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標題: | 以乳房攝影品質保證指標推論乳癌篩檢需求與成果 Demand and Outcome Projection of Breast Cancer Screening Guided by Quality Assurance Mammography Programme |
作者: | Li-Sheue Chan 詹麗雪 |
指導教授: | 陳秀熙 |
關鍵字: | 乳癌篩檢,乳房攝影術,品質保證,逐步反向分析,國際乳癌篩檢網絡, mass screening for breast cancer,mammography,quality assurance,step-by-step backward analysis,International Breast Screening Network (IBSN), |
出版年 : | 2005 |
學位: | 碩士 |
摘要: | 前言: 雖然大規模乳癌篩檢在降低乳癌死亡率上的效益己經被證實,且國際乳癌篩檢網絡組織(International Breast Screening Network, IBSN)在乳房攝影術品質管制的努力也獲得肯定,但大規模乳癌篩檢在降低乳癌死亡率上與乳房攝影術品質管制的關係該如何聯結則鮮少被提出。此外,因應大規模乳癌篩檢的醫師人力供需平衡的問題也缺乏實證研究。
目的: 本論文主要目的有三,一、了解IBSN羅列之乳癌篩檢品質保證元素與主要結果之間的相關;二、利用問卷調查方式了解臺灣地區實證資料;三、利用調查所知醫師全職人力資料推估在大規模乳癌篩檢的需求下,臺灣地區醫師人力的供需平衡。 材料與方法: 由文獻查證的方式得到與乳癌篩檢相關的篩檢前期、篩檢期及篩檢後期的相關指標,並利用反向相關分析(Backward correlation analysis)了解其結構面、過程面及結果面的元素與篩檢成效指標之關聯性。為能了解臺灣地區乳房攝影的品質保證指標,我們針對85家國民健康局認為有能力執行乳房攝影術的醫療機構之乳房外科及放射科醫師做調查。此外,在全國乳癌篩檢的政策下,醫師人力的需求則利用馬可夫鏈樹狀圖進行推算。 結果: 在調整乳癌發生率後,影響乳癌死亡率的最重要結構面因子為乳房外科醫師執照(迴歸係數=-0.23,標準差=0.08,p=0.007),影響乳癌死亡率的最重要過程面因子為乳房攝影術為是否雙面(two views)照影(迴歸係數=-0.28,標準差=0.026, p<0.001),而最重要的結果面指標則是敏感度(迴歸係數=-1.813,標準差=0.9241, p=0.0498)。 逐步反向分析顯示淋巴結陽性比例會被篩檢間隔個案相對於發生率的比例所影響,而此比例又被敏感度及是否有標準化報告的選項所影響,敏感度則被乳房攝影術為是否雙面及重覆判讀所影響。 實際調查資料結果可以預測臺灣地區乳癌死亡率為每十萬人14.4例,非常接近現在臺灣地區的實際乳癌死亡率每十萬人11.32例。 在假設70%的參與率下,臺灣地區於六年期間乳房攝影術的需求量約為125萬張,依據臺灣地區現有醫師人力發現乳房外科約可承受110萬張而放射科醫師約可承受410萬張的需求量。若考慮全職人力(乳房外科醫師現有一人力約相當於貢獻於乳癌病人10%全職人力),則有約99名全職乳房外科人力於六年期間服務222名乳癌個案。 結論: 本研究針對乳房攝影術品質保證指標與死亡率降低之相關性做一連串探索,並利用此資料結合五階段乳癌自然史應用於臺灣地區實施乳房攝影術乳癌篩檢政策下人力供需平衡的推算。 Introduction. While mass screening for breast cancer with mammography in the reduction of mortality has been demonstrated and quality assurance mammography programme has been sponsored by International Breast Screening Network (IBSN) how the components of quality assurance mammography programme affect mortality or relevant outcomes has been rarely addressed. Demand and supply of manpower involved in breast cancer screening is also lacking given this programme. Objective. This thesis aimed (1) to investigate the relationships of components of quality assurance programme of breast cancer screening presented in the IBSN to relate outcome; (2) to conduct an empirical survey in Taiwan following the design inherent from the components of (1); and (3) to assess the balance between supply and demand in association with population-based breast cancer screening following information on full-time equivalent (FTE) and capacity of clinical manpower obtained from (2). Materials and Methods. Data on three dimensions related to pre-screening phase, screening phase and post-screening phase were extracted from literatures. The relationships of structural components, process components, and outcome components to main outcome were analyzed by ecological correlation study based on information collected from previous literatures by using backward correlation analysis. To make a better understanding of the components of quality assurance in Taiwan, we conducted a empirical survey aimed at target population from 85 institutions with mammography screening approved by Bureau of Health Promotion. In order to calculate the demand for mammography in national screening program, and disease burden, we used Markov cycle tree underpinning the five-sate Markov model for natural course of breast cancer to predict the required number. When dependent variables were of incidence of rare event, Poisson regression was conducted. For variables not of rare event, such as sensitivity, specificity, and prediction of positive value, etc., simple linear regression was used. Results. After controlling the underlying incidence rate, the most significant structural components responsible for mortality was licensure of breast surgeon (regression coefficient=-0.23 (SE=0.08), P=0.007). The most significant process components was the number of view to be taken on mammography examination (regression coefficient=-0.28 (SE=0.026), P < 0.001). The most important outcome components was sensitivity (regression coefficient= -1.813 (SE=0.9241), P=0.0498). Step-by-step backward analysis showed the proportion of node positive was determined by high interval cancer as percentage of the underlying incidence rate, which was, in turn, affected by sensitivity and nomenclature. Sensitivity was influenced by number of view to be taken and double reading. In addition, double reading and number of view to be taken play important role in situ detection rate. Based on the results from the empirical survey on components of quality assurance and the developed prediction equation, we predicted 27% proportion of node positive and 14.4/100,000 mortality given significant components for both radiologist and breast surgeon, which is closed to, but slightly higher, than ,11.32/100,000 mortality as observed in Taiwan now. Given 70% attendance rate, 1252544 mammograms are requested during six year period. The number of supply of manpower was 1120940 from breast surgeon and 4099788 from radiologists in six years. The demand of breast cancer for breast surgeon in treating disease was 21837 given 991 breast surgeons. Taking full-time equivalent time (FTE with only 10% breast surgeon get involved in breast cancer into account), approximately 99 FTE from breast surgeons will be involved in treating breast. This implies each FTE of breast surgeon may serve 222 breast cancers during six years. In conclusion, a series of quantitative models pertaining to the relationships of components of quality assurance mammography programme to mortality or related outcome. These models together with the five-state Markov model were further applied to analysis of demand and supply of mass screening for breast cancer with mammography in Taiwan. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/36615 |
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顯示於系所單位: | 流行病學與預防醫學研究所 |
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