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Medscape:2013版USPSTF肺癌筛查指南解读

2014-01-13 sd3212 dxy

本文是Medscape于2013年12月30日针对该建议发布的述评,文章对上述建议进行了仔细解读,今编译于后,希能对读者有所帮助(该文原作者为:Roxanne Nelson)。USPSTF推荐,对于年龄55-80岁的肺癌高危患者,应使用低剂量计算机断层扫描(LDCT)进行每年一度的肺癌筛查。这里的肺癌高危患者是指:有30包-年的吸烟史,且目前仍在吸烟或戒烟时间在15年以内者。此外,新版指南指出:当

本文是Medscape于2013年12月30日针对该建议发布的述评,文章对上述建议进行了仔细解读,今编译于后,希能对读者有所帮助(该文原作者为:Roxanne Nelson)。


USPSTF推荐,对于年龄55-80岁的肺癌高危患者,应使用低剂量计算机断层扫描(LDCT)进行每年一度的肺癌筛查。这里的肺癌高危患者是指:有30包-年的吸烟史,且目前仍在吸烟或戒烟时间在15年以内者。

此外,新版指南指出:当一个人不吸烟时间已经达到15年,或者该人的健康状况已大大限制了其预期寿命或接受治疗性肺部手术的能力或愿意时,即应停止筛查。

USPSTF的共同副主席Michael LeFevre博士认为:“很明显,吸烟的人吸烟时间越长、吸烟量越多,其患肺癌的风险就越大。医生需要通过患者年龄、总体健康状况、吸烟量的多少、是否仍在吸烟、或已经戒烟多少年等情况来确定谁将从筛查中获益最多。”

上述最终建议与USPSTF于2013年7月发布的建议草案中的措辞基本一致。建议草案发布之后,曾经历了一段时间的讨论。而草案文件和最终文件最后得出的结论都是“中度的肯定”,即年度筛查对于具有吸烟史的人有“中度的净效益”。这相对于2004年USPSTF发布的推荐建议有了一定的进步,当时的建议结论是:没有足够的证据来推荐筛查。

上述新建议与美国癌症协会、美国胸内科医师学会、以及美国国家综合癌症网等团体发布的建议是一致的。其中美国国家综合癌症网于2011年11月率先发布了其肺癌筛查指南。

证据和危害

USPSTF强调肺癌筛查不能替代戒烟,而且筛查不能防止大多数与肺癌直接相关的死亡。但他们发现有“中等强度的证据表明:对于所定义的肺癌高危人群而言,使用LDCT对其进行肺癌年度筛查,可以防止大量的与疾病相关的死亡。每位个体从筛查可获益多少,很大程度上也取决于其患肺癌风险的大小,例如,那些面临肺癌风险最高的人,最有可能从筛查中获益。

使用LDCT筛查也会伴随着一些危害,如假阴性和假阳性结果、偶然发现、过度诊断、辐射暴露等。USPSTF指出,有相当比例进行了筛查的个体会受到假阳性的影响,而且绝大多数(95%)的阳性结果并不能导致癌症诊断的确立。虽然进一步的影像学检查可以排除大部分的假阳性结果,但有些患者将会接受更多的侵入性随访。

USPSTF报告说,他们发现了与偶然发现相关危害的“不充分的证据”。而且,虽然在筛查中,对肺癌的过度诊断确有发生,但其“准确的发生程度还不确定。”由USPSTF进行的一个建模研究估计,约10%到12%由筛查确定的癌症病例属于过度诊断。

重要的问题仍然存在

文章的随刊评论中,来自美国康涅狄格州纽黑文市耶鲁大学医学院的弗兰克.C.德特贝克博士,和来自宾夕法尼亚州费城市福克斯蔡斯癌症中心的迈克尔.昂格尔博士强调说,USPSTF推荐的是一个结构化、全面的筛查过程,而不只是一个扫描。

然而,新版指南并没能解决实施肺癌筛查过程中许多实践方面的问题。例如,他们指出,“不适当的筛查会使人们对肺癌的发生产生很大的担心,即使是对那些实际风险并没有那么高的人,也是如此。而这些人在运用相关的推荐建议时,需要通过对他们的肺癌风险、以及对筛查相关问题的讨论来得到安慰。”

筛查存在的另一个问题是关于病人的选择,及其在现实环境中究竟是如何实现的。由于有“充分的证据表明,在适合癌症筛查的人群中,筛查建议往往没有得到充分的利用;而在那些非癌症筛查适应症的人群中,其又被过度使用。”

评论作者还写道:“在研究中设立严格的准入门槛、以及没有肺癌筛查的运作数据是一回事;而坚持认为我们应该进行筛查,然后期望可以通过简单地画一条线即可排除那些可能会导致其担忧的人,又是另一回事。”他们评论说,一个有效的肺癌筛查程序应该真正惠及那些存在高风险的个体,然而,研究表明,存在最高风险的人尽管认识到他们处于风险之中,但这些人对于被筛查似乎较少感兴趣。此外,USPSTF也没有关注应该由谁来对那些对肺癌CT筛查感兴趣或需要考虑该项筛查的人进行评估。

评论指出:在新建议中,许多根本性的问题依然存在,如筛查确定的癌症病例,其自然史是怎样的?此类患者是否需要治疗、以及何时开始治疗?其具体的操作标准是什么?

他们写道:“肺癌筛查是一个充满活力的领域,对于筛查模式的任何细微改进,都可能会很快地见到效果。因此,我们应该从随机的肺癌筛查试验中吸取不同的意见,如果我们偏离了自己已经确知的东西太远,我们将会面临一项艰巨的任务和风险,那就是:纠正错误。”

评论最后指出:根据已经取得的证据,我们需要实施筛查,但是在推进这项工作时,应采用一种循序渐进的方法。”

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    2014-10-01 smlt2008
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    2014-11-20 feather89
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    2014-01-16 dadahuihui

    学习了。。

    0

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    2014-01-15 zhaojie88
  5. [GetPortalCommentsPageByObjectIdResponse(id=1897938, encodeId=040a189e938c3, content=<a href='/topic/show?id=832c404308' target=_blank style='color:#2F92EE;'>#CAP#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=4043, encryptionId=832c404308, topicName=CAP)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c39f145, createdName=smlt2008, createdTime=Wed Oct 01 09:25:00 CST 2014, time=2014-10-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1725567, encodeId=02c41e2556771, content=<a href='/topic/show?id=986913980dd' target=_blank style='color:#2F92EE;'>#PE#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13980, encryptionId=986913980dd, topicName=PE)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f06c33759375, createdName=feather89, createdTime=Thu Nov 20 19:25:00 CST 2014, time=2014-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=6853, encodeId=433368533a, content=学习了。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=128, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/12/24/d2bcde615d7dba749568bd6b71aaf0ac.jpg, createdBy=de2593966, createdName=dadahuihui, createdTime=Thu Jan 16 18:01:00 CST 2014, time=2014-01-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1350937, encodeId=63f4135093ea5, content=<a href='/topic/show?id=f5a31596056' target=_blank style='color:#2F92EE;'>#SCAP#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=15960, encryptionId=f5a31596056, topicName=SCAP)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Wed Jan 15 04:25:00 CST 2014, time=2014-01-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1458538, encodeId=24e1145853878, content=<a href='/topic/show?id=6b5511492e2' target=_blank style='color:#2F92EE;'>#Medscape#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=11492, encryptionId=6b5511492e2, topicName=Medscape)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=e4ab6090887, createdName=bnjfx@128.com, createdTime=Wed Jan 15 04:25:00 CST 2014, time=2014-01-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1536988, encodeId=318c1536988e2, content=<a href='/topic/show?id=7b6e18196cf' target=_blank style='color:#2F92EE;'>#USPSTF#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=18196, encryptionId=7b6e18196cf, topicName=USPSTF)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=315112772198, createdName=lingqf, createdTime=Wed Jan 15 04:25:00 CST 2014, time=2014-01-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1551728, encodeId=44211551e2854, content=<a href='/topic/show?id=305156401eb' target=_blank style='color:#2F92EE;'>#指南解读#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56401, encryptionId=305156401eb, topicName=指南解读)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=eb0214221999, createdName=shuangle, createdTime=Wed Jan 15 04:25:00 CST 2014, time=2014-01-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1606094, encodeId=031f16060940d, content=<a href='/topic/show?id=eb6b1145939' target=_blank style='color:#2F92EE;'>#Med#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=11459, encryptionId=eb6b1145939, topicName=Med)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=552a19396740, createdName=ms3994565386320060, createdTime=Wed Jan 15 04:25:00 CST 2014, time=2014-01-15, status=1, ipAttribution=)]
  6. [GetPortalCommentsPageByObjectIdResponse(id=1897938, encodeId=040a189e938c3, content=<a href='/topic/show?id=832c404308' target=_blank style='color:#2F92EE;'>#CAP#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=4043, encryptionId=832c404308, topicName=CAP)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c39f145, createdName=smlt2008, createdTime=Wed Oct 01 09:25:00 CST 2014, time=2014-10-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1725567, encodeId=02c41e2556771, content=<a href='/topic/show?id=986913980dd' target=_blank style='color:#2F92EE;'>#PE#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13980, encryptionId=986913980dd, topicName=PE)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f06c33759375, createdName=feather89, createdTime=Thu Nov 20 19:25:00 CST 2014, time=2014-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=6853, encodeId=433368533a, content=学习了。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=128, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/12/24/d2bcde615d7dba749568bd6b71aaf0ac.jpg, createdBy=de2593966, createdName=dadahuihui, createdTime=Thu Jan 16 18:01:00 CST 2014, time=2014-01-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1350937, encodeId=63f4135093ea5, content=<a href='/topic/show?id=f5a31596056' target=_blank style='color:#2F92EE;'>#SCAP#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=15960, encryptionId=f5a31596056, topicName=SCAP)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Wed Jan 15 04:25:00 CST 2014, time=2014-01-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1458538, encodeId=24e1145853878, content=<a href='/topic/show?id=6b5511492e2' target=_blank style='color:#2F92EE;'>#Medscape#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=11492, encryptionId=6b5511492e2, topicName=Medscape)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=e4ab6090887, createdName=bnjfx@128.com, createdTime=Wed Jan 15 04:25:00 CST 2014, time=2014-01-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1536988, encodeId=318c1536988e2, content=<a href='/topic/show?id=7b6e18196cf' target=_blank style='color:#2F92EE;'>#USPSTF#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=18196, encryptionId=7b6e18196cf, topicName=USPSTF)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=315112772198, createdName=lingqf, createdTime=Wed Jan 15 04:25:00 CST 2014, time=2014-01-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1551728, encodeId=44211551e2854, content=<a href='/topic/show?id=305156401eb' target=_blank style='color:#2F92EE;'>#指南解读#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56401, encryptionId=305156401eb, topicName=指南解读)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=eb0214221999, createdName=shuangle, createdTime=Wed Jan 15 04:25:00 CST 2014, time=2014-01-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1606094, encodeId=031f16060940d, content=<a href='/topic/show?id=eb6b1145939' target=_blank style='color:#2F92EE;'>#Med#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=11459, encryptionId=eb6b1145939, topicName=Med)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=552a19396740, createdName=ms3994565386320060, createdTime=Wed Jan 15 04:25:00 CST 2014, time=2014-01-15, status=1, ipAttribution=)]
    2014-01-15 lingqf
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       《内科学年鉴》5月14日在线发表的美国预防服务工作组(USPSTF)最新建议声明指出,初级保健临床医生应对年龄≥18岁的所有患者筛查“酒精滥用”,并为被鉴定为存在饮酒问题的患者提供简短的行为指导。此外,该建议声明也强调对风险较低但仍具有危险性的酒精使用模式进行筛查。         “酒精滥用

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