常规筛查发现乳腺密度太高怎么办

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  美国联邦立法要求乳腺钼靶筛查报告应向执业医师和女性提供乳腺密度信息,对于乳腺密度较高的女性,由于筛查间期发生乳腺癌的风险增加,应与执业医师讨论补充影像筛查。不过,磨刀不误砍柴工,与其与所有乳腺致密女性讨论补充影像筛查,不如首先确定补充影像筛查可能获益最大的乳腺癌高风险女性,或许办事效率更高。

  年7月1日,《美国医学会杂志》内科学分册在线发表旧金山加利福尼亚大学、佛蒙特大学、达特茅斯学院盖泽尔医学院、诺里斯科顿癌症中心、凯萨医疗机构、芝加哥伊利诺伊大学、教堂山北卡罗来纳大学、戴维斯加利福尼亚大学的研究报告,探讨了确定常规筛查乳腺癌高风险女性与执业医师进行补充影像筛查必要性讨论的策略。

  该前瞻队列研究于年1月3日~年12月31日入组乳腺癌监测联盟影像筛查单位万次数字化乳腺钼靶筛查的40~74岁女性63万例,平均年龄56.5±8.9岁。年10月10日~年3月20日,根据乳腺影像检查报告数据系统(BI-RADS)乳腺密度分类和乳腺癌监测联盟5年风险评分(根据年龄、种族、一级亲属乳腺癌家族史、乳腺活检史、乳腺密度计算)对乳腺钼靶筛查12个月之内的高分期乳腺癌(分期≥IIB期)进行数据分析,将高分期乳腺癌发生率前25%(每次乳腺钼靶筛查发现高分期乳腺癌≥0.61例)定义为高分期乳腺癌高发,并对预防每例潜在高分期乳腺癌的讨论次数进行分析。

  结果,致密乳腺(不均匀致密或完全致密)女性占全部筛查女性的47.0%、占高分期乳腺癌女性的60.0%。高分期乳腺癌低发(每次乳腺钼靶筛查发现高分期乳腺癌0.61例)占致密乳腺女性的34.5%。

  不均匀致密乳腺女性与完全致密乳腺女性相比,高分期乳腺癌发生风险反而较高(5年风险评分≥2.5%、≥1.0%,占全部筛查女性的6.0%、6.5%)。

  高分期乳腺癌风险较高的密度+风险亚组占全部筛查女性的12.5%、占高分期乳腺癌女性的27.1%。

  根据密度+风险与单纯根据致密乳腺的策略相比,预防每例潜在高分期乳腺癌的补充影像筛查讨论次数较少(比次)。

  对于不均匀致密乳腺和5年风险评分1.67%的女性(占全部筛查女性的21.7%)推荐缩短随访间期而不进行补充影像筛查的假阳性率较高。

  因此,该研究结果表明,乳腺密度告知应与乳腺癌风险评分结合,高分期乳腺癌风险评分最高的女性可以作为补充影像筛查讨论对象,而低风险女性则否。乳腺密度结合乳腺癌监测联盟5年风险评分,可以为所有乳腺致密女性提供更有效率的补充影像筛查讨论策略。

  对此,耶鲁大学医学院和公共卫生学院发表特邀评论:致密乳腺告知后,建议女性补充筛查仍然不可一刀切。

JAMAInternMed.Jul1.[Epubaheadofprint]

StrategiestoIdentifyWomenatHighRiskofAdvancedBreastCancerDuringRoutineScreeningforDiscussionofSupplementalImaging.

KarlaKerlikowske,BrianL.Sprague,AnnaN.A.Tosteson,KarenJ.Wernli,GarthH.Rauscher,DianneJohnson,DianaS.M.Buist,TracyOnega,LouiseM.Henderson,EllenS.OMeara,DianaL.Miglioretti.

UniversityofCalifornia,SanFrancisco;UniversityofVermont,Burlington;GeiselSchoolofMedicineatDartmouth,Lebanon,NewHampshire;NorrisCottonCancerCenter,Lebanon,NewHampshire;KaiserPermanenteWashington,Seattle;UniversityofIllinoisatChicago,Chicago;UniversityofNorthCarolinaatChapelHill,ChapelHill;UniversityofCalifornia,Davis.

Thiscohortstudyassessesstrategiestoidentifywomenathighriskofadvancedbreastcancertotargetpatient-practitionerdiscussionsabouttheneedforsupplementalimaging.

QUESTION:Whichwomenwithdensebreastsundergoingroutinescreeningareathighriskofadvancedbreastcancer?

FINDINGS:Inthiscohortstudyof63women,highratesofadvancedbreastcanceroccurredinwomenwithheterogeneouslydensebreastsanda5-yearriskof2.5%orhigherandthosewithextremelydensebreastsanda5-yearriskof1.0%orhigher.Identificationofdensity-risksubgroupsathighriskofadvancedcancerprovidedthemostefficientapproachfortargetingwomenforsupplementalimagingdiscussions(discussionsperpotentialadvancedcancerprevented).

MEANING:Assessmentof5-yearriskinwomenwithdensebreastsidentifiedsubgroupsathighestriskofadvancedcancerandwasamoreefficientstrategyforsupplementalimagingdiscussionsthanwastargetingallwomenwithdensebreasts.

IMPORTANCE:Federallegislationproposesrequiringthatscreeningmammographyreportstopractitionersandwomenincorporatebreastdensityinformationandthatwomenwithdensebreastsdiscusssupplementalimagingwiththeirpractitionergiventheirincreasedriskofintervalbreastcancer.Insteadofdiscussingsupplementalimagingwithallwomenwithdensebreasts,itmaybemoreefficienttoidentifywomenathighriskofadvancedbreastcancerwhomaybenefitmostfromsupplementalimaging.

OBJECTIVE:Toidentifywomenathighriskofadvancedbreastcancertotargetwoman-practitionerdiscussionsabouttheneedforsupplementalimaging.

DESIGN,SETTING,ANDPARTICIPANTS:Thisprospectivecohortstudyassessed63womenaged40to74yearswhohadscreeningdigitalmammogramstakenatBreastCancerSurveillanceConsortium(BCSC)imagingfacilitiesfromJanuary3,,toDecember31,.DataanalysiswasperformedfromOctober10,,toMarch20,.

EXPOSURES:BreastImagingReportingandDataSystem(BI-RADS)breastdensityandBCSC5-yearbreastcancerrisk.

MAINOUTCOMESANDMEASURES:Advancedbreastcancer(stageIIBorhigher)within12monthsofscreeningmammography;highadvancedcancerrates(≥0.61casespermammograms)definedasthetop25thpercentileofadvancedcancerrates,anddiscussionsperpotentialadvancedcancerprevented.

RESULTS:Atotalof63women(mean[SD]age,56.5[8.9]years)wereincludedinthestudy.Womenwithdensebreasts(heterogeneouslyorextremelydense)accountedfor47.0%ofscreenedwomenand60.0%ofadvancedcancers.Lowadvancedcancerrates(0.61permammograms)occurredin34.5%ofscreenedwomenwithdensebreasts.Highadvancedbreastcancerratesoccurredinwomenwithheterogeneouslydensebreastsanda5-yearriskof2.5%orhigher(6.0%ofscreenedwomen)andthosewithextremelydensebreastsanda5-yearriskof1.0%orhigher(6.5%ofscreenedwomen).Density-risksubgroupsathighadvancedcancerrisk


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