本文選題：婦女　切入點：宮頸癌　出處：《南方醫(yī)科大學》2014年博士論文　論文類型：學位論文

【摘要】：前言:宮頸癌的發(fā)生發(fā)展是從HPV持續(xù)感染,到宮頸癌前病變,再發(fā)展到宮頸浸潤癌的漫長過程,通常需要10～15年。由于宮頸癌的發(fā)生、發(fā)展存在較長且可逆轉(zhuǎn)的癌前病變期,故及時發(fā)現(xiàn)并干預癌前病變的進展和演變,可有效阻斷宮頸癌的發(fā)生,對降低宮頸癌發(fā)病率極為重要。宮頸癌的發(fā)病率居全球女性惡性腫瘤的第二位,全球每年約有27.5萬人死于宮頸癌,多發(fā)生于缺乏預防措施和篩查制度的發(fā)展中國家。在發(fā)達國家,完善的篩查制度使宮頸癌的發(fā)病率減少了30%～60%,而在欠發(fā)達地區(qū),由于缺乏有效的預防措施和篩查制度,宮頸癌的發(fā)病率及死亡率居高不下。我國每年宮頸癌的新發(fā)病例占全球的14%,死亡率占12%。2009年全國范圍開展的農(nóng)村婦女“兩癌”檢查,對降低農(nóng)村地區(qū)宮頸癌的發(fā)病率和死亡率起了重要作用。然而,由于機會性篩查、資金和專業(yè)人員的缺乏,篩查不能覆蓋全國等因素,宮頸癌發(fā)病率和死亡率仍高居不下并有上升趨勢�？梢�,積極探索適合本地區(qū)大規(guī)模宮頸癌篩查的模式和影響因素是宮頸癌防控的前提和關鍵。為此,在中山市政府的高度重視和支持下,本研究于2011年開始建立以多部門協(xié)作為主、區(qū)域醫(yī)療資源整合的篩查模式,應用液基細胞學技術免費對中山市適齡婦女進行大規(guī)模宮頸癌篩查,探索適合我省地市級區(qū)域的大規(guī)模篩查模式,通過大量的數(shù)據(jù)整理和分析,為中山市宮頸癌篩查和防治策略的制定與實施奠定基礎并提供理論依據(jù),為更進一步推動中山市宮頸癌防治工作的開展,為有效降低我市宮頸癌的發(fā)病率和死亡率提供原始數(shù)據(jù)。目的:對2011年1月～2013年12月中山市適齡婦女進行宮頸癌前病變大樣本篩查。探討建立以政府為主導、多部門協(xié)作、區(qū)域醫(yī)療資源整合的篩查模式;通過建立信息平臺,完成中山市宮頸癌篩查數(shù)據(jù)庫,為宮頸癌篩查的深入開展和普及積累資料,為中山市宮頸癌篩查和防治策略的制定與實施奠定基礎,為政府將宮頸癌篩查作為我市長效化工作機制提供理論依據(jù);探索適合經(jīng)濟較發(fā)達地區(qū)宮頸癌篩查模式,為我國宮頸癌篩查策略提供參考模式。方法:1.應用婦科常規(guī)檢查和液基細胞學檢查對中山市已婚婦女進行宮頸癌篩查。2.對召回的婦女行人乳頭瘤病毒檢測。3.在陰道鏡下檢查和多點活檢,并行病理學檢查。4.用FISH法對部分TCT陽性標本行hTERC基因擴增。5.對孕婦進行宮頸癌篩查。6.建立宮頸癌篩查信息化管理與規(guī)范化防治模式。結(jié)果:1. 2011年1月～2013年12月,三年共篩查適齡婦女130,475例,TCT陽性共5559例,召回數(shù)3337例,在召回者中,HPV檢測3122例,陽性1993例;行陰道鏡檢查2060例,陰道鏡檢查率61.73%,其中活檢1400例,活檢率67.96%。2.三年總的召回率為60.03%。23個鎮(zhèn)區(qū)之間的召回率具有顯著性差異(χ2=88.345, P0.001),其中南區(qū)(81.03%)、東升鎮(zhèn)(73.88%)和坦洲鎮(zhèn)(69.41%)最高,而沙溪鎮(zhèn)(48.44%)、三角鎮(zhèn)(47.62%)和橫欄鎮(zhèn)(35. 94%)最低;按地理位置分析,南部(65.88%)及城區(qū)(64.58%)的召回率最高,西部(43.77%)最低。單因素及多因素分析顯示,召回率與文化程度、住址、職業(yè)、是否患過宮頸疾病有關,且為召回的獨立影響因素(P0.05),而與年齡分組、絕經(jīng)情況和親屬是否患宮頸癌無關(P0.05)。TCT陽性不同分型的召回情況分析顯示,HSIL和SCC/AC的召回率最高(χ2=72.092, P=0.008)。3.三年TCT篩查的總陽性率為4.26%(2011年為3.14%,2012年為5.17%,2013年4.51%),其中以南朗鎮(zhèn)(5.73%)、橫欄鎮(zhèn)(5.21%)和板芙鎮(zhèn)(5.15%)最高,以民眾鎮(zhèn)(3.63%)、沙溪鎮(zhèn)(3.44%)和大涌鎮(zhèn)(3.27%)最低(χ2=96.906,P0.001);將中山市劃分為城區(qū)、東部、南部、西部和北部五個區(qū)域進行比較,結(jié)果發(fā)現(xiàn)各區(qū)域間TCT陽性率無顯著性差別(χ2=7.629,P=0.106)。單因素分析顯示,TCT陽性率與篩查者的年齡、初次性生活年齡、文化程度、職業(yè)、絕經(jīng)、工具避孕等因素有關(P0.05),與居住地點、家族史和是否患宮頸疾病無關(P0.05)。4.對TCT陽性的部分婦女行HPV檢測,HPV的總陽性率為63.84%。HPV陽性率最高為三鄉(xiāng)鎮(zhèn)(80.43%),最低為五桂山(52.63%),但23個鎮(zhèn)區(qū)間HPV陽性率無顯著性差異(χ2=27.898, P=0.179);各區(qū)域間HPV陽性率無顯著性差異(χ2=3.899, P=0.420)。不同TCT類型之間的HPV陽性具有顯著性差異,其中以HSIL,SCC和AC最高(⑧2=302.130,P=0.000)。5.對TCT陽性的部分婦女行病理檢查,結(jié)果顯示三年TCT陽性婦女總的病理活檢陽性率為72.93% (1021/1400),其中CIN1 411例,CIN2267例,CIN3 293 例,CA45 例,AC 5 例。6.對TCT聯(lián)合HPV檢測在宮頸癌篩查中的價值進行分析,結(jié)果顯示單獨檢測TCT的病理陽性率為72.93%,而TCT聯(lián)合HPV的病理陽性率為77.99%,兩組間具有顯著性差異(χ2=8.922, P=0.003)。7.對hTERC基因檢測在宮頸癌篩查中的價值進行分析,不同病理分型的hTERC陽性率不同,不同病理分型間具有顯性差異(χ2=358.015, P=0.000),隨著病理級別的上升hTERC陽性率不斷升高。8.與非孕期婦女比較,孕期婦女總的細胞學陽性率、癌前病變及宮頸癌的發(fā)生率均無統(tǒng)計學差異(P0.05)。9.在中山市成功建立以多部門協(xié)作區(qū)域醫(yī)療資源整合的宮頸癌篩查模式。結(jié)論:本研究為宮頸癌大規(guī)模篩查在國內(nèi)經(jīng)濟較發(fā)達地區(qū)范圍內(nèi)的全面鋪開提供了依據(jù)和經(jīng)驗,研究提示在應用TCT進行普篩的前提下,盡早行HPV檢測是及時發(fā)現(xiàn)并治療宮頸癌前病變的有效方法。以多部門協(xié)作區(qū)域醫(yī)療資源整合的宮頸癌篩查模式值得在全國推廣。
[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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