挽救1 394个质量调整寿命年（quality adjusted life year,QALY）。每挽救1个QALY的成本为91 944元。敏感性分析显示,2016年40~64岁女性采用1次/2年的乳腺触诊与乳腺X线检查并联筛查策略,符合成本效果评价标准且效果最大。在该筛查策略下,每挽救1个QALY的成本为159 637元。  结论  开展人群为基础的乳腺癌筛查项目相对符合中国当前国情。随着中国经济水平的不断提升,医疗水平的逐步改善,以及乳腺癌发病率的逐年上升,乳腺癌筛查的单位成本效果预期会有进一步的提高。      

The National Cancer Screening Program for Breast Cancerin the Republic of Korea: Is it Cost-Effective?

This goal of this research was to evaluate the cost-effectiveness of the National Cancer ScreeningProgram (NCSP) for breast cancer in the Republic of Korea from a government expenditure perspective. In2002-2003 (baseline), a total of 8,724,860 women aged 40 years or over were invited to attend breast cancerscreening by the NCSP. Those who attended were identified using the NCSP database, and women weredivided into two groups, women who attended screening at baseline (screened group) and those who did not(non-screened group). Breast cancer diagnosis in both groups at baseline, and during 5-year follow-up wasidentified using the Korean Central Cancer Registry. The effectiveness of the NCSP for breast cancer wasestimated by comparing 5-year survival and life years saved (LYS) between the screened and the unscreenedgroups, measured using mortality data from the Korean National Health Insurance Corporation and theNational Health Statistical Office. Direct screening costs, indirect screening costs, and productivity costs wereconsidered in different combinations in the model. When all three of these costs were considered together,the incremental cost to save one life year of a breast cancer patient was 42,305,000 Korean Won (KW)(1 USD=1,088 KW) for the screened group compared to the non-screened group. In sensitivity analyses,reducing the false-positive rate of the screening program by half was the most cost-effective (incrementalcost-effectiveness ratio, ICER=30,110,852 KW/LYS) strategy. When the upper age limit for screening wasset at 70 years, it became more cost-effective (ICER=39,641,823 KW/LYS) than when no upper age limitwas set. The NCSP for breast cancer in Korea seems to be accepted as cost-effective as ICER estimates werearound the Gross Domestic Product. However, cost-effectiveness could be further improved by increasingthe sensitivity of breast cancer screening and by setting appropriate age limits.     

Breast cancer incidence trends in deprived and affluent Scottish women

OBJECTIVE : Breast cancer is commoner in the affluent and breast cancer rates in many countries are rising; it remains unclear whether this incidence rise is consistent across the different socio-economic groups. The rising incidence of breast cancer may be related to changes in population risk factor profiles. This study aimed to determine breast cancer incidence trends in women of different socio-economic categories and whether these trends were related to breast cancer risk factor trends. DESIGN : Data on breast cancer incidence rates by deprivation quintile in Scotland 1991-2000 were analysed using linear regression. Data on first births at late maternal age, BMI trends (based on the Scottish Health Surveys) and breast screening uptake trends in the different categories were also analysed and their relation to breast cancer incidence trends explored. POPULATION AND SETTING : Breast cancer incidence data was based on all women in Scotland. BMI data was based on representative cross-sectional survey data from the Scottish Health Surveys-women in the 1995, 1998 and 2003 surveys were 16-64, 16-74 and aged 16 and over, respectively. First birth data was based on all women aged 35-39 in Scotland. Breast screening uptake data was studied in women of screening age, that is, aged 50-64. RESULTS : Breast cancer incidence rates in Scottish women are rising in parallel across all socio-economic categories and the incidence gap between deprived and affluent still remains. Since the late 1980s, numbers of first birth in Scottish women aged 35-39 have risen dramatically, especially in the affluent, but numbers were stable before this. The prevalence of obesity and mean BMI has increased over time in all socio-economic classes but BMI continues to be higher in the deprived. Uptake of screening invitations has increased in all socio-economic groups. CONCLUSIONS : Breast cancer is rising in women of all socio-economic status in Scotland and the deprived-affluent gap remains. Trends in late age at first pregnancy, prevalence of obesity and screening uptake do not fully explain the observed trends.     

Cost-effective mammography screening in Korea: High incidence of breast cancer in young women

The epidemiological characteristics of breast cancer in Korean women are different from the characteristics reported in Western women. The highest incidence rate occurs in Korean women in their 40s. The purpose of this study was to determine the most cost-effective screening interval and target age range for Korean women from the perspective of the national healthcare system. A stochastic model was used to simulate breast cancer screenings by varying both the screening intervals and the age ranges. The effectiveness of mammography screening was defined as the probability of detecting breast cancer in the preclinical state and the cost was based on the direct cost of mammography screening and the confirmative tests. The age-specific mean sojourn times and the sensitivity of the mammography were applied in the stochastic model. An optimal cost-effectiveness was determined by the incremental cost-effectiveness ratio and lifetime schedule sensitivity. Sensitivity analyses were undertaken to assess parameter uncertainty. The selected cost-effective strategies were: (1) the current biennial mammography screenings for women who are at least 40 years old; (2) biennial screening for women between the ages of 35 and 75 years; and (3) a combination strategy consisting of biennial screening for women aged between 45 and 54 years, and 3-year interval screening for women aged between 40 and 44 years and 55 and 65 years. Further studies should follow to investigate the effectiveness of mammography screening in women younger than 40 years in Asia as well as in Korea. ( Cancer Sci 2009; 100: 1105–1111)     

乳腺癌筛查研究进展

乳腺癌是危害全世界女性健康最常见的恶性肿瘤.乳腺癌筛查是公认的能够有效提高女性乳腺癌生存率的主要方法.目前国内外常用的乳腺癌筛查手段包括乳房X线摄影术(钼靶X线摄影)、超声成像、临床乳腺检查和磁共振成像等.本文对这些筛查手段的优缺点进行了比较,并对基于这些手段建立的不同筛查方案在人群中的应用效果和卫生经济学评价进行综述,以期为建立符合中国国情的具有成本-效果的女性乳腺癌筛查策略提供参考和依据.     

The Results of a Breast Cancer Screening Camp at a District Level in Rural India

Background: Breast cancer in developing countries is on the rise. There are currently no guidelines to screen women at risk in India. Since mammography in the western world is a well-accepted screening tool to prevent late presentation of breast cancer and improve mortality, it is intuitive to adopt mammography as a screening tool of choice. However, it is expensive and fraught with logistical issues in developing countries like India.Materials and Methods: Our breast cancer screening camp was done at a local district hospital in India after approval from the director and administrators. After initial training of local health care workers, a one-day camp was held. Clinical breast examination, mammograms, as well as diagnostic evaluation with ultrasound and fine needle aspiration biopsy were utilized. Results: Out of total 68 women screened only 2 women with previous history of breast cancer were diagnosed with breast cancer recurrence. None of the women in othergroups were diagnosed with breast cancer despite suspicious lesions either on clinical exam, mammogram or ultrasound. Most suspicious lesions were fibroadenomas. The average cost of screening women who underwentmammography, ultrasound and fine needle aspiration was $30 dollars, whereas it was $16 in women who had simple clinical breast examination. Conclusions: Local camps act as catalysts for women to seek medical attentionor discuss with local health care workers concerns of discovering new lumps or developing breast symptoms.Our camp did diagnose recurrence of breast cancer in two previously treated breast cancer patients, who were promptly referred to a regional cancer hospital. Further studies are needed in countries like India to identify the best screening tool to decrease the presentation of breast cancer in advanced stages and to reduce mortality.     

Cost-effectiveness analysis of screening modalities for breast cancer in Japan with special reference to women aged 40-49 years

Although the introduction of screening mammography in Japan would be expected to reduce mortality from breast cancer, the optimal screening modality in terms of cost-effectiveness remains unclear. We compared the cost-effectiveness ratio, defined as the cost required for a life-year saved, among the following three strategies: (1) annual clinical breast examination; (2) annual clinical breast examination combined with mammography; and (3) biennial clinical breast examination combined with mammography for women aged 30-79 years using a hypothetical cohort of 100 000. The sensitivity, specificity and early breast cancer rates were derived from studies conducted from 1995 to 2000 in Miyagi Prefecture. The treatment costs were based on a questionnaire survey conducted at 13 institutions in Japan. We used updated parameters that were needed in the analysis. Although the effectiveness of treatment in terms of the number of expected survival years was highest for annual combined modality, biennial combined modality had a higher cost-effectiveness ratio, followed by annual combined modality and annual clinical breast examination in all age groups. In women aged 40-49 years, annual combined modality saved 852.9 lives and the cost/survival duration was 3 394 300 yen/year, whereas for biennial combined modality the corresponding figures were 833.8 and 2 025 100 yen/year, respectively. Annual clinical breast examination did not confer any advantages in terms of effectiveness (815.5 lives saved) or cost-effectiveness (3 669 900 yen/year). While the annual combined modality was the most effective with respect to life-years saved among women aged 40-49 years, biennial combined modality was found to provide the highest cost-effectiveness.     

Increasing incidence of breast cancer: distinguishing between the effects of birth cohort and a national breast screening programme

The incidence of breast cancer in post-menopausal women has been affected by the introduction of national breast screening programmes. The study describes the incidence of breast cancer in Scottish women aged 50–64 by year of birth before, during, and after the prevalent round of screening. Breast cancer registrations in Scotland for women aged 45–69 years from 1977 to 2003 were obtained. Birth cohort incidence rates were calculated and interpreted in the light of screening patterns at particular calendar time points. In the years before screening, there was a small rise in breast cancer incidence by birth cohort in women aged 50–54 which was not seen in other ages. During the prevalent screening round, incidence increased significantly with increasing birth cohort and thereafter continued rises in incidence by birth cohort occurred. The observed rise in breast cancer incidence among post-menopausal women is likely to be due to both screening effects and a true increase in incidence.     

依托妇幼卫生服务体系建立乳腺癌筛查机制

目的探讨妇幼卫生服务网络在乳腺癌筛查中的作用。方法采取随机整群抽样的方法,在武汉市中心城区抽取35~59岁妇女33 019名为研究对象,利用妇幼卫生服务网络对筛查工作进行组织管理,采用乳腺临床体检、钼靶X线摄片和彩超检查相结合的筛查方案,所有病变诊断及转归的判定均以组织病理学检查为依据。计算筛查率、复查率和乳腺癌检出率等指标,评价妇幼卫生服务体系对乳腺癌筛查的作用。结果33 019名妇女中,30 478名妇女参与了乳腺癌筛查,筛查率为92.30%;钼靶或彩超的复查率为92.47%。通过临床检查、钼靶和彩超联合检查的乳腺癌或可疑癌患者均接受手术治疗,最终25人确诊为乳腺癌,乳腺癌检出率为82.03/100 000。结论利用妇幼卫生服务网络组织乳腺癌筛查,提高了人群顺应性,技术力量能够得到整合,大大提高乳腺癌筛查的质量。     

Impressive time-related influence of the Dutch screening programme on breast cancer incidence and mortality, 1975-2006

The aim of this study was to assess changes in the trends in breast cancer mortality and incidence from 1975 to 2006 among Dutch women, in relation to the implementation of the national breast cancer screening programme. Screening started in 1989 for women aged 50-69 and was extended to women aged 70-75 years in 1998 (attendance rate approximately >80%). A joinpoint Poisson regression analysis was used to identify significant changes in rates over time. Breast cancer mortality rates increased until 1994 (age group 35-84), but thereafter showed a marked decline of 2.3-2.8% per annum for the age groups 55-64 and 65-74 years, respectively. For the age group of 75-84 years, a decrease started in the year 2001. In women aged 45-54, an early decline in breast cancer mortality rates was noted (1971-1980), which is ongoing from 1992. For all ages, breast cancer incidence rates showed an increase between 1989 and 1993, mainly caused by the age group 50-69, and thereafter, a moderate increase caused by age group 70-74 years. This increase can partly be explained by the introduction of screening. The results indicate an impressive decrease in breast cancer mortality in the age group invited for breast cancer screening, starting to show quite soon after implementation.     

Factors Associated with Breast Cancer Awareness in Thai Women

Background: Breast cancer is the most common cancer in women worldwide. In south-east Asia, both the incidenceand mortality rates of breast cancer are on the rise, and the latter is likely due to the limited access to large-scalecommunity screening program in these resource-limited countries. Breast cancer awareness is an important tool whichmay, through increasing breast self-examination and the seeking of clinical examination, reduce breast cancer mortality.Investigating factors associated with breast cancer awareness of women is likely to help identify those at risk, andprovide insights into developing effective health promotion interventions. Objective: To investigate factors associatedwith breast cancer awareness in Thai women. Methods: A cross-sectional sample of Thai women aged 20-64 yearswas collected during August to October, 2015 from two provinces of southern Thailand (Surat Thani and Songkla). Aquestionnaire including the Breast Cancer Awareness Scale along with demographic characteristics was administeredand Proportional Odds Logistic regression was then used to investigate factors associated with breast cancer awareness.Results: In total, 660 Thai women participated in this study. Factors most often associated with the various breastcancer awareness domains were age and rurality. While rural women had poorer knowledge of breast cancer signs andsymptoms, they also had lower levels of perceived barriers and considerably better breast cancer awareness behaviors.Conclusion: Despite lower knowledge of breast cancer risk factors and no evidence of better knowledge of signs andsymptoms, we found rural Thai women had considerably better breast cancer awareness behavior. This may be due tothese women’s lower levels of perceived barriers to breast cancer screening services. Indeed this suggests, at least inThai women, that interventions aimed at lowering perceived barriers rather than enhancing disease knowledge maybe more successful in engaging women with breast cancer screening services and increasing breast self-examination.     

Screening women with a family history of breast cancer--results from the British Familial Breast Cancer Group.

AIMS: To determine the efficacy of screening women under age 50 with a significant family history of breast cancer. METHODS: Results from 22 Breast Units in the UK identified as being able to provide data were surveyed and pooled through regional data managers or consultant breast specialists. RESULTS: Data relating to 8783 women screened and 9075 woman years of follow-up was analysed. Cancer incidence was 11.3/1000/year. The rate of cancer detection was 4. 78/1000 at prevalent screening and 4.52/1000 at incident screening. Median age at diagnosis was 43 years. Interval cancers presented at a rate of 2.45/1000. Comparison with the National Health Service Breast Screening Programme for women aged 50-64 revealed a similar rate of cancer detection and a similar incidence of ductal carcinoma in situ. The pathological features of screen-detected cancers in this study strongly suggest that prognosis for these women is more favourable than if they had presented symptomatically. CONCLUSIONS: This study provides evidence to suggest that screening young women with a significant family history of breast cancer is effective and that a survival benefit can be expected. As a result the British Familial Breast Cancer Group proposes a co-ordinated prospective observational study.     

Breast Cancer Awareness of Rural Women in Malaysia: is it the Same as in the Cities?

Breast cancer is the most common cancer among women globally. This study was conducted to compare theawareness of breast cancer and the practice of breast self-examination (BSE), clinical breast examination (CBE)and mammography screening among rural females in Pahang and Perak. A cross-sectional study was carried outin five selected rural districts of Pahang and Perak. Two hundred and fifty households were randomly selectedand interviewed face to face using a semi-structured questionnaire. The majority of residents from both stateswere Malay, aged between 50 and 60 years and had a secondary level of education. Malay women aged 40–49years and women with a higher level of education were significantly more aware of breast cancer (p<0.05). Abouthalf of these women practiced BSE (60.7%) and CBE (56.1%), and 7% had underwent mammography screening.The results of this study suggest that women in Pahang and Perak have good awareness of breast cancer andthat more than half practice BSE and CBE. The women’s level of education appears to contribute to their levelof knowledge and health behaviour. However, more effort is needed to encourage all women in rural areas toacquire further knowledge on breast cancer.