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1 預防保健癌症篩檢社區醫學部周騰達

2 預防醫學原理及策略健康無症狀疾病疾病殘障或死亡初段預防次段預防 3. 末段預防 1. 健康促進 2. 特殊保護 3. 早期診斷與治療 4. 限限殘障 5. 復健

4 篩檢 Screening 個人病例發現 (case finding) 症狀求診疾病, 高危險族群社區篩檢 (community screening ) 社區族群疾病, 高危險族群 Asymptomatic Person in Medical Practice

5 社區預防篩檢原則 Asymptomatic Person in Medical Practice 1. 要檢查疾病對生活的質與量有重大影響 2. 高盛行率, 發生率 3. 有方法可以治療, 且治療方法在醫學上可被接受 4. 早期發現, 早期治療可明顯降低死亡率及罹病率 5. 早期或症狀未出現時治療比症狀時才治療, 效益優於後者 6. 經濟效益, 檢查方法敏感性, 特異性, 預測率

6 個案陳女士,50 歲家庭主婦, 在家屬陪伴下前往家庭醫師門診就醫, 主訢最近會感覺胸漲且在一週前於冼澡時發現左側乳房有摸到一顆乳房結節過去病史上病人並無特殊內外科病史, 在藥物史上因發熱, 心悸, 失眠, 盜汗等症狀在婦科醫師之建議下於三個月前開始接受荷爾蒙療法, 家族史病人之姊姊於一年前被診斷為乳癌 ; 最近聽說荷爾蒙療法可能會增加罹患乳癌風險, 加上目前因胸漲及發現乳房結節所以前住家庭醫師門診求診

7 Cancer Screening

8 台灣地區歷年癌症發生人數男女總計 56,323 52, ,189 28,050 26,134 24,

9 國健局 2003, 6 月公佈資料 1999 年全癌症發生率男性女性總計個案數 ( 人 ) 30,189 26,134 56,323 年齡中位數粗發生率年齡標準化發生率性別比 ( 標準化發生率 ) 約每十分鐘就有一人被發現罹癌

10 2003 年所有死亡原因死亡人數死亡率 / 十萬 1 惡性腫瘤 34, 腦血管疾病 12, 心臟疾病 11, 糖尿病 8, 事故傷害 8, 慢性肝病及肝硬化 4, 肺炎 4, 腎炎腎徵候群及腎變性病 4, 自殺 3, 高血壓性疾病 1,

11 2002 年癌症死亡原因順位所有癌症男性癌症女性癌症 1 肝癌肝癌肺癌 2 肺癌肺癌肝癌 3 結腸直腸癌結腸直腸癌結腸直腸癌 4 女性乳癌胃癌女性乳癌 5 胃癌口腔癌子宮頸癌 6 子宮頸癌食道癌胃癌 7 口腔癌攝護腺癌膽囊癌 8 攝護腺癌胰臟癌非何杰金淋巴癌 9 食道癌非何杰金淋巴癌胰臟癌 10 胰臟癌鼻咽癌白血病

12 癌症類別全球八大癌症排名與因應策略初級預防早期診斷治癒緩和醫療肺癌胃癌乳癌大腸直腸癌子宮頸癌口腔咽喉癌食道癌肝癌

13 CASE :Breast Cancer

14 乳癌的篩檢 : 沒摸到腫塊也要定期做檢查

15 台灣地區女性乳癌年齡標準化發生率單位 : 每十萬人口年齡標準化率係使用 2000 年世界標準人口為標準人口,

16 台灣乳癌現況乳癌好發年齡在 40~50 歲之間, 較歐美國家的好發年齡約提早十歲乳癌的十年存活率平均達百分之六十第一期乳癌的存活率則高達百分之八十零期乳癌甚至接近百分之百

17 乳癌篩檢對生活的質與量有重大影響 ˇ 高盛行率, 發生率 ˇ 早期發現, 早期治療可明顯降低死亡率及罹病率 ˇ 早期或症狀未出現時治療比症狀出現時才治療, 益優於後者 ˇ

18 癌症三段五級的預防工作健康無症狀疾病疾病殘障或死亡健康促進特殊保護早期診斷與治療提供安寧療護服務

19 Primary Prevention 高危險群 ( 致癌相對機率大於 4 倍 ): 一側乳房得過乳癌特殊家族史 ( 停經前得過兩側乳癌 ) 乳房切片有不正常細胞增生現象次高危險群 ( 致癌相對機率大於 2-4 倍 ): 母親或姐妹得過乳癌第一胎生育在三十歲以後未曾生育者停經後肥胖卵巢癌及子宮內膜癌患者胸部大量放射線照射

20 略高危險群 ( 致癌相對機率倍 ): 中量飲酒初經在 12 歲以前停經在 55 歲以後可能危險因子 ( 未確定 ) 口服避孕藥更年期荷爾蒙補充

21 MANEUVER EFFECTIVENESS RECOMMENDATION mammography, women aged years. mammography, women aged years Mammography every months. reduces mortality rate Optimum frequency of screening has not been determined. Relative risk reduction of 18-45% for breast cancer mortality at 10 years was shown in 2 trials and one meta-analysis; no benefit was shown in 6 other trials Good evidence for screening women aged years annually by clinical examination and mammography. (A) Does not support the recommendation that screening mammography be included in or excluded from the periodic health examination of women aged at average risk of breast cancer (C)

22 Breast Self-Examination Teaching breast self-examination (BSE) Increased survival and other indicators of early detection demonstrated but studies subject to bias. Insufficient evidence to include or exclude from the periodic health examination Inadequate evidence that the practice of BSE improves survival; (C)

23 MANEUVER EFFECTIVENESS RECOMMENDATION Routine teaching of BSE to women aged yr Evidence of no benefit in terms of survival from breast cancer. Evidence of increased no of physician visits for breast problems and increased rate of benign biopsy results FAIR EVIDENCE TO SUPPORT Because there is fair evidence of no benefit, and good evidence of harm, there is fair evidence to recommend that routine teaching of BSE be excluded from the periodic health examination of women aged (grade D) Routine teaching of BSE to women aged yr Evidence of no benefit in terms of survival from breast cancer Evidence of increased no. of physician visits for breast problems and increased rate of benign biopsy results FAIR EVIDENCE TO SUPPORT Because there is fair evidence of no benefit, and good evidence of harm, there is fair evidence to recommend that routine teaching of BSE be excluded from the periodic health examination of women aged (grade D)

24 乳癌的篩檢 : 沒摸到腫塊也要定期做檢查 CASE FINDING vs COMMUNITY SUVERY

25 Differential Diagnosis

26 病人自我檢查醫師理學檢查可觸摸到的乳房腫塊乳房超音波 ± 乳房 X 光攝影 ± 細針抽吸 ± 細胞學檢查乳癌纖維腺瘤囊腫纖維囊腫變化組織切片檢查治療切片檢查或定期追蹤抽吸穿刺並定期追蹤定期追蹤

27 社區介入

28 台灣常見癌症與初級預防策略癌症類別 Primary prevention 預防重點肺癌 ++ 抽煙胃癌 + 多量動物蛋白質及脂肪高複雜性澱粉高鹽醃漬之肉類或魚類和飲用水內含硝酸鹽 ; 幽門螺旋桿菌乳癌 + 第一胎生育在三十歲以後未曾生育者停經後肥胖口服避孕藥更年期荷爾蒙補充大腸直腸癌 + 較低的蔬菜水果攝取量及較低的體能活動量子宮頸癌 + 性對象複雜 (HPV), 太早有性生活口腔咽喉癌 ++ 嚼檳榔抽煙喝酒肝癌 ++ 肝炎

29 次級預防策略癌症類別 Early diagnosis Curative therapy Method 肺癌 - - CXR, sputum cytology 胃癌 - - 胃鏡乳癌乳房攝影,BSE 大腸直腸癌 + + Stool OB, 腸鏡子宮頸癌 Pap Smear 口腔癌 + ++ Clinical Examination 肝癌 - - Hepatitis marker,echo, AFP

30 Age Group 19-39y/o 40-64y/o >=65y/o Interval Every 1-3yr Every 1-3yr Every Year PE Oral Exam cig:/alc/bn:+ cig:/alc/bn:+ cig:/alc/bn:+ Pap Smear + + previous not screeing Breast Exam + Mammography USPSTF >35, FH >FH1 av 1-2 >50y/o 65-69:av 1-2 yr >70:- OB/Sigmoidscopy /Colonscopy FH+ age >50 age >50 Diet andexercise Substance Use Sexual Practices Pap Smear: who have been sexually active and have a cervix FH1: 1 st degree relative with breat cancer diagnosis before menopause FH : 1 st degree relative with Familial polyposis coli or Cancer family syndrome PH:Endometrial, Ovarian, Breast CA, Inflammatory BD, adenomatous polyp, colonca

31 Liver Cancer Screening LFT AFP eag (-) 6M 6M eag(+), LC:+ abnormal LFT, 實質病變 3M 3-6M ECHO 12M 3-6M

32 CANCAR MARKER AFP CEA CA19-9 PSA-1 男 ) EB-VCA IgA CA-125 CA-153 SCC HPV 肝腫瘤直腸癌乳癌胰臟癌胃癌肺癌胰臟癌胃癌膽道癌前列腺癌鼻咽癌卵巢腫瘤乳房腫瘤子宮頸癌檢查

33 社區醫療群參與癌症防治策略 ( 一 ) 初段預防健康社區營造推動全民戒菸戒檳榔無菸餐廳無菸校園無菸職腸門診戒菸菸害宣導及檳榔健康危害宣導推廣防癌飲食均衡飲食天天五蔬果低脂高纖飲食全民接種 B 型肝炎疫苗

34 社區醫療群癌症防治策略 ( 二 ) 二段預防電腦在健康管理應用, 電子病歷管理國人常見癌症篩檢子宮頸癌篩檢工作二階段乳癌篩檢工作口腔癌高危險群篩檢台灣常見癌症高危險群篩檢研究計畫 - 癌症宣導教育癌症篩檢

35 THANK FOR YOUR ATTENTION

防癌講座 90 HPV CIN 子宮頸的 HPV 感染 HPV HPV HPV HPV HPV HPV CIN HPV 70% 2 HPV 20-30% CIN CIN HPV 1618

婦癌的防治何志明國泰綜合醫院婦癌中心主任從子宮頸癌成功防治經驗談起 1750 800 80% 2 (human papillomavirus, HPV) 2-3 30 H P V 10-15% 99.7% 子宮頸癌篩檢 50 30 3 50% 80% 30% 2 防癌講座 90 HPV CIN 子宮頸的 HPV 感染 HPV HPV HPV-16 18 26 31 33 35 39 45 51