Analysis of Screening Data for Colorectal Cancer in Residents in Pudong New Area, Shanghai, 2013-2023
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摘要:目的
分析上海市浦东新区居民大肠癌筛查基本情况，为大肠癌筛查项目推广和策略优化提供参考。
方法以2013—2023年上海市浦东新区参加大肠癌筛查项目的50~74岁居民为研究对象，分析初筛和肠镜检查情况，同时根据年龄开展亚组分析。组间比较采用卡方检验。
结果2013—2023年浦东新区大肠癌完成社区初筛907 030人次，其中初筛阳性183 724人次，整体初筛阳性率为20.3%，50~54岁年龄组最低，70~74岁年龄组最高，男性初筛阳性率大于女性。总体肠镜检查参与率为27.1%，男、女性肠镜检查参与度最高的年龄段分别为50~54岁和55~59岁，肠镜检查参与率随着每轮筛查的开展有增加趋势。经肠镜检查发现肠道病变19 094例，其中大肠癌1 147例，占6.0%，人群检出率为126.5/10万；癌前病变4 751例，占24.9%，人群检出率为523.8/10万。
结论大肠癌筛查有效提高了癌前病变及早期癌检出率，对于降低大肠癌发病率和死亡率具有重要意义。尚需针对年龄亚组采取措施优化筛查策略，提高初筛参与率和肠镜检查参与率，从而进一步提升大肠癌的防治效果。
Abstract:ObjectiveTo analyze the colorectal cancer screening of community residents in Pudong New Area in Shanghai and provide reference for the promotion and strategy optimization of colorectal cancer screening programs.
MethodsResidents aged 50-74 years in the colorectal cancer screening project of Pudong New Area in Shanghai from 2013 to 2023 were recruited in this analysis. The situation of primary screening and colonoscopy in the community was described, and results of different age groups in primary screening and colonoscopy surveys were evaluated. Chi-square test was used to determine differences between groups.
ResultsFrom 2013 to 2023, 907 030 residents were screened in Pudong New Area, of which 183 724 residents were positive, and the positive rate was 20.3%. The positive rate was the lowest in the 50-54 age group and the highest in the 70-74 age group. The positive rate was higher in men than in women. The overall colonoscopy rate was 27.1%, with the highest rates in the 50-54 age group in men and the 55-59 age group in women, respectively. The participation rate of colonoscopy increased with the increase of the year. A total of 19 094 cases of intestinal lesions were found by colonoscopy. Among these lesions, 1 147 cases were colorectal cancer, accounting for 6.0%, and the population detection rate was 126.5/100 000. In addition, 4 751 cases of precancerous lesions were found, accounting for 24.9%, and the detection rate was 523.8/100 000.
ConclusionColorectal cancer screening improves the detection rate of precancerous lesions and early cancer and is of great significance for reducing the incidence and mortality of colon cancer. Measures should be taken to optimize the screening strategy based on age differences and increase the participation rate of primary screening and colonoscopy to achieve the best effect of local colorectal cancer prevention and treatment.
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Key words:
- Colorectal cancer /
- Screening /
- Colonoscopy /
- Precancerous lesion /
- Shanghai
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0 引言
大肠癌是世界范围内常见的消化系统恶性肿瘤之一。GLOBOCAN 2022最新数据显示，大肠癌发病率位居全球第3位，死亡率位居第2位[1]。中国的大肠癌发病率位居男性第2位，女性第4位[2] ，已接近发达国家水平。2017年上海市大肠癌标化发病率25.3/10万，其中男性标化发病率30.7/10万，女性标化发病率20.2/10万，分别位于男、女性恶性肿瘤发病率的第2位和第4位[3]。浦东新区是上海市最大的市辖区，含有典型的中心城区、城镇地区和农村地区生态[4]。2019年浦东新区大肠癌标化发病率25.3/10万，其中男性标化发病率31.0/10万，女性标化发病率19.8/10万，分别位于男、女性恶性肿瘤发病率的第2位和第4位。
大肠癌筛查是大肠癌防治的重要手段，成为许多国家的公共卫生服务项目[5-7]。西方发达国家通过筛查、早期病变的监测和及时治疗，大大降低了大肠癌的死亡率[8-10]，美国更是将大肠癌筛查立法，使大肠癌发病率出现了明显的下降趋势[11]。上海市重大公共卫生项目“社区居民大肠癌筛查”自2013年开展以来，已惠及区域内数百万居民。本研究将整理2013—2023年上海市浦东新区的筛查数据，分析参加筛查对象的基本情况，为大肠癌筛查项目推广和策略优化提供基础数据。
1 资料与方法
1.1 研究对象
研究对象纳入标准：（1）居住于浦东新区的50~74岁上海市常住居民（包括本市户籍居民和本市居住满6个月以上的非本市户籍居民）；（2）按照上海市社区居民大肠癌筛查流程完成危险度评估和两次便隐血检测；（3）所有纳入研究的对象均签署知情同意书。排除结直肠癌，严重心、脑、肺疾病，有严重出血倾向、肝肾功能障碍和严重精神障碍患者。本研究以2013—2023年参加初筛的50~74岁的居民作为研究对象，共纳入记录907 030人次。肠镜检查随访共收集58 137例，剔除重复项后保留49 724例，发现肠道病变19 094例。
1.2 筛查方法与结果判定
居民在其居住地所在的社区卫生服务中心参加初筛，按实施方案的要求，采用《上海市社区居民大肠癌筛查危险度评估表》结合两次粪便潜血检测（Fecal occult blood teats, FOBT）的筛查模式[12]。两次粪便隐血检测间隔7天，危险度评估阳性或任意1次FOBT阳性者被判定为初筛阳性。社区卫生服务中心应向所有完成初筛的参与对象发放书面的初筛结果通知。
1.3 结肠镜检查
在上海浦东新区内选择具有结肠镜检查和诊疗资质的二、三级医疗机构作为筛查定点医院，根据居民居住地的地理可及性，每家定点医院对应3~5家社区卫生服务中心。初筛阳性者建议3个月内携带社区提供的转诊单自行前往定点医院接受全结肠镜检查。定点医疗机构在收到转诊单后，告知预约时间、肠镜检查和肠道准备的注意事项。检查时肠镜进入深度需到达回盲部。肠镜检查结果包括无任何病变、肠炎、增生性息肉、进展期腺瘤、伴中重度异型增生的其他病变和大肠癌等。
1.4 质量控制
社区卫生服务中心负责风险评估表填写、录入和现场质量控制。浦东新区疾控中心依托“大肠癌筛查登记管理系统”，每月自动抽取每个社区前1个月录入所有评估表数量的1%进行质量控制，并填写《筛查登记和危险度评估质量控制表》。采用危险度评估表填写合格率和危险度评估表输入与书面内容符合率进行质量评估，合格率和一致率要求达到100%。所有肠镜检查结果通过定点医院报告、社区医生电话和上门随访的方式获得。市疾病预防控制中心组织专家组对定点医疗机构每年进行一次质控，内容包括查阅定点医疗机构各项大肠癌筛查相关的资料，包括肠镜检查、病理和临床治疗的规范性。
1.5 统计方法
本研究数据描述和分析采用以下统计指标：初筛阳性率=（初筛结果判定为阳性的人次数/参加初筛的有效总人次数）×100%；肠镜检查参与率=（初筛结果为阳性者中参加肠镜检查的人次数/初筛结果判定为阳性的总人次数）×100%；检出率=（筛出某种疾病的例数/参加初筛的有效总人次数）×10万/10万[13]。
应用SPSS 29.0软件对数据资料进行整理和统计学分析。组间比较采用χ2检验。采用双侧检验，以P<0.05为差异有统计学意义。
2 结果
2.1 大肠癌筛查初筛阳性率情况
2013—2023年浦东新区大肠癌完成社区初筛907 030人次，仅危险度评估阳性94 048人次，仅FOBT阳性105 381人次，初筛阳性者183 724人次，初筛阳性率为20.3%。其中男性仅危险度评估阳性36 823人次，仅FOBT阳性48 483人次，初筛阳性者78 274人次，阳性率为21.0%；女性仅危险度评估阳性57 225人次，仅FOBT阳性56 898人次，初筛阳性者105 450人次，阳性率为19.7%；男性初筛阳性率高于女性，男女初筛阳性率差异有统计学意义（χ2=270，P<0.001）。初筛阳性率在各年龄段的差异有统计学意义，50~54岁年龄组最低，70~74岁年龄组最高（χ2=1707，P<0.001），见表1。
表 1 2013—2023年上海市浦东新区大肠癌筛查初筛阳性率情况Table 1 Positive results among participants screened for colorectal cancer in Pudong New Area, Shanghai, 2013–2023Age
(years)Male Female Total Risk
assessment
positiveFOBT
positiveScreening
positiveNumber
of
screeningPositive
rates* (%)Risk
assessment
positiveFOBT
positiveScreening
positiveNumber
of
screeningPositive
rates* (%)Risk
assessment
positiveFOBT
positiveScreening
positiveNumber
of
screeningPositive
rates* (%)50-54 1 573 2 401 3 729 23 946 15.6 4 269 4 229 8 016 50 730 15.8 5 842 6 630 11 745 74 676 15.7 55-59 4 170 6 603 10 023 53 318 18.8 9 543 9 830 17 995 99 788 18.0 13 713 16 433 28 018 153 106 18.3 60-64 9 175 13 231 20 629 95 025 21.7 14 793 15 288 27 827 136 554 20.4 23 968 28 519 48 456 231 579 20.9 65-69 13 153 16 495 27 100 124 241 21.8 18 113 17 732 33 025 159 509 20.7 31 266 34 227 60 125 283 750 21.2 70-74 8 752 9 753 16 793 75 904 22.1 10 507 9 819 18 587 88 015 21.1 19 259 19 572 35 380 163 919 21.6 Total 36 823 48 483 78 274 372 434 21.0 57 225 56 898 105 450 534 596 19.7 94 048 105 381 183 724 907 030 20.3 Notes: *: Positive rate=(number of screening positive/numbers of screening)×100%. FOBT: fecal occult blood test. 2.2 大肠癌筛查肠镜参与情况
在参加肠镜检查的49 724人次中，男性占45.7% （22 744/49 724），男性肠镜检查参与率为29.1%；女性占54.3%（26 980/49 724），女性肠镜参与率为25.6%，男女性肠镜检查参与率差异有统计学意义，男性肠镜检查参与率高于女性（χ2=301，P<0.001），总体肠镜检查参与率为27.1%。肠镜检查参与率在各年龄段的差异有统计学意义（χ2=288，P<0.001），男、女肠镜检查参与率最高的年龄段分别为50~54岁、55~59岁，均为31.8%。另外，肠镜检查参与率随着每轮筛查的开展有增加趋势，见表2。
表 2 2013—2023年上海市浦东新区大肠癌筛查肠镜参与率情况Table 2 Colonoscopy participation results for colorectal cancer screening in Pudong New Area, Shanghai, 2013–2023Items Male Female Total Number of
enteroscopePositive
casesParticipation
rates (%)Number of
enteroscopePositive
casesParticipation
rates (%)Number of
enteroscopePositive
casesParticipation
rates (%)Age (years) 50-54 1 186 3 729 31.8 2 128 8 016 26.5 3 314 11 745 28.2 55-59 3 184 10 023 31.8 4 983 17 995 27.7 8 167 28 018 29.1 60-64 6 438 20 629 31.2 7 501 27 827 27.0 13 939 48 456 28.8 65-69 7 544 27 100 27.8 8 058 33 025 24.4 15 602 60 125 25.9 70-74 4 392 16 793 26.2 4 310 18 587 23.2 8 702 35 380 24.6 Year First round(2013) 5 037 15 658 32.2 6 607 22 982 28.7 11 644 38 640 30.1 Second round(2014-2016) 6 449 24 095 26.8 7 466 32 721 22.8 13 915 56 816 24.5 Third round(2017-2019) 6 142 21 278 28.9 7 050 27 658 25.5 13 192 48 936 27.0 Fourth round(2020-2022) 3 667 12 726 28.8 4 165 16 125 25.8 7 832 28 851 27.1 Fifth round(2023) 1 449 4 517 32.1 1 692 5 964 28.4 3 141 10 481 30.0 Total 22 744 78 274 29.1 26 980 105 450 25.6 49 724 183 724 27.1 2.3 肠镜结果分析
经肠镜检查发现肠道病变19 094例。其中大肠癌1 147例，占6.0%，人群检出率为126.5/10万；癌前期病变4 751例，占24.9%，人群检出率为523.8/10万；炎性息肉3 889例，占20.4%，人群检出率为428.8/10万；增生性息肉7 242例，占37.9%，人群检出率为798.4/10万；肠炎1 389例，占7.3%，人群检出率为153.1/10万。各年龄段的检出情况详见表3。
表 3 2013—2023年上海市浦东新区居民肠镜检出率情况Table 3 Colonoscopy detection results among participants in Pudong New Area, Shanghai, 2013–2023Age
(years)Cancer Precancerous
lesion*Inflammatory
polypsHyperplastic
polypsEnteritis Other Total N Rates
(/100000 )N Rates
(/100000 )N Rates
(/100000 )N Rates
(/100000 )N Rates
(/100000 )N Rates
(/100000 )N Rates
(/100000 )50-54 31 41.5 241 322.7 195 261.1 389 520.9 88 117.8 39 52.2 983 1 316.4 55-59 108 70.5 659 430.4 560 365.8 1 022 667.5 232 151.5 128 83.6 2 709 1 769.4 60-64 266 114.9 1 366 589.9 1 037 447.8 1 981 855.4 405 174.9 167 72.1 5 222 2 255.0 65-69 410 144.5 1 582 557.5 1 331 469.1 2 430 856.4 450 158.6 225 79.3 6 428 2 265.4 70-74 332 202.5 903 550.9 766 467.3 1 420 866.3 214 130.6 117 71.4 3 752 2 288.9 Total 1 147 126.5 4 751 523.8 3 889 428.8 7 242 798.4 1 389 153.1 676 74.5 19 094 2 105.1 Notes: *: precancerous lesions include tubular adenomas, villous adenomas, tubular villous adenomas, sessile (broad-based) serrate adenomas, traditional serrate adenomas, hamartomatous polyps, and intraepithelial neoplasia. 3 讨论
本研究表明，参加筛查的初筛阳性率为20.3%，男性高于女性，50~54岁年龄组最低，70~74岁年龄组最高。肠镜检查分析结果显示，总体肠镜检查参与率为27.1%，男、女肠镜检查参与率最高的年龄段分别为50~54岁、55~59岁。经肠镜检查发现大肠癌1 147例，癌前病变4 751例，以及其他类别的肠道病变共13 196例。
50~59岁年龄段参加筛查的人数比例居少，参与者以60岁以上老年人为主，但该年龄段肠镜检查参与率较高。且随着老龄化进程的发展，如何提高此年龄段人群的初筛参与率，值得探讨。分析原因，可能由于50~59岁年龄段居民部分还在上班，工作日不便于参加筛查。但大肠癌发病率在50岁之后急剧上升[14]，在以后的筛查工作中，可以采取相应措施大力发动50~59岁居民参加筛查。
大肠癌筛查和诊断欧洲指南中指出，肠镜顺应性应超过90.0%[15]。英国的大肠癌筛查中，83.0%初筛阳性者参与了肠镜检查[16]。在加拿大五个省筛查项目中，初筛结果阳性者中完成肠镜检查的比例为80.5%[17]。浙江海宁市大肠癌筛查肠镜检查参与率达到72.9%[18]。袁平等[19]对2006—2015年中国大肠癌筛查依从性进行了Meta分析，发现肠镜依从率为44.0%。2012—2013年中国城市人口大肠癌筛查项目的肠镜检查率为33.3%[20]，广州市仅为21.1%[21]，天津市为20.5%[22]，本研究整体肠镜检查参与率为27.1%，低于发达国家水平，但高于部分国内水平。低年龄组肠镜检查参与率高于高年龄组，与上海嘉定区筛查结果基本一致[23]，主要原因可能是年龄较大的居民因身体情况不能耐受肠镜检查[24]。女性肠镜检查参与率低于男性，与大部分文献报告的结果基本相同[13,21,23]，原因可能是女性居民存在对肠镜创伤性损害或者承受疼痛的忧虑[25]。
肠镜检查参与率低会造成较多的大肠癌以及癌前期病变的漏诊，直接影响大肠癌筛查效率。大肠癌筛查参与率不高，尤其是肠镜检查参与率低是我国大肠癌项目面临的共同问题，也是大肠癌筛查推广需要面对的最大挑战。上海作为国内首个将大肠癌筛查纳入重大公共卫生服务项目的城市，自2013年项目开展以来，第一轮筛查的肠镜顺应性仅为27.8%，限制了筛查效果[26]。由此可见，如何提高肠镜检查参与率是大肠癌筛查项目成败的关键。研究显示，影响肠镜检查参与率的因素包括年龄、民族、受教育程度、既往粪便潜血试验结果、息肉史、结肠癌家族史和炎性反应性肠病的病史[27]。此外，还受到包括筛查模式、筛查实施者、宣传方式等多种因素的影响[28-29]。适宜的筛查策略是提高大肠癌筛查效果的有效手段。除此之外，相关部门需大力加强大肠癌防控知识宣教，扩大筛查范围，让居民了解大肠癌筛查的意义和重要性，并进一步提升肠镜依从性。
研究发现，大肠癌早期患者5年生存率可达90%以上[30]，大肠癌筛查的目的不仅在于发现早期癌，还能发现进展期腺瘤等癌前病变。在大肠癌可干预的阶段进行二级预防，可以有效降低发病率和死亡率，改善患者预后，提高生命质量。浦东新区社区居民大肠癌筛查项目癌前病变和大肠癌检出率为650.3/10万。文献报道上海黄浦区的检出率为1 200.2/10万[13]，杭州市上城区为565.0/10万[31]，天津市为302.1/10万[32]，浙江海宁第一轮筛查为552.3/10万[33]。英国的大肠癌筛查中，癌前病变和大肠癌的检出率为770.4/10万[16]，意大利为927.8/10万[34]，法国巴黎为1 056.4/10万[35]。本研究的癌前病变和大肠癌检出率低于发达国家水平，但高于国内部分地区水平，体现出大肠癌筛查及早诊、早治的重要意义。
本项目也存在一些缺点和不足，例如50~59岁年龄段参加筛查的人数比例居少，肠镜检查参与率偏低。我们需要及时优化筛查策略，提高高危人群的肠镜检查参与率及癌前病变检出率，从而达到防治大肠癌的最好效果。总之，本研究结果为今后完善大肠癌筛查项目方案、提高居民肠镜依从性、降低大肠癌发病风险提供了有力依据和基础数据。
Competing interests: The authors declare that they have no competing interests.利益冲突声明：所有作者均声明不存在利益冲突。作者贡献：王莹莹：提出选题，研究设计与实施，数据统计分析，文章撰写与修改乔羽、李卓颖：整理数据和统计分析谭玉婷、杨琛、陈涵一、李牧庭：数据收集项永兵：提供方法学支持，提出修改意见，审核文章张 莉：文章修改与审核 -
表 1 2013—2023年上海市浦东新区大肠癌筛查初筛阳性率情况
Table 1 Positive results among participants screened for colorectal cancer in Pudong New Area, Shanghai, 2013–2023
Age
(years)Male Female Total Risk
assessment
positiveFOBT
positiveScreening
positiveNumber
of
screeningPositive
rates* (%)Risk
assessment
positiveFOBT
positiveScreening
positiveNumber
of
screeningPositive
rates* (%)Risk
assessment
positiveFOBT
positiveScreening
positiveNumber
of
screeningPositive
rates* (%)50-54 1 573 2 401 3 729 23 946 15.6 4 269 4 229 8 016 50 730 15.8 5 842 6 630 11 745 74 676 15.7 55-59 4 170 6 603 10 023 53 318 18.8 9 543 9 830 17 995 99 788 18.0 13 713 16 433 28 018 153 106 18.3 60-64 9 175 13 231 20 629 95 025 21.7 14 793 15 288 27 827 136 554 20.4 23 968 28 519 48 456 231 579 20.9 65-69 13 153 16 495 27 100 124 241 21.8 18 113 17 732 33 025 159 509 20.7 31 266 34 227 60 125 283 750 21.2 70-74 8 752 9 753 16 793 75 904 22.1 10 507 9 819 18 587 88 015 21.1 19 259 19 572 35 380 163 919 21.6 Total 36 823 48 483 78 274 372 434 21.0 57 225 56 898 105 450 534 596 19.7 94 048 105 381 183 724 907 030 20.3 Notes: *: Positive rate=(number of screening positive/numbers of screening)×100%. FOBT: fecal occult blood test. 
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表 2 2013—2023年上海市浦东新区大肠癌筛查肠镜参与率情况
Table 2 Colonoscopy participation results for colorectal cancer screening in Pudong New Area, Shanghai, 2013–2023
Items Male Female Total Number of
enteroscopePositive
casesParticipation
rates (%)Number of
enteroscopePositive
casesParticipation
rates (%)Number of
enteroscopePositive
casesParticipation
rates (%)Age (years) 50-54 1 186 3 729 31.8 2 128 8 016 26.5 3 314 11 745 28.2 55-59 3 184 10 023 31.8 4 983 17 995 27.7 8 167 28 018 29.1 60-64 6 438 20 629 31.2 7 501 27 827 27.0 13 939 48 456 28.8 65-69 7 544 27 100 27.8 8 058 33 025 24.4 15 602 60 125 25.9 70-74 4 392 16 793 26.2 4 310 18 587 23.2 8 702 35 380 24.6 Year First round(2013) 5 037 15 658 32.2 6 607 22 982 28.7 11 644 38 640 30.1 Second round(2014-2016) 6 449 24 095 26.8 7 466 32 721 22.8 13 915 56 816 24.5 Third round(2017-2019) 6 142 21 278 28.9 7 050 27 658 25.5 13 192 48 936 27.0 Fourth round(2020-2022) 3 667 12 726 28.8 4 165 16 125 25.8 7 832 28 851 27.1 Fifth round(2023) 1 449 4 517 32.1 1 692 5 964 28.4 3 141 10 481 30.0 Total 22 744 78 274 29.1 26 980 105 450 25.6 49 724 183 724 27.1
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表 3 2013—2023年上海市浦东新区居民肠镜检出率情况
Table 3 Colonoscopy detection results among participants in Pudong New Area, Shanghai, 2013–2023
Age
(years)Cancer Precancerous
lesion*Inflammatory
polypsHyperplastic
polypsEnteritis Other Total N Rates
(/100000 )N Rates
(/100000 )N Rates
(/100000 )N Rates
(/100000 )N Rates
(/100000 )N Rates
(/100000 )N Rates
(/100000 )50-54 31 41.5 241 322.7 195 261.1 389 520.9 88 117.8 39 52.2 983 1 316.4 55-59 108 70.5 659 430.4 560 365.8 1 022 667.5 232 151.5 128 83.6 2 709 1 769.4 60-64 266 114.9 1 366 589.9 1 037 447.8 1 981 855.4 405 174.9 167 72.1 5 222 2 255.0 65-69 410 144.5 1 582 557.5 1 331 469.1 2 430 856.4 450 158.6 225 79.3 6 428 2 265.4 70-74 332 202.5 903 550.9 766 467.3 1 420 866.3 214 130.6 117 71.4 3 752 2 288.9 Total 1 147 126.5 4 751 523.8 3 889 428.8 7 242 798.4 1 389 153.1 676 74.5 19 094 2 105.1 Notes: *: precancerous lesions include tubular adenomas, villous adenomas, tubular villous adenomas, sessile (broad-based) serrate adenomas, traditional serrate adenomas, hamartomatous polyps, and intraepithelial neoplasia.
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