Pisani Paola, Parkin D M, Ngelangel Corazon, Esteban Divina, Gibson Lorna, Munson Marilou, Reyes Mary Grace, Laudico Adriano
Unit of Descriptive Epidemiology, International Agency for Research on Cancer, Lyon, France.
Int J Cancer. 2006 Jan 1;118(1):149-54. doi: 10.1002/ijc.21343.
The value of screening by Clinical Examination of the Breast (CBE) as a means of reducing mortality from breast cancer (BC) is not established. The issue is relevant, as CBE may be a suitable option for countries in economic transition, where incidence rates are on the increase but limited resources do not permit screening by mammography. Our aims were to assess whether mass screening by CBE carried out by trained para-medical personnel is feasible in an urban population of a low-income country, and its efficacy in reducing BC mortality. Our study was designed as a randomised controlled trial of the effect on BC mortality of 5 annual CBE carried out by trained nurses. The target population was women aged 35-64 years, resident in 12 municipalities of the National Capital Region of Manila, Philippines. The units of randomization were the 202 health centres (HC) within the selected municipalities. During 1995 nurses and midwives were recruited and trained in performing CBE. The first round of screening took place in 1996-1997. The intervention however showed a refractory attitude of the population with respect to clinical follow-up and was discontinued after the completion of the first screening round. Cases of breast cancer occurring in the study population during 1996-1999 were identified by the 2 local population-based registries. In the single screening round 151,168 women were interviewed and offered CBE, 92% accepted (138,392), 3,479 were detected positive for a lump and referred for diagnosis. Of these only 1220 women (35%) completed diagnostic follow-up, whereas 42.4% actively refused further investigation even with home visits, and 22.5% were not traced. Of 53 cases that occurred among screen-positive women in the 2 years after CBE only 34 were diagnosed through the intervention. Eighty cases occurred among screen-negative women. The test sensitivity for CBE repeated annually was 53.2%. The actual sensitivity of the programme was 25.6% and positive predictive value 1%. Screen-detected cases were non-significantly less advanced than the others. Previous studies have shown that most breast cancer cases in the Philippines present at advanced stages and have an unfavourable outcome. Although CBE undertaken by health workers seems to offer a cost-effective approach to reducing mortality, the sensitivity of the screening programme in the real context was low. Moreover, in this relatively well-educated population, cultural and logistic barriers to seeking diagnosis and treatment persist and need to be addressed before any screening programme is introduced.
通过乳腺临床检查（CBE）进行筛查作为降低乳腺癌（BC）死亡率的一种手段，其价值尚未确定。这个问题很重要，因为对于经济转型国家而言，CBE可能是一个合适的选择，这些国家的发病率在上升，但资源有限，无法进行乳腺X线摄影筛查。我们的目的是评估由经过培训的辅助医务人员进行的CBE群体筛查在低收入国家的城市人口中是否可行，以及其在降低BC死亡率方面的效果。我们的研究设计为一项随机对照试验，研究由经过培训的护士进行的5次年度CBE对BC死亡率的影响。目标人群是年龄在35 - 64岁之间、居住在菲律宾马尼拉国家首都地区12个市的女性。随机分组单位是所选市辖区内的202个健康中心（HC）。1995年，招募了护士和助产士并对其进行CBE操作培训。第一轮筛查于1996 - 1997年进行。然而，干预措施显示出人群对临床随访持抵触态度，在第一轮筛查完成后就停止了。1996 - 1999年研究人群中发生的乳腺癌病例由2个基于当地人群的登记处确定。在单次筛查轮次中，对151,168名女性进行了访谈并提供CBE，92%的人接受了（138,392人），3479人被检测出乳房有肿块并被转诊进行诊断。其中只有1220名女性（35%）完成了诊断随访，而42.4%的人即使进行家访也积极拒绝进一步检查，22.5%的人无法追踪到。在CBE后2年中，筛查呈阳性的女性中有53例发病，其中只有34例通过干预措施被诊断出来。筛查呈阴性的女性中有80例发病。每年重复进行的CBE的检测灵敏度为53.2%。该项目的实际灵敏度为25.6%，阳性预测值为1%。筛查发现的病例与其他病例相比，病情进展程度无显著差异。先前的研究表明，菲律宾的大多数乳腺癌病例发现时已处于晚期，预后不佳。尽管卫生工作者进行的CBE似乎为降低死亡率提供了一种具有成本效益的方法，但在实际情况下筛查项目的灵敏度较低。此外，在这个受教育程度相对较高的人群中，寻求诊断和治疗的文化及后勤障碍仍然存在，在引入任何筛查项目之前都需要加以解决。
