中山地区宫颈癌前病变大样本筛查研究

发布时间：2018-03-21 15:42

  本文选题：妇女　切入点：宫颈癌　出处：《南方医科大学》2014年博士论文　论文类型：学位论文

【摘要】：前言:宫颈癌的发生发展是从HPV持续感染,到宫颈癌前病变,再发展到宫颈浸润癌的漫长过程,通常需要10～15年。由于宫颈癌的发生、发展存在较长且可逆转的癌前病变期,故及时发现并干预癌前病变的进展和演变,可有效阻断宫颈癌的发生,对降低宫颈癌发病率极为重要。宫颈癌的发病率居全球女性恶性肿瘤的第二位,全球每年约有27.5万人死于宫颈癌,多发生于缺乏预防措施和筛查制度的发展中国家。在发达国家,完善的筛查制度使宫颈癌的发病率减少了30%～60%,而在欠发达地区,由于缺乏有效的预防措施和筛查制度,宫颈癌的发病率及死亡率居高不下。我国每年宫颈癌的新发病例占全球的14%,死亡率占12%。2009年全国范围开展的农村妇女“两癌”检查,对降低农村地区宫颈癌的发病率和死亡率起了重要作用。然而,由于机会性筛查、资金和专业人员的缺乏,筛查不能覆盖全国等因素,宫颈癌发病率和死亡率仍高居不下并有上升趋势。可见,积极探索适合本地区大规模宫颈癌筛查的模式和影响因素是宫颈癌防控的前提和关键。为此,在中山市政府的高度重视和支持下,本研究于2011年开始建立以多部门协作为主、区域医疗资源整合的筛查模式,应用液基细胞学技术免费对中山市适龄妇女进行大规模宫颈癌筛查,探索适合我省地市级区域的大规模筛查模式,通过大量的数据整理和分析,为中山市宫颈癌筛查和防治策略的制定与实施奠定基础并提供理论依据,为更进一步推动中山市宫颈癌防治工作的开展,为有效降低我市宫颈癌的发病率和死亡率提供原始数据。目的:对2011年1月～2013年12月中山市适龄妇女进行宫颈癌前病变大样本筛查。探讨建立以政府为主导、多部门协作、区域医疗资源整合的筛查模式;通过建立信息平台,完成中山市宫颈癌筛查数据库,为宫颈癌筛查的深入开展和普及积累资料,为中山市宫颈癌筛查和防治策略的制定与实施奠定基础,为政府将宫颈癌筛查作为我市长效化工作机制提供理论依据;探索适合经济较发达地区宫颈癌筛查模式,为我国宫颈癌筛查策略提供参考模式。方法:1.应用妇科常规检查和液基细胞学检查对中山市已婚妇女进行宫颈癌筛查。2.对召回的妇女行人乳头瘤病毒检测。3.在阴道镜下检查和多点活检,并行病理学检查。4.用FISH法对部分TCT阳性标本行hTERC基因扩增。5.对孕妇进行宫颈癌筛查。6.建立宫颈癌筛查信息化管理与规范化防治模式。结果:1. 2011年1月～2013年12月,三年共筛查适龄妇女130,475例,TCT阳性共5559例,召回数3337例,在召回者中,HPV检测3122例,阳性1993例;行阴道镜检查2060例,阴道镜检查率61.73%,其中活检1400例,活检率67.96%。2.三年总的召回率为60.03%。23个镇区之间的召回率具有显著性差异(χ2=88.345, P0.001),其中南区(81.03%)、东升镇(73.88%)和坦洲镇(69.41%)最高,而沙溪镇(48.44%)、三角镇(47.62%)和横栏镇(35. 94%)最低;按地理位置分析,南部(65.88%)及城区(64.58%)的召回率最高,西部(43.77%)最低。单因素及多因素分析显示,召回率与文化程度、住址、职业、是否患过宫颈疾病有关,且为召回的独立影响因素(P0.05),而与年龄分组、绝经情况和亲属是否患宫颈癌无关(P0.05)。TCT阳性不同分型的召回情况分析显示,HSIL和SCC/AC的召回率最高(χ2=72.092, P=0.008)。3.三年TCT筛查的总阳性率为4.26%(2011年为3.14%,2012年为5.17%,2013年4.51%),其中以南朗镇(5.73%)、横栏镇(5.21%)和板芙镇(5.15%)最高,以民众镇(3.63%)、沙溪镇(3.44%)和大涌镇(3.27%)最低(χ2=96.906,P0.001);将中山市划分为城区、东部、南部、西部和北部五个区域进行比较,结果发现各区域间TCT阳性率无显著性差别(χ2=7.629,P=0.106)。单因素分析显示,TCT阳性率与筛查者的年龄、初次性生活年龄、文化程度、职业、绝经、工具避孕等因素有关(P0.05),与居住地点、家族史和是否患宫颈疾病无关(P0.05)。4.对TCT阳性的部分妇女行HPV检测,HPV的总阳性率为63.84%。HPV阳性率最高为三乡镇(80.43%),最低为五桂山(52.63%),但23个镇区间HPV阳性率无显著性差异(χ2=27.898, P=0.179);各区域间HPV阳性率无显著性差异(χ2=3.899, P=0.420)。不同TCT类型之间的HPV阳性具有显著性差异,其中以HSIL,SCC和AC最高(⑧2=302.130,P=0.000)。5.对TCT阳性的部分妇女行病理检查,结果显示三年TCT阳性妇女总的病理活检阳性率为72.93% (1021/1400),其中CIN1 411例,CIN2267例,CIN3 293 例,CA45 例,AC 5 例。6.对TCT联合HPV检测在宫颈癌筛查中的价值进行分析,结果显示单独检测TCT的病理阳性率为72.93%,而TCT联合HPV的病理阳性率为77.99%,两组间具有显著性差异(χ2=8.922, P=0.003)。7.对hTERC基因检测在宫颈癌筛查中的价值进行分析,不同病理分型的hTERC阳性率不同,不同病理分型间具有显性差异(χ2=358.015, P=0.000),随着病理级别的上升hTERC阳性率不断升高。8.与非孕期妇女比较,孕期妇女总的细胞学阳性率、癌前病变及宫颈癌的发生率均无统计学差异(P0.05)。9.在中山市成功建立以多部门协作区域医疗资源整合的宫颈癌筛查模式。结论:本研究为宫颈癌大规模筛查在国内经济较发达地区范围内的全面铺开提供了依据和经验,研究提示在应用TCT进行普筛的前提下,尽早行HPV检测是及时发现并治疗宫颈癌前病变的有效方法。以多部门协作区域医疗资源整合的宫颈癌筛查模式值得在全国推广。
[Abstract]:Objective: cervical cancer is the development of the HPV persistent infection to cervical precancerous lesions, to the development of the long process of invasive cervical cancer, usually takes 10~15 years. Due to the occurrence of cervical cancer, there is a long and reversible precancerous stage of development, the timely discovery and intervention development and evolution of precancerous lesions and can effectively prevent the occurrence of cervical cancer, to reduce the incidence of cervical cancer is very important. The incidence of cervical cancer in the global women malignant tumor second, about 275 thousand people died of cervical cancer worldwide every year, mostly occurs in the lack of preventive measures and screening system in developing countries. In developed countries, to improve the system of the screening the incidence of cervical cancer decreased from 30% to 60%, while in underdeveloped areas, due to the lack of effective prevention and screening system, high morbidity and mortality of cervical cancer. Cervical cancer each year in China for new cases 14% of the world's mortality accounted for 12%.2009 years of nationwide rural women, two cancer checks, played an important role to reduce cervical cancer incidence and mortality in rural areas. However, due to opportunistic screening, lack of funds and professional personnel, can not cover the national screening and other factors, the incidence of cervical cancer and mortality is still high don't and there is a rising trend. Therefore, actively explore the factors for the local large-scale cervical cancer screening mode and effect is the premise and key of cervical cancer prevention and control. Therefore, the attention and support of the Zhongshan municipal government, the study began in 2011 to establish multi sectoral collaboration, the screening model of regional medical resources integration application of liquid based cytology, free mass screening of cervical cancer of women in Zhongshan City, to explore large-scale screening model for the province's municipal area, through a large number of Data collation and analysis, Zhongshan city for the development of cervical cancer screening and prevention strategies and lay the foundation for the implementation and to provide a theoretical basis for further promoting the Zhongshan city to carry out the work of prevention and treatment of cervical cancer, provide original data for our city to reduce the morbidity and mortality of cervical cancer. Objective: from January 2011 to December 2013 in Zhongshan city women for a large sample of cervical precancerous lesion screening. To establish a government led, multi sectoral collaboration, screening model of regional medical resources integration; through the establishment of information platform, the completion of the Zhongshan cervical cancer screening database for screening of cervical cancer development and popularization of the accumulation of information, for the development of cervical cancer screening and prevention in Zhongshan city strategy and implementation of the government will lay the foundation for cervical cancer screening as the working mechanism of the Mayor I provide a theoretical basis for exploring the effect of cervical cancer; developed area The screening model, to provide a reference model for cervical cancer screening strategies in China. Methods: 1. routine gynecological examination and application of liquid based cytology for cervical cancer screening for women.2. detection pedestrian papilloma virus.3. recall in colposcopy examination and multiple biopsy of married women in Zhongshan City, pathological examination of.4..5. for pregnant women cervical cancer screening.6. establish the control model of cervical cancer screening and standardized information management on the part of the TCT positive samples hTERC gene was amplified by FISH method. Results: 1.2011 years from January to December 2013, a total of three years of screening women in 130475 cases, TCT positive in 5559 cases, 3337 cases in the number of recall, recall of HPV detection 3122 cases, positive 1993 cases; 2060 cases underwent colposcopy, colposcopy was 61.73%, the rate of biopsy and biopsy in 1400 cases, 67.96%.2. three years total recall rate is between 60.03%.23 Township recall rate has a significant 鎬у樊寮，

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