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重新审视前列腺癌死亡率——PSA筛查的未来
Reconsidering Prostate Cancer Mortality — The Future of PSA Screening


H. Gilbert Welch ... 肿瘤 • 2020.04.16
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与20世纪90年代初的峰值相比,美国的前列腺癌死亡率已经从每10万名男性中39例下降至每10万名男性中19例,基本上下降了一半。虽然所有人都认为死亡率下降是好消息,但在死亡率下降的原因方面却有很大分歧。这一争论对于前列腺特异性抗原(PSA)筛查的未来具有深远意义。

图1A绘制了自1950年以来,在癌症相关死因中,三种常见死因患者的癌症特异性死亡率的长期趋势。肺癌死亡率是癌症相关死亡率的最大组成部分,其大幅上升和下降反映了几十年前吸烟率的上升和下降。相比之下,乳腺癌死亡率在1990年之前非常稳定,之后开始下降。前列腺癌死亡率在1970年之前也很稳定,并且从20世纪90年代初开始下降。但在中间的这20多年却有所增加。

 

图1. 19502016年的美国前列腺癌死亡率

作为背景资料,图A显示了肺癌(男性)和乳腺癌(女性)死亡率。图B显示了1950—1970年稳定的基线前列腺癌死亡率,以及之后最有可能影响所报告死亡率的系统性暴露。所有比率均根据美国2000年标准人口进行了年龄校正。PSA表示前列腺特异性抗原,TURP表示经尿道前列腺切除术。

 

死亡率增加的可能原因如图1B所示。在20世纪70年代和80年代初,泌尿科医师为了治疗老年男性的良性前列腺肥大而实施的经尿道前列腺切除术(TURP)越来越多。随着送到病理科的前列腺切除标本的增多,偶然检出的前列腺癌也增多,因此(被发现的)前列腺癌的发病率逐渐上升。到1986年时,有一半前列腺癌是通过TURP检出1。在老年男性这一死亡相对常见的年龄组中,前列腺癌诊断率的提高导致了更多的死亡被归因于前列腺癌,这一现象被称为黏性诊断偏倚(sticky diagnosis bias)2





作者信息

H. Gilbert Welch, M.D., M.P.H., and Peter C. Albertsen, M.D.
From the Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston (H.G.W.); and the Division of Urology, Department of Surgery, University of Connecticut Health Center, Farmington (P.C.A.).

 

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