4月9日,，《內(nèi)科學(xué)文獻(xiàn)》（Archives of Internal Medicine）發(fā)表的一項(xiàng)研究表明,，對(duì)于結(jié)直腸癌中危患者,，如果僅建議其進(jìn)行結(jié)腸鏡檢查,，則患者對(duì)篩查的依從性較低，而如果讓其自行從結(jié)腸鏡檢查和糞便潛血試驗(yàn)(FOBT)中選擇一種,，則患者對(duì)篩查的依從性較高,。
在這項(xiàng)研究中，華盛頓大學(xué)胃腸科的John M. Inadomi博士及其同事納入997例結(jié)直腸癌中危受試者,。研究者讓公共衛(wèi)生診所的初級(jí)保健醫(yī)生對(duì)例行就診的這些受試者隨機(jī)提出3種結(jié)直腸癌篩查建議之一：僅進(jìn)行結(jié)腸鏡檢查,，或僅進(jìn)行糞便潛血試驗(yàn)(FOBT)，或兩者選其一,。這些患者的平均年齡為58歲(50歲~79歲),，53%為女性，34%為西班牙裔,，30%為亞裔(主要為華人),、18%為美國(guó)黑人、15%為白人,、4%為其他人種/族裔,。
在FOBT組中，醫(yī)生為患者提供試劑盒,，并依照患者的習(xí)慣用語(yǔ)(英語(yǔ),、西班牙語(yǔ),、粵語(yǔ)或普通話)為其提供使用說(shuō)明，讓其回家自行檢查,，同時(shí)囑其遞交所有3份樣本,。在結(jié)腸鏡組中，也是依照患者的習(xí)慣用語(yǔ)為其提供有關(guān)該檢查和腸道準(zhǔn)備的標(biāo)準(zhǔn)信息,。同意結(jié)腸鏡檢查的患者被立即安排在2周內(nèi)接受檢查,，從而避免了通常阻礙篩查的檢查前胃腸科就診。如有必要,，診所還在檢查后為患者提供專車護(hù)送回家的服務(wù),。
總體而言，共有58%的患者完成醫(yī)生建議或其自行選擇的結(jié)直腸癌篩查,。結(jié)腸鏡組完成結(jié)腸鏡檢查的患者比例為38.2%,，顯著低于FOBT組完成FOBT檢查的患者比例(67.2%)和“自選”組完成自選篩查的患者比例(68.8%)。
不同人種/族裔背景的受試者的依從率存在顯著差異,。美國(guó)黑人的總體依從率最低(48%),，而西班牙裔(63%)和亞裔受試者(61%)的依從率最高。非白人受試者對(duì)FOBT的依從性較高,，而白人受試者對(duì)結(jié)腸鏡檢查的依從性較高,。講西班牙語(yǔ)、粵語(yǔ)或普通話的西班牙裔和華人受試者對(duì)篩查的依從性高于講英語(yǔ)的同一族裔受試者,。
該研究結(jié)果表明,，與讓患者在結(jié)腸鏡檢查和FOBT中選其一的策略相比，建議患者僅進(jìn)行結(jié)腸鏡檢查的策略實(shí)際上降低了篩查完成率,。另外,，在減少不利于患者獲取醫(yī)療服務(wù)的障礙后，低收入的少數(shù)族裔人群對(duì)結(jié)直腸癌篩查的依從性可達(dá)到較高水平,。
該研究獲美國(guó)國(guó)立癌癥研究所等多家機(jī)構(gòu)支持,。研究者聲明無(wú)相關(guān)經(jīng)濟(jì)利益沖突。（生物谷Bioon.com）
doi:10.1001/archinternmed.2012.332
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Adherence to Colorectal Cancer Screening:A Randomized Clinical Trial of Competing Strategies
John M. Inadomi, MD, MD; Sandeep Vijan, MD, MS, MD, MS; Nancy K. Janz, PhD, PhD; Angela Fagerlin, PhD, PhD; Jennifer P. Thomas, BS, BS; Yunghui V. Lin, RN, MA, RN, MA; Roxana Muoz; Chim Lau, BA, BA; Ma Somsouk, MD, MAS, MD, MAS; Najwa El-Nachef, MD, MD; Rodney A. Hayward, MD, MD
Background Despite evidence that several colorectal cancer (CRC) screening strategies can reduce CRC mortality, screening rates remain low. This study aimed to determine whether the approach by which screening is recommended influences adherence.
Methods We used a cluster randomization design with clinic time block as the unit of randomization. Persons at average risk for development of CRC in a racially/ethnically diverse urban setting were randomized to receive recommendation for screening by fecal occult blood testing (FOBT), colonoscopy, or their choice of FOBT or colonoscopy. The primary outcome was completion of CRC screening within 12 months after enrollment, defined as performance of colonoscopy, or 3 FOBT cards plus colonoscopy for any positive FOBT result. Secondary analyses evaluated sociodemographic factors associated with completion of screening.
Results A total of 997 participants were enrolled; 58% completed the CRC screening strategy they were assigned or chose. However, participants who were recommended colonoscopy completed screening at a significantly lower rate (38%) than participants who were recommended FOBT (67%) (P < .001) or given a choice between FOBT or colonoscopy (69%) (P < .001). Latinos and Asians (primarily Chinese) completed screening more often than African Americans. Moreover, nonwhite participants adhered more often to FOBT, while white participants adhered more often to colonoscopy.
Conclusions The common practice of universally recommending colonoscopy may reduce adherence to CRC screening, especially among racial/ethnic minorities. Significant variation in overall and strategy-specific adherence exists between racial/ethnic groups; however, this may be a proxy for health beliefs and/or language. These results suggest that patient preferences should be considered when making CRC screening recommendations.
