乳腺癌筛查指南：几家争鸣，何去何从？

　　2016年1月12日，美国《内科学年鉴》（Annals of Internal Medicine）杂志在线发表了美国预防服务工作组（USPSTF）颁布的最终版乳腺癌筛查指南，该指南再次引起了广泛争议，争议主要集中在乳腺X线摄影的筛查起始年龄及筛查频率问题，最终版的筛查指南依旧不建议40～49岁女性接受常规乳腺X线摄影检查，对于50～74岁女性的推荐检查频率也依旧为每两年1次。

　　事实上，USPSTF于2009年公布的推荐指南就曾受到过各方专家的质疑，主要原因是该指南不推荐40～49岁女性进行常规乳腺X线摄影检查，当时美国许多机构都建议医师与患者不要太在意USPSTF指南的这一推荐。而针对质疑，USPSTF曾表示，这一推荐为C级推荐，即需要权衡利弊、依据个人意愿进行个体化决策。

　　乳腺癌筛查的目的是通过对无症状女性进行检查来减少乳腺癌死亡率、减轻其晚期症状，其筛查方案一直是颇具争议的话题。近年来，随着晚期乳腺癌治疗疗效的改善以及对过度诊断的关注，除了USPSTF外，各组织机构也根据研究数据对乳腺X线摄影、临床乳腺检查和乳腺自检等乳腺癌筛查手段进行了重新评估，并对其公布的乳腺癌筛查指南进行了新。2015年，世界卫生组织国际癌症研究署（WHO/IARC）和美国癌症学会（ACS）就曾分别于6月和10月先后更新了各自的乳腺癌筛查指导意见或指南，其更新后的推荐意见均与USPSTF更加接近。例如ACS此前公布的指南推荐所有女性从40岁开始进行每年1次的乳腺X线摄影检查及临床乳房体检，而新版指南则推荐45～54岁女性每年进行1次乳腺X线摄影检查。

　　本期B6～B8版乳腺癌筛查指南专题，比较了USPSTF、ACS及IARC三个组织公布的最新指南内容，并特邀中国医学科学院肿瘤医院乔友林教授与张保宁教授结合我国乳腺癌筛查的实际情况作以点评，探讨国外乳腺癌筛查指南对我国的指导意义。

各机构乳腺癌筛查指南或指导意见比较

各机构乳腺癌筛查指南或指导意见主要更新内容

Ann Intern Med. 2016 Jan 12. [Epub ahead of print]

Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement.

Siu AL; U.S. Preventive Services Task Force.

DESCRIPTION: Update of the 2009 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for breast cancer.

METHODS: The USPSTF reviewed the evidence on the following: effectiveness of breast cancer screening in reducing breast cancer-specific and all-cause mortality, as well as the incidence of advanced breast cancer and treatment-related morbidity; harms of breast cancer screening; test performance characteristics of digital breast tomosynthesis as a primary screening strategy; and adjunctive screening in women with increased breast density. In addition, the USPSTF reviewed comparative decision models on optimal starting and stopping ages and intervals for screening mammography; how breast density, breast cancer risk, and comorbidity level affect the balance of benefit and harms of screening mammography; and the number of radiation-induced breast cancer cases and deaths associated with different screening mammography strategies over the course of a woman's lifetime.

POPULATION: This reccommendation applies to asymptomatic women aged 40 years or older who do not have preexisting breast cancer or a previously diagnosed high-risk breast lesion and who are not at high risk for breast cancer because of a known underlying genetic mutation (such as a BRCA1 or BRCA2 gene mutation or other familial breast cancer syndrome) or a history of chest radiation at a young age.

RECOMMENDATIONS: The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. (B recommendation) The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years. (C recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging (MRI), DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram. (I statement).

PMID: 26757170

DOI: 10.7326/M15-2886