由國外經驗檢視我國子宮頸癌篩檢政策

Abstract

民國71年起癌症即為國人十大死因首位，而子宮頸癌為我國婦女高發生率、高死亡率之癌症，國外研究顯示三年一次的子宮頸抹片檢查可降低60-90％子宮頸癌發生率及死亡率，歐美國家在推行子宮頸抹片檢查後，成功的將子宮頸癌的發生率和死亡率降為原來的三分之一至五分之一；而我國政府亦積極推廣子宮頸抹片篩檢工作，以防治子宮頸癌對我國婦女之威脅。 為瞭解我國子宮頸癌篩檢政策及其成果，以及其與國外篩檢政策之差異，本研究用檔案分析方法蒐集資料，並以子宮頸癌的篩檢率、發生率、死亡率作為評估指標，檢視台灣過去資料，將台灣子宮頸癌篩檢相關政策作一系統性整理；此外，簡要整理英國、加拿大子宮頸癌篩檢政策相關資料，期從國外經驗中找出適合我國的可行建議。 目前國外長期推廣子宮頸抹片篩檢的結果顯示均可有效降低子宮頸癌的死亡率、發生率；國際癌症研究協會（IARC）研究結果顯示每年篩檢一次的效果和每3年篩檢一次的效果相當。由各國經驗顯示組織性篩檢（如加拿大、英國）相較於伺機性篩檢（美國）可更有效的篩檢出高危險群，對降低子宮頸的發生率、死亡率上有更好的篩檢效益。我國雖自1960年代引進子宮頸抹片技術，惟至1990年代，尤其是全民健保實施後才全面推廣抹片篩檢工作，由於推廣時間相較於國外自1950、60年代即全面推廣的時間短，致使我國雖已開始顯現篩檢成果，篩檢效益卻不如國外的明顯。此外，由於我國醫療制度、民眾就醫習慣、風俗習慣與國外不同，也使我國面臨篩檢涵蓋率無法突破54%的瓶頸，相較於國外80%仍有努力的空間。 至於近幾年許多新科技的發明，如薄膜檢查（liquid based cytology test）、人類乳突病毒（HPV）檢驗、HPV疫苗等，勢將影響各國的子宮頸癌防治政策、篩檢政策，當然也讓我國在子宮頸癌防治上未來有更多努力的空間。 本研究建議政府應依據實證研究結果，將每年一次篩檢的篩檢政策更改為每三年篩檢一次；建立有效的組織性篩檢機制；將子宮頸抹片檢查日期及結果（陽性、陰性）列入健保IC卡中；並將預防保健服務獨立於健保總額支付制度外；配合家庭醫師的推動制度，將子宮頸抹片檢查列入其合約中，依採檢單位的採檢比率支付不同費用；配合實際需要，修訂相關法規、制度、政策；繼續教育民眾，勇於接受抹片篩檢。此外，建議家庭醫師是可以開放時段，提供抹片篩檢服務；醫學會（醫師）應拋開私利，配合衛生單位之政策提供篩檢服務；組成研究團隊，定期回顧國外發展情形並配合國內現況，定期檢討評估以制訂更適合我國之篩檢政策。

Cancer has become the leading cause of death in Taiwan since 1982, and cervical cancer is the one with the highest incidence and mortality to women. A number of studies showed that mass Pap smear screening once every 3 years reduced cervical cancer incidence and mortality by 60%-90%. Similarly, the experience from European and American countries has demonstrated that cervical cancer incidence and mortality has reduced from 1/3 to 1/5 after the implementation of Pap smear test. Now, Taiwan’s government has adopted and implemented Pap smear test actively to prevent women from the threaten of cervical cancer. The purposes of this study are to understand cervical cancer screening policy and its impact in Taiwan and to examine the differences between Taiwan and other countries. Archival analysis was used for managing and examining Taiwan cervical cancer policy. Main indicators include screening regulation and promotion, screening rate, incidence rate and mortality rate. We also summarized the information from UK and Canada cervical screening policy in order to compare the policies. The findings indicate that Pap smear test can effectively reduce mortality and incidence in cervical cancer from the experience of many countries. The International Agency for Research on Cancer (IARC) researches also indicated the effectiveness gains from once-per-year screening is about the same as that from onec-in-3 years. Several countries’ experience indicate that organized (active) screening used in Canada, UK has greater ability in detecting risk factor, which can effectively reduce mortality and incidence, comparing to the opportunistic screening used in the US. Taiwan has introduced Pap smear since 1960s, but until 1990s, especially after the implement of National Insurance Health, it was adopted generally. Due to the late implementation compared with the western countries, the impact of Taiwan’s cervical cancer screening is not as good as that of above-mentioned countries. Furthermore, owing to the differences in medical care system, medicine use, and health-seeking customs, the screening coverage rate in Taiwan is only 54% compared with the rate of 80% in those countries. Therefore, our government has to make more efforts in promoting cervical cancer screening. The recent new technical inventions such as liquid based cytology test, human papillomavirus test and human papillomavirus vaccine may have great effects on cervical cancer prevention. Of course, this will influence Taiwan’s cervical cancer prevention and our government should pay attention to the most up-to-dated development in the future. Several suggestions are made in our study. First, the government should change screening interval policy from once a year to once in three years based on evidence, and to introduce organized screening system into Taiwan. Second, the government may put the Pap smear test record in the NIH IC card, and separate the expenditure for health protection and prevention service from the NIH global budget system. Third, the government can integrate the cervical cancer examination service into family physician program, and the screening fee can be calculated based on the physician’s performance. Fourth, the government should amend related regulation, system and policies to meet patient’s needs, and should continuously encourage people to receive Pap smear test via public education. Finally, family doctors should provide flexible time for carrying out Pap smear tests to support the government’s policy, and the research team should be established to review and revise our cancer screening policies regularly in Taiwan.