美專家小組建議女性不要每年做乳腺癌篩查
In 2009, an influential panel of Medical experts ignited a nationwide uproar by suggesting that women needed fewer mammograms than had long been recommended. Instead of starting at age 40 and being screened every year, women with average risk of breast cancer could safely begin at 50 and be tested every other year, the group said, citing extensive data to support its advice. It also said that after 74, there was not enough evidence to determine whether routine mammography was worthwhile.
2009年，一權威醫學專家小組提出，女性並不像此前長期以來建議的那樣需要接受那麼多乳腺X線影像檢查。這個觀點引發舉國譁然。該小組表示，乳腺癌風險爲普通級別的女性無需從40歲起每年篩查，等到50歲以後開始每隔一年進行檢查也一樣安全。該小組還引用了大量的數據來支持自己的上述建議，並表示，目前尚無充足的證據確定對74歲以上女性進行常規乳腺攝影篩查是否還有價值。
Outrage ensued, from advocates for screening who said the advice would lead to delayed diagnoses and deaths.
原篩查方案的擁護者隨即表達了自己的憤怒之情，稱這些新建議將會延誤診斷並導致更多的死亡。
On Monday, the same panel issued an update of its guidelines — and it is sticking to its guns. The basic advice, which applies to women with an average risk of breast cancer, was unchanged.
1月11日，該小組更新了自己的指南，但並未讓步，他們沒有對適用於普通乳腺癌風險的婦女的基本建議作出更改。
The recommendations are not immediately expected to affect insurance coverage. In December, Congress passed a bill requiring private insurers to pay for screening mammograms for women 40 and over every one to two years without copays, coinsurance or deductibles, through 2017.
預計這些建議不會立即影響到醫療保險的覆蓋範圍。去年12月，美國國會通過了一項法案，要求私營保險公司爲年滿40歲的婦女支付其每一到兩年進行一次乳腺X線影像檢查的費用，且不產生共付醫療費（copay，指超過了醫保報銷額度而需要患者自己支付的那部分醫藥費——譯註）、共同保險(coinsurance)和自付額度。該法案的有效期到2017年爲止。
But advocacy groups said they were worried about what will happen after 2017. “It would be great if screening could be covered forever,” said Carli Feinstein, chief of staff for Bright Pink, a national group focused on prevention and early detection of breast and ovarian cancer.
但倡導組織表示，他們擔心2017年之後會怎樣。專注乳腺癌和卵巢癌早期檢測和預防的全國性組織Bright Pink的辦公室主任卡利·范斯坦(Carli Feinstei)說：“如果篩查能永遠涵蓋在醫保範圍內就太好了。”
The Susan G. Komen for the Cure foundation also expressed concerns about insurance payment, and issued a statement saying that a lack of coverage would hit “high risk and underserved” women hardest, particularly black women, who are more prone than whites to aggressive types of breast cancer.
蘇珊·科曼乳腺癌防治基金會(Susan G. Komen For the Cure Foundation)也對醫保報銷問題表示憂慮，並發表聲明稱，如果不將乳腺癌篩查納入保險範圍之內，那麼“本身風險就高且得不到足夠醫護服務”的婦女，尤其是黑人婦女將受害最深，因爲她們比白人婦女更容易患侵襲性乳腺癌。
The panel issuing the guidelines is the United States Preventive Services Task Force, an independent board of doctors and other experts appointed by the Department of Health and Human Services to evaluate screening tests, counseling and medications intended to prevent disease or detect it early. Panel members are volunteers, and consider only the scientific evidence in their evaluations, not cost or insurance coverage.
發佈上述新指南的小組名爲美國預防服務工作組(United States Preventive Services Task Force)，這是一個由美國衛生和公衆服務部(Department of Health and Human Service)指派的醫生和其他專家所組成的獨立委員會，其主要任務是評估那些旨在預防或及早發現疾病的篩查檢測、諮詢和藥物。小組成員均爲志願者，其評估也只考慮到了科學證據，並沒有涉及費用或保險覆蓋面等問題。
The mammography guidelines, along with four editorials and seven supporting articles, were published on Monday in the Annals of Internal Medicine.
該乳腺攝影篩查指南，以及四篇評論文章和七篇配套的支持性文章1月11日發表在《內科醫學年鑑》(Annals of Internal Medicine)上。
The task force emphasized that it was not advising against screening for women under 50 or over 74, or against screening every year as opposed to every other year. Rather, it says that women should choose for themselves — but that its guidelines offer the best overall balance of benefits and risks.
該工作組強調，這些建議並不代表他們反對50歲以下或74歲以上的婦女進行篩查或每年篩查。更確切的說，他們認爲女性應該自己選擇——只是他們的指南提供了利益與風險的最佳綜合平衡而已。
The task force also examined data for two subjects not included in its 2009 report, and concluded that there was not enough evidence to recommend for or against either of them. One was additional testing, such as M.R.I. or ultrasound, for women with “dense” breast tissue, which makes it difficult to detect tumors with mammography. The other was screening with a newer test called 3-D mammography or digital breast tomosynthesis.
該工作組還審查了其2009年報告中未囊括的兩個主題：一是對乳房組織呈“緻密”狀態的婦女進行MRI或超聲等額外檢查（因爲此時使用乳腺攝影篩查也難以發現腫瘤）；二是使用最新的三維乳腺攝影或數字化乳腺斷層攝影來進行篩查。但他們的結論是：尚無足夠的證據支持或反對其中任何一條。
Breast cancer is the second-leading cause of cancer death in women in the United States, after lung cancer. In 2015, there were about 232,000 new cases of breast cancer, and 40,000 deaths. The highest incidence is in women aged 55 to 64.
乳腺癌是造成美國婦女因癌症死亡的第二大原因，僅次於肺癌。2015年，美國約有23.2萬例乳腺癌新發病例，4萬例死亡。55歲至64歲的婦女發病率最高。
Dr. Constance Lehman, a professor of radiology at Harvard Medical School and director of breast imaging at Massachusetts General Hospital, who is not on the task force, said she was pleased to see that although its advice had not changed, the group had placed more of an emphasis than before on the importance of women’s having the freedom to decide how often to be screened and when to start.
康斯坦絲·萊曼(Constance Lehman)博士是哈佛醫學院(Harvard Medical School)的放射學教授，也是美國麻省總醫院(Massachusetts General Hospital)的乳腺影像科主任，但並非該工作組的成員。她表示，雖然工作組的建議最後並沒有更改，但看到該小組比以往更加重視婦女選擇何時開始篩查及篩查頻率的自由，令她十分欣慰。
The guidelines state that from ages 40 to 74, screening will reduce the odds of dying from breast cancer, with women 40 to 49 benefiting the least and those 60 to 69 benefiting the most. The task force said it concluded “with moderate certainty” that the benefit was moderate in women 50 to 74 and small in women 40 to 49.
指南指出，在40歲到74歲的婦女中進行篩查都可以降低乳腺癌死亡率，40歲至49歲的婦女得益最少，而60歲至69歲的婦女受益最大。該工作組表示，他們有“中度把握”得出結論：50歲至74歲的婦女受益中等，而40歲至49歲的婦女受益較小。
For every 10,000 women screened repeatedly over 10 years, four lives are saved in women 40 to 49; eight in women 50 to 59; 21 in women 60 to 69; and 13 in women 70 to 74, the task force found.
工作組發現，對於每1萬名在10年期間多次接受篩查的婦女，40歲至49歲年齡段中有4人避免了因乳腺癌死亡，在50歲至59歲年齡段中有8人，在60歲至69歲年齡段中有21人，在70歲至74歲年齡段中有13人。
“The science supports mammography as an important tool in the fight against breast cancer,” said Dr. Michael LeFevre, a former chairman of the task force and a professor of medicine at the University of Missouri. He noted that breast cancer deaths have decreased since mammography came into widespread use in the 1980s, though some of the decline, he said, was also due to better treatments. “We believe the benefits increase with age. But there are harms, and particularly in their 40s, women have to make a decision for themselves.”
工作組的前任主席，密蘇里大學(University of Missouri)的醫學教授邁克爾·勒菲弗(Michael LeFevre)博士說：“科學支持以乳腺攝影篩查作爲與乳腺癌作鬥爭的重要工具。”他指出，自從20世紀80年代乳腺攝影篩查的廣泛使用以來，乳腺癌的死亡人數有所減少（儘管其中也有一部分應該歸功於更好的治療方法）。“我們認爲，收益隨着年齡的增長而增加。只是篩查也有危害，尤其是對40多歲的女性，因此女性必須爲自己拿主意。”
One potential harm is false positives, in which a suspicious mammogram finding leads to more tests, sometimes even biopsies, but turns out to be harmless. The guidelines relied in part on a study of records from 405,191 women who had digital mammograms from 2003 to 2011, which found that false positives were common, especially in younger women. Among those 40 to 49 who had regular screening, for every 1,000 women tested, 121.2 had a false positive.
其中一個潛在的危害是假陽性，從乳腺攝影篩查結果來看疑似發現了病竈，結果做了更多的檢測，甚至組織活檢，最後卻發現是一場虛驚。該指南依據的一項研究顯示，在2003年至2011年間接受數字化乳腺攝影篩查的40.5191萬名婦女中，假陽性十分常見，在較年輕的女性中尤其如此。在定期接受篩查的40歲至49歲婦女中，每1000人中就有121.2例假陽性。
Another study, in 2011, found that 61 percent of women who had yearly mammograms starting at age 40 had at least one false positive by the time they were 50. Being tested every other year instead of every year cut the rate of false positives significantly, to about 42 percent.
2011年的另一項研究發現，在從40歲開始每年接受篩查的婦女中，有61%在50歲前至少遇到過一次假陽性結果。與每年篩查相比，每隔一年接受篩查時的假陽性率顯著降低，約爲42%。
Another potential risk is overdiagnosis, meaning that some of the tiny cancers found in mammograms might never progress or threaten the patient’s life. But because there is now no way to be sure which cancers will turn dangerous, they are treated anyway. Researchers agree that overdiagnosis occurs, but they do not know how often.
另一個潛在風險是過度診斷，意即，在乳腺攝影篩查中發現的某些微小的癌症病竈可能永遠不至於進展到會威脅患者的生命。但是，因爲目前無法確知哪些癌症病竈將來會帶來危險，因此就對它們一視同仁地進行了治療。研究人員也認同過度診斷確有發生，但他們也不清楚其發生率如何。
Dr. Therese Bevers, medical director of the Cancer Prevention Center at the University of Texas MD Anderson Cancer Center in Houston, said she thought the task force overemphasized the importance of drawbacks like false positives.
休斯敦的得州大學安德森癌症中心(University of Texas M.D. Anderson Cancer Center)癌症防治中心(Cancer Prevention Center)的醫務主任特蕾澤·貝弗斯(Therese Bevers)博士表示，她認爲工作組過分強調了假陽性等不利因素的重要性。
Dr. Clifford A. Hudis, the chief of breast cancer medicine at Memorial Sloan Kettering Cancer Center, also expressed concern: “The harm of a missed curable cancer is something profound. The harm of an unnecessary biopsy seems somewhat less to me.”
紀念斯隆-凱特琳癌症中心(Memorial Sloan Kettering Cancer Center)的乳腺癌藥物主管克利福德·A·休迪斯(Clifford A. Hudis)博士也表示擔憂：“如果錯過了本來可以治癒的癌症，將會貽害深遠。在我看來，與此相比，接受不必要的活檢造成的危害不值一提。”
Leading medical groups offer different advice about screening that leaves women and their doctors to puzzle it out for themselves. The National Comprehensive Cancer Network, an alliance of prominent cancer centers, recommends mammograms every year starting at age 40. The American College of Obstetricians and Gynecologists recommends them every year or two from ages 40 to 49, and every year after that.
權威醫療團體提出的建議各不相同，令婦女們及其醫生在決策時不知所措。美國頂尖癌症中心的聯盟——美國國家綜合癌症網絡(National Comprehensive Cancer Network)建議從40歲開始，每年進行乳腺攝影篩查。美國婦產科醫師學會(American College of Obstetricians and Gynecologists)的建議是，在40歲到49歲之間每一年或兩年篩查一次，其後每年一次。
In October, one of the most influential groups, the American Cancer Society, dialed back its advice. Although for many years the society recommended mammograms once a year starting at age 40, it now advises that screening start at 45, continue yearly through 54 and then shift to every other year.
去年10月，美國最有影響力的團體之一，美國癌症協會(American Cancer Society)撤回了自己原先的建議。雖然多年來該協會一直建議從40歲開始每年進行乳腺攝影篩查，但他們現在建議從45歲到54歲之間每年篩查，其後改爲每隔一年篩查一次。
Recognizing the confusion, the cancer society, the cancer network and other groups will attend a private meeting in Washington on Jan. 28 and 29 to try to produce a single set of guidelines.
癌症協會、癌症網絡和其他團體紛紛意識到了這種亂象，他們將於1月28日和29日在華盛頓舉行私人會議，嘗試制定一套統一的指南。
Representatives from the preventive services task force will attend, but the task force cannot sign onto consensus statements. It can change its advice only by issuing new guidelines, Dr. LeFevre said.
預防服務工作組的代表亦將參會，但工作組不能在一致的聲明上署名。勒菲弗博士表示，他們只能通過發佈新的指南來更改其建議。
