由于乳房钼靶检查的准确率高于乳房临床检查（视诊、触诊），美国癌症学会在其最新指南中，不推荐乳房临床检查用于任意年龄平均风险女性的乳腺癌筛查。但是，在世界上的绝大多数中低收入地区，首先根据临床体征和症状确定乳腺癌，乳房钼靶检查并不切合实际。乳房临床检查可以通过发现较早期乳腺癌而直接改善早期诊断，或者通过提高女性对乳房健康问题的认知而间接改善早期诊断。那么曾经接受乳房临床检查，是否与自我检出病变的较早就诊和乳腺癌确诊时的较早分期有相关性？
2017年5月25日，《美国医学会杂志肿瘤学分册》在线发表西雅图华盛顿大学、纽约西奈山医院、西雅图皮吉特湾退伍军人医疗管理局、秘鲁北部地区肿瘤疾病研究中心、西雅图弗雷德哈钦森癌症研究中心的横断面研究报告，调查了乳腺癌患者确诊时发病至就诊时间和分期的影响因素，以确定既往乳房临床检查史是否与较早就诊和（或）癌症较早分期有相关性。
该横断面分析于2015年2月1日～5月31日在特鲁希略（秘鲁第三大城市、秘鲁北部经济中心、拉利伯塔德大区和特鲁希略省的首府）联邦公立三级医疗转诊癌症中心使用经过验证的《乳腺癌延迟调查问卷》对159例接受乳腺癌治疗女性患者进行访谈，其中113例（占71.1%，平均年龄54±10.8岁，范围32～82岁）参与研究。主要结局衡量指标为乳腺癌检测方法、诊断时发病至就诊时间和分期的影响因素。
结果发现，其中105例（92.9%）自行检出乳腺癌。
在93例分期有案可查的女性中，45例（48.4%）被诊断为早期病变（AJCC：0～II期），48例（51.6%）被诊断为晚期病变（AJCC：III～IV期）。
从症状出现至治疗开始的总延迟平均407±665天，患者所致延迟平均198±449天，医疗系统所致延迟平均241±556天。
52例女性（46.0%）有乳房临床检查史，23例（20.4%）有乳房钼靶检查史。
有、无乳房临床检查史的女性相比，发病至就诊的延迟时间缩短2.92倍（95%置信区间：1.30～6.60，P=0.01）。
患者所致延迟较短与较长女性相比，被诊断为早期病变（AJCC：0～II期）比例较高（58.5%比30.6%，P=0.01）。
有、无乳房临床检查史的女性相比，被诊断为早期病变的比例高2.74倍（95%置信区间：1.18～6.36，P=0.02）。
排除医疗保险和家庭收入因素影响，被诊断为早期病变的比例高2.44倍（95%置信区间：1.01～5.95，P=0.048）。
因此，在大多数乳腺癌被自我检出的人群中，既往乳房临床检查与乳腺癌诊断时患者所致延迟较短、分期较早有相关性。在世界上缺乏乳房钼靶检查的地区，在依赖于出现乳腺癌症状的女性医疗体系中，常规使用乳房临床检查可为改善乳腺癌早期诊断提供解决资源的策略，与医疗专业人士的互动（包括乳房临床检查）可使认知提高、延迟减少，确诊时的病变分期提前。
JAMA Oncol. 2017 May 25. [Epub ahead of print]
Association of Previous Clinical Breast Examination With Reduced Delays and Earlier-Stage Breast Cancer Diagnosis Among Women in Peru.
Romanoff A, Constant TH, Johnson KM, Guadiamos MC, Vega AMB, Zunt J, Anderson BO.
University of Washington, Seattle, Washington; Mount Sinai Hospital, New York, New York; Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Instituto Regional de Enfermedades Neoplásicas del Norte, Trujillo, Peru; Fred Hutchinson Cancer Research Center, Seattle, Washington.
This cross-sectional study investigates whether history of previous clinical breast examination is associated with earlier presentation and/or earlier cancer stage at diagnosis among women in Peru.
QUESTION: Is previous clinical breast examination associated with earlier presentation of self-detected disease and earlier breast cancer stage at diagnosis?
FINDINGS: In this cross-sectional investigation of 113 women studied at a regional cancer center in Peru, 105 had self-detected breast cancers. Women who underwent previous clinical breast examination were more likely to have shorter delays from symptom development to presentation and be diagnosed with early-stage cancer.
MEANING: In a health care system that relies on women presenting with symptoms of breast cancer, interaction with a health care professional, including clinical breast examination, may improve awareness, reduce delays, and lead to earlier-staged disease at diagnosis.
IMPORTANCE: Mammographic screening is impractical in most of the world where breast cancers are first identified based on clinical signs and symptoms. Clinical breast examination may improve early diagnosis directly by finding breast cancers at earlier stages or indirectly by heightening women's awareness of breast health concerns.
OBJECTIVE: To investigate factors that influence time to presentation and stage at diagnosis among patients with breast cancer to determine whether history of previous clinical breast examination is associated with earlier presentation and/or earlier cancer stage at diagnosis.
DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional analysis of individual patient interviews using a validated Breast Cancer Delay Questionnaire, 113 (71.1%) of 159 women with breast cancer treated at a federally funded tertiary care referral cancer center in Trujillo, Peru, from February 1 through May 31, 2015, were studied.
MAIN OUTCOMES AND MEASURES: Method of breast cancer detection and factors that influence time to and stage at diagnosis.
RESULTS: Of 113 women with diagnosed cancer (mean [SD] age, 54 [10.8] years; age range, 32-82 years), 105 (92.9%) had self-detected disease. Of the 93 women for whom stage was documented, 45 (48.4%) were diagnosed with early-stage disease (American Joint Committee on Cancer [AJCC] stage 0, I, or II), and 48 (51.6%) were diagnosed with late-stage disease (AJCC stage III or IV). Mean (SD) total delay from symptom onset to initiation of treatment was 407 (665) days because of patient (mean [SD], 198 [449] days) and health care system (mean [SD], 241 [556] days) delay. Fifty-two women (46.0%) had a history of clinical breast examination, and 23 (20.4%) had undergone previous mammography. Women who underwent a previous clinical breast examination were more likely to have shorter delays from symptom development to presentation compared with women who had never undergone a previous clinical breast examination (odds ratio, 2.92; 95% CI, 1.30-6.60; P=.01). Women diagnosed with shorter patient delay were more likely to be diagnosed with early-stage disease (AJCC stage 0, I, or II) than those with longer patient delay (31 [58.5%] vs 11 [30.6%], P=.01). Women who underwent a previous clinical breast examination were more likely to be diagnosed with early-stage disease compared with women who had never undergone previous clinical breast examination; this relationship remained significant after controlling for insurance and household income (odds ratio, 2.44; 95% CI, 1.01-5.95; P=.048).
CONCLUSIONS AND RELEVANCE: In a population in which most breast cancers are self-detected, previous clinical breast examination was associated with shorter patient delay and earlier stage at breast cancer diagnosis. In regions of the world that lack mammographic screening, the routine use of clinical breast examination may provide a resource-appropriate strategy for improving breast cancer early diagnosis.
PMID: 28542677
DOI: 10.1001/jamaoncol.2017.1023
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