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[2012-3-5. û³âÀÇ»ç ] °Ç°­°ËÁø ¿À³²¿ë, ¡®ºê·¹ÀÌÅ©¡¯ ÇÊ¿äÇÏ´Ù (link2)

"°ËÁøÀº À§¾ç¼º°ú °úÁø´ÜÀ» ¾ç»êÇÑ´Ù!" ±×·¯³ª ¾ÏÀ̶ó°í ´Ù ¶È°°Àº °ÍÀº ¾Æ´Ï´Ù. ¾Ï¿¡´Â 3°¡Áö°¡ ¾Æ´Ï¶ó 4°¡ÁöÀÇ ³ðÀÌ ÀÖ´Ù. 'ºü¸£°Ô ÁøÇàÇÏ´Â ³ð', 'õõÈ÷ ÁøÇàÇÏ´Â ³ð', '¾ÆÁÖ ÃµÃµÈ÷ ÁøÇàÇÏ´Â ³ð', ±×¸®°í ¸¶Áö¸·À¸·Î '¾Æ¿¹ ÁøÇàÇÏÁö ¾Ê°Å³ª ÅðÇàÇÏ´Â ³ð'ÀÌ´Ù. Á¶Á÷ÇÐÀûÀÎ ¿©·¯ Ư¡À¸·Î º¸¾Æ ¾ÏÀº ºÐ¸íÇϳª, ¾ÏÀÌ ¾Æ¿¹ ÁøÇàÇÏÁö ¾Ê¾Æ ±× »óÅ·Π¸Ó¹°·¯ Àְųª ¾ÆÁÖ ÃµÃµÈ÷ ÁøÇàÇÏ¿© ¾ÏÀ¸·Î »ç¸ÁÇÏÁö ¾Ê°í ´Ù¸¥ ¿øÀÎÀ¸·Î - ¿¹¸¦ µé¾î ³úÁßdzÀ¸·Î - »ç¸ÁÇÒ °æ¿ì '°¡Â¥º´'('pseudo-disease')À̶ó°í ÇÑ´Ù


[2014-11-17. ÀÌÁØÇà] ±¹°¡Â÷¿øÀÇ screening program¿¡ ´ëÇÑ ³»¿ÜÀÇ ¾´¼Ò¸®°¡ °è¼ÓµÇ°í ÀÖ½À´Ï´Ù. ¿À´Ã ¿ì¿¬È÷ ÇÑ ¸®ºä¸¦ Àоú½À´Ï´Ù. ¹«Ã´ ³¯Ä«·Î¿î ¾´¼Ò¸®ÀÔ´Ï´Ù. ÇѸ¶µð·Î national cancer screening programÀÇ ±Ù°Å°¡ ¾ø´Ù´Â ÁÖÀåÀÔ´Ï´Ù. Bias°¡ ½ÉÇÏ°í positive predictive valueµµ ³·´Ù°í ÇÕ´Ï´Ù. ¾ûÅ͸®("poorly designed and inaccurately evaluated")¶ó°í ±¹¹Î¿¡°Ô ¾Ë·Á¾ß ÇÑ´Ù´Â À̾߱⵵ ÀÖ½À´Ï´Ù (Citizens must be informed about this). National screening programÀÇ À¯¿ë¼º°ú Á¦ÇÑÁ¡¿¡ ´ëÇÏ¿© ÇѹøÀÌ¶óµµ °í¹ÎÇϽŠºÐµéÀº ²À Àо½Ã±â ¹Ù¶ø´Ï´Ù.

Àú´Â °Ç°­°ËÁøÀ̳ª cancer screeningÀº ¸Å¿ì ¸Å¿ì individualized µÇ¾î¾ß ÇÑ´Ù°í »ý°¢ÇÕ´Ï´Ù. ±×·¸Áö ¾ÊÀ¸¸é µæº¸´Ù ½ÇÀÌ ¸¹À» È®·üÀÌ ³ô½À´Ï´Ù. ¸çÄ¥ Àü ¿ÜºÎ °Ç°­°ËÁø¿¡¼­ amylase ¼öÄ¡°¡ ¾à°£ ³ô´Ù°í ¿À½Å ºÐÀÌ ÀÖ¾ú½À´Ï´Ù. ¹«½¼ Àǹ̰¡ ÀÖ³Ä°í ¹¯±æ·¡ Àú´Â "¿Ö °Ë»ç¸¦ ÇϼÌÁö¿ä?"¶ó°í ¹Ý¹®ÇÒ ¼ö ¹Û¿¡ ¾ø¾ú½À´Ï´Ù. ÇÒ ÇÊ¿ä°¡ ÀÖ´Â °Ë»ç´Â ÇÏ°í, ÇÒ ÇÊ¿ä°¡ ¾ø´Â °Ë»ç´Â ¾ÈÇÏ´Â °ÍÀÌ ÃÖ¼±À̶ó°í »ý°¢ÇÕ´Ï´Ù. ÇÊ¿ä°¡ Àִ°¡ ¾ø´Â°¡´Â (1) ±Ù°Å, (2) °æÇ踹Àº ÀÇ·áÁøÀÇ °æÇèÀ¸·Î ÆÇ´ÜÇÏ¸é µË´Ï´Ù. '±×³É °ËÁø'Àº ¾Æ´Ï¶ó°í º¾´Ï´Ù.

Minsoo Jung. National Cancer Screening Programs and Evidence-Based Healthcare Policy in South Korea. Health Policy (2014)


[2014-11-19. ¾Öµ¶ÀÚ ÆíÁö (Á÷¾÷ȯ°æÀÇÇаú)]

±¹°¡¾Ï°ËÁø»ç¾÷¿¡ ´ëÇÑ Jung MS (2014)ÀÇ ³í¹®¿¡ °üÇÑ »ç¼ÒÇÏ°í °³ÀÎÀûÀÎ ÀÇ°ßÀÔ´Ï´Ù. Àüü ±ÛÀÇ ¸Æ¶ôÀº ÀüÀûÀ¸·Î µ¿ÀÇÇÕ´Ï´Ù...^^

1) ¾ç¼º¿¹Ãøµµ(PPV)¸¦ °è»êÇÒ ¶§, ¾Ï°ËÁø¿¡¼­ÀÇ 'positive cases(°ËÁø¿¡¼­ ¾ÏÀ¸·Î ÆÇÁ¤ÇÔ)'À» ¾î¶»°Ô Á¤ÀÇÇÏ¿´´ÂÁö ±Ã±ÝÇÕ´Ï´Ù. ´Ù¸¥ ¾ÏÁ¾Àº Â÷Ä¡ÇÏ´õ¶óµµ ÀڱðæºÎ¾Ï °ËÁøÀÎ °æ¿ì 'ÀڱðæºÎ¼¼Æ÷°Ë»ç(Pap smear)' °á°ú·Î ÆÇÁ¤À» ÇÏ°í Àִµ¥, Pap smear¿¡¼­ ¾Ï¼¼Æ÷°¡ ¹ß°ßµÇ¾î 'ÀڱðæºÎ¾Ï ÀǽÉ'À¸·Î ÆÇÁ¤µÈ »ç¶÷ Áß¿¡¼­ Æò±Õ 1.3%¸¸ 'true positive cases'ÀÌ´Ù´Â °ÍÀº ¼ö±àÇϱ⠾î·Æ½À´Ï´Ù. Á¶ÀÛÀû Á¤ÀǸ¦ ¸íÈ®ÇÏ°Ô ¹àÈú ÇÊ¿ä°¡ ÀÖ½À´Ï´Ù.

2) Fig. 1, 2 --> Ãâó°¡ 2000³â¿¡ NEJM¿¡ ¹ßÇ¥µÈ ³í¹®(N Engl J Med 2000; 343:1627-1633)ÀÎ °Í °°½À´Ï´Ù. µµÇØ ¼³¸í¹®µµ °ÅÀÇ ¶È°°½À´Ï´Ù.

3) Table 1 --> ±¹°¡¾Ï°ËÁø»ç¾÷¿¡¼­ °£¾Ï °ËÁøÀº °íÀ§Ç豺¿¡ ÇÑÇÏ¿© 1³â¿¡ 1ȸ ½ÃÇàÇÕ´Ï´Ù.


[2014-11-20. ÀÌÁØÇà ´äº¯]

Á¦°¡ ¼Ò°³ÇÑ ¹®Çå¿¡ ´ëÇÑ ÀÇ°ß¿¡ °¨»çµå¸³´Ï´Ù. Àúµµ µ¿ÀÇÇÕ´Ï´Ù. ¿Ï¼ºµµ°¡ ´Ù¼Ò ³·°í »ó¼¼ÇÑ detailÀÌ ºÎÁ·ÇÑ ¹®ÇåÀÚ·áÀÎ °ÍÀº Ʋ¸²¾ø½À´Ï´Ù. ±×·¯³ª °á·ÐÀº ÀûÀýÇß´Ù°í »ý°¢ÇÕ´Ï´Ù. Pap smear °Ë»ç¿¡ ´ëÇÑ ºÎºÐµµ ÀÚ·á°¡ Á¦½ÃµÇÁö ¾Ê¾Æ Á¤È®È÷ ÆÇ´ÜÇϱ⠾î·Æ½À´Ï´Ù. ±×¸²ÀÌ NEJM ³í¹®°ú ºñ½ÁÇÏ´Ù´Â ÁöÀû °¨»çÇÕ´Ï´Ù. New Engl J Med¿¡¼­ ±×¸² ºÎºÐÀ» ¿Å±é´Ï´Ù. Âü ºñ½ÁÇϱº¿ä. ³í¹®ÀÇ originality¿¡ ´ëÇؼ­´Â Á¦°¡ Æò°¡ÇÏ°í ½ÍÁö ¾Ê½À´Ï´Ù. ´Ù¸¸ screening¿¡´Â ¸î °¡Áö Áß¿äÇÑ bias°¡ ÀÖ´Ù´Â °ÍÀ» ´Ù½Ã Çѹø °­Á¶ÇÏ°í ½Í½À´Ï´Ù.


NEJM (2000) Figure 1. Lead-Time Bias. In the example shown, the diagnosis of disease is made earlier in the screened group, resulting in an apparent increase in survival time (lead-time bias), although the time of death is the same in both groups.


NEJM (2000) Figure 2. Length-Time Bias. The probability of detecting disease is related to the growth rate of the tumor. Aggressive, rapidly growing tumors have a short potential screening period (the interval between possible detection and the occurrence of symptoms). Thus, unless the screening test is repeated frequently, patients with aggressive tumors are more likely to present with symptoms. More slowly growing tumors have a longer potential screening period and are more likely to be detected when they are asymptomatic. As a result, a higher proportion of indolent tumors is found in the screened group, causing an apparent improvement in survival.


NEJM (2000) Figure 3. Overdiagnosis Bias. Overdiagnosis bias is an extreme form of length-time bias. The detection of very indolent tumors in the screened group produces apparent increases in the number of cases of lung cancer (three in the screened group in the figure and one in the control group) and in survival (two of three patients in the screened group were treated and died of natural causes, without evidence of disease [66 percent survival], and the one patient in the control group did not survive [0 percent survival]), with no effect on mortality (one death from lung cancer in each group). Two patients in the control group died with undiagnosed lung cancer that did not affect their natural life span.


2014³â JAMA 10¿ùÈ£¿¡ overscreening¿¡ ´ëÇÑ µÎ °³ÀÇ ³í¹®ÀÌ ½Ç·È½À´Ï´Ù. µÎ ³í¹® ¸ðµÎ Ÿ ÁúȯÀ¸·Î ±â´ë¿©¸íÀÌ Âª°Å³ª ÃÊ°í·É¿¡¼­´Â ¾Ï°ËÁø Áß´ÜÀ» ±ÇÇÏ°í ÀÖ½À´Ï´Ù.


JAMA 2014;174(10):1558

°í·É, ȤÀº ´Ù¸¥ ÁúȯÀ¸·Î ±â´ë¿©¸íÀÌ ÂªÀº »ç¶÷¿¡¼­´Â ¾Ï°ËÁø Áß´ÜÀÌ ±Ç°íµË´Ï´Ù. ´ç¿¬ÇÑ ÀÏÀÔ´Ï´Ù. º¸Åë 10³â ÀÌ»óÀÇ ±â´ë¿©¸íÀÌ ÀÖÀ» ¶§ ¾Ï°ËÁøÀ» ±ÇÇÏ´Â °ÍÀÌ »ó½ÄÀÔ´Ï´Ù. ±×·¯³ª °¡À̵å¶óÀÎÀÌ Àß ÁöÄÑÁú °Í °°Àº ¹Ì±¹¿¡¼­µµ °¡À̵å¶óÀÎÀº Àß ÁöÄÑÁöÁö ¾Ê°í ÀÖ¾ú½À´Ï´Ù.

¿¬±¸ÀÚµéÀº »ç¸ÁÀ§Çè¿¡ µû¶ó ¾Ï°ËÁøÀÇ ºñÀ²ÀÌ ¾î¶°ÇÑÁö, Áï ±â´ë¿©¸íÀÌ ÂªÀº »ç¶÷¿¡¼­ ¾ó¸¶³ª ¾Ï°ËÁøÀÌ ÀÌ·ç¾îÁö°í ÀÖ´ÂÁö¸¦ ºÐ¼®ÇÏ¿´½À´Ï´Ù. 9³â »ç¸Á À§ÇèÀº NHIS ÀÚ·á¿¡ ±âÃÊÇÏ¿´½À´Ï´Ù (A validated mortality index based on NHIS data,with a C statistic of0.75,wasused tocalculate 9-year mortality risk for each participant. Schonberg 2011). °á°ú´Â ½Ç¸Á½º·¯¿ü½À´Ï´Ù. ±â´ë¿©¸íÀÌ ÂªÀº »ç¶÷¿¡¼­µµ ¾Ï°ËÁøÀÌ ÈçÈ÷ ½ÃÇàµÇ°í ÀÖ¾ú±â ¶§¹®ÀÔ´Ï´Ù.

»ç¸Á À§ÇèÀÌ ¸Å¿ì ³ôÀº »ç¶÷ÀÇ 31% - 55%°¡ ÃÖ±Ù ¾Ï°ËÁøÀ» ¹Þ¾Ò½À´Ï´Ù. ½ÉÁö¾î´Â ÀÚ±ÃÀýÁ¦¼úÀ» ¹ÞÀº »ç¶÷, µû¶ó¼­ ÀڱðæºÎ¾Ï¿¡ °É¸± ¼ö ¾ø´Â »ç¶÷ÀÇ 34% - 56%°¡ ÃÖ±Ù 3³â À̳»¿¡ Pap smear¸¦ ¹Þ¾Ò½À´Ï´Ù. ÀÚ±ÃÀÌ ¾ø´Â ¿©¼º¿¡°Ô ÀÚ±Ã¾Ï °ËÁøÀ̶ó´Ï...

ÀúÀÚ´Â ¾Æ·¡¿Í °°ÀÌ °á·ÐÀ» ¸Î°í ÀÖ½À´Ï´Ù. OverscreeningÀº ºñ¿ëÀ» ÃÊ·¡ÇÒ »Ó¸¸ ¾Æ´Ï¶ó ȯÀÚ¿¡°Ô Çظ¦ Áشٰí...

CONCLUSION: A substantial proportion of the US population with limited life expectancy received prostate, breast, cervical, and colorectal cancer screening that is unlikely to provide net benefit. These results suggest that overscreening is common in both men and women, which not only increases health care expenditure but can lead to net patient harm.



JAMA 2014;174(10);1568

´ëÀå³»½Ã°æ °Ë»ç¿¡´Â ¹Ýµå½Ã ÀÏÁ¤ ¼öÁØÀÇ ÇÕº´ÁõÀÌ ¹ß»ýÇÕ´Ï´Ù. ÃâÇ÷, õ°ø, »ç¸Á µîÀÌ ¸ðµÎ °¡´ÉÇÕ´Ï´Ù. ÇÕº´Áõ ¹ß»ý·üÀº ¾Æ·¡ modeling ±×¸²°ú °°ÀÌ ³ªÀÌ¿¡ µû¶ó Áõ°¡ÇÕ´Ï´Ù.

¿¬±¸ÀÚµéÀº modelingÀ» ÅëÇÏ¿© ´ëÀå³»½Ã°æ °Ë»ç°£°ÝÀ» ´ÜÃàÇϰųª 75¼¼ ÀÌÈÄ¿¡ °Ë»ç¸¦ °è¼ÓÇÏ¿´À» ¶§ µæÀÌ ÀÖ´ÂÁö °ËÅäÇÏ¿´½À´Ï´Ù. °á°ú´Â ¿¹»óÇÑ ±×´ë·Î¿´½À´Ï´Ù. ÀúÀÚ´Â °¡À̵å¶óÀκ¸´Ù ´ëÀå³»½Ã°æ °Ë»ç°£°ÝÀ» ´ÜÃà½ÃÅ°°Å³ª 75¼¼ ÀÌÈÄ¿¡µµ °Ë»çÇÏ´Â °üÇàÀº ÁߴܵǾî¾ß ÇÑ´Ù°í ÁÖÀåÇÏ°í ÀÖ½À´Ï´Ù.


°Ë»ç °£°ÝÀ» ´ÜÃàÇÑ´Ù°í, 75¼¼ ÀÌ»ó±îÁö °Ë»çÇÑ´Ù°í ´õ ¿À·¡ »ç´Â °ÍÀº ¾Æ´Ï¾ú½À´Ï´Ù.


°Ë»ç °£°ÝÀ» ´ÜÃàÇϰųª 75¼¼ ÀÌ»ó±îÁö °Ë»çÇϸé ÇÕº´ÁõÀº ¶Ñ·ÇÇÏ°Ô Áõ°¡µÇ¾ú½À´Ï´Ù.

CONCLUSION: Screening Medicare beneficiaries more intensively than recommended is not only inefficient from a societal perspective; often it is also unfavorable for those being screened. This study provides evidence and a clear rationale for clinicians and policy makers to actively discourage this practice.


JAMA 10¿ùÈ£¿¡ ½Ç¸° µÎ ³í¹®Àº ¹Ì±¹ ÀÇÇа迡¼­ Å« ¹ÝÇâÀ» ÀÏÀ¸Å°°í ÀÖ´Â ¸ð¾çÀÔ´Ï´Ù. ¹Ì±¹ ¼ÒÈ­±âÇÐȸ¿¡¼­ ³»°í ÀÖ´Â GI & Hepatology News¿¡¼­´Â Unnecessary cancer screening 'substantial' in U.S.¶ó´Â Á¦¸ñÀÇ ±â»ç¸¦ headline news·Î »Ì¾Ò½À´Ï´Ù. ÀϺθ¦ ¿Å±é´Ï´Ù.

A substantial proportion of older adults in the United States undergo unnecessary and even harmful screening for colon, prostate, breast, and cervical cancer, contrary to clear guidelines that are widely recognized and well publicized, according to two separate studies published online Aug. 18 in JAMA Internal Medicine.

In the case of colon cancer, most of these unnecessary screenings can be attributed to patients getting rescreened more frequently than at the 10-year intervals recommended and continued screening past the age of 75 years is also a culprit. With the other cancers, the main reason for these unnecessary procedures is continuing screening in patients who have a short life expectancy because of advanced age or irreversible health problems.

In both reports, the investigators emphasized that unnecessary cancer screening is not only inefficient and expensive from a societal perspective but is also harmful for individual patients because it exposes them to invasive procedures and complications, impairs their quality of life, and sometimes leads to downstream overdiagnosis and overtreatment of cancers that would have remained asymptomatic until the patient died of other causes.

(...) Chief among these obstacles is the lack of a simple, reliable tool for assessing life expectancy in clinical practice. In addition, physicians may find it difficult to communicate to patients that they are very likely to die within the next few years, and patients may find it difficult to accept that they have a limited life expectancy or that cancer screening is no longer warranted for them. Physicians¡¯ fear of litigation further contributes to overscreening.

¿ì¸®³ª¶ó¿¡¼­´Â ¾ðÁ¦ overscreening ¹®Á¦°¡ ³íÀÇµÉ ¼ö ÀÖÀ»Áö ´ä´äÇÒ µû¸§ÀÔ´Ï´Ù.


[2015-6-20] °úÀ×Áø´Ü

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´Ã °úÀ×Áø´ÜÀÇ ¹®Á¦¸¦ °í¹ÎÇÏ°í °øºÎÇÏ´Â Àú·Î¼­´Â ³»¿ëÀÌ »õ·Î¿ü´Ù±âº¸´Ù´Â ÀÌó·³ ü°èÀûÀ¸·Î ¸¹Àº ÀڷḦ Á¤¸®ÇÏ¿© ¾Ë±â ½±°Ô ¾µ ¼ö ÀÖ¾ú´Ù´Â Á¡¿¡ ³î¶ú½À´Ï´Ù.

Àú´Â ½±°Ô »ý°¢ÇÕ´Ï´Ù. Àü ¼¼°è ¾î´À ³ª¶ó¿¡¼­µµ ÇÏ°í ÀÖÁö ¾ÊÀºµ¥ ¿ÀÁ÷ ¿ì¸®³ª¶ó¿¡¼­¸¸ ÇÏ°í ÀÖ´Ù¸é ±×°ÍÀº ÀÌ»óÇÑ ÀÏÀÏ °¡´É¼ºÀÌ ³ô½À´Ï´Ù. ³²µéÀÌ ´Ù ¹Ùº¸°í ¿ì¸®¸¸ ¶È¶ÈÇÒ È®·üº¸´Ù´Â ¹Ý´ëÀÏ È®·üÀÌ ³ô±â ¶§¹®ÀÔ´Ï´Ù.

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Gastric cancer screening in USA

ºÎ»ê´ëÇб³ ±è±¤ÇÏ ±³¼ö´Ô²²¼­ ¹Ì±¹ ¿¬¼ö Áß¿¡ GIE¿¡ Åõ°íÇÑ Á¾¼³ÀÌ ³ª¿Ô½À´Ï´Ù (Kim GH. GIE 2016 - Epub). Á¦¸ñÀº "Screening and Surveillance for Gastric Cancer in the United States: Is it needed?" À§¾ÏÀÌ ¸¹Àº ³ª¶ó¿¡¼­ ¿Â À̹ÎÀÚ³ª À§¾Ï °¡Á··ÂÀÌ ÀÖ´Â »ç¶÷¿¡¼­´Â °ËÁøÀÌ ÇÊ¿äÇÏ´Ù°í ÁÖÀåÇϼ̽À´Ï´Ù.


[References]

1) EndoTODAY °ÇÁø ³»½Ã°æ

2) Minsoo Jung. National Cancer Screening Programs and Evidence-Based Healthcare Policy in South Korea. Health Policy (2014)

© ÀÏ¿ø³»½Ã°æ±³½Ç ¹Ù¸¥³»½Ã°æ¿¬±¸¼Ò ÀÌÁØÇà. EndoTODAY Endoscopy Learning Center. Lee Jun Haeng.