Lancet Diabetes Endocrinol:甲状腺癌发病率快速上升,因为过度诊断?

2020-05-23 医学新视点 医学新视点

全球的甲状腺癌发病率都在持续上升,据中国肿瘤登记中心的数据,中国甲状腺癌将以每年20%的速度持续增长。不过,甲状腺癌的死亡率仍然相对稳定,甚至有所下降。

全球的甲状腺癌发病率都在持续上升,据中国肿瘤登记中心的数据,中国甲状腺癌将以每年20%的速度持续增长。不过,甲状腺癌的死亡率仍然相对稳定,甚至有所下降。发病率的增加反映了超声检查等诊断技术的进步,也引起了人们对于过度诊断的担忧。以前报道:全球甲状腺癌数据,不要错过这篇综述!

由于相对是一种“懒癌”,进展缓慢,很多患者并没有症状或不适。如果没有进行相关诊断检测和组织学检查,有些患者可能在一辈子都不会被查出甲状腺癌。

为了量化评估甲状腺癌过度诊断的全球趋势和影响程度,世界卫生组织下属国际癌症研究机构(IARC)分析了横跨四大洲的26个国家/地区,1998-2012年期间15-84岁人群报告的所有甲状腺癌病例。报告最新发表在《柳叶刀-糖尿病和内分泌学》。

 

截图来源:The Lancet Diabetes & Endocrinology

IARC研究人员分析发现,1998-2002年到2008-2012年,在所有高收入国家中,甲状腺癌发病率持续稳定增长,并且在中低收入地区也观察到了这一趋势,尤其是中国、哥伦比亚、立陶宛和白俄罗斯。

各国的发病率增长情况不尽相同,中年女性(35-64岁)中的发病率都尤为高。这一趋势最突出的是韩国:2008-2012年50-59岁女性甲状腺癌的发病率(每10万人260例),相较于2003-2007年翻了一倍(每10万人120例),更是1998-2002年(每10万人35例)的7倍多。从曲线图上看,中国这一趋势也比较明显

 

▲1998年-2012年不同国家/地区各年龄段女性的甲状腺癌发病率,实线为实际观察值,虚线为没有过度诊断(即先进诊断技术和高水平检测筛查)情况下的预测值

位了评估过度诊断的影响,研究人员绘制了一条“历史特定年龄曲线”,用于对比引入超声检查前的有症状甲状腺癌发病率,并将实际值与预测值的差距归因于过度诊断,即对甲状腺结节(实际很少导致中年人群死亡)的强化检测。

对比发现,2008-2012年期间,过度诊断带来的女性甲状腺癌病例的预计比例,在韩国约为93%,在白俄罗斯为91%,在中国为87%,在意大利和克罗地亚为84%,在斯洛伐克和法国为83%。换言之,2008-2012年之间,这26个国家/地区中超过83万多女性患者属于过度诊断,包括中国约39万女性,韩国约14万女性,美国12万女性,意大利3.1万女性和法国2.5万女性。

丹麦、挪威、爱尔兰、英国、日本、泰国的过度诊断比例相对较低,但也基本超过了所有女性患者的半数。

在男性中观察到的情况相似,尽管幅度稍小,每个国家男性中的过度诊断病例占比约比女性少10%。总体而言,在26个研究国家/地区中,2008-2012年之间有超过22万名男性被过度诊断为甲状腺癌。

研究团队认为,虽然放射线暴露、超重和肥胖等危险因素也可能增加甲状腺癌发病率,但从上述流行病学特征来看,状腺癌发病率上升主要还是过度诊断的影响

国家/地区之间发病率的差异可能也反映了当地医疗习惯。比如,韩国的国家筛查计划额外提供了甲状腺检查,而在其他国家,过度诊断可能取决于监测的强度以及超声波和其他诊断技术的应用程度。在其他疾病的影像学检查中,也会偶尔意外发现甲状腺癌。

女性中过度诊断更常见,也反映了甲状腺疾病的性别差异——在26个研究国家/地区中发病率约为3:1。甲状腺与女性生殖激素的相互作用可能会诱发甲状腺疾病和甲状腺结节的发展,而且由于生殖和绝经等因素,女性通常更多就医,潜在甲状腺检查机会也更多。

不过,男性和女性的甲状腺癌死亡率均很低,每10万人中<1人死亡,从尸检中发现的甲状腺癌患病率没有明显性别差异。

报告最后,IARC研究人员强调指出,尽管有证据表明过度诊断的危害更大,但更多国家/地区都在越来越多地提供甲状腺癌诊断技术。这增加了个体的医疗成本和医疗系统的资源负担;更重要是,这可能会让健康个体变为患者,接受原本不必要的终身治疗

大多数被诊断出患有甲状腺癌的患者都会接受全甲状腺切除术和放疗、颈部淋巴结清扫术等其他治疗。虽然甲状腺癌手术的确是有效的,但也可能带来伤害,比如损伤控制声带的神经,或损伤控制血钙的腺体,虽然这种风险很小。除此之外,切除了甲状腺的患者需要终生服用激素来维持机体功能。

目前,包括梅奥诊所和纪念斯隆-凯特琳癌症中心(Memorial Sloan Kettering Cancer Center)在内的全球多家顶级医院,以及不少指南目前已经建议,不要在无症状的个体中筛查甲状腺癌,并提倡对微小肿瘤进行积极监测而非立即治疗。纪念斯隆-凯特琳癌症中心曾在《美国医学会杂志》子刊发表研究证明,在甲状腺癌中最常见的乳头状甲状腺癌中,主动监测合理有效。

根据中国卫健委《甲状腺癌诊疗规范(2018年版)》建议,需要监测筛查甲状腺癌的高危人群包括:

①童年期头颈部放射线照射史或放射性尘埃接触史;

②全身放射治疗史;

③有以下疾病的既往史或家族史:分化型甲状腺癌、甲状腺髓样癌或多发性内分泌腺瘤病2型(MEN2型)、家族性多发性息肉病、某些甲状腺癌综合征[如多发性错构瘤综合征 (multiple hamartoma syndrome)、Carney综合征、沃纳综合征(Werner syndrome)和加德纳综合征(Gardner syndrome)]等。

原始出处:

Mengmeng Li, et al., (2020). Global trends in thyroid cancer incidence and the impact of overdiagnosis. The Lancet Diabetes & Endocrinology, DOI: 10.1016/S2213-8587(20)30115-7

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    2020-06-28 howi
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    2020-05-28 ms8000001295944851

    不要低估甲状腺乳头状癌的侵袭性,临床中经常遇到甲状腺癌就诊时候已经明显累及临近的重要组织,有的甚至失去手术机会。因为国人的依从性,很少有人做到定期准时复查,所以还是建议明确甲状腺乳头状癌的还是尽快手术,手术范围不一定所有患者都要全切。

    0

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    2020-05-23 goodbing

    顶刊就是不一样,质量很高,内容精彩!学到很多

    0

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