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解决过度诊断的问题
Solving the Problem of Overdiagnosis


Joann G. Elmore ... 肿瘤 • 2016.10.13

我的患者对于乳腺癌的恐惧显而易见。我看到他们为是否要拍摄乳房X线片而烦恼不安,为假阳性异常而担心忧虑,以及为不予报销的诊断性评估的费用而挣扎。临床医师可以明显看到筛查带来的这一附带损害。但是,现在有越来越多的证据表明癌症筛查带来的一个不太明显的后果——本来永远不会引起症状或死亡的疾病被过度诊断。过度诊断的存在及其影响不太明晰,它们埋藏在人群统计结果中,而不是患者就诊时。

乳腺癌过度诊断是在多项研究的基础上提出的,这些研究应用不同的设计和方法,并且获得美国癌症学会(American Cancer Society)和美国预防服务工作组(U.S. Preventive Services Task Force)等全国性组织的认可1,2。其他癌症的过度诊断也已引起关注。甲状腺癌的过度诊断伴随超声筛查的引入而出现3,黑色素瘤的过度诊断伴随皮肤癌的广泛筛查而出现4。伴随小剂量计算机化断层成像筛查而出现的肺癌的过度诊断以及前列腺特异性抗原检测后出现的前列腺癌的过度诊断也有报告5,6





作者信息

Joann G. Elmore, M.D., M.P.H.

 

参考文献

1. Oeffinger KC, Fontham ET, Etzioni R, et al. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA 2015;314:1599-1614

2. Nelson HD, Pappas M, Cantor A, Griffin J, Daeges M, Humphrey L. Harms of breast cancer screening: systematic review to update the 2009 U.S. Preventive Services Task Force recommendation. Ann Intern Med 2016;164:256-267

3. Ahn HS, Welch HG. South Korea’s thyroid-cancer “epidemic” — turning the tide. N Engl J Med 2015;373:2389-2390

4. Glusac EJ. The melanoma ‘epidemic’: lessons from prostate cancer. J Cutan Pathol 2012;39:17-20

5. Patz EF Jr, Pinsky P, Gatsonis C, et al. Overdiagnosis in low-dose computed tomography screening for lung cancer. JAMA Intern Med 2014;174:269-274

6. Vickers AJ, Sjoberg DD, Ulmert D, et al. Empirical estimates of prostate cancer overdiagnosis by age and prostate-specific antigen. BMC Med 2014;12:26-26

7. Welch HG, Prorok PC, O’Malley AJ, Kramer BS. Breast-cancer tumor size, overdiagnosis, and mammography screening effectiveness. N Engl J Med 2016;375:1438-1447

8. Elmore JG, Wells CK, Lee CH, Howard DH, Feinstein AR. Variability in radiologists’ interpretations of mammograms. N Engl J Med 1994;331:1493-1499

9. Elmore JG, Longton GM, Carney PA, et al. Diagnostic concordance among pathologists interpreting breast biopsy specimens. JAMA 2015;313:1122-1132

10. National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. Washington, DC: National Academies Press, 2015.

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