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The Lancet:宫颈癌HPV筛查优于细胞学检查

2014-02-26 PCMC www.thelancet.com

尽管敏感性不高,但传统的宫颈癌细胞学检查方法(宫颈癌刮片检查)一直以来都是最成功的癌症筛查方案。在大规模、高质量开展该项检查手段的国家和地区,侵袭性宫颈癌发生率和死亡率呈直线下降趋势。在此前提下,为什么要改变这一检查手段呢? 自从鉴别出人乳头瘤病毒(HPV)是侵袭性宫颈癌的原因,人们开发了HPV DNA检查手段以应对这一疾病。分子学技术在检出2级或3级宫颈上皮内瘤(CIN2或CIN3)病

尽管敏感性不高,但传统的宫颈癌细胞学检查方法(宫颈癌刮片检查)一直以来都是最成功的癌症筛查方案。在大规模、高质量开展该项检查手段的国家和地区,侵袭性宫颈癌发生率和死亡率呈直线下降趋势。在此前提下,为什么要改变这一检查手段呢?【原文下载

自从鉴别出人乳头瘤病毒(HPV)是侵袭性宫颈癌的原因,人们开发了HPV DNA检查手段以应对这一疾病。分子学技术在检出2级或3级宫颈上皮内瘤(CIN2或CIN3)病变的敏感性和可重复性方面比宫颈癌细胞学检查更佳,CIN2或CIN3是侵袭性宫颈癌的高级别病变前体。

然而,上述检查手段还不足以更好地检出这些中间病变。通过消融或切除手术治疗筛查检出的病灶必定还可以制止侵袭性宫颈癌的自然发展,并减少该病的发生率和死亡率。

随机对照试验发现,与基于细胞学的检查手段相比,HPV检查可预防一系列侵袭性宫颈癌及相关性死亡事件。迄今为止,仅有印度农村的试验数据证明HPV常规高质量筛查无益。此外,发达国家更多的随机对照试验里细胞学检查手段早已成熟且在这些国家宫颈癌的发生率低。

因此,CIN2或CIN3的检出往往作为预定研究终点。大部分的CIN2或CIN3损伤不会发生侵袭或导致宫颈癌死亡,若要更新基于HPV筛查的推荐,还需要进一步的证据、纵向研究的结局等数据。

本期Lancet杂志中,Guglielmo Ronco博士及其同事汇集分析了四个欧洲随机试验的个人水平的数据,对HPV检查和细胞学宫颈癌检查手段进行了比较。在瑞典筛查试验、POBASCAM、 ARTISTIC和NTCC试验中,总共有超过175000例女性接受随机分组,并得到第二轮筛查结果。

与细胞学检查相比,基于HPV的筛查手段导致侵袭性宫颈癌发生率减少了60—70%。在入组2.5年内,基于HPV检查的侵袭性宫颈癌发生率的下降不具有统计学意义,但长期随访的结果才具有说服力。

上述发现突出了一点:HPV检查增加了受检女性CIN2和CIN3的检出机率,因此可获得侵袭性宫颈癌的早期治疗机会并进而减少风险。然而,HPV筛查的最重要的性质在于其安全性,大多数女性HPV检查呈阴性结果。

Ronco和其同事们发现,与出现细胞学检查阴性结果后3.5年相比,HPV检查出现阴性结果后5.5年观察到的侵袭性宫颈癌的累积发生率更低,指示HPV筛查后5年结果较传统细胞学检查后3年的结果更安全。

尽管四种随机对照试验的研究特征差异很大,Ronco及其同事指出,这些试验的异质性其实很小,HPV筛查组侵袭性宫颈癌总检出率相似。上述发现似乎指出HPV筛查侵袭性宫颈癌的效果比其他试验方案的潜在效应都大。该项工作显示,出色的荟萃分析可以带来更深邃更有力更精确的有效性评估结果。

宫颈癌筛查的未来更可能融合初始HPV检查,特别是后HPV疫苗时代的获益更加明确的情况下。随着原始HPV检查的广泛开展以及筛查介入的深入,宫颈癌筛查的成本可能会下降,而其带来的安全性优于传统的细胞学检查手段。为达到上述目标,国家也需要考虑必要的政策倾斜,如:推进HPV筛查的应用;确定适合的筛查年龄和时间间隔;定义HPV阳性女性的分类和管理策略等。

原始出处

Ronco G1, Dillner J2, Elfström KM2, Tunesi S3, Snijders PJ4, Arbyn M5, Kitchener H6, Segnan N7, Gilham C8, Giorgi-Rossi P9, Berkhof J4, Peto J8, Meijer CJ4; International HPV screening working group.Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials.Lancet. 2014 Feb 8【原文下载

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    2014-12-04 howi
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    2014-07-07 sunxiaofei4457

    HPV检测还是不同于细胞学检查的,最好是二者结合。

    0

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    2014-02-28 一闲
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    2014-02-26 122.227.241.60

    这种大样本研究,相当棒

    0

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