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研究生： 李致慧
Lee, Chih-Hui
論文名稱： 上消化道內視鏡檢查間隔與胃癌死亡率的相關性
Association between Panendoscopic Examination Interval and Gastric Cancer Mortality
指導教授： 呂宗學
Lu, Tsung-Hsueh
學位類別： 碩士
Master
系所名稱： 醫學院 - 公共衛生學系
Department of Public Health
論文出版年： 2016
畢業學年度： 104
語文別： 中文
論文頁數： 64
中文關鍵詞： 胃癌 、上消化道內視鏡 、胃鏡 、檢查間隔 、整體死亡風險 、存活分析
外文關鍵詞： gastric cancer, panendoscopy, gastroscopy, examination interval, hazard ratio, all-cause mortality, survival analysis
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    • 研究目的：了解台灣胃癌病人接受上消化道內視鏡檢查的檢查間隔是否與胃癌的整體死亡率有顯著的相關
    研究方法：本研究資料來源為健保資料庫2000年百萬歸人檔，資料區間1997-2012年。此研究胃癌個案採「國際疾病分類臨床診斷碼第九版ICD-9」來定義，凡2000-2007年之間，住院與門診主次診斷碼新出現151.0-151.9，串聯重大傷病檔登錄註記，即確認為胃癌新診斷個案。個案基本資料包括年齡、性別、投保地區、投保金額、重大共病等。胃癌個案於診斷前使用上消化道內視鏡檢查的時間與次數，利用住院醫療費用醫令清單明細檔、門診處方醫令明細檔來進行資料建檔並分組。胃癌個案在診斷後一年內是否接受胃切除手術也納入變項分析。個案追蹤至2012年，五年期間的死亡事件。死亡事件以承保資料檔、重大傷病證明明細檔、住院醫療費用清單明細檔來確認。最後，分析五年整體死亡風險與診斷前使用上消化道內視鏡檢查的時間間隔與次數各組間的相關性。
    結果：本研究顯示胃癌病人將近8成在診斷胃癌前半年到五年之內，從未接受上消化道內視鏡的檢查。依照診斷前的上消化道內視鏡檢查間隔分組，胃癌診斷前兩年內接受上消化道內視鏡檢查組(兩年組)與從未檢查組(Never組)，五年整體死亡風險相近HR=1.02(95% CI 0.79-1.33；p=0.86) 。胃癌診斷前兩年到五年以內接受上消化道內視鏡檢查組(五年組)，五年整體死亡風險較Never組顯著為低HR=0.56 (95% CI 0.44-0.71；p<0.0001)。若將上消化道內視鏡檢查次數納入考慮，五年組接受兩次以上的消化道內視鏡檢查組，其五年整體死亡風險比上Never組為最低HR=0.48 (95% C.I. 0.35-0.66; p<.0001)。
    結論：在胃癌診斷前兩年到五年之內有接受上消化道內視鏡檢查之胃癌個案，經過年齡、性別、投保資料、共病、胃切除手術等因素的調整之後，整體死亡風險較低。顯示此間隔的上消化道內視鏡檢查是胃癌預後的獨立影響因子。而執行上消化道內視鏡的次數對胃癌的整體死亡風險也有保護作用。

    SUMMARY
    We sought to examine the interval of gastric cancer (GC) patients received panendoscopic examination before cancer diagnosis and their all-cause mortality. Gastric cancer patients were identified from Taiwan's National Health Insurance Research Database (NHIRD) between 2000 and 2007 from the milliona. A total of 1054 newly diagnosed GC patients were classified into different cohorts according to the time intervals in which they had received panendoscopy prior to the diagnosis. These GC patients were classified into the following cohorts according to the interval they received panendoscopic examination prior to cancer diagnosis: 6-24months (2Yr group), 24-60 months (5Yr group), and no examination before 6M and within 5 years (Never group). Nearly 80% patients of gastric cancer in Taiwan never received an upper gastrointestinal endoscopy examination prior to six months of the cancer diagnosis. After adjusting sex, gender, insurance data, comorbidity, and post-GC surgical treatment, hazard ratios (HRs) of 5-year all-cause mortality were calculated. Compared with "Never group", the "5Yr group" had significant better survival outcome; HR=0.56 (95% CI 0.44-0.71；p<.0001). And hazard ratio of all-cause mortality was even lower in patients received more than twice examination for the "5Yr group"; HR=0.48 (95% C.I. 0.35-0.66；p<.0001). However, the beneficial effect was not prominent in "2Yr group", which was classified as the shorter examination interval prior to the GC diagnosis; HR=1.02 (95% CI 0.79-1.33；p=0.86). Evidences have showed that the interval between the most recent benign panendoscopy and the diagnosis of gastric cancer is an independent risk factor for gastric cancer outcome. The number of gastrointestinal panendoscopy performed prior the cancer diagnosis also had a protective effect on the risk of all-cause mortality in gastric cancer patients. These were important findings which deserve further evaluations.

    第1章 前言…………………………………………………………………………..1 第2章 文獻探討…………………………………………….……………………………..2 2.1胃癌的流行病學與危險因子…............………….……………2 2.1.1以全球的觀點看胃癌的發生率與死亡率……….....…………………………...2 2.1.2亞洲與我國的胃癌流行病學……………….........................…………………...3 2.1.3胃癌的主要危險因子…………….........................…………….......................... 4 2.1.4 小結………………………………………................................………………...7 2.2胃癌的早期診斷與篩檢…..........……………………………..7 2.2.1非侵入性的胃癌篩檢方式……………………...................…………………….7 2.2.2上消化道內視鏡篩檢胃癌…………………………………...............………….9 2.2.3亞洲的胃癌篩檢計畫… ………… …………………………............................10 2.2.4小結……………………………………………………………………..............13 2.3上消化道內視鏡篩檢間隔與胃癌的預後… ……………………...…............14 2.3.1上消化道內視鏡篩檢間隔與胃癌的死亡率................…………………….….15 2.3.2上消化道內視鏡篩檢間隔與胃癌發現期別................. ...............…………….17 2.3.3小結………………………………….........................................……………….19 2.4 文獻查證小結………………………………………………………………..20 第3章 研究問題………….………………………………………………………………21 第4章 研究方法……………………….………………………………………………....22 4.1 資料來源……………………………………………………………………..22 4.2 個案定義……………………………………………………………………..22 4.3 研究設計與資料分析………………………………………………………..24 4.3.1 胃癌個案的基本特徵分析.................................................................................25 4.3.2 胃癌個案五年死亡風險與存活率分析.............................................................25 第5章 研究結果……….…………………………………………………………………26 5.1.胃癌個案的基本特徵分析....................................………………………...26 5.2胃癌個案的五年死亡風險分析..................................................………………….27 5.2.1使用上消化道內視鏡間隔分組........................................................27 5.2.2使用上消化道內視鏡間隔與次數分組 …………………………….....28 第6章 討論…………………….………………………………………………………....30 6.1 研究主要發現………………………………………………………………..30 6.2 與過去研究結果比較...............................................................30 6.2.1上消化道內視鏡在胃癌的篩檢與診斷……………………………………….30 6.2.2胃切除手術的胃癌個案死亡風險較低.....…………………………………….32 6.2.3消化性潰瘍與胃癌預後的關係...........................……………………………..33 6.3 研究限制與未來方向………………………………………………………..34 第7章 結論……………….………………………………………………………………35 第8章 參考文獻………….…………………………………........………………………36 表………………………………………………………………………………40 圖……………………………………………………………………………………52

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