- 學位論文
子宮內膜異位症與癌症的相關性
Endometriosis and the risks of cancers: a case-control cohort study in Taiwan
摘要
研究重點: 子宮內膜異位症定義為內膜長在子宮外面、骨盆腔和鄰近的器官，是被認為跟雌激素相關的疾病。子宮內膜異位症其發生率在有生育功能的女性約為6-10%且長久被視為一個良性的疾病。但是有一些文獻研究顯示出子宮內膜異位症和癌症有正相關性，像是卵巢癌、子宮內膜癌以及乳癌。其中可能原因為子宮內膜異位症本身會造成局部侵襲性和基因傷害，而這些和惡性腫瘤的細胞特性相類似。基於這些原因，想要探討在台灣子宮內膜異位症和癌症的關係以及手術是否是一個降低癌症相關性的保護因子。 方法: 此論文使用台灣健保資料庫兩百萬人抽樣檔串聯癌登檔及死因檔來統計台灣女性子宮內膜異位症和一般健康女性得到癌症的發生率的差別。子宮內膜異位症的定義為:門診追蹤的病人一年至少有兩次因為健保ICD-9-617(子宮內膜異位症)而前往就醫或是因為開刀証實有子宮內膜異位症的病患。排除條件:年紀小於18歲或是大於60歲的女性、子宮之前已被切除的病患、在子宮內膜異位症診斷之前已有癌症病史、子宮內膜異位症診斷90天內發現有癌症的患者。 經由此設計總共取得在西元2000年1月到西元2006年子宮內膜異位症的病患(人數=25,342)，並用配對1比4的方式來跟沒有子宮內膜異位症的健康女性比對(人數=101,368)。其中配對因子為如下: 年紀、糖尿病、高血壓、高血脂、停經症候群、肥胖、過重和Charlson合併症指標分數。進一步分析子宮內膜異位症患者和健康女性(沒有子宮內膜異位症)的整體癌症和分別種類癌症有無差異。 此外在子宮內膜異位症這個族群裡面利用前面的方法，將有開刀和沒有開過刀的病人，利用配對1比1和其配對因子來比較開刀有無是否會影響癌症的發生率。分別是:沒有開刀治療(人數=9,478)以及有開刀治療(人數=9,478) 而子宮內膜異位症的患者(人數=25,342)再細分成子宮內膜異位瘤(人數=5,091)、子宮肌腺症(人數=12,288)、子宮內膜異位瘤合併子宮肌腺症(人數=4,306)以及其他部位子宮內膜異位症(人數=3,657)。 而子宮內膜異位症的患者(人數=25,342)再細分開刀方式: 卵巢手術(人數=3,492)、切除子宮手術(人數=4,822)、卵巢合併子宮手術(人數=669)、子宮內膜異位症電燒(人數=495)以及沒有手術(人數=9,478)的族群。 結果: 台灣女性患有子宮內膜異位症其癌症整體發生率比一般健康女性來的高(p<0.001)。其中子宮內膜異位症的病人與得到大腸癌、乳癌、甲狀腺癌、卵巢癌和子宮內膜癌的風險性遠大於沒有子宮內膜異位症的女性(P<0.05)。其中子宮內膜異位瘤變成惡性卵巢癌的比率比其他族群高。而在開刀和沒有開刀的族群裡面，整體的癌症並沒有顯著統計學上的意義(P=0.5207 )。在內膜異位瘤的族群中卵巢癌的發生比其他群組來的高，而其他癌症並沒有差異性。在有開部分卵巢或是卵巢切除的病人，其卵巢癌發生率比沒有開刀或是開其他刀的族群高(P=0.0010)。 結論 台灣女性患有子宮內膜異位症其癌症整體發生率比一般健康女性來的高。而子宮內膜異位症長在卵巢的患者得到卵巢的風險性比其他族群來的高；在開刀和沒有開刀的族群裡面，整體的癌症並沒有顯著統計學上的意義。但是有開部分卵巢或是卵巢切除的病人，其卵巢癌發生率比沒有開刀或是開其他刀的族群高，但是還是需要更多的文獻支持此研究結果。
並列摘要
Purpose Endometriosis is defined as the endometrial tissues growing outside the uterine cavity, usually involving pelvic cavity and adjacent organs is considered as an estrogen-dependent disease. Endometriosis affects approximately 6-10% of reproductive-age women and is characterized to be a benign disorder in the decades. However, some studies have mentioned the possible link between endometriosis and cancer, such as ovarian cancer, endometrial cancer and breast cancer due to the malignancy-like behavior of endometriosis, the local invasion and genetic damages. Therefore, we analyzed the risks of endometriosis and associated cancers and to search whether operation is a protective factor or not. Material and Methods We conducted a population-based study using a 2-million-sample longitudinal health and welfare database, cancer Register and death registry in Taiwan. The patients were included with ICD-9-617 with endometriosis diagnosis in outpatient department clinics followed-up at least 2 times within one year or pathology improvement during operation. The exclusion criteria were as follows: age below 18 or above 60 years old, hysterectomy history, patients who have been previously diagnosed with cancer before endometriosis and patients with cancer diagnosed after endometriosis diagnosis within 90 days. We identified that 25,342 patients who were diagnosed with endometriosis between January 2000 to December 2006 with a 2-million-sample longitudinal health and welfare database. Patients with endometriosis (case group, N=25,342) were matched 1:4 with patients without endometriosis (control group, N=101,368) by their age, diabetes mellitus, hypertension, hyperlipidemia, menopause, obesity, overweight and Charlson comorbidity score. We followed each endometriosis and non-endometriosis patient until December 31, 2012. The Cox proportional hazards regression model was used to evaluate the occurrence event of cancers. The same analysis method was used for further evaluating the risk of operation in endometriosis patients. The endometriosis patients were divided into operation and non-operation groups. These two groups were matched with 1:1 by their age, diabetes mellitus, hypertension, hyperlipidemia, menopause, obesity, overweight and Charlson comorbidity score. The patients with endometriosis were divided into several groups depend on the implantation site, following as the endometriosis of uterus (N=12,288), endometriosis of ovary (N=5,091), endometriosis of uterus and ovary (N=4,306), other implantation sites (N=3,657). The endometriosis patients were divided into subgroups depends on operation, following as partial oophorectomy or oophorectomy (N=3,492), hysterectomy (N=4,822), partial oophorectomy or oophorectomy with hysterectomy (N=669), laparoscopic fulguration (N=495), and non-operation (N=9,478). Results Women with endometriosis in Taiwan had increased risk for development of cancers, particularly in colon cancer, breast cancer, thyroid cancer, ovarian cancer, and endometrial cancer. (P<0.05)。The ovarian cancer risk is increased in endometriosis of ovary group compared other groups. The overall cancer incidence is no significant different between endometriosis women with operation and non-operation (P=0.5207). The ovarian cancer is significant different in the subgroup of patients with endometriosis who have received partial oophorectomy or oophorectomy. (P=0.0010) Conclusion Our data showed women with endometriosis had increased risk for development of cancers. The ovarian cancer risk is increased in endometriosis of ovary group. Besides, operation in endometriosis patients showed no significant difference compared with non-operation in endometriosis patients. The risk of ovarian cancer is increased in endometriosis patients with partial oophorectomy or oophorectomy. However, we still need more studies to explain the connection between malignant diseases and endometriosis.