Leitch A M, Garvey R F
Department of Surgery, University of Texas, Southwestern Medical Center, Dallas 75235.
Ann Surg Oncol. 1994 Nov;1(6):516-20. doi: 10.1007/BF02303618.
Indigent patients in a county hospital setting typically present with breast cancer at a later stage than do patients in the private sector. In the early 1980s, 50% of all breast cancers diagnosed in our county hospital were stages III and IV. This contrasted markedly with the findings of an American College of Surgeons study, which showed < 15% of breast cancers diagnosed as stages III and IV.
Recognizing this disparity, we instituted a breast screening project in the county teaching hospital targeted at women who routinely received medical care in the county hospital clinics. Between 1985 and 1992, 14,567 mammograms were performed.
Two hundred eighty-nine breast biopsies were performed and 76 cancers were identified (26%). Ninety-five patients advised to have surgical consultation for biopsy declined further evaluation. The stage distribution of cancers diagnosed was as follows: stage 0, 20%; stage I, 43%; stage II, 28%; stage III, 8%; and stage IV, 1%. This compares favorably with National Cancer Data Base statistics for 1988. In contrast, symptomatic nonscreened patients diagnosed at the county hospital in 1992 presented at a significantly more advanced stage: stage 0, 1%; stage I, 14%; stage II, 45%; stage III, 26%; and stage IV, 13%.
Mammographic screening has lowered the stage of cancers diagnosed in the screened indigent population. However, a significant percentage of patients are presenting to our hospital with stage III and IV disease. Problems identified in the screening project included noncompliance with recommendations for follow-up of abnormal studies and noncompliance with appointments. In order to broaden the impact of our breast screening project, we have instituted outreach programs with community-based clinics and the American Cancer Society.
与私立医院的患者相比，县医院的贫困患者通常在乳腺癌晚期才前来就诊。在20世纪80年代早期，在我们县医院诊断出的所有乳腺癌中，50%为III期和IV期。这与美国外科医师学会的一项研究结果形成了显著对比，该研究显示诊断为III期和IV期的乳腺癌不到15%。
认识到这种差异后，我们在县教学医院开展了一项针对在县医院诊所定期接受医疗护理的女性的乳房筛查项目。1985年至1992年间，共进行了14567次乳房X光检查。
共进行了289次乳房活检，确诊76例癌症（26%）。95名被建议进行手术活检咨询的患者拒绝了进一步评估。确诊癌症的分期分布如下：0期，20%；I期，43%；II期，28%；III期，8%；IV期，1%。这与1988年国家癌症数据库统计数据相比情况较好。相比之下，1992年在县医院诊断出的有症状未筛查患者的病情明显更晚：0期，1%；I期，14%；II期，45%；III期，26%；IV期，13%。
乳房X光筛查降低了在接受筛查的贫困人群中诊断出的癌症分期。然而，仍有相当比例的患者以III期和IV期疾病前来我院就诊。筛查项目中发现的问题包括不遵守异常检查随访建议以及不遵守预约安排。为了扩大我们乳房筛查项目的影响，我们已与社区诊所和美国癌症协会开展了外展项目。
