即使是年輕婦女 乳房X光攝影和觸診也很重要


  【24drs.com】根據一項大型分析結果,即使是50歲以下女性,乳房X光攝影和胸部觸診依舊是乳癌篩檢重要的工具;此外,這些結果確認了50歲以上女性每年乳房X光攝影篩檢的重要性。
  
  加州舊金山2011年乳癌研討會舉辦之前的簡報中,發表了這些研究結果的重點。
  
  在6,000名乳癌婦女中,65.5%的乳癌是由乳房X光攝影發現,29.8%是藉由觸診,4.7%是其他方法。
  
  50歲以下的婦女中,約半數(48.3%)的腫瘤是由乳房X光攝影發現,觸診發現的腫瘤比率相當(46.1%)。
  
  相較於那些由醫師發現者,幾乎所有觸診發現乳癌者都是由病患發現。
  
  密西根州Lacks癌症中心綜合乳房中心醫療主任Jamie Caughran醫師解釋,值得注意的是,相較於藉由乳房X光攝影發現腫瘤的婦女,腫瘤可觸及的婦女傾向是比較末期的癌症,這可應用於40-49歲以及50歲以上的婦女。
  
  作者們也發現,觸診發現腫瘤的婦女比較可能會進行乳房切除術(46%),藉由乳房X光攝影發現者進行手術的比率則為27%;類似的是,觸診發現腫瘤的婦女也比較可能進行化療(22.7%),藉由乳房X光攝影發現者進行化療的比率則為15.7%。
  
  美國臨床腫瘤協會癌症溝通委員會委員Andrew Seidman醫師表示,這是相當重要的成果。
  
  擔任簡報主持人的Seidman醫師表示,有爭論的是,要根據你的想法或者是發表於個別研究或大型回顧的資料,這些和年輕婦女的篩檢運用有關。我們知道,年輕婦女的乳房組織比較緻密,這對於敏感度方面會比年長婦女更有所影響,但是,並不會讓乳房X光攝影無效。
  
  Seidman醫師指出,大部分的爭議和關注是關於使用乳房X光攝影對於整體存活和乳癌特定存活的影響。
  
  他表示,這是最重要的終點,但也引起了另一個重要議題,年輕族群的篩檢使用導致乳房切除術比率低是不是因為比較早發現與較低的可能性,約只有7%需要使用後輔助化療。
  
  Seidman醫師指出,這是除了可能的存活效益之外相當重要的收穫。
  
  他指出,根據診斷,進行破壞程度較小的手術且給予較少的化療就是進步,無疑地,這還是會有一些爭論,但是這個年齡層的婦女應該對這些資料有所暸解。
  
  2009年時,美國預防服務工作小組修改了他們的乳癌篩檢建議,決議文件與現有的美國癌症協會及美國放射科學院的乳癌篩檢指引相左。
  
  Caughran醫師解釋,新版建議在病患和醫師之間都引起爭論。她表示,他們特別建議40-49歲婦女進行乳房X光攝影篩檢,然後50歲開始改為每兩年進行一次,而不用每年。他們也未鼓吹教育婦女自我乳房檢查,也質疑了40歲以上婦女進行臨床乳房檢查的效用。
  
  這篇研究中,Caughran醫師等人試圖確認這些新建議對於乳癌診斷與治療的效益,他們使用了Michigan Breast Oncology Quality Initiative (MiBOQI)所管理的全州乳癌登記資料,包括了州內17個機構在2006-2009年間的資料。
  
  Caughran醫師指出,這個世代包括了5,903名乳癌婦女,診斷時的平均年紀為59.4歲,追蹤至少270天,排除了第4期的癌症病患,因為他們無法完成分析所需的資料。
  
  由乳房X光攝影發現腫瘤的婦女(3,869人)大部分(81%)是在50歲後發現,而觸診發現腫瘤的婦女(1,759人)則有40%是在50歲以下。
  
  觸診發現的病患比較年輕(55.8歲vs. 61.2歲;P < .001),觸診發現的癌症比較後期(50.0%是第II期),乳房X光攝影則有52.5%是第I期( P < .001)。
  
  她表示,觸診組中,重點在指出90%是由自己發現乳房腫塊,而僅9.8%是由醫師發現。不清楚這些病患是否藉由自我乳房檢查發現,還是意外發現這些腫塊。
  
  乳房X光攝影發現癌症的婦女比較會進行乳房保留手術(觸診組為54.2%;乳房X光攝影組為72.9;P < .001),相對的,觸診發現癌症的婦女比較會進行乳房切除術。
  
  Caughran醫師提醒,這篇研究並不代表整體的篩檢族群,因為所有研究對象都有乳癌,診斷日期前90天以上的篩檢資料不足,但是,我們結論認為,對可觸及的乳房腫塊每年進行乳房攝影和評估,這對乳癌偵測很重要。

Mammography and Palpation Important, Even in Younger Women

By Roxanne Nelson
Medscape Medical News

September 6, 2011 — Mammography and breast palpation remain important tools for detecting breast cancer, even for women under the age of 50, according to the results of a large analysis. In addition, the results validated the importance of annual screening mammography in women aged 50 years and older.

Highlights of the study were presented at a press briefing given in advance of the start of the 2011 Breast Cancer Symposium, being held in San Francisco, California.

In a cohort of almost 6000 women with breast cancer, 65.5% of breast cancers were detected by mammography, 29.8% by palpation, and 4.7% by other methods.

In women under the age of 50 years, approximately half of the tumors (48.3%) were detected by mammography, while a similar percentage of tumors (46.1%) were detected by palpation.

Almost all of the breast cancers detected by palpitation were detected by the patient, as compared with those detected by a clinician.

Of note, women with palpable tumors tended to have more advanced cancers, as compared with those whose tumors were detected by mammography, and this was applicable to women age 40 to 49 years and those over age 50, explained lead author Jamie Caughran, MD, medical director of the Comprehensive Breast Center at the Lacks Cancer Center in Grand Rapids, Michigan.

The authors also found that women with tumors detected by palpation were more likely to undergo mastectomy (46%) than those with tumors found via mammography (27%). Similarly, women with tumors detected by palpation were also more likely to undergo chemotherapy (22.7%) than those detected by mammography (15.7%).

Lower Rate of Mastectomy and Chemotherapy

This is very important work for a number of reasons, commented Andrew Seidman, MD, American Society of Clinical Oncology Cancer Communications Committee member.

"There has been controversy — depending on your perspective or data presented in individual studies or in large overviews — regarding the utility of screening in younger women," said Dr. Seidman, who served as the moderator of the press briefing. "We do know that younger women have denser breast tissue, which can impact or reduce the sensitivity as compared to older women. But it certainly doesn't negate the utility of mammography as a screening test."

Dr. Seidman pointed out that much of the debate and focus regarding the utility of mammography have been on its impact on overall survival and breast cancer–specific survival.

"That is certainly the most important endpoint," he said. "But this raises another important issue, which is that the use of screening in the younger age population has led to a lower rate of mastectomy due to earlier detection and the lower likelihood — by about 7% — of needing to employ postadjuvant chemotherapy."

Dr. Seidman noted that this was a "very important gain independent of any potential survival benefit."

"Having less disfiguring surgery and the ability to deliver less chemotherapy based on the diagnosis is a step forward," he added. "Undoubtedly this will remain an area of controversy for some, but women in this age group will be well served to know about this data."

Ignited Controversy

In 2009, the US Preventive Services Task Force revised their breast cancer screening recommendations, and the resulting document was in opposition to other existing breast cancer screening guidelines from organizations such as the American Cancer Society and the American College of Radiology.

The new recommendations ignited controversy among both patients and clinicians, explained Dr. Caughran. "They specifically recommended against screening mammography in women aged 40 to 49, and changed screening mammography beginning at age 50 to every other year, rather than annually," she said. "They also did not advocate for teaching women self-breast examination and also questioned the utility of clinical breast examination in women over the age of 40."

Lower Stage With Mammography

In this study, Dr. Caughran and colleagues sought to determine the effect of these new recommendations on diagnosing and treating breast cancer. They used data from a statewide breast cancer registry managed by the Michigan Breast Oncology Quality Initiative (MiBOQI), which included data from women at 17 statewide institutions, from 2006 to 2009.

The cohort included 5903 women with breast cancer, who were diagnosed at an average age of 59.4 years. There were at least 270 days of follow-up, Dr. Caughran pointed out, and patients with stage 4 cancer were excluded because they had incomplete data for analysis.

The majority of women whose tumors were detected by mammography (3869) were over age 50 years (81%). For women whose tumors were found by palpation (1759), 40% were under age 50.

Patients with palpable presentations were younger (55.8 years vs. 61.2 years; P < .001). Cancers with a palpable presentation were diagnosed at higher stages (50.0% stage II) than those diagnosed with mammography (52.5% stage I; P < .001).

"In that palpation group, it is important to note that 90% had a breast mass that they discovered themselves, compared to 9.8% discovered by a clinician," she said. "It's unclear if the patients who found the masses were practicing self-breast examination or they were incidental."

Women with cancers detected by mammography were more likely to undergo breast conservation surgery (palpation, 54.2%; mammography, 72.9; P < .001). Conversely, women with cancers detected through palpation were more likely to undergo mastectomy procedures.

The study does not represent an overall screening population, cautioned Dr. Caughran, because all these patients had breast cancer, and screening data were not available beyond 90 days before the date of diagnosis. "But we conclude that annual mammogram and evaluation of palpable breast masses are important tools of breast cancer detection."

2011 Breast Cancer Symposium. Abstract #1. San Francisco, California. To be presented September 8, 2011.

    
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