Doroudi Maryam, Schoen Robert E, Pinsky Paul F
Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland.
Department of Medicine and Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania.
Cancer. 2017 Dec 15;123(24):4815-4822. doi: 10.1002/cncr.31034. Epub 2017 Oct 4.
BACKGROUND: Screening for colorectal cancer (CRC) with flexible sigmoidoscopy (FS) has been shown to reduce CRC mortality. The current study examined whether the observed mortality reduction was due primarily to the prevention of incident CRC via removal of adenomatous polyps or to the early detection of cancer and improved survival. METHODS: The Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial randomized 154,900 men and women aged 55 to 74 years. Individuals underwent FS screening at baseline and at 3 or 5 years versus usual care. CRC-specific survival was analyzed using Kaplan-Meier curves and proportional hazards modeling. The authors estimated the percentage of CRC deaths averted by early detection versus primary prevention using a model that applied intervention arm survival rates to CRC cases in the usual-care arm and vice versa. RESULTS: A total of 1008 cases of CRC in the intervention arm and 1291 cases of CRC in the usual-care arm were observed. Through 13 years of follow-up, there was no significant difference noted between the trial arms with regard to CRC-specific survival for all CRC (68% in the intervention arm vs 65% in the usual-care arm; P =.16) or proximal CRC (68% vs 62%, respectively; P = .11) cases; however, survival in distal CRC cases was found to be higher in the intervention arm compared with the usual-care arm (77% vs 66%; P<.0001). Within each arm, symptom-detected cases had significantly worse survival compared with screen-detected cases. Overall, approximately 29% to 35% of averted CRC deaths were estimated to be due to early detection and 65% to 71% were estimated to be due to primary prevention. CONCLUSIONS: CRC-specific survival was similar across arms in the PLCO trial, suggesting a limited role for early detection in preventing CRC deaths. Modeling suggested that approximately two-thirds of avoided deaths were due to primary prevention. Future CRC screening guidelines should emphasize primary prevention via the identification and removal of precursor lesions. Cancer 2017;123:4815-22. © 2017 American Cancer Society.
背景：已证实，使用乙状结肠镜检查（FS）筛查结直肠癌（CRC）可降低CRC死亡率。本研究旨在探讨观察到的死亡率降低主要是由于通过切除腺瘤性息肉预防了新发CRC，还是由于癌症的早期发现及生存率的提高。 方法：前列腺、肺、结直肠和卵巢（PLCO）癌症筛查试验将154,900名年龄在55至74岁的男性和女性随机分组。个体在基线时以及3年或5年后接受FS筛查，与常规护理组进行对比。使用Kaplan-Meier曲线和比例风险模型分析CRC特异性生存率。作者使用一种模型估计了通过早期发现与一级预防避免的CRC死亡百分比，该模型将干预组生存率应用于常规护理组的CRC病例，反之亦然。 结果：在干预组共观察到1008例CRC病例，在常规护理组观察到1291例CRC病例。经过13年的随访，在所有CRC病例（干预组为68%，常规护理组为65%；P = 0.16）或近端CRC病例（分别为68%和62%；P = 0.11）的CRC特异性生存率方面，试验组之间未观察到显著差异；然而，发现干预组远端CRC病例的生存率高于常规护理组（77%对66%；P<0.0001）。在每组中，有症状发现的病例与筛查发现的病例相比，生存率显著更差。总体而言，估计约29%至35%的避免CRC死亡归因于早期发现，65%至71%归因于一级预防。 结论：PLCO试验中各试验组的CRC特异性生存率相似，表明早期发现在预防CRC死亡方面的作用有限。模型显示，约三分之二的避免死亡归因于一级预防。未来的CRC筛查指南应强调通过识别和切除前驱病变进行一级预防。《癌症》2017年；123：4815 - 22。©2017美国癌症协会。
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