CA Cancer J Clin :简化宫颈癌筛查,起始年龄和检查方式都有变化

2020-08-09 药明康德内容团队 医学新视点

近日,美国癌症协会(ACS)发布了最新宫颈癌筛查指南。根据指南建议,筛查措施将有所简化。其中一个重要更新是:建议25-65岁女性首选每5年通过人类乳头瘤病毒(HPV)检查来筛查宫颈癌。

近日,美国癌症协会(ACS)发布了最新宫颈癌筛查指南。根据指南建议,筛查措施将有所简化。其中一个重要更新是:建议25-65岁女性首选每5年通过人类乳头瘤病毒(HPV)检查来筛查宫颈癌。如果无法进行初级HPV检查(primary HPV tests),则可以每3年进行一次细胞学(俗称巴氏涂片)检查,或每5年进行一次细胞学和HPV联合检查。

这意味着,ACS新指南首推单独使用初级HPV检查,要知道,细胞学检查一直是宫颈癌筛查金标准;而且比起目前大多指南建议的21岁开始筛查,起始筛查年龄要推迟了4年。

美国癌症协会HPV和妇科癌症主任Debbie Saslow博士表示:“这些简化的筛查建议可以改善女性依从性,并减少潜在的危害。”

Saslow博士补充解释,过去积累了大量研究比较HPV检查和细胞学检查的效果,现在已有更强有力的证据支持延迟筛查、并首选HPV检查。与现行推荐相比,最新推荐的25岁开始接受初级HPV检查可以“多预防13%的宫颈癌病例和7%的死亡”。模型表明,“可以通过增加9%的随访来实现这一目标,但总体上需要进行的检查减少了45%。”

将起始筛查年龄推迟到25岁,也考虑到了年轻人中HPV疫苗接种率越来越高。指南制定团队指出,“在接种疫苗人群中,细胞学检查的效率要低得多。因为疫苗可以预防高危HPV型感染,细胞学检查异常结果中,大多是低危HPV型导致的轻微病变。随着接种率的提高,这种假阳性的比例还会增加。”因此,ACS也建议医生同时考虑宫颈癌筛查发现和疫苗接种情况,来准确评估筛查结果。

另一方面,只有不到1%的宫颈癌是在25岁前被诊断的,随着疫苗接种率增加,这一比例还会更低。此外,年轻患者的假阳性率要高得多,而假阳性结果可能对妊娠结局产生负面影响。

Saslow博士还表示,这些新建议不会影响医护人员的工作量,因为联合检查和初级HPV检查的操作方式相似。

显然,最新建议和ACS现行指南或其他机构的指南都有着很大不同:

美国癌症协会(ACS)、美国阴道镜和宫颈病理协会(ASCCP)和美国临床病理协会(ASCP)的现行联合推荐是,“21岁-65岁女性每3年一次细胞学检查,从30岁开始可改为每5年一次联合检查”。

美国妇产科学会(ACOG)目前也推荐,从21岁开始每3年接受一次细胞学检查,30岁起每5年进行一次联合检查。

美国预防服务工作组(USPSTF)在2018年开始将筛查建议调整为,“21-65岁女性每3年一次细胞学检查,从30岁开始可每5年进行HPV检查或联合检查”。这也是USPSTF首次推荐单独进行HPV检查。

此次ACS新指南指出,仍然保留细胞学检查的选项,是因为在某些情况下女性可能无法获得获批用于初级筛查的HPV检查。随着逐渐向初级HPV检查过渡,未来指南将不再推荐单独进行细胞学检查或联合细胞学检查。目前,FDA已批准两项一线初级HPV检查用于宫颈癌筛查。

新指南中地位变化显着的细胞学检查和HPV检查,它们的差别在于:

细胞学检查需要通过宫颈刮片先收集宫颈细胞,然后染色、进行显微镜检查。虽然自75年前问世以来一直是宫颈癌的筛查“金标准”,但细胞学检查只能发现约50%的宫颈癌前病变。

检查有无HPV的DNA则更准确,因为HPV是导致宫颈癌的主要感染原因。不过HPV检查只能确定女性是否感染了致癌HPV,而不能确定实际患癌风险,这会给很多女性带来不必要的担忧。HPV检查还有一个优势,筛查间隔更久,频率更低。

目前,ASCCP和ACOG这两大专业机构都表示,正在对ACS最新建议进行更全面的审查,以确定是否需要跟进这些更新。ACOG实践活动副总裁Christopher M. Zahn博士表示,现行筛查建议“平衡了筛查好处和潜在危害。由于广泛的筛查,过去30年中美国宫颈癌的发病率已经降低了一半,基于证据的宫颈癌筛查方法将继续推动宫颈癌发病率的降低。”

ACS指南其他主要建议包括:

超过65岁的女性,应停止所有筛查。除非她们在过去25年中有癌前病变史(宫颈上皮内瘤变[CIN],2级或以上),或缺乏足够充分的阴性筛查记录。

足够充分的阴性筛查记录定义为:过去10年中连续2次初级HPV检查结果呈阴性,或2次阴性联合检查或3次细胞学检查阴性,且最近一次检查在过去5年内进行。这些标准不适用于当前因异常筛查结果而需要继续接受监测的人群。

如果没有充分的筛查记录,超过65岁且没有患病影响预期寿命,那么仍应继续筛查,直到符合停止筛查的标准。

无论年龄,如果预期寿命有限,可以中断宫颈癌筛查。

上述建议与现有指南的推荐相似。

原始出处:

Elizabeth T H Fontham, Andrew M D Wolf, Timothy R Church,et al.Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society.CA Cancer J Clin. 2020 Jul 30. doi: 10.3322/caac.21628.

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    2020-11-04 pazilia

    HPV TCT

    0

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    2020-08-11 一闲
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    2020-08-10 ms9000000457302034

    现在我们医院都是HPV,TCT一起联合筛查的

    0

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    2020-08-09 1240394fm61暂无昵称

    学习

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=896753, encodeId=c4ba896e53a0, content=HPV TCT , beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201021/91b58accde114474abf3be8c8b87a1ae/34252556a07149988798e8fcfaa28eb3.jpg, createdBy=3e652197923, createdName=pazilia, createdTime=Wed Nov 04 01:39:36 CST 2020, time=2020-11-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1408238, encodeId=2f63140823833, content=<a href='/topic/show?id=92194628826' target=_blank style='color:#2F92EE;'>#宫颈#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=46288, encryptionId=92194628826, topicName=宫颈)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=11102737131, createdName=一闲, createdTime=Tue Aug 11 02:51:06 CST 2020, time=2020-08-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1448939, encodeId=23d51448939c1, content=<a href='/topic/show?id=2dcd4631494' target=_blank style='color:#2F92EE;'>#宫颈癌筛查#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=46314, encryptionId=2dcd4631494, topicName=宫颈癌筛查)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b0415457691, createdName=般若傻瓜, createdTime=Tue Aug 11 02:51:06 CST 2020, time=2020-08-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=807191, encodeId=b5dd80e19118, content=现在我们医院都是HPV,TCT一起联合筛查的, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200809/8efc7089f83541b58578e05f1e9ed30c/867bb46e36f24fbf97010ce808c86275.jpg, createdBy=1db55409746, createdName=ms9000000457302034, createdTime=Mon Aug 10 08:22:35 CST 2020, time=2020-08-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=807108, encodeId=81c480e1088a, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=83, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4b972455532, createdName=1240394fm61暂无昵称, createdTime=Sun Aug 09 15:03:18 CST 2020, time=2020-08-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=807097, encodeId=b3bb80e0972a, content=学到了, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200822/b4ea7b614a2f44058d2ee7550da5aa99/0a410f15b95946019df4b84086b90665.jpg, createdBy=64642447770, createdName=123eaf1bm35暂无昵称, createdTime=Sun Aug 09 13:54:01 CST 2020, time=2020-08-09, status=1, ipAttribution=)]
    2020-08-09 123eaf1bm35暂无昵称

    学到了

    0

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