大腸直腸癌篩檢對大腸癌發生、分期、醫療費用及預後影響

研究目的本研究目的探討醫院介入癌症篩檢前後結腸直腸癌個案在人口學、發生數、分期分布及存活趨勢變化，了解癌症篩檢計畫對結腸直腸癌發生、存活及醫療利用趨勢，探討國家癌症防治計畫在大腸癌防治業務推廣，對結腸直腸癌發生率、疾病分期、醫療資源耗用及結直腸癌個案存活之影響。研究方法本研究設計採回溯性研究，對象為南部某醫學中心癌症登記資料庫，原發部位為結腸直腸癌個案(ICD-O-3編碼為C18.0~C20.9)且臨床確診日期為2005年1月1日至2013年12月31日止個案，依結腸直腸癌個案清單進行病歷審閱區辨病人確診來源出自疾病就診或癌症篩檢轉介就醫，再勾稽疾病分類資料庫取得病人住院號、住院診斷碼、教育程度、婚姻狀況等住院就診及人口學資料後，再串聯住院批價費用及門診批價費用檔，使用SPSS 20.0版的統計軟體進行資料分析，以T-test、卡方檢定、迴歸分析、COX存活分析等探討人口學、疾病特質及癌症特質、治療方式等影響醫療資源耗用及存活差異。研究結果本研究確診為結腸直腸癌共有4707人，其中結腸直腸癌確診經由癌症篩檢發現者計550(11.7%)人，因有症狀就醫確診者為4157(88.3%),年齡部份，無篩檢組顯著長於有篩檢組分別為63.9±13.8歲及60.4±6.0歲(p<0.001)；性別比率部份，男性57.6%較女性42.4%多；癌症發生部位結腸癌53.6%直腸癌46.4%；有篩檢組癌症分期Ⅰ期有59.8%、Ⅳ期為7.3%相較於無篩檢組Ⅰ期19.5%、Ⅳ期24.2%(p<0.001)，顯示癌症篩檢能發現早期癌症；治療方式以手術加輔助治療最多佔50.2%，其次為純手術治療41.2%。大腸直腸癌確診數申報數由2005~2013年成長了44.1%。確診後第一年總費用無篩檢組高於有篩檢組，分別為NT$440,860±361,020元及NT$286,430±233,050元(p<0.001)；研究發現腸直腸癌醫療費用一期與二期在總醫療費用、住院費用上無顯著差異。門診費用與健保醫療費用微幅上升，自費醫療費用、門診次數、住院天數是下降的，顯示篩檢計畫成功的止住了大腸直腸癌確診第一年醫療費用成長。在存活率方面，有癌症篩檢病患一年、三年、五年存活率分別為95.1%、89.1%、85.9%，遠超過未篩檢組的84.1%、66.6%、58.1%，(Log rank <0.001)，有篩檢組五年存活率高無無篩檢組27.8%，顯示有無癌症篩檢對病患存活有顯著影響。結論與建議結腸、直腸癌病人隨著癌症防治政策推動時程有逐漸增加趨勢，研究結果發現人口學變項、疾病特性、癌症特性與病人確診後醫療資源耗用及與療效具有顯著相關，建議主管機關應持續積極整合政府與醫療機構資源，有效提高結腸直腸癌防治效益，為民眾健康把關，提高民眾確診後存活期。

關鍵字

大腸直腸癌；癌症篩檢；醫療資源耗用；存活率

並列摘要

Research purposes: This research is to discuss the changing patterns on demography, cancer stage distribution as well as survival rates before and after colorectal cancer screening program. Firstly, we purposed to learn how cancer screening appears on colorectal cancer causes, survival rates and medical treatment trends. Secondly, we discussed what national cancer preventive care plans will have affected on promoting colorectal cancer preventives, colorectal cancer incidence rates, colorectal cancer staging, medical resource consumption and colorectal cancer survival cases. Research methods: Subjects from one medical center in southern Taiwan with the primary-site case number ICD-O-3(code number C18.0~C20.9) from January 1st, 2013 to December 31st, 2015 were included into the study. Three steps are conducted to collect data: first, differentiate the cancer primary site which is no other than colorectal cancer no matter which individual colorectal cancer patient list in the record review room are from bowl disease check-up or from other cancer screening referrals. Second, look out disease category database to obtain subjects’ demography including inpatients’ patient numbers, disease codes, education levels, marital status…etc. Third, combine the subjects’ co-pay and deductible payment files to analyze data with SPSS 20.0 software. Finally, T-test, Chi-square test, regression analysis, and COX survival analysis are employed to probe how demography, nature of disease, nature of cancer, and therapies influence medical resource consumption and patient survival difference. Research summary: The research has shown that 11% (505 out of 4,707) colorectal cancer patients are from colorectal cancer screening, and 88.3% (4,157 out of 4,707) are from clinic symptom checkup. In terms of age, none-cancer screening versus cancer screening is 63.9±13.8 and 60.4±6.0 (p<0.001) individually which means none-cancer screening group has wider survival age range. As to gender ratio, males outnumber females at 57.6% versus 42.4%. As to cancer primary sites, colon cancer occupies 53.6% while rectal cancer is 46.4%. Subjects with cancer-screening at stage one is 59.8% and 7.3% at stage four; as to none-cancer screening, stage one is 19.5% and stage four is 24.2%(p<0.001). This shows that cancer screening can result early stage cancer findings. As to therapy, surgery with adjuvant therapy is no more than 50.2% and surgery without adjuvant therapy is 41.2%. Reported colorectal cancer cases have grown by 44.1% from 2005 to 2013. The first year therapy cost on none-cancer screening patients weighs more than those with cancer screening program. They are separately at NT $440,860±361,020 and NT $286,430±233,050 (p<0.001). However, there is no obvious expense difference at overall treatment and hospital between first stage and second stage. Subjects’ co-pay and public health insurance pay both go slightly up while subjects’ insurance deductibles, doctor visits, as well as days of hospital stays decrease. It appears cancer screening set back the growth on first stage therapy cost. When it comes to colorectal cancer survival rate, subjects’ survival rate with cancer screening in the first year, third year and fifth year are 95.1%, 89.1%, and 85.9%, respectively. Subjects with cancer screening exceeds none-cancer screening subjects because none-cancer screening survival rates are 84.1%, 66.6%, and 58.1%, respectively (Log rank p<0.001). Survival rate on subjects with cancer screening outpace none-cancer screening by 27.8%. This shows that cancer screening does make a clear difference at survival rate. Conclusions and suggestions: While cancer screening awareness is promoted, the numbers of colorectal cancer patients also increased gradually. It also showed that demographic variables, nature of disease, nature of cancer, medical resource consumption and therapies are highly correlated. Thus, health department should aggressively integrate other government authorities and medical institution resource to effectively improve colorectal cancer preventive care, to set up good medical guarding system and to increase the post-therapy survival rate.