卵巢癌筛查,JAMA

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卵巢癌筛查
JAMA ( IF 63.1 ) Pub Date : 2018-02-13 , DOI: 10.1001/jama.2017.21421
Jillian T. Henderson ₁ , Elizabeth M. Webber ₁ , George F. Sawaya ₂

Affiliation

重要性卵巢癌相对罕见，但却是美国女性癌症死亡的第五大原因。目的系统地审查关于中等风险女性进行卵巢癌筛查的益处和危害的证据，以告知美国预防服务工作组。数据来源 MEDLINE、PubMed、Cochrane 对照试验协作登记处；2003 年 1 月 1 日至 2017 年 1 月 31 日期间以英文发表的研究；在目标出版物中持续监测至 2017 年 11 月 22 日。研究选择对报告死亡率或生活质量结果的平均风险女性进行卵巢癌筛查的随机临床试验。干预措施包括经阴道超声、癌抗原 125 (CA-125) 检测或它们的组合。比较者通常护理或不筛查。数据提取和综合由 2 位审稿人进行独立的批判性评估和数据提取。由于研究数量少和干预措施的异质性，未对结果进行荟萃分析汇总。主要结果和措施卵巢癌死亡率、假阳性筛查结果和手术、手术并发症和筛查的心理影响。结果包括四项试验（N = 293 587）；其中，3 (n = 293 038) 评估了卵巢癌死亡率，1 (n = 549) 仅报告了心理结果。评估的筛查干预包括单独的经阴道超声、经阴道超声加 CA-125 检测和单独的 CA-125 检测。CA-125 的测试阳性由固定的血清水平临界点或基于 CA-125 水平的专有风险算法定义，CA-125 水平随时间和年龄的变化（卵巢癌风险算法 [ROCA]）。没有试验发现筛查对卵巢癌死亡率有显着差异。在 2 项大型筛查试验（PLCO 和 UKCTOCS，n = 271 103）中，与筛查相关的卵巢癌、输卵管癌和腹膜癌病例的完整意向筛查分析（PLCO：比率， 1.18 [95% CI，0.82-1.71]；UKCTOCS：风险比 [HR]，经阴道超声和 HR 为 0.91 [95% CI，0.76-1.09]，CA-125 ROCA 为 0.89 [95% CI，0.74-1.08] ）。在这 2 项试验中，筛查导致 1% 的无癌女性因 CA-125 ROCA 接受疑似卵巢癌手术，3% 接受或不接受 CA-125 筛查的经阴道超声筛查导致疑似卵巢癌手术，主要并发症发生率为 3% 至 15%的手术。关于心理伤害的证据有限但不显着，但重复随访扫描和测试除外，这会增加基于一般健康问卷 12（得分≥4）（优势比， 1.28 [95% CI，1.18-1.39])。结论和相关性在对平均风险、无症状女性进行的随机试验中，筛查过的女性与未筛查或接受常规治疗的女性之间的卵巢癌死亡率没有显着差异。筛查危害包括对未发现癌症的女性进行手术（伴有重大手术并发症）。需要进一步研究以确定降低卵巢癌发病率和死亡率的有效方法。根据一般健康问卷 12（得分≥4）（优势比，1.28 [95% CI，1.18-1.39]），这增加了 UKCTOCS 参与者子样本的心理发病风险。结论和相关性在对平均风险、无症状女性进行的随机试验中，筛查女性与未筛查或接受常规治疗的女性之间的卵巢癌死亡率没有显着差异。筛查危害包括对未发现癌症的女性进行手术（伴有重大手术并发症）。需要进一步研究以确定降低卵巢癌发病率和死亡率的有效方法。根据一般健康问卷 12（得分≥4）（优势比，1.28 [95% CI，1.18-1.39]），这增加了 UKCTOCS 参与者子样本的心理发病风险。结论和相关性在对平均风险、无症状女性进行的随机试验中，筛查女性与未筛查或接受常规治疗的女性之间的卵巢癌死亡率没有显着差异。筛查危害包括对未发现癌症的女性进行手术（伴有重大手术并发症）。需要进一步研究以确定降低卵巢癌发病率和死亡率的有效方法。结论和相关性在对平均风险、无症状女性进行的随机试验中，筛查过的女性与未筛查或接受常规治疗的女性之间的卵巢癌死亡率没有显着差异。筛查危害包括对未发现癌症的女性进行手术（伴有重大手术并发症）。需要进一步研究以确定降低卵巢癌发病率和死亡率的有效方法。结论和相关性在对平均风险、无症状女性进行的随机试验中，筛查过的女性与未筛查或接受常规治疗的女性之间的卵巢癌死亡率没有显着差异。筛查危害包括对未发现癌症的女性进行手术（伴有重大手术并发症）。需要进一步研究以确定降低卵巢癌发病率和死亡率的有效方法。

"点击查看英文标题和摘要"

Screening for Ovarian Cancer

Importance Ovarian cancer is relatively rare but the fifth-leading cause of cancer mortality among United States women. Objective To systematically review evidence on benefits and harms of ovarian cancer screening among average-risk women to inform the United States Preventive Services Task Force. Data Sources MEDLINE, PubMed, Cochrane Collaboration Registry of Controlled Trials; studies published in English from January 1, 2003, through January 31, 2017; ongoing surveillance in targeted publications through November 22, 2017. Study Selection Randomized clinical trials of ovarian cancer screening in average-risk women that reported mortality or quality-of-life outcomes. Interventions included transvaginal ultrasound, cancer antigen 125 (CA-125) testing, or their combination. Comparators were usual care or no screening. Data Extraction and Synthesis Independent critical appraisal and data abstraction by 2 reviewers. Meta-analytic pooling of results was not conducted because of the small number of studies and heterogeneity of interventions. Main Outcomes and Measures Ovarian cancer mortality, false-positive screening results and surgery, surgical complications, and psychological effects of screening. Results Four trials (N = 293 587) were included; of these, 3 (n = 293 038) assessed ovarian cancer mortality, and 1 (n = 549) reported only on psychological outcomes. Evaluated screening interventions included transvaginal ultrasound alone, transvaginal ultrasound plus CA-125 testing, and CA-125 testing alone. Test positivity for CA-125 was defined by a fixed serum level cutpoint or by a proprietary risk algorithm based on CA-125 level, change in CA-125 level over time, and age (risk of ovarian cancer algorithm [ROCA]). No trial found a significant difference in ovarian cancer mortality with screening. In the 2 large screening trials (PLCO and UKCTOCS, n = 271 103), there was not a statistically significant difference in complete intention-to-screen analyses of ovarian, fallopian, and peritoneal cancer cases associated with screening (PLCO: rate ratio, 1.18 [95% CI, 0.82-1.71]; UKCTOCS: hazard ratio [HR], 0.91 [95% CI, 0.76-1.09] for transvaginal ultrasound and HR, 0.89 [95% CI, 0.74-1.08] for CA-125 ROCA). Within these 2 trials, screening led to surgery for suspected ovarian cancer in 1% of women without cancer for CA-125 ROCA and in 3% for transvaginal ultrasound with or without CA-125 screening, with major complications occurring among 3% to 15% of surgery. Evidence on psychological harms was limited but nonsignificant except in the case of repeat follow-up scans and tests, which increased the risk of psychological morbidity in a subsample of UKCTOCS participants based on the General Health Questionnaire 12 (score ≥4) (odds ratio, 1.28 [95% CI, 1.18-1.39]). Conclusions and Relevance In randomized trials conducted among average-risk, asymptomatic women, ovarian cancer mortality did not significantly differ between screened women and those with no screening or in usual care. Screening harms included surgery (with major surgical complications) in women found to not have cancer. Further research is needed to identify effective approaches for reducing ovarian cancer incidence and mortality.

更新日期：2018-02-13

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