越来越多的科学共识认为，乳腺钼靶对避免乳腺癌死亡有一定影响，同时使女性面临一些危害【1】。然而，尚不明确普通女性如何看待乳腺钼靶筛查的利弊。虽然既往研究已经报道了公众对筛查的热情和对危害的低估，但是这些发现可能已经过时【2-4】。
2017年6月26日，《美国医学会杂志内科学分册》在线发表明尼苏达大学、卫斯理大学、旧金山加利福尼亚大学的2016年全国调查结果，剖析了普通女性在大众媒体有关癌症的信息影响下，如何看待乳腺钼靶筛查的利弊。
参与调查者由GfK入组，GfK是一家总部位于德国纽伦堡的调查研究机构，其维护着大约5.5万成年人的随机抽样数据库。GfK根据地址随机抽样入组，并向完成调查的入组者提供小额经济奖励。2016年5月24日～6月6日，1519位（51%）被随机选择参与的符合条件入组者完成了在线调查。本文报告的数据仅限于40～59岁美国女性407人，其收到关于对乳腺钼靶利弊认知、对这些利弊评价的单独问卷表格。问题分组及其项目均为随机。在回答这些项目之前，受访者回答了关于其普通和乳腺钼靶相关新闻和健康媒体消费的问题。她们还回答了2个问题（是否接受过乳腺钼靶、最近何时接受乳腺钼靶检查乳腺癌），以构成3类乳腺钼靶检查史：1、从未接受过乳腺钼靶，2、一年多以前，3、不到一年前。使用有序分对数回归，通过乳腺钼靶检查史，检验对重要性评价的差异。采用GfK调查权重，校正无反馈偏倚和无反馈入组者，以估计全国的代表性。本研究由明尼苏达大学伦理委员会确定免除审查。
结果发现：
其中58人（14.2%）从未接受乳腺钼靶，197人（56.4%）过去一年内接受乳腺钼靶，103人（29.4%）一年多以前接受乳腺钼靶。
几乎所有受访者（366，＞90%）都认知乳腺钼靶的4项益处。
当被要求评价其重要性时，超过半数（223，54.8%）认为每项益处都“非常重要”。然而，受访者对危害的关注度差异较大。
虽然仅108人（26.5%）和161人（39.7%）关注过度诊断和过度治疗，但是305人（74.9%）关注假阳性结果和潜在心理困扰。
与其对益处的评价相反，较少女性将危害评为非常重要，范围从关注医疗费用61人（15.1%）到关注过度治疗117人（28.7%）。
年龄组（40～49岁比50～59岁）之间的关注度或重要性评级无统计学显著差异。
过去一年内接受乳腺钼靶与从未接受乳腺钼靶的女性者相比：
显著较多地将所有的益处评为非常重要（62.4%～74.9%比44.9%～58.0%，P＜0.05）。
显著较少地将费用和辐射评为非常重要（11.5%和15.1%比22.9%和25.7%，P＜0.05）。
因此，女性对乳腺钼靶益处的关注大于对危害的关注，最近接受乳腺钼靶的女性更有可能将这些益处评为重要。这可能由于来自医生【5】、公共卫生官员、新闻媒体、疾病宣传组织的信息缺乏平衡，长期以来强调筛查的益处。本研究结果表明，在普通公众和个体层面，都有机会进行有的放矢的教育和沟通，着重教育女性筛查的危害，因为她们更有可能体验益处。然而，女性事实上倾向于将益处视为比危害更重要，对筛查的知情决策构成挑战，表明需要新的形式对利弊累积风险进行沟通。
JAMA Intern Med. 2017 Jun 26. [Epub ahead of print]
Women's Awareness and Perceived Importance of the Harms and Benefits of Mammography Screening: Results From a 2016 National Survey.
Jiani Yu, Rebekah H. Nagler, Erika Franklin Fowler, Karla Kerlikowske, Sarah E. Gollust.
University of Minnesota, Minneapolis; Wesleyan University, Middletown, Connecticut; University of California-San Francisco, San Francisco.
This survey study examines how women in the general US population perceive the benefits and harms of mammography screening.
There is growing scientific consensus that mammography has a modest impact on averting deaths from breast cancer, while exposing women to a number of harms.[1] Yet it is not well known how women in the general US public perceive the benefits and harms of mammography screening. Previous research has been published on public enthusiasm for screening and underestimates of harms, but these findings may be outdated.[2-4] In this study, we present 2016 data on women's awareness and perceptions of the benefits and harms of mammography, drawn from a larger survey of US adults on exposure to cancer-related information in the media.
METHODS: Study participants were recruited by GfK, a survey research firm that maintains a probability-based panel of approximately 55000 adults. GfK recruits panel participants through address-based probability sampling and provides small financial incentives to panel members for completing surveys. Among eligible panelists randomly selected to participate, 1519 (51%) completed the online survey between May 24 and June 6, 2016. Data reported herein are restricted to US women aged 40 to 59 years (n=407) who received a stand-alone module about (1) awareness of the benefits/harms of mammograms, and (2) evaluations of the importance of these benefits/harms (Table 1 and Table 2). Both the question blocks, and the items within these blocks, were randomized. Prior to these items, respondents answered questions about their general and mammogram-related news and health media consumption. They also answered 2 items ("have you ever had a mammogram" and "when did you have your most recent mammogram to check for breast cancer"), which we used to construct 3 categories of mammogram history: (1) never had a mammogram, (2) had over a year ago, and (3) had less than a year ago. We tested for differences in importance evaluations by mammogram history using ordered logit regression. Analyses applied the GfK survey weights to adjust for nonresponse bias and panel nonresponse to produce nationally-representative estimates. The study was determined to be exempt from review by the University of Minnesota institutional review board.
RESULTS: Fifty-eight (14.2%) participants reported never having a mammogram, 197 (56.4%) reported having a mammogram within the past year, and 103 (29.4%) reported having a mammogram less recently. Nearly all respondents (366, >90% for each) were aware of 4 statements describing mammography benefits (Table 1). When asked to rate their importance, most (223 [54.8]) concluded that each benefit was "very important." Respondents' awareness of harms, however, was much more variable (Table 2). Although only 108 (26.5%) reported prior awareness of overdiagnosis and 161 (39.7%) of overtreatment, 305 (74.9%) were aware of false-positive results and the potential of psychological distress. In contrast to their evaluations of benefits, fewer women rated harms as very important, ranging from 61 (15.1%) (health care system costs) to 117 (28.7%) (overtreatment). There were no statistically significant differences in awareness or ratings of importance by age group (40-49 years vs 50-59 years). Women who reported having a mammogram within the past year were significantly more likely to rate all 4 benefits as very important, compared with those who who never had a mammogram (62.4%-74.9% vs 44.9%-58.0%; differences significant at P<0.05). Women who reported having a mammogram within the past year were significantly less likely to rate health care system costs and radiation harms as very important compared with those who never had a mammogram (11.5% and 15.1% vs 22.9% and 25.7%; differences significant at P<0.05).
DISCUSSION: Women are more aware of the benefits of mammography screening than the harms, and women who have recently undergone mammography are more likely to judge these benefits as important. This may be owing to a lack of balanced information from physicians,[5] public health officials, news media, and disease advocacy groups that have long emphasized screening's benefits. Our findings suggest that there are opportunities for targeted education and communication at both the general public and individual levels, with a focus on educating women on the harms of screening, which they are much more likely to experience than benefits. However, the fact that women are predisposed to consider benefits as more important than harms poses a challenge to informed decision making about screening, suggesting the need for new paradigms in communicating the cumulative risks of the benefits and harms.
1.Pace LE, Keating NL. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA. 2014;311(13):1327-1335.
2.Schwartz LM, Woloshin S, Fowler FJ Jr, Welch HG. Enthusiasm for cancer screening in the United States. JAMA. 2004;291(1):71-78.
3.Hoffmann TC, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175(2):274-286.
4.Schwartz LM, Woloshin S, Sox HC, Fischhoff B, Welch HG. US women's attitudes to false positive mammography results and detection of ductal carcinoma in situ: cross sectional survey. BMJ. 2000;320(7250):1635-1640.
5.Wegwarth O, Gigerenzer G. Less is More: overdiagnosis and overtreatment: evaluation of what physicians tell their patients about screening harms. JAMA Intern Med. 2013;173(22):2086-2087.
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