体检联合超声补充X射线钼靶检查乳腺癌筛查模式初步应用评价

Primary efficacy of physical examination combined with ultragraphy and complemented with mammography for breast cancer screening

目的:探讨临床体检联合超声补充X射线钼靶检查的乳腺癌筛查模式在普通妇女群体中的应用价值。方法:采用临床体检联合超声补充X射线钼靶检查的乳腺癌筛查模式对35～59岁的广州市郊区农村户籍妇女进行群体性乳腺癌筛查。全部妇女先行临床体检和乳腺超声检查,超声BI-RADS 4c级和5级者活检,BI-RADS 1级和2级者于1年后随访;0、3、4a和4b级补充行X射线钼靶检查,超声和X射线钼靶均为4级以上者行活检,其余由临床医师决定随访或活检。结果:2010-01-01-2011-12-31共完成乳腺癌筛查284 168人,确诊乳腺癌151例。乳腺癌检出率为53.14/10万,检出率与活检率呈正相关,r=0.771;P=0.042。乳腺癌分期构成比0期8.6%,Ⅰ期38.4%,与住院病例相比,Ⅰ期病例明显增多,χ2=13.345,P=0.01。0～Ⅱ期病例检出率为44.7/10万,每检出1例0～Ⅱ期病例需花费13.4万元;其中50～59岁组早期病例检出率为67.0/10万,明显优于35～39岁组(χ2=17.172,P<0.001)和40～49岁组(χ2=4.887,P=0.027),每检出1例0～Ⅱ期病例需花费9.0万元,少于其他年龄组,和2010年广州市人均GDP值(8.8万元)相当。本项目筛查模式的敏感性为97.35%,特异性为99.89%;敏感性显著优于单纯临床体检模式(79.5%),χ2=4.528,P=0.033;与超声检查模式(92.1%)和体检联合超声而不补充X射线钼靶的模式(94.0%)相比较则差异无统计学意义,P>0.05;但其假阳性活检率(110.15/10万)显著低于超声检查模式的129.15/10万,χ2=4.293,P=0.038;也低于体检联合超模式的135.48/10万,χ2=7.436,P=0.006。结论:体检联合超声补充X射线钼靶检查的乳腺癌筛查模式明显提高了Ⅰ期乳腺癌的构成比例,和不含X射线钼靶的筛查模式相比,在得到高敏感性同时又能降低假阳性活检率。成本效益分析显示,50～59岁年龄组具有最优的成本效益。

OBJECTIVE：To evaluate the efficacy of physical examination combined with ultragraphy and complemented with mammography for breast cancer screening. METHODS： A breast cancer screening project was conducted in 35-59 years old female who live in suburb of Guangzhou with clinical breast physical examination and ultragraphy. Those whose ultrasound findings categorized as BI-RADS 4e and 5 were biopsied;and those as BI-RADS 1 and 2 were followed up after 1 year;and those as EI-RADS 0,3,4a and 4b accepted mammography additionally,categorized as BI-RADS 4 and 5 were biopsied,and others were disposed by physicians to accept biopsy or follow-up. RESULTS： From January lst,2010 to December 31st,2011,284 168 women were screened in this project. We identified 151 breast cancers. The detective rate of breast cancer was 53.14/100 000 and had positive correlation with the rate of biopsy（r=0. 771 ,P=0. 042）. Percentage of stage 0 and I breast cancer were 8.6% and 38.4% ,and significantly more stage I patients were detected compared with those in hospital（X2= 13. 345, P= 0.01）. The detective rate of early breast cancer （Stage 0-II ） was 44.7/100 000, and the cost for each early detective breast cancer was ￥134 000. The early detective rate in group aged 50--59 years was 67.0/100 000,which was significantly higher than that in group aged 35--39 years and group aged 40--49 years （X2 = 17. 172,P〈0. 001 and 72 =4. 887,P=0. 027）. The cost for each early detective breast cancer was the least （￥90 000）, similar to Real GDP per capita of Guangzhou in 2010（￥88 000）. The sensitivity of this project was 97.35% and specificity was 99.89%. The sensitivity was much higher than that of the modality only include physical examination （79.5%, X2 =4. 528,P=0. 033）, whereas had no significant difference to that of ultragraphy and physical examination combined with ultragraphy（92.1% and 94.0%）,but the false positive rate of biopsy was much lower than that of them （110.15/ 100 000 vs 129.15/100 600 and 135.48/100 000,X2=4. 293,P=0. 038;X2 =7. 436;P=0. 006）. CONCLUSIONS： Physical examination combined with ultragraphy and complemented with mammography for breast cancer screening can improve the proportion of stage I tumor significantly. It has gained the highest sensitivity and the lowest false positive rate of biopsy simultaneously compared with those modalities without mammography. In aged 50-59 years group the cost-effectiv result is the best. [