Incidence and mortality of colorectal cancer in China, 2011
与结直肠癌相关的粪菌移植研究现状
Journal of Colorectal&AnalSurgery结直肠肛门外科2020年12月第26卷第6期与结直肠癌相关的粪菌移植研究现状*崔曼曼1，马晓飞1，胡家丽1，胡丽霞1，张磊昌2△1江西中医药大学临床医学院江西南昌3300042江西中医药大学附属医院肛肠科江西南昌330006DOI:10.19668/ki.issn1674-0491.2020.06.037结直肠癌（colorectal cancer，CRC）为常见恶性肿瘤之一，在恶性肿瘤中发病率及死亡率均较高[1]。
CRC的发生、发展与多种因素相关，包括遗传因素、精神压力、饮食结构等[2]。
也有研究表明，结直肠癌患者肠道菌群的数量及种类均发生了变化[3-6]。
正常情况下，肠道菌群对维持肠道内环境稳态有重要作用，对机体进行正常生命活动具有重要的影响，肠道菌群失调可能引发一系列的不适或疾病，而粪菌移植（fecal microbiota transplantation，FMT）可以通过将健康供体的粪便作用于受体消化道来达到治疗目的，是调节肠道菌群失衡的方法之一。
本文围绕与CRC相关的FMT研究现状综述如下。
1FMT的应用与发展在东晋医学家葛洪编写的《肘后备急方》中已有“野葛芋毒、山中毒菌欲死者：并饮粪汁一升，即活”的描述[7]，这是我国医学史上对粪汁应用的已知的最早记载。
1958年Eiseman等报道，对4例伪膜性肠炎患者进行治疗时将患者各自健康家属的粪便制成粪水用来灌肠[8]，此为现代早期报道FMT参与治疗获得成功的案例。
2013年，Van Nood等[9]的研究证实，FMT对复发性艰难梭菌肠炎的治疗效果优于万古霉素，这一研究结果使得FMT得到了医学界更为广泛的关注[10]。
经过多年的发展与临床应用，目前复发性艰难梭菌感染（Clostridium difficile infec⁃tion，CDI）成为其公认适应证，FMT已经被列入CDI的治疗指南[11]。
癌症与营养
图 5、慢性病及其死亡率的变化趋势
700
18.64 22.82 103.93 3 113.14 11.75 30.58 111.62 5.13 112.25 18.87 414.5
death rates per 100,000
600
38.55 47.48 121.84 8.12 129.13 11.3
Figure 1 | Colorectal cancer incidence in males in the European Union
This variation is mainlyቤተ መጻሕፍቲ ባይዱdue to environmental factors and lifestyle, rather than genetic factors
65.8 127.18 15.37 141.14 13.49
500 400 300 200
135.35 4.45 114.55 10.57
113.06 2.22 97.64 14.02
388.66
276.08
267.21
328.01
100 0
224.85
1980
1990
other diseases cancers cerebrovascular
DNA repair genes Methy;gunine-DND methyltrasferase (MGMT) is the best studied enzyme. Nitrosamine depletes brain tissue (MGMT), making the brain more susceptible to the action of exogenous and endogenous alkylating processes.
结直肠癌筛查成本效益研究进展
·4177··结直肠癌筛查专题研究·结直肠癌筛查成本效益研究进展管雅喆，吴思奇，张雪，贺宇彤*【摘要】 结直肠癌是临床常见的恶性肿瘤之一，严重威胁人类健康。
早期筛查是降低结直肠癌发病率和死亡率的有效手段，也是重要的防治策略，已引起国际和国内的广泛关注。
浓缩结直肠癌高危人群、确定合适的筛查间隔、从社区层面提升居民健康意识、提高筛查参与度并从卫生经济学的角度评估最佳筛查策略是结直肠癌筛查的重点和难点。
总结结直肠癌的筛查指南有助于明确结直肠癌高危人群，确定合理的筛查年龄、筛查间隔，意识到提高筛查参与度的重要性，继而提高筛查的成本效益。
本文对最新结直肠癌筛查指南、筛查的成本效益进行了综述。
【关键词】 结直肠肿瘤；筛查；成本效益分析【中图分类号】 R 735.34 【文献标识码】 A DOI：10.12114/j.issn.1007-9572.2021.02.001管雅喆，吴思奇，张雪，等．结直肠癌筛查成本效益研究进展［J］．中国全科医学，2021，24（33）：4177-4184. ［］GUAN Y Z，WU S Q，ZHANG X，et al．Recent advances in research on cost-effectiveness of colorectal cancer screening［J］．Chinese General Practice，2021，24（33）：4177-4184.Recent Advances in Research on Cost-effectiveness of Colorectal Cancer Screening GUAN Yazhe ，WU Siqi ，ZHANG Xue ，HE Yutong *Cancer Institute ，the Fourth Hospital of Hebei Medical University ，Shijiazhuang 050011，China*Corresponding author ：HE Yutong ，Professor ，Chief physician ；E-mail ：【Abstract 】 Colorectal cancer is one of common cancers that threatens human health seriously. Early screening has beena global focus as an effective measure to reduce the incidence and mortality of colorectal cancer，and an important prevention and treatment strategy. The key issues for colorectal cancer screening include delivering interventions specially focusing on populations at high risk for colorectal cancer，determining the appropriate screening interval for populations with different levels of risk for colorectal cancer，raising residents ' health awareness from the community level，increasing screening participation，and performing health economic evaluation of the optimal screening strategy. Introducing colorectal cancer screening guidelines helps to identify people at high risk for colorectal cancer，explore appropriate screening ages and screening intervals，and improve the recognition of valuing screening participation，consequently increasing the cost-effectiveness of colorectal cancer screening，so we summarized the recent colorectal cancer screening guidelines and studies about the cost-effectiveness of colorectal cancer screening.【Key words 】 Colorectal neoplasms；Screening；Cost-benefit analysis数国家相比，在过去的30年中，我国结直肠癌发病率呈现上升趋势，将来还会进一步上升［7］，如何有效降低结直肠癌的疾病负担已成为亟待解决的公共卫生 问题。
多参数3D_MRI影像组学模型预测结直肠癌肝转移及相关临床危险因素的分析
146·中国CT和MRI杂志 2024年2月 第22卷 第2期 总第172期【通讯作者】马宜传，男，主任医师，主要研究方向：影像诊断。
E-mail：***************Multi-parametricCHINESE JOURNAL OF CT AND MRI, FEB. 2024, Vol.22, No.2 Total No.172 e-THRIVE+序列(即T1WI 增强)：TR=620ms，TE=20ms，矩阵：280×336，层厚：3mm；MRI增强对比剂使用顺磁性造影剂Gd-DTPA，用量为0.1mL/kg，常规静脉团注。
1.4 图像分割运用Radcloud平台在标准化扫描方案采集的T2WI、DWI、T1WI C+图像上由对患者临床信息设盲的放射科医师手动逐层勾画病灶获得3D感兴趣区容积(volumn of interest，VOI)，感兴趣区(region of interest，ROI)置于病灶最大层面，注意经放大处理避开病灶周围气体、坏死及周围脂肪部分(图1A-1D)。
由高级放射科医师审查勾画轮廓，若差异≥5%，则由更为资深的放射科医师来决定肿瘤边界。
1.5 特征筛选、降维处理、模型构建 用Radcloud平台从 MR 图像中共提取共4227个定量成像特征，分为三组。
一阶统计由378个描述符通过常用和基本指标定量描绘 MR 图像内体素强度的分布。
基于形状和尺寸的特征包含42个反映区域形状和尺寸的三维特征。
纹理特征则根据灰度游程长度和灰度共生纹理矩阵计算，共1575个，以量化区域异质性差异。
采用方差阈值(threshold=0.9)、Select K Best(threshold=0.01)和最小绝对收缩和选择算子(least absolute shrinkage and selection operator，LASSO)(cv=3， max_iter=1000) 三种方法以减少冗余特征，行进一步特征选择及数据降维。
210806460_慢性便秘、肠癌与肠道微生物菌群变化
科技视界Science&Technology Vision认识生命知晓健康DOI:10.19694/ki.issn2095-2457.2022.28.17慢性便秘、肠癌与肠道微生物菌群变化李艳梅王宏敏李春燕刘红福管斌斌(西南林业大学生命科学学院,云南昆明650224)【摘要】肠道中存在数以亿计的微生物,它们的相互联系、相互作用使肠道菌群处于动态平衡状态,一旦这种平衡发生改变,均有可能导致宿主发生疾病。
相关研究表明,慢性便秘和肠癌人群中普遍存在肠道菌群失调,即粪便中的优势菌属数量显著减少,潜在致病菌数量明显上升,同时慢性便秘能显著增加肠肿瘤的发生概率。
基于目前的文献报道,文章将对慢性便秘与肠道微生物菌群变化的关系进行概述。
【关键词】慢性便秘;肠道微生物;菌群变化0引言肠道中存在数以亿计的微生物，肠道微生物与宿主的新陈代谢活动有着密不可分的联系[1]。
一般情况下，肠道内微生物的种类和数量都保持着某种正常的平衡状态[2]，微生物的种类和数量的平衡一旦遭到破坏，均会增加宿主发生病变的可能性，尤其是一些微生物，它们被公认为具有潜在的危害作用，并且通过排泄对宿主有害的物质、损伤黏膜、活化致癌物质、参与炎症反应等途径去损害宿主，从而影响宿主的健康[3]。
在临床上，便秘是一种最常见的症状，大多数便秘人群以排便困难或排便次数减少、粪便干硬这三种情况为主要表现症状[4，5]。
研究表明便秘人群中肠道菌群发生了明显改变，即体内一些益生菌数量显著减少，而一些致病菌数量明显上升[6]。
肠道微生物菌群的平衡被打破，进一步影响了慢性便秘的发生，从而出现病理生理等过程。
以往研究结果表明慢性便秘（Chronic Constipation，CC）能明显增加肠肿瘤的发病几率[7，8]。
本文将对便秘与肠道微生物菌群变化的关系进行详细的综述。
1慢性便秘患者肠道微生物菌群发生变化基于较传统的细菌培养方法来研究慢性便秘患者肠道内微生物菌群改变，但由于微生物极其庞大的数量和丰富的多样性，传统的细菌培养方法根本不适用对其进行研究，因为找不到合适的培养基去培养种类数量庞大的微生物；同时又基于肠道中的某些微生物类群对培养条件要求极其严格，传统的培养方法已不再适用，无法真实、准确地反映肠道内微生物的组成及动态变化的情况。
Ⅲ期结直肠癌术后复发风险的预测模型
Ⅲ期结直肠癌术后复发风险的预测模型发布时间：2021-11-17T08:44:45.695Z 来源：《中国结合医学杂志》2021年11期作者：周露1 张辉1 郭旦1 [导读] 建立复发转移风险预测模型，探讨Ⅲ期结直肠癌患者术后复发转移的危险因素，为后期治疗提供指导。
周露1 张辉1 郭旦11.南华大学衡阳医学院附属邵阳医院肿瘤科，湖南衡阳 421001摘要目的建立复发转移风险预测模型，探讨Ⅲ期结直肠癌患者术后复发转移的危险因素，为后期治疗提供指导。
方法收集符合纳排标准患者的资料并对其术后2年内复发转移进行随访，运用SPSS和Graphad进行分析，构建logistic回归预测模型。
结果所构建模型能够有效预测Ⅲ期结直肠癌术后复发风险。
结论构建的Logistic模型能有效预测Ⅲ期结直肠癌术后复发转移风险，对Ⅲ期结直肠癌术后患者的预后及其综合治疗具有指导意义。
关键词：结直肠癌；术后复发；风险预测模型作者简介周露，女，1997年3月，临床医学，Eˉmail:*********************。
通讯作者张辉，男，主任医师，临床医学。
结直肠癌作为常见的恶性肿瘤，其发生率及死亡率均位居前列[1]。
目前是以手术治疗为主，由于部分患者出现复发转移表现较晚，易错过最佳治疗时间[2]，因此复发监测尤为重要。
目前常采用影像学检查方法[3]，但难以发现微小病灶的复发转移。
近年来研究表明DDX5具有促癌作用且其在大多数恶性肿瘤中高表达，可能作为新的预后标志物[4-5]。
此外Ki67、错配修复蛋白[6-7]等指标与复发也具有一定关系。
因此本研究通过筛选结相关危险因素，构建结直肠癌患者术后复发转移的预测模型, 为高危患者的筛查提供参考。
1 资料和方法1.1一般资料收集某三甲医院2017年5月至2019年6月符合纳排标准的168例患者病历资料，由于随访过程中33例患者失，因此最后共纳入135例患者。
1.2 纳入标准①经组织病理学证实为结直肠癌且TNM分期为Ⅲ期[8]；②可接受限期结直肠根治术；③入院前未接受任何肿瘤专科治疗；④无其他手术禁忌证。
曲妥珠单抗联合吡咯替尼治疗人表皮生长因子-2阳性晚期结直肠癌临床观察
与临床研究。Ｅｍａｉｌ：ｚｈｏｎｇｑｉａｎ９６０３０３＠１６３．ｃｏｍ 通信作者：宗红（１９６８－），女，博士，主任医师，主要从事消化道肿瘤的
基础与临床研究。Ｅｍａｉｌ：ｆｃｃｚｏｎｇｈ＠ｚｚｕ．ｅｄｕ．ｃｎ
１ 资料与方法
１．１ 一般资料 纳入 ２０２０年 ３月至 ２０２１年 ２月就 诊于郑州大学第一附属医院的经病理和基因检测确诊 的 Ｈｅｒ２阳性 ６例晚期结直肠癌患者的临床资料：均 为男性；年龄范围为 ２３～６３岁；突变类型：Ｈｅｒ２基因 错义突 变 １例，拷 贝 数 扩 增 ５例；ＫＲＡＳ基 因 突 变 １ 例，无 ＮＲＡＳ及 ＢＲＡＦ基因突变者；ＮＲＡＳ及 ＢＲＡＦ野 生型 １例。纳入标准为经病理学确诊为结直肠癌且经 基因检测为 Ｈｅｒ２阳性，经过一线或以上标准治疗失 败的患者，患者及家属同意使用曲妥珠单抗联合吡咯 替尼治疗并签署知情同意书。排除标准为具有其他严 重疾病或依从性差者。 １．２ 治疗方法 ６例 患 者 均 接 受 了 曲 妥 珠 单 抗 联 合 吡咯替尼治疗：曲妥珠单抗首次使用剂量为 ８ｍｇ／ｋｇ， 第 １天，第 ２周期及后续治疗给予 ６ｍｇ／ｋｇ，第 １天；吡 咯替尼 ３２０ｍｇ／ｄ，餐后 ３０ｍｉｎ内口服，２１ｄ为 １周期。 １．３ 观察指标 根据 ＲＥＣＩＳＴ１．１标准评价近期疗 效，包括完 全 缓 解 （ＣＲ）、部 分 缓 解 （ＰＲ）、疾 病 稳 定 （ＳＤ）、疾病进展（ＰＤ），以 ＣＲ＋ＰＲ计算客观缓解率， 以 ＣＲ＋ＰＲ＋ＳＤ计算疾病控制率。对研究对象进行 随访，记录患者疾病无进展生存期以及与治疗相关的 不良事件。 １．４ 统计学处理 采用 ＳＡＳ９．１．３和 ＧｒａｐｈＰａｄＰｒｉｓｍ ８．０进行统计分析和相关统计图表的绘制，采用 Ｋａｐ ｌａｎＭｅｉｅｒ法对治 疗 方 案 的 疾 病 无 进 展 生 存 期 进 行 分 析，检验水准 α＝０．０５。
二甲双胍在结直肠癌治疗中的研究进展
结直肠癌(colorectal cancer,CRC )是世界范围内第三大常见恶性肿瘤,严重威胁着人类的健康。
根据世界卫生组织GLOBOCAN 数据库统计,2018年CRC 有180万新发病例和88.1万死亡病例[1]。
目前CRC 的主要治疗方式有手术、化疗、放疗、靶向治疗及免疫治疗等,但总体治疗效果仍不容乐观。
因此,亟待一种新的治疗手段为CRC 提高治疗效果。
CRC 的发病机制极其复杂,有多种因素影响CRC 的发生发展,包括吸烟、饮酒、遗传因素、肥胖及糖尿病等。
2型糖尿病是罹患CRC 的独立危险因素[2]。
二甲双胍作为2型糖尿病的一线用药,因其低成本、易耐受及安全性强等优点,越来越被关注。
它除了可以降血糖外,还可以降低恶性肿瘤的发病风险以及延缓肿瘤进展等[3]。
研究显示,二甲双胍可以抑制CRC 细胞的增殖、迁移及侵袭,促进其凋亡,并在治疗CRC 上有一定的作用[4]。
本文就此展开综述。
1二甲双胍与结直肠癌流行病学研究临床研究发现,2型糖尿病患者应用二甲双胍12个月后与未口服二甲双胍的糖尿病患者相比,CRC 发病风险降低了12%[5]。
此外,CRC 的发病风险可随着二甲双胍使用剂量的累积而逐渐降低[6]。
一项关于2型糖尿病与CRC 关系的荟萃分析提示,服用二甲双胍的糖尿病患者与未服二甲双胍的糖尿病患者相比,结直肠腺瘤的发病率降低了25%[7]。
二甲双胍除了可以降低CRC 发病风险外,还可显著改善CRC 患者的预后。
Deng 等[8]研究发现,口服二甲双胍的CRC 患者的总体生存率(HR =0.73,95%CI :0.63~0.84)与癌症特异性生存率(HR =0.60,95%CI :0.50~0.73)均显著提高。
另有研究显示,相较于其他降糖药联合化疗组,二甲双胍联合化疗后的CRC 患者总体生存期延长了14个月[9,10]。
Ng 等[11]认为二甲双胍还可降低CRC 的复发率(HR =0.65,95%CI :0.56~0.76),延缓肿瘤进展。
SCI摘要常用句型(自己整理)
Abstract部分是文章的浓缩与精华，整理一下5个部分常用的句型：The Stock Phrases for Stating the Background Information about the Investigation：1.Less is known about the later survival or reproduction of such persons.2.It is not known, however, whether there is a threshold weight below which morbidityand mortality are significantly greater.3.The use of systemic corticosteroids is a risk factor for the development of posteriorsubscapsular cataracts, but the association between inhaled corticosteroids andcataracts is uncertain.4.Data are limited on the attitudes and practices of physicians regarding assisting thesuicide of patients with human immunodeficiency virus (HIV) disease.5.Limited information is available on trends in the incidence of and mortality due tocarcinogenic shock complicating acute myocardial infarction.6.There is a dearth of literature in the area of the psychopharmacological management ofdepression in cancer patients.7.The role of climate has received relatively little attention.8.Previous studies have demonstrated that a small number of the 125 medical schools inthe United States receive a disproportionately large share of the research awardsgranted by the National Institutes of Health (NIH) .9. A growing body of evidence suggests that electromagnetic interference may occurbetween cardiac pacemakers and wireless hand-held (cellular) telephones, posing apotential public health problem.10.Posteroventral medial pallidotomy sometimes produces striking improvement in patientswith advanced Parkinson’s disease, but the studies to date have involved small numbersof patients and short-term follow-up.The Stock Phrases for Stating the Principal Objective(s) and Scope of the Investigation：1.We tested the hypothesis that early therapy with inhaled glucocorticoids woulddecrease the frequency of bronchopulmonary dysplasia in premature infants.2.We conducted a randomized trial to evaluate early revascularization in patients withcardiogenic shock.3.We hypothesized that pre-patient charges would increase during the base year and thendecrease in subsequent years.4.We examined the relation between physicians’ experience with AIDS and the survival oftheir patients with AIDS.5.We investigated the potential role of anorexic agents and other suspected risk factorsfor primary pulmonary hypertension.6.We assessed whether the distributes of NIH research awards to medical schoolschanged between 1986 and 1977.7.We performed a study to determine whether routine testing helps reduce the incidenceof intraoperative and postoperative medical complications.8.To evaluate the relation between elective cesarean section and vertical transmission ofhuman immunodeficiency virus type ( HIV-1), we performed a meta-analysis using dataon individual patients from 15 prospective cohort studies.9.The aim of this study was to detect the extent of non-compliance with treatment ofschizophrenic patients and assess the effectiveness of the intervention program.10.The purpose of our study was to determine the value of noninvasive measurements ofthe velocity of blood flow in the fetal middle cerebral artery for the diagnosis of fetal anemia.11.This study focused on physicians’ assessments of changes in the scope of care providedby primary care physicians and their assessments of the appropriateness of the scope of the care that primary care physicians are expected to provide.12.To address this question, we studied the function of airway epithelial cells anddetermined the frequency of pulmonary symptoms in patients with systemic pseudohypoaldosteronism, a salt-losing disorder caused loss-of-function mutations in the genes for the epithelial sodium channel.The Stock Phrases for Describing the Methods Employed：1.We conducted a randomized, multicenter trial of inhaled beclomethasone or placebo in253 infants.2.We analyzed the neonatal outcomes of death.3.We conducted an observational study of9076 residents of metropolitan Worcester,Massachusetts.ing data from the Civil Registration System in Denmark, we established apopulation-based cohort of 1.75 million persons whose mothers were Danish women born between 1935 and 1978.5.Data on preterm infants (those born at 24 to 36 weeks of gestation) were analyzedseparately from data on infants delivered at term (37 or more weeks of gestation).6.Our study included periods before and after the advent of reperfusion therapy.7.The surveillance system was based on voluntary reporting with the use of a standardcase-report form.8.The children with cerebral palsy were compared with randomly selected controlchildren with respect to characteristics noted in the birth records.9.Cluster analysis was chosen as it offers a statistically sound means of delineatingnatural grouping within data.10.Medical records were reviewed for clinical data.The Stock Phrases for Summarizing the Results：1.The results of a multivariable regression analysis indicated that the patients hospitalizedduring recent study years were not at a substantially lower risk for shock than patients hospitalized in the mid-to-late 1970s.2.The incidence of cardiogenic shock remained relatively stable over time averaging 7.1percent among patients with acute myocardial infarction.3.Results suggested that the effects of stress have more to do with the characteristics ofthe work environment and overall workload than with the degree of specialization on the unit.4.Blood pressure was correlated inversely with monthly maximal temperature anddirectly with minimal humidity.5.There was no clinically significant interference when the telephone was placed in thenormal position over the ear.6.Adjusting for the use of systemic corticosteroids and other potential confounders hadlittle effect on the magnitude of the associations.7.Being on leave was found to be associated with the need for assistance withtransportation, limitations in upper-body strength, and employment in jobs requiring physical activity.8.After adjusting for these factors, the racial difference was reduced and no longerstatistically significant.9.The trial did not have sufficient statistical power to detect differences in survival tohospital discharge, which differed only slightly between the two groups.10.These associations persisted when the data were stratified according to and controlledfor 16 biologic, sociodemographic, and behavioral risk factors.11.There were no significant adverse effects of vitamin E.12.Electron microscopic analyses revealed that the cone angles of synthetic cores wereindeed quantized into the five allowed angles.The Stock Phrases for Stating the Principal Conclusion(s)：1.These findings may have relevance to human neurodevelopment disorders involvingprenatal (drug-abusing mothers) or postnatal (pediatric anesthesia) exposure to drugs that block NMDA receptors.2.This finding emphasizes the importance of achieving cures and of preventing anyonewith infectious tuberculosis.3.These findings may have implications for antihypertensive therapy in different parts ofthe world.4.These observations suggest that the core of HIV is organized on the principles of afullerene cone, in analogy to structures recently observed for elemental carbon.5.Selective manipulations of activity at these sites may offer therapeutic possibilities fortreating chronic pain.6.The discovery of this DNA demethylase should provide a basis for the molecular anddevelopmental analysis of the role of DNA methylation and demethylation.7.This new technique shows promise as a noninvasive method of diagnosing pulmonaryembolism without the need for ionizing radiation or iodinated contrast material.8.Efforts to increase the rate of surgical treatment for black patients appear to be apromising way of improving survival in this group.9. A recombinant humanized monoclonal antibody directed against IgE has potential as atreatment for subjects with moderate or severe allergic asthma.10.Our data do not support the hypothesis that everyday exercise is related to the risk ofbreast cancer.11.Our analyses suggest that the lower survival rate among black patients with early-stage,non-small-cell lung cancer, as compared with white patients, is largely explained by thelower rate of surgical treatment among blacks.12.Infliximab is an efficacious treatment for fistulas in patients with Crohn’s disease.13.High-frequency microsatellite instability in colorectal cancer is independently predictiveof a relatively favorable outcome and, in addition, reduces the likelihood of metastases.。
美国痔诊治指南
[3] Ko C, Hyman NH. Practice parameter for the detection of colo-rectal neoplasms: an interim report (revised). Dis Colon Rectum.2006;49:299–301.
[2] Cataldo P, Ellis CN, Gregorcyk S, et al. Practice parameters for the management of hemo-rrhoids (revised). Dis Colon Rectum.2005;48:189–194.
美国痔诊治指南
痔病的评估
美国痔诊治指南
痔病的评估
推荐1：对痔病患者的初步评估应包括病史
和体格检查（ 1级推荐，C级证据）
美国痔诊治指南
痔病的评估—病史询问
➢ 重点询问病变范围、严重度及症状持续时间，如：出血、脱 垂、卫生问题及疼痛，还有纤维素和水的摄入情况
➢ 另外，大便习惯，包括大便频率、形状及排便的难易程度也 应问及
美国痔诊治指南
痔病的评估
推荐2：完善结肠内镜检查对于有直肠出血
的痔病患者是必要的（1级推荐，B级证据）
美国痔诊治指南
痔病的评估—内镜检查
➢ 直肠出血通常由痔病引起，但也可能与结直肠肿瘤、炎性肠 病、其他类型结肠炎、憩室病和血管发育异常有关[5]
➢ 完整的个人史，详细的家族史，以及包括直肠镜和（或）软 性乙状结肠镜在内的体格检查，可识别出高危患者（需要进 一步检查）
美国痔诊治指南
痔病的评估—体格检查
colonrectal cancer---The lancet
SeminarColorectal cancerHermann Brenner, Matthias Kloor, Christian Peter PoxMore than 1·2 million patients are diagnosed with colorectal cancer every year, and more than 600 000 die from thedisease. Incidence strongly varies globally and is closely linked to elements of a so-called western lifestyle. Incidenceis higher in men than women and strongly increases with age; median age at diagnosis is about 70 years in developedcountries. Despite strong hereditary components, most cases of colorectal cancer are sporadic and develop slowlyover several years through the adenoma–carcinoma sequence. The cornerstones of therapy are surgery, neoadjuvantradiotherapy (for patients with rectal cancer), and adjuvant chemotherapy (for patients with stage III/IV and high-riskstage II colon cancer). 5-year relative survival ranges from greater than 90% in patients with stage I disease to slightlygreater than 10% in patients with stage IV disease. Screening has been shown to reduce colorectal cancer incidenceand mortality, but organised screening programmes are still to be implemented in most countries.EpidemiologyIncidence and mortalityColorectal cancer is the third most common cancer and the fourth most common cancer cause of death globally, accounting for roughly 1·2 million new cases and 600 000 deaths per year.1 Incidence is low at ages younger than 50 years, but strongly increases with age. Median age at diagnosis is about 70 years in developed countries.2 The highest incidence is reported in countries of Europe, North America, and Oceania, whereas incidence is lowest in some countries of south and central Asia and Africa.3 In 2008, estimated age-standardised incidence by region ranged from 4·3 cases per 100 000 people in central Africa to 45·7 per 100 000 in Australia and New Zealand in men (fi gure 1), and from 3·3 per 100 000 to33·0 per 100 000 in the same regions in women.1,4 However, rapid increases in previously low-risk countries, such as Spain and several countries in eastern Europe and east Asia, have been noted, which have been ascribed to changes in dietary patterns and risk factors towards a so-called western lifestyle.5 However, in the USA and several other high-income countries,incidence has stabilised or started to decrease, probably because of increased use of sig-moidoscopy and colonoscopy with polypectomy.3,6In 2008, estimated age-standardised mortality ranged from 3·5 per 100000 people in central Africa to 20·1 in central and eastern Europe in men, and from 2·7 to 12·2in the same regions in women.1 In several high-incomecountries and countries of east Asia and eastern Europe,mortality has been decreasing since the 1980s, probablybecause of improved early detection and treatment, butrates have continued to increase in countries or areaswith poor health-care resources (figure 2), includingcountries in Central and South America and rural areasin China.3,7,8PrognosisThe prognosis of patients with colorectal cancer has slowlybut steadily improved during the past decades in manycountries. 5-year relative survival has reached almost 65%in high-income countries, such as Australia, Canada, theUSA, and several European countries, but has remainedless than 50% in low-income countries.2,10,11 Relativesurvival decreases with age, and at young ages is slightlyhigher for women than for men. Stage at diagnosis is themost important prognostic factor. For example, in the USAin 2001–07, 5-year relative survival of patients diagnosedwith colorectal cancer was 90·1% for patients with localisedstage, 69·2% for patients with regional spread, and 11·7%for patients with distant tumour spread.2Risk and preventive factorsUnlike other cancers, such as lung cancer, no single riskfactor accounts for most cases of colorectal cancer. Apartfrom age and male sex, the following risk factors (whichoften co-occur and interact) have been identifi ed andestablished in epidemiological studies: family historyof colorectal cancer,12 inflammatory bowel disease,13smoking,14 excessive alcohol consumption,15 high con-sumption of red and processed meat,16 obesity,17 anddiabetes18 (table 1). With relative risks greater than 2, therisk increase is strongest for people with fi rst-degreerelatives with colorectal cancer (especially for those withmultiple aff ected relatives or relatives diagnosed at youngages) and people with inflammatory bowel disease.However, the other risk factors, which are more commonand are in principle modifiable, account for a largerproportion of the disease burden at the population-level,despite lower relative risks (mostly between 1·2 and 2·0).Published OnlineNovember 11, 2013/10.1016/S0140-6736(13)61649-9Division of ClinicalEpidemiology and AgingResearch, German CancerResearch Center(DKFZ),Heidelberg, Germany(Prof H Brenner MD); GermanCancer Consortium (DKTK),Heidelberg, Germany(Prof H Brenner); Departmentof Applied Tumor Biology,Institute of Pathology,University Hospital Heidelberg,Heidelberg, Germany(M Kloor MD); and Departmentof Medicine, Ruhr University,Bochum,Germany (C P Pox MD)Correspondence to:Prof Hermann Brenner,Division of Clinical Epidemiologyand Aging Research, GermanCancer Research Center,69120 Heidelberg, Germanyh.brenner@dkfz.deSearch strategy and selection criteriaData for this Seminar were identifi ed by searches of PubMed, Cochrane, and ISI Web of Knowledge databases, and references from relevant articles, with various combinations of the search terms “colon cancer”, “colorectal cancer”, “colorectal neoplasms”, “colorectal tumor”, “chromosomal instability”, “diagnosis”, “drug therapy”, “epidemiology”, “genomic instability”, “microsatellite instability”, “molecular pathogenesis”, “mortality”, “prevention”, “prognosis”, “radiotherapy”, “risk factors”, “screening”, “surgery”, “survival”, and “therapy”. Articles solely reported in the form of abstracts or meeting reports were excluded. Articles published only in English between January, 1980, and March, 2013, were included.SeminarFurther emerging evidence suggests that infection with Helicobacter pylori, Fusobacterium spp, and other potential infectious agents might be associated with an increased risk of colorectal cancer.19–21Established preventive factors include physical activity,22 use of hormone replacement therapy,23 and aspirin,24,25 with risk reduction in the order of 20–30%, and endoscopy with removal of precancerous lesions,26,27 for which the strongest risk reduction has been reported (table 1). Although not as consistent, some data suggest a weak protective eff ect of diets rich in fruit, vegetables, cereal fi bre and whole grains,28,29 dairy products,30 or fi sh31 and, possibly, statin therapy.32 Epidemiological studies33 have consistently shown an inverse association between serum vitamin D concentrations and risk of colorectal cancer, but whether and to what extent this association is causal needs to be established.Colorectal cancer has a substantial heritable component. According to a large twin study,34 35% of colorectal cancer risk might be attributable to heritable factors. Apart from hereditary forms, such as familial adenomatous polyposis and hereditary non-polyposis colon cancer (Lynch syn-drome), which are determined by well known genetic aberrations, but account for less than 5% of all colorectal cancer,35 genetic factors that determine the risk of disease are still incompletely understood. Genome-wide asso-ciation studies have identifi ed an increasing number of single nucleotide polymorphisms (SNPs) showing statis-tically significant but typically very small associations with risk of colorectal cancers. F urthermore, meta-analyses suggest that few of these SNPs seem to show true associations,36 that the SNPs identifi ed so far together account for only a small proportion of colorectal cancer risk,37 and that interactions with known environmental risk factors do not play a major part.38 Histopathological classifi cationColorectal cancers are classifi ed according to local inva-sion depth (T stage), lymph node involvement (N stage), and presence of distant metastases (M stage; table 2).39 These stages are combined into an overall stage defi ni-tion (table 3), which provides the basis for thera-peutic decisions.39Although classifi cation according to TNM and Union Internationale Contre le Cancer(UICC) stage provides valuable prognostic information and guides therapy decisions, the response and outcome of individual patients’ therapy is not predicted. This is a drawback for patients with UICC stage II and III colorectal cancer in particular. Adjuvant chemotherapy is recommended forFigure 1: Estimated age-standardised colorectal cancer incidence for men in 2008Data from Globocan 2008.1Figure 2: Trends in age-standardised colorectal cancer mortality for men in selected countries, 1955–2010Data from WHO mortality database.9SeminarUICC stage III patients and for stage II patients with additional risk factors; however, a substantial proportion of these patients do not seem to benefi t from chemo-therapy. Improved informative markers could help to identify patients at high risk of relapse who might benefi t from adjuvant therapy.Molecular pathogenesisThe molecular pathogenesis of colorectal cancer is hetero g eneous. The molecular mechanisms underlying develop m ent of this cancer are clinically important because they are related to the prognosis and treatment response of the patient.40,41 The interconnections between molecular patho g ene s is, prognosis, and therapy response have become increasingly apparent during the past two decades, includ i ng the identification of the molecular mechanisms and genetic changes that cause the hereditary forms of colorectal cancer.42Adenoma–carcinoma sequenceColorectal cancer often develops over more than 10 years, and dysplastic adenomas are the most common form of premalignant precursor lesions.43APC gene mutations are an early event in the multistep process of colorectal cancer formation and occur in more than 70% of colorectal adenomas.42 The adenoma–carcinoma sequence is further promoted by activating mutations of the KRAS oncogene and inactivating mutations of the TP53 tumour suppressor gene.44 These characteristic gene mutations are often accompanied by chromosomal instability—ie, changes in numbers of chromosomes and profound structural changes of the chromosomes.45However, more than 15% of sporadic colorectal cancers develop through fundamentally different pathways of molecular events. These cancers include those originating from serrated precursor lesions, which are typical pre-malignant precursor lesions in the proximal colon,46 and are often characterised by the CpG island methylator phenotype and activating BRAF oncogene mutations. Identifi cation of these lesions during colonoscopy can be diffi cult because of their fl at, inconspicuous nature.Most cancers arising from sessile serrated adenomas display the high-level microsatellite instability (MSI-H) phenotype as a consequence of MLH1 gene promoter methylation,47 and occur in the proximal colon of elderly people, with a female predominance.48Inherited formsHereditary forms contribute to about 3–5% of all colorectal cancers.49,50 Hereditary colorectal cancer is a highly valuable model for the study of the molecular pathogenesis of colorectal cancer. In hereditary cancer,Seminarimportant tumour suppressor or DNA repair genes areinactivated by mono a llelic gene expression in the germline, and a somatic event (second hit) abrogating thefunctionality of the remaining wildtype allele can lead totumour formation.51The two most common forms of hereditary colorectalcancers are hereditary non-polyposis colon cancer (Lynchsyndrome, estimated allele frequency 1:350 to 1:1700)52and familial adenomatous polyposis coli (estimated allele frequency 1:10 000). Both syndromes are autosomal dominant disorders and follow the molecular pathogenesis typical of colorectal cancer: Lynch syndrome-associated cancers show signs of mismatch repair defi ciency and con s equently MSI-H,49,53 whereas familial adenomatous polyposis-associated cancers follow the classic adenoma–carcinoma sequence.54 Figure 3 shows the contribution of inherited tumours to all colorectal cancer.Mismatch repair defi ciency and MSI-HMismatch repair-defi cient colorectal cancers are charac-terised by the accumulation of many insertion or deletion mutations at microsatellites spread along the genome.53 Clinically, MSI-H cancers show the following charac-teristics: localisation in the proximal colon, manifestation in people younger than 50 years (hereditary form) or in elderly people (sporadic form), synchronous occurrence with additional tumours,55 and large local tumours, and are only rarely accompanied by organ metastases. Identific ation of MSI-H cancers by histopathology can be supported by: poor or mixed diff erentiation (high grade), dense infiltration with tumour -infi ltrating lympho-cytes, and expansive and cohesive pattern of invasion.56 Immuno h istochemically, MSI-H cancers display loss of expression of at least one DNA mismatch repair protein in greater than 90% of lesions.57 F igure 4 shows a representative colorectal cancer section.Although inactivation of DNA mismatch repair genes seems to accelerate rather than initiate colorectal cancer formation,44 the exact time of DNA mismatch repair inactivation during development of this cancer is still unclear. The discovery of non-dysplastic mismatch repair-defi cient crypt foci in the intestinal mucosa from carriers of Lynch syndrome mutation suggests that colorectal carcinogenesis might be initiated by mismatch repair defi ciency at least in a subset of MSI-H cancers.58 The clinical significance of the MSI-H phenotype relates to the identification of patients and families affected by Lynch syndrome. In these cases, BRAF mutation analysis can be useful to distinguish between sporadic and Lynch syndrome-associated MSI-H colo-rectal cancers because BRAF oncogene mutations are almost exclusively restricted to sporadic MSI-H type.48 Molecular markers of prognosis and therapy predictionMicrosatellite instabilityIn addition to the identifi cation of families with heredit-ary colorectal cancer, microsatellite instability analysis can provide valuable information about the prognosis and therapy response of patients. Patients with MSI-H colorectal cancer have a better prognosis than do patients with microsatellite stability. A systematic review59 of 32 eligible studies (7642 patients with colorectal cancer) estimated a hazard ratio (HR) of 0·65 (95% CI 0·59–0·71) for overall survival. Additionally, the MSI-H phenotypeFigure 3: Molecular subtypes of colorectal cancerMost colorectal cancers (85%, light blue and dark blue) show MSS or MSI-L phenotype, but are characterised by chromosomal changes. Most of these cancers develop through the classic adenoma–carcinoma pathway, but about 1% develop with inherited syndrome FAP (dark blue). About 15% of colorectal cancers (red and pink) have the MSI-H phenotype as a result of DNA mismatch repair defi ciency. About 3% of colorectal cancers have MSI-H in context of the inherited Lynch syndrome (red), whereas 12% develop as sporadic tumours (pink), with sessile serrated adenomas as a typical precursor lesion. The distribution of typical molecular changes including the CIMP and mutations of the BRAF or KRAS oncogenes are sketched in green. Dark green is the proportion of positive or mutant changes and light green is the proportion of negative or wildtype changes. MSI-H=high-level microsatellite instability in relation to the phenotypes in the fi rst bar. CIMP=CpG island methylator phenotype.MSS=microsatellite-stable. MSI-L=low-level microsatellite instability.FAP=familial adenomatous polyposis.Seminar seems to be useful for prediction of the response tochemotherapy. Patients with MSI-H colorectal cancer didnot show benefi t from adjuvant therapy with fl uorouracil(HR 1·24, 95% CI 0·72–2·14).59 By contrast, patients withMSI-H colorectal cancer had an improved response toirinotecan-based chemo t herapy,60,61 but results are contro-versial. Such findings have nurtured the ongoing dis-cussion of the need to undertake molecular tumouranalysis in all patients with colorectal cancer givenadjuvant chemotherapy.Infi ltration with cells of the immune systemThe MSI-H phenotype is closely associated with a highdensity of tumour-infi ltrating lymphocytes.56,62 This asso-ciation is probably attributable to a pronounced anti-tumoural immune response, resulting from thegener a tion of frameshift antigens induced by a defi ciencyin mismatch repair, which might be recognised by thehost’s immune system as tumour antigens.63 Thisimmune response could contribute to the improvedprognosis of MSI-H colorectal cancer. Local immune cellinfiltration has been shown to be a potent factor forprognostic classifi cation. Patients with colorectal cancerlesions showing dense infi ltration with CD45R0-positiveand CD3-positive lymphocytes in the tumour centre andinfi ltration front showed excellent prognosis, irrespectiveof UICC stage. Conversely, low lymphocyte infi ltrationwas independently associated with a poor outcome.64 Amultinational eff ort is currently underway to develop animmunoscore as a novel instrument for classifi cation ofcolorectal cancer.65KRAS and other mutations as predictive markersThe most prominent example of molecular markers thathave entered clinical routine is analysis of KRASmutation in patients with metastatic colorectal cancer.Mutations of the KRAS oncogene render aff ected cellsunresponsive to treatment with anti-EGF R antibodies,thus lowering response rates from monotherapy fromabout 20% to almost 0%.66 Whether mutations of BRAFhave a similar predictive potency is under in v estigation.67,68Novel classifi cation systems that are based on complexmutational profiles or gene expression patterns ofcolorectal cancer lesions are promising methods for theidentification of patients that could respond to certain therapy regimens.40 Molecular classifi cation has led to the prognostically relevant identification of a subtype of colorectal cancer that is distinct from types of colorectal cancer that have classic unstable chromosomes or MSI-H. Tumours of this subtype, which cannot be characterised by typical tumour suppressor or oncogene mutations, have a dismal prognosis, are mostly microsatellite stable, and often show the CpG island methylator phenotype.41 Diagnosis and stagingDiagnosis of colorectal cancer is made histologically from biopsy samples taken during endoscopy. Complete colonoscopy or CT colonography is mandatory to detectsynchronous cancers that are present in about 2–4% ofpatients.69,70 If this is not possible preoperatively, completevisualisation of the colon should be done within 6 monthsafter curative resection.F or rectal cancer, exact local staging at the time ofdiagnosis is essential and is the basis for requirement ofneoadjuvant treatment. Apart from the exact distancefrom the anal verge, defi nition of the local tumour extentis important. Endoscopic ultrasononography is accuratefor determination of the T-stage of rectal cancer,71 and isthe method of choice for regional tumours because ofhigh accuracy to diff erentiate between non-invasive andFigure 4: Histology sections of a colorectal carcinoma(A) Overview and (B) detailed HE staining of a poorly diff erentiated colorectal carcinoma. Dense lymphocyteinfi ltration that is characteristic of DNA mismatch repair-defi cient cancers is shown by asterisks. Immunohistochemical staining of DNA mismatch repair proteins shows retained expression of all four proteins: MLH1, PMS2, MSH2, and MSH6 in non-malignant colon crypts (blue arrows). Tumour cells show lack of MLH1 expression (C, green arrow) and PMS2 expression (D, green arrow), but retained expression of MSH2 expression (E, green arrow) and MSH6 expression (F, green arrow). Objective magnifi cations are given in brackets.HE=haematoxylin-eosin.MLH1 (4x)PMS2 (4x)****C DA BMSH6 (4x)MSH2 (4x)E FSeminarinvasive neoplasia.72 The most accurate method to defi ne advanced T-stages is MRI (fi gure 5).73,74 Local staging of rectal cancer after neoadjuvant therapy is less reliable for all methods because of changes induced by radiation.75F or both rectal and colon cancer, distant metastases should be ruled out. About 20% of patients with newly diagnosed colorectal cancer present with distant meta-stases.76 The most common location is the liver, and thus liver imaging should be done for all patients with colorectal cancer. In a meta-analysis77 of prospective studies with 3391 patients who had not undergone treatment, the sensitivity of CT on a per-patient basis was slightly lower than that of MRI (83·6% vs 88·2%). MRI had a signifi cantly higher sensitivity than did CT for lesions less than 10 mm. The sensitivity of abdominal ultrasononography for the detection of liver metastases was lower than the sensitivity of other staging methods.78 The sensitivity can be improved with contrast enhanced ultrasononography, with similar results to multislice CT in some studies.79,80 Investigators identified lung metastases in 2·1% of patients newly diagnosed with colorectal cancer in a large cancer registry in France.81 Frequency was nearly three times higher for patients with rectal cancer than for patients with colon cancer. Smaller studies82–84 using chest CT have shown isolated lung metastases in 9–18% of patients with rectal cancer. The clinical eff ect of detection of lung metastases is unknown. Staging of colorectal cancer is generally advised to include a chest radiograph. With respect to the prevalence of lung metastases, a chest CT in patients with locally advanced rectal cancer seems justified. Although distant meta-stases can be identifi ed in other organs including the bone and brain, no evidence supports routine investi-gation of these locations. F urthermore, data do not support routine use of PET-CT in patients without suspected metastatic disease. Investigators of a trial85 comparing PET-CT with CT in patients with liver metastases eligible for hepatic resection reported reduced futile laparoscopies, but no benefi t in survival. ManagementRole of multidisciplinary teamsLike other patients with cancer, those with colorectal cancer should be assessed by a multidisciplinary team. The multidisciplinary team should include a colorectal surgeon, a medical oncologist, a gastroenterologist, a radiotherapist, a radiologist, and a pathologist. Depending on the tumour extent, the addition of a hepatic or thoracic surgeon is necessary. Patients with rectal cancer for whom a decision has to be made about need for neo-adjuvant therapy and all patients with distant metastases should be assessed before treatment is started. F or patients with colon cancer without signs of distant meta-stases, assessment of the need for adjuvant therapy after surgery is probably sufficient. The assessment by a multidisciplinary team has been associated with a reduced rate of positive circumferential resection margins for rectal cancer86 and increased rates of adjuvant therapy for patients with colon cancer87 and of metastasis surgery for patients with stage IV disease.88 In a study89 in Denmark where multidisciplinary teams were introduced in all hospitals, investigators identifi ed an increased use of MRI and reduced perioperative mortality for patients with rectal cancer, but no eff ect on survival.SurgeryThe standard surgical procedure for the treatment of rectal cancer is total mesorectal excision—ie, removal of the rectum together with the mesorectum around it and the surrounding envelope, the mesorectal fascia.90 Com-plete removal of the mesorectum is important because it contains most of the involved lymph nodes and tumour deposits. Several studies91 have shown the importance of achievement of clear lateral margins (the so-called circumferential margin). A clear circumferential margin is generally defi ned as a distance of greater than 1 mm between the tumour border and the resection margin. Patients with involved circumferential margin have increased risk of local recurrence and development of distant metastases.91,92 The plane of the mesorectal fascia is used for resection, but resection has to be extended laterally if the tumour spreads beyond the fascia.In colon cancer surgery, the tumour and the corres-ponding lymph vessels are removed. The extent of surgery is predetermined by the tumour localisation and the supplying blood vessels. In analogy with total mesorectal excision for surgery of rectal cancers, some experts have proposed complete mesocolic excision for colon cancer surgery, with separation of the mesocolicFigure 5: MRI of a patient with T3 rectal cancerT3 rectal cancer extends beyond the muscularis propria (blue arrow) with positive lymph nodes (red arrows). The mesorectal fascia (green arrows) is not involved by the tumour, and although small the lymph nodes containstumour cells.Seminarplane from the parietal plane and central ligation of the supplying arteries and draining veins. Complete meso-colic excision results in resection of increased mesocolon and lymph nodes.93 Further data for the risks and benefi ts of complete mesocolic excision are needed.Open surgery used to be the only option available; however, laparoscopic resection has developed as an alternative. Several meta-analyses94–96 have shown that laparoscopic resection of colorectal cancer achieves the same long-term results as open surgery, and is associated with a reduced number of patients requiring blood transfusions (3·4% vs 12·2%), faster return of bowel function (first bowel movement after 3·3 days vs 4·6 days), and a shorter duration of hospital stay (9·1 days vs 11·7 days); however, operating times are longer (208 min vs 167 min) and operative costs are higher. Some evidence supports the use of robotic surgery for rectal cancer,97 but further data are needed. Neoadjuvant therapySince the introduction of total mesorectal excision, the rate of local recurrences after surgery of rectal cancer has fallen substantially. van Gijn and colleagues98 have shown that the rate of local recurrence for total mesorectal excision with neoadjuvant therapy was reduced after neoadjuvant radiotherapy (5% vs 11% overall, 9% vs 19% stage III), which shows a remaining role for neoadjuvant therapy. The question is whom to treat and how. Patients with stage I disease should not be given any treatment in addition to surgery because the local recurrence rate is low (about 3%) and the benefi t from neoadjuvant treat-ment very small (number needed to treat to prevent one local recurrence=38).98 Patients with stage III disease benefit from additional treatment, whereas the benefi t for patients with stage II disease is less clear.98–100 Benefi t is generally accepted for patients with T4 and advanced T3 tumours infi ltrating the mesorectal fascia. The use of neoadjuvant treatment for T3 tumours with greater than 1 mm distance from the mesorectal fascia (irres-pective of N status) has been questioned by some investi-gators,101 and is under investigation in the OCUM-trial (NCT01325649).With respect to the timing of radiotherapy, neoadjuvant therapy is better than adjuvant therapy, with reduced rates of local recurrences and toxic eff ects.102 However, ques-tions remain about the use of short-course radiotherapy (5×5 Gy) versus long-course radiotherapy (50·4 Gy) com-bined with chemotherapy. In the USA and some European countries, long-course radiotherapy is preferred, whereas other countries (eg, Sweden, Norway, and Netherlands) mainly use short-course radiotherapy.Short-course radiotherapy is generally followed, with-out delay, by surgery, and thus does not achieve pro-nounced downsizing of the tumour. In cases in which downsizing or staging of the tumour is desired (patients with T4 or T3 tumours infiltrating the mesorectal fascia), long-course radiotherapy combined with chemo-therapy is the preferred option. In a randomised trial,103 long-course radiotherapy achieved lower rates of involved circumferential margins than did short-course radio t herapy(4%vs 13%). The ideal treatment of patients with T3 tumours is less clear. The fi rst randomised trial104 comparing short-course radiotherapy with long-course radiotherapy in combination with chemotherapy of T3 rectal cancers showed that the local recurrence rate was lower for long-course radiotherapy than short-course, particularly in patients with distal rectal cancer, but the difference was not statistically signifi cant. Nevertheless, these and other data suggest that for patients with T3 distal rectal cancer, long-course radiotherapy with chemo t herapy might be preferred, whereas for proximal rectal cancer short-course radio-therapy is a valid alter n ative if the mesorectal fascia does not seem involved. Most studies100 have used fluorouracil for combined radiochemotherapy but capecitabine seems to be a valid alternative.Several studies are examining the exact role and timing of chemotherapy in patients undergoing short-course radiotherapy and the eff ect of delayed surgery.105 Most studies have not shown differences in rates of distant metastases and overall survival for the use of radiotherapy.102Data for the role of neoadjuvant treatment in locally advanced colon cancer are scarce. A pilot trial106 including 150 patients with radiologically staged locally advanced tumours showed that preoperative chemotherapy was feasible, with acceptable toxicity and perioperative mor-bidity, and statistically significantly (p=0·002) increased the rate of R0 resections. However, further data from randomised trials are needed for defi nitive conclusions. Adjuvant therapyPatients with stage III colon cancer have a risk of recurrence ranging between 15% and 50%. Adjuvant chemotherapy is recommended for all patients with stage III colon cancer without contraindications after curative resection. Regimens containing fl uorouracil reduce recurrence rate by 17% units and increase overall survival by 13–15% units.107 Alternatively, capecitabine, an oral prodrug of fluorouracil, can be used with comparable effi cacy.108 To improve disease-free survival and overall survival, several large prospective trials have investigated the addition of oxaliplatin to fl uorouracil and capecitabine (table 4). The addition of oxaliplatin increased the absolute 5-year disease-free survival by 6·2 to 7·5% units and the overall survival by 2·7 to 4·2% units in patients with stage III colon cancer.109–111 However, secondary subset analyses of two studies suggest that the benefi t of oxaliplatin might be limited to patients younger than 65 years112 or younger than 70 years.111 In large randomised trials,112,113 the addition of bevacizumab or cetuximab to an oxaliplatin containing regimen did not show any benefit on disease-free survival. Additionally, the use of irinotecan combined。
我国结直肠癌30年变迁与应对策略
作者单位：四川大学华西医院a.胃肠外科中心；b.生物治疗国家重点实验室；c.肿瘤科，四川成都610041通讯作者：周总光，E-mail：zhou767@ 述评文章编号：1005-2208（2012）09-0693-04我国结直肠癌30年变迁与应对策略周总光a，b，杨烈a，b，李园b，于永扬a，王存a，b，胡建昆a，b，卢铀b，c，莫显明b【摘要】30年来，结直肠癌（CRC）的发病率、病死率在世界范围呈现明显的经济、文化和地域特点。
总体趋势是：发达国家和地区的CRC发病率及病死率缓慢增高约30%，近10年逐渐降低并趋于稳定，这主要归功于CRC筛查。
而我国CRC发病率及病死率则高速增长，达30年前的400%~ 500%，CRC防治面临巨大考验。
我国CRC发病率及病死率高速增长有诸多特定因素，亟待分析阐明。
应从专业和科普角度提高全民的CRC防治意识，需将CRC可以预防的理念深入人心；应提高CRC目标人群的筛查率；应定期在CRC高危人群实施结肠镜、乙状结肠镜检查及肛门指检等CRC防治简单而最有效手段。
调整防治策略，重心向预防倾斜，势在必行。
【关键词】结直肠癌；发病率；病死率；结直肠癌筛查中图分类号：R6文献标志码：CThe30years’changes of colorectal cancer and the strategies in China ZHOU Zong-guang*,YANG Lie,LI Yuan,et al.*Department of Gastrointestinal Surgery,West China Hospital,Sichuan University,Chengdu610041,China Corresponding author:ZHOU Zong-guang,E-mail：zhou767@ Abstract For30years,the incidence and mortality of colorectal cancer(CRC)has displayed obvious economy, culture and region characteristics in the world.Generally,the CRC incidence and mortality slowly increased by about30% while gradually decreased and tended to stability in recent10 years in developed countries and regions,largely due to CRC screening.In China,the CRC incidence and mortality have rapidly increased to400~500%of that before30years.The grim situation poses a huge challenge on the strategy and wisdom of CRC control.Multiple specific factors underlie the rapid increasing of the CRC incidence and mortality in China, which should be elucidated urgently.The CRC control awareness should be improved by professional and science popularizing approaches,making the CRC-preventable concept deeply into the mind of people.The CRC screening rate should be increased in target population.The simple and the most effective methods colonoscopy,sigmoscopy and digital rectal examination,should be regularly carried out in the population with high risks of CRC.It is imperative to adjust CRC control strategy and tilt the focus to prevention. Keywords colorectal cancer；incidence；mortality；colorectal cancer screening1西方国家结直肠癌30年来现状与特点30年前，国际癌症研究署（IARC，1982）的数据显示，世界105个国家和地区中，每年结直肠癌（CRC）发病率最高的是美国康涅狄克州（33.3/10万），其次是美国纽约州（32.4/10万），最低的是塞内加尔的达喀尔市（0.6/10万），我国为7/10万［1］。
211240428_结直肠癌筛查对结直肠肿瘤早期诊断的意义
结直肠癌筛查对结直肠肿瘤早期诊断的意义*孙颖#马瑾顾玮胡梅洁郑雄&上海交通大学医学院附属瑞金医院卢湾分院消化内科（200020）背景：我国结直肠癌（CRC）发病率和死亡率呈上升趋势，发病年龄趋于年轻化。
目的：分析CRC筛查初筛阳性人群的结肠镜检查结果，探讨高危问卷联合粪便隐血试验的CRC筛查模式对于结直肠肿瘤早期诊断的意义。
方法：连续纳入2013年5月—2019年10月参与上海市黄浦区社区CRC筛查，因初筛结果阳性至瑞金医院卢湾分院接受结肠镜检查的高危个体，内镜检查发现病变者取活检或摘除送病理检查。
同期因排便习惯改变行结肠镜检查的患者作为对照组。
分析两组结直肠肿瘤检出情况以及筛查阳性组的病变特征。
结果：共1329例初筛阳性者纳入研究，结肠镜检查病变总体检出率为63.3%，CRC、息肉和腺瘤性息肉检出率分别为2.6%（34例）、60.7%（807例）和35.2%（468例），均显著高于对照组（n=22438）的43.6%、1.8%、41.5%和21.6%（P均<0.05）。
筛查阳性组病变检出率男性显著高于女性（73.7%对54.2%,P<0.05），且随年龄增长呈增高趋势（P<0.05）。
CRC主要分布于60~79岁年龄组，无性别分布差异，病变直径均≥1cm；发生异型增生的腺瘤直径亦多≥1cm，无异型增生的腺瘤以及增生性和炎性息肉直径则多<1cm。
结论：我国现阶段实行的社区CRC筛查模式可有效提高CRC及其癌前病变检出率。
关键词结直肠癌筛查；结肠镜检查；早期诊断；结直肠肿瘤；肠息肉；腺瘤Significance of Colorectal Cancer Screening for Early Diagnosis of Colorectal Neoplasms SUN Ying,MA Jin,GU Wei,HU Meijie,ZHENG Xiong.Department of Gastroenterology,Luwan Branch,Ruijin Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai(200020)Correspondence to:ZHENG Xiong,Email:****************Background:The incidence rate and mortality of colorectal cancer(CRC)in China are increasing,and the age of onset is tending to be younger.Aims:To analyze the results of colonoscopy in patients positive for CRC screening,and to explore the significance of a CRC screening protocol that combines risk assessment questionnaire with fecal occult blood test (FOBT)in early diagnosis of colorectal neoplasms.Methods:Individuals who were positive for the first stage of screening (questionnaire+FOBT)in a community CRC screening program in Shanghai Huangpu District from May2013to October 2019and then received the second stage of screening(colonoscopy)in Ruijin Hospital Luwan Branch were enrolled consecutively.Biopsy or polypectomy specimens were taken for pathological examination if any lesions were found endoscopically.Patients who underwent colonoscopy due to changes in bowel habits in the same period were served as controls.The detection rates of colorectal neoplasms in these two groups and the disease characteristics in the screening positive group were analyzed.Results:The screening positive group included1329residents positive for the first stage of screening.The overall detection rate of colorectal lesions was63.3%,and the detection rates of CRC,colorectal polyps and adenomatous polyps were2.6%(34cases),60.7%(807cases)and35.2%(468cases),respectively.While in control group (n=22438),the rates were43.6%,1.8%,41.5%,and21.6%,respectively,all were significantly lower than those in screening positive group(all P<0.05).In screening positive group,the overall detection rate of colorectal lesions was higher in male than in female(73.7%vs.54.2%,P<0.05)and increased with aging(P<0.05).Most of the CRC cases were in60⁃79 years old age group with no gender difference.All CRC and most of the adenomas with dysplasia were greater than or equal to1cm in diameter,while most of the adenomas without dysplasia,hyperplastic polyps and inflammatory polyps were less than1cm in diameter.Conclusions:The community CRC screening program practiced in China can increase the detection rates of CRC and precancerous lesions effectively.Key words Colorectal Cancer Screening;Colonoscopy;Early Diagnosis;Colorectal Neoplasms;Intestinal Polyps;AdenomaDOI：10.3969/j.issn.1008⁃7125.2022.03.007*基金项目：上海市黄浦区科研项目（HKW201504）#Email:**************&本文通信作者，Email:****************结直肠癌（colorectal cancer,CRC）是一种常见的消化系统恶性肿瘤，根据国际癌症研究机构GLOBOCAN2020数据，其发病率和死亡率在全球恶性肿瘤统计中分居第3和第2位[1]。
PG-SGA营养筛查对结直肠癌术后并发症预测的研究
PG-SGA营养筛查对结直肠癌术后并发症预测的研究PG-SGA营养筛查对结直肠癌术后并发症预测的研究摘要：本文探讨了PG-SGA营养筛查在结直肠癌术后并发症预测方面的应用。
采用纵向队列研究方法，共选取280例结直肠癌术后患者为研究对象，其中有112例发生了术后并发症。
通过PG-SGA营养筛查对患者进行评分，分析各项指标得分与术后并发症的关系。
结果显示，PG-SGA总分、体重下降、食欲、营养摄入量、身体组成、血液检查等指标与术后并发症发生有关。
其中PG-SGA总分是最主要的预测因素，其风险比为3.78（95%CI：2.14-6.68）。
此外，根据不同PG-SGA总分水平划分的患者预后，术后并发症发生率也呈现出显著差异（P<0.05）。
本研究表明，PG-SGA营养筛查能够在结直肠癌术后并发症预测方面发挥重要作用，能够帮助临床医生更好地进行干预管理和预防措施。
关键词：结直肠癌；术后并发症；PG-SGA；营养筛查；预测；临床应用Abstract: This paper explores the application of PG-SGA nutritional screening in predicting postoperative complications of colorectal cancer. A longitudinal cohort study was conducted, including 280 patients undergoing colorectal cancer surgery, of which 112developed postoperative complications. By using PG-SGA nutritional screening, patients were scored and the relationship between various indicators and postoperative complications was analyzed. The results showed that PG-SGA total score, weight loss, appetite, nutrient intake, body composition, blood tests, and other indicators were related to postoperative complications. Among them, the PG-SGA total score was the most important predictor, with a risk ratio of3.78 (95%CI: 2.14-6.68). In addition, the prognosis of patients divided according to different PG-SGA total score levels also showed significant differences inthe incidence of postoperative complications (P<0.05). This study suggests that PG-SGA nutritional screening can play an important role in predicting postoperative complications of colorectal cancer and can helpclinical doctors better intervene and prevent measures.Keywords: Colorectal cancer; Postoperative complications; PG-SGA; Nutritional screening; Prediction; Clinical applicationIn recent years, there has been increasing evidence suggesting that malnutrition significantly impacts the morbidity and mortality of patients undergoing colorectal cancer surgery (1,2). Therefore, early nutritional screening and intervention are importantfor improving patient outcomes (3). The PG-SGA is a widely used tool for screening nutritional status in patients with cancer, which evaluates both thepatient's nutritional status and the impact of the cancer and its treatment on the patient's nutritional status (4).In this study, we evaluated the accuracy of PG-SGA in predicting postoperative complications in patientswith colorectal cancer. The results showed thatpatients with high PG-SGA scores were at asignificantly greater risk of postoperative complications compared to those with low PG-SGA scores. This finding indicates that PG-SGA could be used as a reliable predictor of postoperative complications in colorectal cancer surgery.Moreover, the study also found that the incidence of postoperative complications increased as the PG-SGA score increased. This suggests that early nutritional intervention may help prevent postoperative complications in colorectal cancer patients with high PG-SGA scores.Overall, the findings of this study demonstrate the potential clinical utility of PG-SGA in predicting postoperative complications in patients undergoingcolorectal cancer surgery. By using PG-SGA as a screening tool, clinicians can identify patients at high risk for postoperative complications and design targeted interventions to reduce these risks. Early nutritional intervention may significantly improve patient outcomes and reduce the economic burden on healthcare systemsIn addition to its potential use in predicting postoperative complications, the PG-SGA can also be a useful tool for monitoring the nutritional status of cancer patients throughout the course of their disease. The PG-SGA has been shown to be a sensitive andreliable measure of nutritional status in cancer patients, and it can be used to track changes in nutritional status over time.Using the PG-SGA to monitor nutritional status canhelp clinicians identify patients who are at risk for malnutrition and provide early nutritionalinterventions to prevent further deterioration. Early nutritional interventions have been shown to improve patient outcomes, including physical function, quality of life, and overall survival.Furthermore, the PG-SGA can be used to tailornutritional interventions to the individual needs ofeach patient. For example, patients with different types of cancer may have different nutritional needs based on the type and stage of their disease. The PG-SGA can help clinicians identify these individual needs and design targeted nutritional interventions to meet them.The PG-SGA can also be a useful tool for assessing the effectiveness of nutritional interventions in cancer patients. By monitoring changes in nutritional status over time, clinicians can evaluate the impact of interventions and make adjustments as needed. This can help ensure that patients are receiving the most appropriate and effective nutritional care.In summary, the PG-SGA is a valuable tool for predicting postoperative complications in colorectal cancer patients and monitoring the nutritional status of cancer patients throughout the course of their disease. By using the PG-SGA, clinicians can identify patients at high risk for complications and provide early nutritional interventions to improve patient outcomes. The PG-SGA can also be used to tailor nutritional interventions to individual patient needs and assess their effectiveness over timeIn addition to predicting postoperative complications and monitoring nutritional status, the PG-SGA has several other benefits for cancer patients.1. Identifying malnutrition earlyMalnutrition is a common problem among cancer patients and can lead to a host of negative outcomes, including worse treatment tolerance and response, decreased quality of life, and higher rates of hospitalization and mortality. The PG-SGA is a sensitive tool for identifying malnutrition early in the course of cancer treatment, allowing clinicians to intervene before patients become severely malnourished.2. Customizing nutrition interventionsEvery cancer patient is unique, and their nutritional needs may vary depending on their diagnosis, treatment plan, and other factors. The PG-SGA assesses patients' individualized nutritional needs and provides a framework for developing tailored nutrition interventions to meet those needs. This can include dietary counseling, oral supplements, enteral or parenteral nutrition, and other strategies.3. Monitoring treatment responseThe PG-SGA is not a one-time assessment but rather a tool for ongoing monitoring of patients' nutritional status. By repeating the PG-SGA at regular intervals, clinicians can track patients' progress and adjust their nutrition interventions as needed. This can help maximize the effectiveness of nutrition interventions and improve patient outcomes over time.4. Enhancing patient-provider communicationThe PG-SGA is a patient-centered tool that fosters communication and collaboration between patients and their healthcare providers. By asking patients about their symptoms, diet, and other factors, the PG-SGA helps clinicians understand patients' experiences and identify areas for intervention. This can promote shared decision-making and help patients feel more engaged in their care.5. Improving quality of lifePoor nutrition can have a significant impact on patients' quality of life, and addressing nutrition-related concerns can help improve patient well-being. The PG-SGA can help clinicians identify and address nutrition-related symptoms, such as nausea, vomiting,or dry mouth, which can help patients feel more comfortable and better able to tolerate treatment.Overall, the PG-SGA is a valuable tool for improving the nutritional status and outcomes of cancer patients. By identifying malnutrition early, customizingnutrition interventions, monitoring treatment response, enhancing communication, and improving quality of life, the PG-SGA can help clinicians provide more effective, patient-centered care to cancer patientsIn conclusion, the Patient-Generated Subjective Global Assessment (PG-SGA) is a useful tool for assessing the nutritional status of cancer patients. It allows clinicians to identify malnutrition, tailor nutrition interventions, monitor treatment response, improve communication, and enhance quality of life. By addressing nutritional needs along with cancer treatment, patients may experience fewer side effects, better outcomes, and an overall improvement in their well-being。
血浆中lncrna作为结直肠癌潜在诊断标志物的研究
血浆中LncRNA作为结直肠癌潜在诊断标志物的临床研究摘要【目的】：结直肠癌是最常见的恶性肿瘤之一，其年发病率和死亡率均排在恶性肿瘤的前列。
目前，全世界男女发病数和死亡数比分别为1.21和1.17，发达国家结直肠癌发病率高于发展中国家，而且结直肠癌的发病率和死亡率呈逐年上升趋势。
考虑到结直肠癌的现状，新的筛检和评估方式显得迫切需求。
现有的研究表明，LncRNA能通过参与染色质修饰、转录干扰及核内外运输等多种途径，在各个方面影响目的基因的表达，进而影响到肿瘤发生和发展。
LncRNA在肿瘤形成的过程中起到关键作用，本实验研究旨在能为结直肠癌的诊断提供新的方法。
【方法】：收集78例临床病理证实为结直肠癌患者的术前血浆及76例正常对照组的血浆。
采用 Real-time RT-PCR 法，先在20对样本中(20例结直肠癌患者的术前血浆及20例正常对照组的血浆)检测待选13个LncRNA（PVT-1、UCA1、H19、RMRP、NEAT1、NEAT1_2、CCAT1-L、CCAT2、HOTAIR、MALAT1、91H、GAS5、MEG3）的表达情况，筛选出存在表达差异的LncRNA，之后再在剩余血浆样本中验证初筛存在差异的的LncRNA。
通过比较两组血浆中LncRNA的表达差异，探讨LncRNA表达水平与结直肠癌发生的相关性。
从而得到具有一定诊断意义的LncRNA。
【结果】：LncRNA 91H在结直肠癌患者血浆中的表达量高于正常对照组，具有统计学差异（P=0.0231<0.05），ROC曲线AUC=0.870>0.7(当标准值>0.0095时，敏感度=86.2，特异度=80.4,)，LncRNA 91H可作为一种潜在的独立的诊断指标。
LncRNA PVT-1在结直肠癌患者血浆中的表达量高于正常人对照组，具有显著的统计学差异（P=0.0001<0.01），ROC曲线AUC=0.786>0.7(当标准值>0.0165时，敏感度=69.0，特异度=82.1)，LncRNA PVT-1可作为一种潜在的独立诊断指标。
黏液性与非黏液性结直肠腺癌中PD-L1、CD8的表达
网络出版时间：２０２１－４－２２１６：３０ 网络出版地址：ｈｔｔｐｓ：／／ｋｎｓ．ｃｎｋｉ．ｎｅｔ／ｋｃｍｓ／ｄｅｔａｉｌ／３４．１０７３．Ｒ．２０２１０４２２．１１０３．００４．ｈｔｍｌ黏液性与非黏液性结直肠腺癌中ＰＤ Ｌ１、ＣＤ８的表达李贵兰１，陆丽平２，饶晓松１摘要：目的 探讨黏液性结直肠腺癌（ｍｕｃｉｎｏｕｓｃｏｌｏｒｅｃｔａｌａｄｅｎｏｃａｒｃｉｎｏｍａ，ＭＣＡ）与非黏液性结直肠腺癌（ｎｏｎ ｍｕｃｉｎｏｕｓｃｏｌｏｒｅｃ ｔａｌａｄｅｎｏｃａｒｃｉｎｏｍａ，ｎｏｎ ＭＣＡ）中程序性死亡蛋白－配体１（ｐｒｏｇｒａｍｍｅｄｄｅａｔｈｐｒｏｔｅｉｎ ｌｉｇａｎｄ１，ＰＤ Ｌ１）和ＣＤ８的表达。
方法 收集结直肠腺癌标本１０６例，其中ｎｏｎ ＭＣＡ９０例，ＭＣＡ１６例，采用免疫组化法检测ｎｏｎ ＭＣＡ和ＭＣＡ的肿瘤细胞和肿瘤浸润免疫细胞中ＰＤ Ｌ１和ＣＤ８表达，计算ＰＤ Ｌ１和ＣＤ８的阳性率，比较ｎｏｎ ＭＣＡ和ＭＣＡ中ＰＤ Ｌ１和ＣＤ８表达的差异。
结果 ｎｏｎ ＭＣＡ组织中ＰＤ Ｌ１表达比ＭＣＡ高（Ｐ＜０ ００１），两组肿瘤组织中ＰＤ Ｌ１均大部分表达于肿瘤间质的免疫细胞。
在ｎｏｎ ＭＣＡ组中有２３％的ＰＤ Ｌ１和ＣＤ８同时高表达，有４８％的ＰＤ Ｌ１和ＣＤ８同时低表达，７％的ＰＤ Ｌ１高表达和ＣＤ８低表达，２２％的ＰＤ Ｌ１低表达和ＣＤ８高表达。
在ＭＣＡ组中有４０％的ＰＤ Ｌ１和ＣＤ８同时低表达，６０％的ＰＤ Ｌ１低表达而ＣＤ８高表达。
ｎｏｎ ＭＣＡ与ＭＣＡ组织中ＣＤ８＋Ｔ细胞的表达，差异无统计学意义。
结论 结直肠腺癌中ＰＤ Ｌ１主要表达于肿瘤间质的免疫细胞，且ｎｏｎ ＭＣＡ较ＭＣＡ高表达ＰＤ Ｌ１；部分ｎｏｎ ＭＣＡ中ＰＤ Ｌ１和ＣＤ８同时高表达。
关键词：结直肠肿瘤；腺癌；ＰＤ Ｌ１；ＣＤ８；免疫组织化学中图分类号：Ｒ７３５ ２ 文献标志码：Ａ 文章编号：１００１－７３９９（２０２１）０４－０３９４－０５ｄｏｉ：１０．１３３１５／ｊ．ｃｎｋｉ．ｃｊｃｅｐ．２０２１．０４．００４接受日期：２０２０－１２－１０作者单位：１北京大学国际医院病理科，北京 １０２２０６２北京大学人民医院病理科，北京 １０００４４作者简介：李贵兰，女，硕士，技师。
2015年中国结直肠癌发病和死亡情况分析
根据世界卫生组织下属国际癌症研究机构 （International Agency for Research on Cancer， IARC）的全球癌症统计（GLOBOCAN 2018）估 算，2018年全球结肠、直肠和肛门恶性肿瘤（以 下简称“结直肠癌”）新发病例约185万例，位 居恶性肿瘤发病谱的第3位，因结直肠癌死亡约 88万人，位居恶性肿瘤死亡谱的第2位［1］。结直 肠癌发病率和死亡率在许多低收入和中等收入国 家仍在快速增长，处于流行最高水平的发达国家 则呈现出稳定或下降的趋势［2］。 本研究根据国家癌症中心收集的2015年全国 肿瘤登记地区的结直肠癌资料，估计中国结直肠 癌的发病和死亡情况，为科学制定大肠癌预防和 控制策略提供数据支撑和参考依据。
in China, in 2015, based on population-based cancer registration data collected by the National Cancer Center. Methods: Based on the data quality review and assessment, the cancer registration data from 501 cancer registries in China were included in this study, which included new cases and deaths during 2015. According to the national population data in 2015, the nationwide incidence and mortality of colorectal cancer were estimated. Results: The data from 368 cancer registries were qualified, which covered a total of nearly million populations in China, accounting for 22.52% of the national population. There were 387.6 thousand new colorectal cancer cases (225.0 thousand males and 162.6 thousand females) estimated in China in 2015. The age-standardized incidence rate by Chinese standard population (ASRC) was 18.02 per 100 000 (male: 21.36 per 100 000; female: 14.79 per 100 000). The age-standardized incidence rate by World Segi′s population (ASRW) was 17.81 per 100 000 (male: 21.21 per 100 000; female: 14.54 per 100 000). There were 187.1 thousand colorectal cancer deaths (109.5 thousand males and 77.6 thousand females) estimated in China in 2015. The ASRC of mortality was 8.21 per 100 000 (male: 10.08 per 100 000; female: 6.47 per 100 000). The ASRW of mortality was 8.12 per 100 000 (male: 10.01 per 100 000; female: 6.37 per 100 000). When comparing ASRW of colorectal cancer incidence and mortality in different regions stratified by gender, all rates of urban areas were higher than rural areas, and those of eastern areas of China were higher than those of middle areas and the western areas. The differences in rates between the middle areas and the western areas were less than 1 per 100 000. The age-specific rates of incidence and mortality of colorectal cancer all increased with age. The growth trends of different genders were similar. Conclusion: Colorectal cancer is one of the common cancers in China with significant gender and regional differences. The ASRW of incidence among female was higher than the average rate of worldwide. The other ASRW of incidence and mortality were lower than the average rates of worldwide. ［Key words］ Colorectal cancer; Incidence; Mortality; Cancer Registry; China
河北省40年结直肠癌发病和死亡分析
《中国癌症杂志》2017年第27卷第3期212CHINA ONCOLOGY 2017 Vol.27 No.3河北省40年结直肠癌发病和死亡分析李道娟，梁 迪，靳 晶，温登瑰，单保恩，贺宇彤河北医科大学第四医院肿瘤研究所，河北 石家庄，050011 ［摘要］ 背景与目的：结直肠癌是常见的消化道肿瘤之一，2012年全球约有136万结直肠癌新发病例，是世界第3高发恶性肿瘤，居恶性肿瘤死亡第4位，严重威胁着人类健康。
该研究通过肿瘤登记地区结直肠癌发病死亡情况估计河北省结直肠癌疾病负担，与河北省三次全死因回顾调查资料比较，分析结直肠癌死亡率的时间变化趋势。
方法：河北省肿瘤登记办公室收集到9个肿瘤登记处上报的2010—2012年恶性肿瘤发病和死亡资料。
数据分性别、年龄别(0、1～4、5～9、10～14……80以上)计算恶性肿瘤发病率、死亡率和构成；采用2000年中国标准化人口构成和Segi’s世界人口构成分别计算中国和世界人口年龄标准化发病率和死亡率。
整理分析河北省1973—1975年、1990—1992年和2004—2005年三次全死因回顾调查的结直肠癌数据。
采用Joinpoint回归模型分析磁县肿瘤登记处1988—2012年和涉县肿瘤登记处2000—2012年结直肠癌发病和死亡趋势。
结果：河北省肿瘤登记地区2010—2012年结直肠癌新发病例2 303例，死亡1 229例。
结直肠癌发病率为16.48/10万(男性18.12/10万，女性14.77/10万)，中国人口标准化发病率为13.74/10万；结直肠癌死亡率为8.79/10万(男性10.23/10万，女性7.31/10万)，中国人口标准化死亡率7.59/10万。
河北省2010—2012年结直肠癌死亡率较1973—1975年升高了28.03%。
磁县1988—2012年男性结直肠癌发病率年度平均变化百分比(annual percentage changes，APC)为3.55，死亡率APC为1.64。
2、乳腺癌一病一品
2、乳腺癌一病一品标题：乳腺癌：“病”与“品”的探讨乳腺癌，作为女性最常见的恶性肿瘤之一，近年来在世界范围内的发病率不断上升。
在这一背景下，我们不仅需要深入了解这一疾病的病理学特征，更需要从患者的角度出发，理解她们所面临的身心挑战。
一、乳腺癌的“病”与“品”“病”是指乳腺癌的医学属性和技术可治性。
现代医学已经可以将乳腺癌视为一种可治愈的疾病。
通过手术、放疗、化疗、内分泌治疗和靶向治疗等多种手段，乳腺癌患者的生存率得到了显著提高。
而“品”则强调了乳腺癌对患者生活质量和心理状态的影响。
乳腺癌患者需要面对身体形象的改变、生活计划的打乱、以及对于疾病复发的恐惧。
这种心理压力，可能会对患者的社会交往、工作能力和生活质量产生深远影响。
二、从“病”到“品”：患者的视角对于患者来说，乳腺癌不仅仅是一种身体疾病，更是一种心理挑战。
她们需要适应身体形象的改变，处理疾病带来的情绪波动，并学会在疾病治愈后重新融入社会。
在这一过程中，患者的家庭、朋友以及医疗团队的支持和理解至关重要。
三、提升乳腺癌患者的“品”为了提升乳腺癌患者的“品”，我们需要从多个方面进行努力。
首先，医生们需要在治疗疾病的同时，关注患者的心理需求，提供全面的医疗支持。
其次，社会应当提供更多的理解和支持，减少对乳腺癌患者的歧视和偏见，帮助她们重新融入社会。
此外，患者自身也需要学习如何应对疾病带来的心理压力，通过积极的生活态度和心理调适，提升生活质量。
四、结论综上所述，乳腺癌不仅是一种身体疾病，更是一种心理挑战。
我们需要从医学技术、社会环境和个人心理等多个方面出发，全面提升乳腺癌患者的“品”。
只有这样，我们才能真正实现乳腺癌的全面治愈，让患者在治愈疾病的同时，也能享受到生活的美好。
参考文献：1、Siegel RL, Miller KD, Jemal A. Cancer statistics, 2022. CA:a cancer journal for clinicians. 2022;72(1):7-33.2、Bray F, Ferlay J, Soerjomataram I, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2021;71(3):209-249.3、Edge SB, Byrd DR, Compton CC, et al. AJCC cancer staging manual. Springer; 2017.4、Winawer SJ, Fuchs CS, Goddard E, et al. Colorectal cancer prevention: medical review and recommendations from the National Colorectal Cancer Roundtable. Gastroenterology. 2008;134(6):2135-2151.。
最权威：几岁一定要做肠癌筛查？45！热心肠日报
最权威：⼏岁⼀定要做肠癌筛查？45！热⼼肠⽇报今天是第1846期⽇报。
JAMA：美国最新指南建议45岁开始⼤肠癌筛查JAMA[IF:45.54]①建议对所有50⾄75岁的成⼈进⾏结直肠癌筛查（A级推荐）；②建议对45⾄49岁的成⼈进⾏结直肠癌筛查（B级推荐）；③建议临床医⽣有选择地为76⾄85岁的成⼈提供结直肠癌筛查，有证据表明对这个年龄段的所有⼈进⾏筛查的净收益很⼩，应考虑患者的整体健康状况、既往筛查史和偏好（C级推荐）；④建议筛查策略包括：每年进⾏粪便隐⾎/粪便免疫化学检测、每5年进⾏⼀次结肠CT或柔性⼄状结肠镜、每10年进⾏⼀次结肠镜检查等。
Screening for Colorectal Cancer: US Preventive Services Task Force RecommendationStatement (2021)05-18, doi: 10.1001/jama.2021.6238【主编评语】结直肠癌最常在65-74岁的⼈群中被诊断出来。
但据估计10.5%的新发结直肠癌病例发⽣在50岁以下的⼈群中，且近年来40-49岁⼈群的结直肠癌发病率上升了约15%。
美国预防服务⼯作组（USPSTF）近期在JAMA发布了最新的（2021）结直肠癌筛查的建议：对50-75 岁的成年⼈进⾏结直肠癌筛查具有显著的净收益；对45-49岁的成年⼈进⾏结直肠癌筛查有⼀定的净收益；对先前接受过筛查的76-85岁成年⼈进⾏结肠癌筛查的净收益很⼩，⽽从未接受过结直肠癌筛查的成年⼈更有可能受益。
2016年，USPSTF建议50-75岁⼈群均应进⾏结直肠癌筛查，⽽2021年的建议中将结直肠癌筛查开始年龄提前到了45岁。
（@szx）5万⼈数据：45岁就该开始肠癌筛查Gastroenterology[IF:17.373]①纳⼊17项研究（涉及来⾃4个⼤洲的51,811名平均风险的受试者）进⾏荟萃分析；②早发性结直肠新⽣物（EAO-CRN）的总体患病率为13.7%，早发性进展期结直肠新⽣物（EAO-aCRN）的总体患病率为2.2%；③男性的EAO-CRN患病率显著⾼于⼥性，美国的EAO-CRN患病率最⾼，其次是欧洲及东亚，中东地区最低；④ 45-49岁及50-59岁⼈群的EAO-CRN患病率分别为17.8%及24.8%；⑤ 45-49岁及50-59岁⼈群的EAO-aCRN患病率分别为3.6%及4.2%。