24530例妇女宫颈癌机会性筛查方法探讨
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摘要
目的评估5种宫颈癌筛查方案,探索适合不同临床特征人群的宫颈癌筛查模式。方法收集2013年1月至2015年12月重庆市13家妇幼保健院就诊并完成全部随访的妇女24 530人。根据其临床特征分为5组:A组(年轻女性组)、B组(哺乳期人群组)、C组(不孕症人群组)、D组(围绝经期及老年期女性人群组)、E组(育龄期普通人群组),联合使用4种方法[醋酸肉眼观察法(visual inspection after acetic acid,VIA),液基细胞学检查(thinprep cytologic test,TCT),人乳头瘤病毒(human papillomavirus,HPV)-DNA检测,阴道镜检查]进行筛查,任一检查结果阳性即行宫颈活检送病理学检测,必要时行宫颈锥切术,其后每年随访1次,共随访2年。本研究以组织学诊断宫颈上皮内瘤变(cervical intraepithelial neoplasia,CIN)Ⅱ级及以上病变作为随访终点,分别计算不同筛查方案(单独采用VIA、TCT、HPV、阴道镜及联合采用TCT+HPV)诊断CINⅡ+的灵敏度、特异度、阳性预测值、阴性预测值、约登指数及曲线下面积(area under curve, AUC),以AUC评价不同检测方法诊断的准确性。结果①A组中,5种筛查方案的AUC之间差异无统计学意义(P>0.005)。②B组中,HPV及联合方案的AUC大于其他3种筛查方案,差异有统计学意义(P<0.005);③C组中,联合方案的AUC大于其他4种筛查方案,差异有统计学意义(P<0.005);④D组中,TCT、HPV及联合方案的AUC大于其他2种筛查方案,差异有统计学意义(P<0.005);⑤E组中,HPV的AUC大于其他4种筛查方案,差异有统计学意义(P<0.005)。结论不同临床特征人群采取的宫颈癌筛查方案不尽相同,采取适宜的筛查方案可提高检出率。
Objective To evaluate the 5 protocols of opportunistic screening for cervical carcinoma among different female populations, in order to explore optional protocol for the women with different clinical characteristics. Methods A total of 24 530 women who admitted in 13 maternal and child health hospitals from January 2013 to December 2015 and completed our follow-up were recruited in this study. According to their clinical characteristics, they were divided into 5 groups: group A(young females, 21～24 years old), group B(lactating women), group C(with identified infertility, 25～39 years old), group D(perimenopausal and elderly women), group E(women of childbearing age, 25～39 years old). Five protocols were used for opportunistic screening, that is, visual inspection after acetic acid(VIA), thinprep cytologic test(TCT), human papillomavirus(HPV)-DNA test, colposcopy, and combination of TCT and HPV-DNA test. All the suspected cases(at least 1 positive result) underwent biopsy, and/or cervical conization when necessary. All the cases were followed up once a year, for 2 years. Histological diagnosis of cervical intraepithelial neoplasia(CIN) grade Ⅱ and above lesions was regarded as the follow-up endpoints. The sensitivity, specificity, positive predictive value, negative predictive value, Youden's index and area under curve(AUC) of CIN Ⅱ+ were calculated for different screening schemes(VIA, TCT, HPV, colposcopy and TCT+HPV) in order to evaluate the diagnostic accuracy of these protocols. Results ①In group A, there was no significant difference in AUC among the 5 protocols(P>0.005). ② In group B, the AUCs of HPV and TCT+HPV were significantly greater than those of the other protocols(P<0.005). ③In group C, the AUC of the combined screening was greater than those of the other ones, with statistical differences(P<0.005). ④In group D, the AUCs of TCT, HPV, and the combined screening were significantly greater than those of the other ones(P<0.005). ⑤ In group E, the AUC of HPV was significantly greater than those of the other ones(P<0.005). Conclusion Different opportunistic screening protocols for cervical carcinoma are suitable for the women with different clinical characteristics. Optional screening protocols can improve the detection rate.
Objective To evaluate the 5 protocols of opportunistic screening for cervical carcinoma among different female populations, in order to explore optional protocol for the women with different clinical characteristics. Methods A total of 24 530 women who admitted in 13 maternal and child health hospitals from January 2013 to December 2015 and completed our follow-up were recruited in this study. According to their clinical characteristics, they were divided into 5 groups: group A(young females, 21～24 years old), group B(lactating women), group C(with identified infertility, 25～39 years old), group D(perimenopausal and elderly women), group E(women of childbearing age, 25～39 years old). Five protocols were used for opportunistic screening, that is, visual inspection after acetic acid(VIA), thinprep cytologic test(TCT), human papillomavirus(HPV)-DNA test, colposcopy, and combination of TCT and HPV-DNA test. All the suspected cases(at least 1 positive result) underwent biopsy, and/or cervical conization when necessary. All the cases were followed up once a year, for 2 years. Histological diagnosis of cervical intraepithelial neoplasia(CIN) grade Ⅱ and above lesions was regarded as the follow-up endpoints. The sensitivity, specificity, positive predictive value, negative predictive value, Youden's index and area under curve(AUC) of CIN Ⅱ+ were calculated for different screening schemes(VIA, TCT, HPV, colposcopy and TCT+HPV) in order to evaluate the diagnostic accuracy of these protocols. Results ①In group A, there was no significant difference in AUC among the 5 protocols(P>0.005). ② In group B, the AUCs of HPV and TCT+HPV were significantly greater than those of the other protocols(P<0.005). ③In group C, the AUC of the combined screening was greater than those of the other ones, with statistical differences(P<0.005). ④In group D, the AUCs of TCT, HPV, and the combined screening were significantly greater than those of the other ones(P<0.005). ⑤ In group E, the AUC of HPV was significantly greater than those of the other ones(P<0.005). Conclusion Different opportunistic screening protocols for cervical carcinoma are suitable for the women with different clinical characteristics. Optional screening protocols can improve the detection rate.
引文
[1] DEL CARMEN M G,RICE L W,SCHMELER K M.Global health perspective on gynecologic oncology[J].Gynecol Oncol,2015,137(2):329-334.DOI:10.1016/j.ygyno.2015.03.009.
[2] 魏丽惠,赵昀,沈丹华,等.中国子宫颈癌筛查及异常管理相关问题专家共识(一)[J].中国妇产科临床杂志,2017,18(2):190-192.DOI:10.13390/j.issn.1672-1861.2017.02.032.WEI L H,ZHAO J,SHEN D H,et al.Expert consensus on cervical cancer screening and abnormal management in China (1) [J].Chin J Clin Obstet Gynecol,2017,18(2):190-192.DOI:10.13390/j.issn.1672-1861.2017.02.032.
[3] WANG B,HE M,CHAO A,et al.Cervical cancer screening among adult women in China,2010[J].Oncologist,2015,20(6):627-634.DOI:10.1634/theoncologist.2014-0303.
[4] NAZ U,HANIF S.Agreement between visual inspection with acetic acid and Papanicolaou’s smear as screening methods for cervical cancer[J].J Coll Physicians Surg Pak,2014,24(4):228-231.DOI:04.2014/JCPSP.228231.
[5] SOLOMON D,DAVEY D,KURMAN R,et al.The 2001 Bethesda System:terminology for reporting results of cervical cytology[J].JAMA,2002,287(16):2114-2119.
[6] BORNSTEIN J,BENTLEY J,B?SZE P,et al.2011 colposcopic terminology of the International Federation for Cervical Pathology and Colposcopy[J].Obstet Gynecol,2012,120(1):166-172.DOI:10.1097/ AOG.0b013e318254f90c.
[7] SASLOW D,SOLOMON D,LAWSON H W,et al.American Cancer Society,American Society for Colposcopy and Cervical Pathology,and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer[J].CA Cancer J Clin,2012,62(3):147-172.DOI:10.3322/caac.21139.
[8] 张丽丽,李爱华,张师前.2016 ACOG宫颈癌筛查指南解读[J].妇产与遗传(电子版),2016,6(1):21-24.DOI:10.3868 /j.issn.2095-1558.2016.01.005.ZHANG L L,LI A H,ZHANG S Q.Interpretation of 2016 ACOG Guidelines for Cervical Cancer Screening[J].Obstet Gynecol Genet (Electr Ed),2016,6(1):21-24.DOI:10.3868 /j.issn.2095-1558.2016.01.005.
[9] HUH W K,AULT K A,CHELMOW D,et al.Use of primary high-risk human papillomavirus testing for cervical cancer screening:interim clinical guidance[J].Gynecol Oncol,2015,136(2):178-182.DOI:10.1016/j.ygyno.2014.12.022.
[10] 余松林.医学统计学[M].北京:人民卫生出版社,2002:164-178.YU S L.Medical Statistics [M].Beijing:People’s Health Publishing House,2002:164-178.
[11] 张飞雪,黄太华.2014-2016年贵州省农村妇女宫颈癌检查项目结果分析[J].现代预防医学,2019,46(3):447-451.ZHANG F X,HUANG T H.Analysis of the rural women cervical cancer screening project in Guizhou[J].Mod Prev Med,2019,46(3):447-451.
[12] 孙可欣,郑荣寿,张思维,等.2015年中国分地区恶性肿瘤发病和死亡分析[J].中国肿瘤,2019,28(1):1-11.SUN K X,ZHENG R S,ZHANG S W,et al.Report of cancer incidence and mortality in different areas of China,2015[J].China Cancer,2019,28(1):1-11.
[13] 何鑫,陶绘丞,刘晨,等.医院机会性筛查人群HR-HPV感染的流行病学特征及与宫颈癌前病变的关系[J].首都医科大学学报,2015,36(2):219-225.DOI:10.3969/j.issn.1006-7795.2015.02.011.HE X,TAO H C,LIU C,et al.Epidemiologic characteristics of high risk human papillomavirus (HR-HPV) infection in population undergone hospital opportunistic health screening and the relationship between cervical cancer lesion and HR-HPV infection[J].J Capit Med Univ,2015,36(2):219-225.DOI:10.3969/j.issn.1006-7795.2015.02.011.
[14] CHELMOW D.Cervical cancer screening and prevention[J].Obstet Gynecol,2016,127(1):e1-e20.DOI:10.1097/AOG.0000000000001263.
[15] 魏丽惠,沈丹华,赵方辉,等.中国子宫颈癌筛查及异常管理相关问题专家共识(二)[J].中国妇产科临床杂志,2017,18(3):286-288.DOI:10.13390/j.issn.1672-1861.2017.03.041.WEI L H,SHEN D H,ZHAO F F,et al.Expert consensus on cervical cancer screening and abnormal management in China (2)[J].Chin J Clin Obstet Gynecol,2017,18(3):286- 288.DOI:10.13390/j.issn.1672-1861.2017.03.041.
[16] 周红娣,金福明,沈铿.2016年美国妇产科医师学会推荐的宫颈癌筛查及预防指南的解读[J].现代妇产科进展,2016,25(6):401-405,410.DOI:10.13283 /j.cnki.xdfckjz.2016.06.001.ZHOU H D,JIN F M,SHEN K.Interpretation of guidelines for screening and prevention of cervical cancer recommended by the american society of obstetricians and gynecologists in 2016[J].Prog Obstet Gynecol,2016,25(6):401-405,410.DOI:10.13283/j.cnki.xdfckjz.2016.06.001.
[17] 杨君,周德平,龙馨,等.不同女性人群生殖道人乳头瘤病毒感染状况分析[J].实用妇产科杂志,2017,33(6):430-434.YANG J,ZHOU D P,LONG X,et al.Investigation and analysis on HPV infection status of different female groups[J].J Prac Obstet Gynecol,2017,33(6):430-434.
[18] 周潞,黄薇.不孕与宫颈人乳头瘤病毒感染的关系研究[J].实用妇产科杂志,2015,31(2):147-149.ZHOU L,HUANG W.Relationship between tubal infertility and cervical human papillomavirus infection[J].J Prac Obstet Gynecol,2015,31(2):147-149.
[19] ASCIUTTO K C,FORSLUND O,BORGFELDT C.Prevalence of high-risk HPV in postmenopausal women with benign cervical cytology-A population-based cohort study[J].Anticancer Res,2018,38(7):4221-4228.DOI:10.21873/anticanres.12718.
[2] 魏丽惠,赵昀,沈丹华,等.中国子宫颈癌筛查及异常管理相关问题专家共识(一)[J].中国妇产科临床杂志,2017,18(2):190-192.DOI:10.13390/j.issn.1672-1861.2017.02.032.WEI L H,ZHAO J,SHEN D H,et al.Expert consensus on cervical cancer screening and abnormal management in China (1) [J].Chin J Clin Obstet Gynecol,2017,18(2):190-192.DOI:10.13390/j.issn.1672-1861.2017.02.032.
[3] WANG B,HE M,CHAO A,et al.Cervical cancer screening among adult women in China,2010[J].Oncologist,2015,20(6):627-634.DOI:10.1634/theoncologist.2014-0303.
[4] NAZ U,HANIF S.Agreement between visual inspection with acetic acid and Papanicolaou’s smear as screening methods for cervical cancer[J].J Coll Physicians Surg Pak,2014,24(4):228-231.DOI:04.2014/JCPSP.228231.
[5] SOLOMON D,DAVEY D,KURMAN R,et al.The 2001 Bethesda System:terminology for reporting results of cervical cytology[J].JAMA,2002,287(16):2114-2119.
[6] BORNSTEIN J,BENTLEY J,B?SZE P,et al.2011 colposcopic terminology of the International Federation for Cervical Pathology and Colposcopy[J].Obstet Gynecol,2012,120(1):166-172.DOI:10.1097/ AOG.0b013e318254f90c.
[7] SASLOW D,SOLOMON D,LAWSON H W,et al.American Cancer Society,American Society for Colposcopy and Cervical Pathology,and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer[J].CA Cancer J Clin,2012,62(3):147-172.DOI:10.3322/caac.21139.
[8] 张丽丽,李爱华,张师前.2016 ACOG宫颈癌筛查指南解读[J].妇产与遗传(电子版),2016,6(1):21-24.DOI:10.3868 /j.issn.2095-1558.2016.01.005.ZHANG L L,LI A H,ZHANG S Q.Interpretation of 2016 ACOG Guidelines for Cervical Cancer Screening[J].Obstet Gynecol Genet (Electr Ed),2016,6(1):21-24.DOI:10.3868 /j.issn.2095-1558.2016.01.005.
[9] HUH W K,AULT K A,CHELMOW D,et al.Use of primary high-risk human papillomavirus testing for cervical cancer screening:interim clinical guidance[J].Gynecol Oncol,2015,136(2):178-182.DOI:10.1016/j.ygyno.2014.12.022.
[10] 余松林.医学统计学[M].北京:人民卫生出版社,2002:164-178.YU S L.Medical Statistics [M].Beijing:People’s Health Publishing House,2002:164-178.
[11] 张飞雪,黄太华.2014-2016年贵州省农村妇女宫颈癌检查项目结果分析[J].现代预防医学,2019,46(3):447-451.ZHANG F X,HUANG T H.Analysis of the rural women cervical cancer screening project in Guizhou[J].Mod Prev Med,2019,46(3):447-451.
[12] 孙可欣,郑荣寿,张思维,等.2015年中国分地区恶性肿瘤发病和死亡分析[J].中国肿瘤,2019,28(1):1-11.SUN K X,ZHENG R S,ZHANG S W,et al.Report of cancer incidence and mortality in different areas of China,2015[J].China Cancer,2019,28(1):1-11.
[13] 何鑫,陶绘丞,刘晨,等.医院机会性筛查人群HR-HPV感染的流行病学特征及与宫颈癌前病变的关系[J].首都医科大学学报,2015,36(2):219-225.DOI:10.3969/j.issn.1006-7795.2015.02.011.HE X,TAO H C,LIU C,et al.Epidemiologic characteristics of high risk human papillomavirus (HR-HPV) infection in population undergone hospital opportunistic health screening and the relationship between cervical cancer lesion and HR-HPV infection[J].J Capit Med Univ,2015,36(2):219-225.DOI:10.3969/j.issn.1006-7795.2015.02.011.
[14] CHELMOW D.Cervical cancer screening and prevention[J].Obstet Gynecol,2016,127(1):e1-e20.DOI:10.1097/AOG.0000000000001263.
[15] 魏丽惠,沈丹华,赵方辉,等.中国子宫颈癌筛查及异常管理相关问题专家共识(二)[J].中国妇产科临床杂志,2017,18(3):286-288.DOI:10.13390/j.issn.1672-1861.2017.03.041.WEI L H,SHEN D H,ZHAO F F,et al.Expert consensus on cervical cancer screening and abnormal management in China (2)[J].Chin J Clin Obstet Gynecol,2017,18(3):286- 288.DOI:10.13390/j.issn.1672-1861.2017.03.041.
[16] 周红娣,金福明,沈铿.2016年美国妇产科医师学会推荐的宫颈癌筛查及预防指南的解读[J].现代妇产科进展,2016,25(6):401-405,410.DOI:10.13283 /j.cnki.xdfckjz.2016.06.001.ZHOU H D,JIN F M,SHEN K.Interpretation of guidelines for screening and prevention of cervical cancer recommended by the american society of obstetricians and gynecologists in 2016[J].Prog Obstet Gynecol,2016,25(6):401-405,410.DOI:10.13283/j.cnki.xdfckjz.2016.06.001.
[17] 杨君,周德平,龙馨,等.不同女性人群生殖道人乳头瘤病毒感染状况分析[J].实用妇产科杂志,2017,33(6):430-434.YANG J,ZHOU D P,LONG X,et al.Investigation and analysis on HPV infection status of different female groups[J].J Prac Obstet Gynecol,2017,33(6):430-434.
[18] 周潞,黄薇.不孕与宫颈人乳头瘤病毒感染的关系研究[J].实用妇产科杂志,2015,31(2):147-149.ZHOU L,HUANG W.Relationship between tubal infertility and cervical human papillomavirus infection[J].J Prac Obstet Gynecol,2015,31(2):147-149.
[19] ASCIUTTO K C,FORSLUND O,BORGFELDT C.Prevalence of high-risk HPV in postmenopausal women with benign cervical cytology-A population-based cohort study[J].Anticancer Res,2018,38(7):4221-4228.DOI:10.21873/anticanres.12718.
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