摘要
近年来,随着我国人口老龄化、饮食结构的变化以及在结直肠癌监测与管理方面不完善、防治体系相对薄弱,结直肠癌的发病率和死亡率呈迅速上升趋势。在目前结直肠癌治疗手段尚未取得突破性进展的情况下,三级预防是降低结直肠癌发病率和死亡率的重要手段。如何建立以结直肠癌筛查和早渗早治为重点、中医在结直肠癌的防治中的全程干预、普及结直肠癌防治知识的三级防治网络,降低结直肠癌的发病率和死亡率,是当前结直肠癌防治研究的热点。本课题来源于北京市“首都医学科技发展基金项目(编号：SF-2007-I-05)：“基于信息协作平台的结直肠癌中西医结合三级防治体系的研究”中的社区结直肠癌中医慢病管理信息协作平台建设部分。通过对城市社区居民的问卷调查、结直肠癌筛查研究,进行业务目标及系统需求设计,将中医养生、食疗及结直肠癌高危人群干预、结直肠癌患者的中医康复治疗等移植到社区结直肠癌慢病管理方案中,借助信息技术和数据库管理技术,实现社区人群的防癌健康教育、结直肠癌筛查、高危人群干预、检查预约、转诊以及社区医生的技术培训网络化、信息化,以期大幅提高结直肠癌防治的工作效率,降低医务人员的工作强度。对社区结直肠癌中医慢病管理信息化、网络化进行探索和研究,加强社区结直肠癌中医慢病管理能力。本文主要由四部分组成
第一部分文献研究包括两篇综述。
综述一对区域卫生信息化的现状、存在的问题、发展趋势以及我国在区域卫生信息化方面的政策进行了分析和研究。综述二了解目自订结直肠癌发病特点及结直肠癌筛查方法,为社区结直肠癌中医慢病管理信息系统建设选取适合我国国情的结直肠癌筛查方案。
第二部分居民肿瘤防治知识认知程度及肿瘤三级防治网络可行性研究
目的：通过990例社区居民进行问卷调查,了解居民对肿瘤防治知识的认知程度、对中医药在肿瘤防治中的作用和就诊行为流向,寻找普及防癌健康教育及实施肿瘤“三早”策略的有效途径,为社区结直肠癌中医慢病管理信息系统业务和系统需求设计提供依据。
方法：选取参加肿瘤科普知识讲座的北京“抗癌乐园”会员及参加社区结直肠癌的筛查的社区居民共990名,进行肿瘤防治科普知识及建立肿瘤三级防治体系可行性的的结构化问卷调查,用SPSS13.0软件进行统计分析。
结果：在肿瘤科普宣传是否充分方面,选择不充分的人群高达88.9%。对肿瘤的防治知识认知程度分析结果显示,只有21.4%的人表示知道癌前病变,32%的人了解肿瘤的早期症状,38.9%的人知道肿瘤高危人群的概念。关于中医养生是否有助于肿瘤的预防,74.4%的被调查者认为中医养生有利于建立良好的生活习惯,对肿瘤的预防有正面的效应。在肿瘤三级防治网络是否可行的调查中,93.4%的人认为可行,87.3%的被调查人表示会参加。93%的人认为有必要进行社区肿瘤筛查,97.6%的人表示会参加筛查。在肿瘤发现及确诊医院类别中,选择三级综合医院和肿瘤医院的患者超过80%,在548名肿瘤患者中83.7%的患者接受过或正在接受中医治疗。在如何发现肿瘤方面,有73.3%的患者是因身体不适才到医院就诊诊断的,仅有19.0%的患者是单位体检时发现并诊断的。
结论：社区居民防癌意识强,但缺乏正确的癌症防治知识,中医在养生及癌症防治方面有着良好的群众基础,缺乏权威的覆盖面广的肿瘤科普宣传,传统肿瘤防治监控网络效率低下。利用媒体、网络优势,加大肿瘤防治知识的宣传力度,建立以癌症筛查和早诊早治为重点,社区、区域二级医院、三级医院优势互补的三级肿瘤防控体系,是当前肿瘤防控的迫切要求。第三部分城市社区结直肠癌筛查研究及高危人群随访结果分析
目的：在北京市海淀区两个社区进行结直肠癌筛查实践研究,通过分析不同类型城市社区筛查结果,探索适合我国城市社区的结直肠癌筛查模式,从居民、社区医务人员、二、三级医院医务人员、肿瘤防治机构、医疗保险机构及政府管理部门等角度进行业务需求分析,并提出针对性的解决方案。为社区结直肠癌慢病管理信息系统业务目标设计及系统需求设计提供依据。
方法：采用《中国癌症筛查及早诊早治技术方案(试行)》2009年第一版结直肠癌筛查方案,2010年6-9月在北京市海淀区两个社区进行结直肠癌筛查,对象为户籍所在地在筛查区域内,年龄为40-74岁的社区居民,筛查目标人群为3002人,共有1414名社区居民参加了筛查；筛查结果采用SPSS13.0软件进行统计学分析。
结果：在3002名目标人群中,共有1414人完成了问卷调查,问卷顺应性为47.1%有1105人完成FOBT检查,FOBT顺应性36.8%。两组高危人群大肠癌初筛顺应性比较,中央民族大学社区初筛顺应性高于双榆树社区,差异有统计学意义(P<0.05)
1414名社区人群中,筛查出高危人群366人,初筛阳性率25.9%,两个社区的问卷阳性率及FOBT阳性率比较,双榆树社区初筛阳性率明显高于中央民族大学社区。
366例高危人群中,共65例参加了全结肠镜复筛,肠镜检查顺应性17.8%,肠镜早期癌及癌前病变总检出率32.3%。中央民族大学肠镜检查顺应性明显高于双榆树社区；结直肠癌及癌前病变检出率对比,P>0.05,无统计学意义。
258例结直肠癌高危人群进行干预,初筛后有11例高危人群接受肠镜检查。进行电话随访及社区健康讲座干预后,共有21例高危人群接受肠镜检查,干预前后肠镜检查顺应性比较,P<0.05,有统计学意义。
结论：提高公众对大肠癌筛查的认识、对筛查相关知识的了解程度越高,筛查顺应性就越高。探索更便捷、高效的筛查方法,优化筛查方案,简化筛查流程,对社区医务人员进行有效的癌症防治知识的培训,可以提高社区结直肠癌慢病管理效率和水平。
第四部分基于信息协作平台的社区结直肠癌中医慢病管理模式的方案研究
目的：通过建立适用共享的社区结直肠癌中医慢病管理信息系统,健全癌症预防及康复治疗网络。发挥中医药在结直肠癌防治中的作用,促进分级医疗和双向转诊制度的实施,实现一、二、三级医院信息的互联互通、共建共用和业务联动,实现对服务对象的长期、连续追踪管理,提高服务效率和管理能力。同时提高医疗机构的医疗服务质量和服务效率,带动整体结直肠癌防治水平的提高。
方法：以上述两个研究为基础,根据业务目标设计和系统需求分析,以中医理论的为指导,结合西苑医院肿瘤科制定的结直肠癌防治中医干预方案,将中医养生、食疗及结直肠癌高危人群干预、结直肠癌患者的中医康复治疗等在结直肠癌防治中积累的丰富经验移植到社区结直肠癌慢病管理方案中,借助信息技术和数据库管理技术,实现社区人群的防癌健康教育、CRC筛查、高危人群干预、检查预约、转诊以及社区医生的技术培训网络化、信息化,对系统功能模块进行详细实施和构建,实现系统基本架构和数据库结构,完成信息系统开发。由合作单位北京康途尚邦健康科技有限公司负责社区结直肠癌中医慢病管理信息系统的建设和实现。
结论：社区结直肠癌中医慢病管理信息系统采用B/S模式设计,配置简单,易于安装和维护。整个信息协作平台共用一个医疗数据中心,消除了传统模式下医疗信息孤岛,社区人群的防癌抗癌信息资源得到有效共享,也保证了社区人群得到防癌信息的权威性、准确性和持续性。使社区医务人员的肿瘤防治技术培训在工作中实现,解决了肿瘤防治知识专业性强,社区医务人员肿瘤防治知识匮乏的难题。实现分级医疗、双向转诊预约功能,使医疗资源的利用最大化、配置合理化。同时社区结直肠癌中医慢病管理信息系统可以和医疗管理部门、医疗保险机构、肿瘤登记机构链接,为肿瘤防治政策制定、医疗资源合理分配、诊疗绩效分析提供数据支持。
Background:With the aging of our population, diet changes and economic conditions continued to improve, the imperfect monitoring and management of colorectal cancer, prevention and control system of colorectal cancer is relatively weak, morbidity and mortality of colorectal cancer showed a rapid upward trend in recent years. In the case of colorectal cancer treatment has not been a breakthrough, three prevention is an important means to reduce colorectal cancer morbidity and mortality. It is a research focus how to create network on prevention and treatment of colorectal cancer based on colorectal cancer screening, early diagnosis and early treatment to reducing the morbidity and mortality of colorectal cancer. This study comes from Capital's Medical Science and Technology Development Fund of Beijing (No.:SF-2007-Ⅰ-05).This portion is system about colorectal cancer of Chinese medicine chronic disease management in community based on the information collaboration platform,a part Study of Tertiary prevention and control system of the colorectal cancer based on information collaboration platform. In this management program, we join the content about healthcare and diet therapy of TCM, intervention of colorectal cancer in high-risk groups and colorectal cancer patients by traditional Chinese medicine rehabilitation therapy. With the help of IT and database management techniques,we realize the community population health education for cancer prevention, screening for colorectal cancer, intervention of high-risk groups, Colonoscopy appointments, referral and community physicians' technical training in this information platform. In order to improve efficiency of colorectal cancer prevention and control, reduce the working strength of the medical personnel. To explore and research model On the community of colorectal cancer TCM chronic disease management, strengthening management ability of colorectal cancer in community.
This paper consists of four parts.
Part I include two review. A review of Regional Health Information is mainly described the status and trends of regional health information in domestic and international,as well as informatization policies in regional health our country.The other one introduces epidemiology of colorectal cancer and methods of colorectal cancer screening,in order to select suitable program for information system on colorectal cancer's TCM chronic disease management in community.
Part II Investigation on the Cancer Prevention and treatment knowledge level of of residents and the feasibility study of establishment tumor's tertiary prevention and control network.
Objective:By way of questionnaire survey for community residents, to know the current awareness of cancer prevention knowledge, the status of TCM in cancer prevention and therapy, hospital's choosing of residents in cancer therapy behavior, looking for effective way to anti-cancer health education.
Methods:Conducting structured questionnaires survey for990case community residents in Haidian District of Beijing, with SPSS13.0software for statistical analysis.
Results:Population who choose the inadequate In popular science propaganda promotion of tumor accounted for88.9%. Analysis showed that only21.4percent said they know of precancerous lesions,32%of people know the early symptoms of the tumor,38.9%of people know the concept of tumor high risk population,74.4%of respondents believe that TCM have a positive effect on cancer prevention. About93.4%of people considered three prevention network of tumor was feasible in the investigation, and87.3%of those surveyed indicated that they would participate.93%of people think that there is a need for community cancer screening,97.6%said they would participate in screening. In tumor detection and diagnosis of hospital category, more than80%select the three general hospitals and Cancer Hospital patients.83.7%of patients in the548cancer patients have received or are receiving TCM treatment.73.3%of cancer patients go to see a doctor for diagnosis and treatment because of physical discomfort, only19.0%of patients are found and diagnose in health examination t.
Conclusion:Community residents have a strong awareness of preventing cancer generally, but they lack of proper cancer prevention knowledge. Traditional Chinese medicine has a good mass base in healthcare, prevention and control of cancer. Traditional prevention monitoring network of tumor is inefficiency. It is the urgent requirements of tumor prevention currently that expanding publicity about cancer prevention knowledge by means of media and Internet,to establish a novel prevention and control system of tumor.
Part III City community screening for colorectal cancer and follow-up results analysis of high risk population
Objective:by analyzing results of colorectal cancer screening in different type community of city, to explore the model of colorectal cancer screening for city community of our country, providing basis for the design of system demand and medical program of colorectal cancer TCM chronic disease management information system.
Methods:Accord to "The Chinese cancer screening in the early diagnosis and early treatment technology program (Trial)",we make colorectal cancer screening from June to September,2010, in two community of Haidian District for the age of40-74, community residents, there are1414community residents participating in the screening; screening results were analyzed statistically by SPSS13.0software.
Results:There are1414cases who completed the questionnaireIn3002cases target population,1105cases completed FOBT check. Questionnaire compliance was47.1%, FOBT compliance was36.8%. Comparing compliance of two communities for colorectal cancer screening, the difference was statistically significant (P<0.05).366high-risk groups was screened in1414Community population, positive rate was25.9percent. Comparing the questionnaire and FOBT positive rate of the two communities, Shuangyushu community's screening positive rate was significantly higher than that the communities of the Central University for Nationalities.
A total of65cases of participants in rescreening of colonoscopy In366cases high-risk groups, colonoscopy compliance was17.8%. The total detection rate of colonoscopy for early cancer and precancerous lesions is32.3%. The community of Minzu University of China was significantly higher than the Shuangyushu community In the respect of colonoscopy compliance. The detection rate of colorectal cancer and precancerous lesion was not statistically significant.
258cases high risk population of colorectal cancer was intervented by telephone follow-up and community health lecture. A total of21cases of high-risk groups received colonoscopy, Comparison of colonoscopy compliance before and after intervention was statistically significant, P<0.05.
Conclusion:It is very important to raise community residents'public awareness of colorectal cancer screening. The higher the degree of understanding of screening-related knowledge, higher screening compliance. It can improve colorectal cancer chronic illness management efficiency and level of the community to explore more convenient and efficient screening methods, optimizing the screening program, simplified screening process, to strengthen the community medical personnel training.
Part IV Design and construction of community colorectal cancer TCM chronic disease management model based on the information collaboration platform community program
Objective:Constructing network of cancer prevention and rehabilitation by way of establishing suitable community colorectal cancer TCM chronic disease management information system. Play the role of Chinese medicine in prevention and treatment of colorectal cancer. Promoting the implementation of the classification of medical and two-way referral system, to achieve the interoperability of information in tertiary hospitals, to implement continuous tracking management of the service object's long-term. Improving the medical service quality and efficiency of medical institutions, to improve the level of overall colorectal cancer prevention by raising efficiency and management capabilities.
Methods:This part incolude the design for TCM intervention programs of colorectal cancer and Construction of information system mainly. We designed TCM intervention program of colorectal cancer in community according to the colorectal cancer TCM treatment program of Xiyuan Hospital's oncology Department, we join the content about healthcare and diet therapy of TCM, intervention of high-risk groups in colorectal cancer and colorectal cancer patients by traditional Chinese medicine rehabilitation therapy. With the help of IT and database management techniques, we realize the community population health education for cancer prevention, screening for colorectal cancer, intervention of high-risk groups, Colonoscopy appointments, referral and community physicians' technical training in this information platform. Based on the former two study, Beijing Kang Tu Shang bang health Technology Co., Ltd. is responsible for the construction of the information system for TCM chronic disease management of colorectal cancer.
Conclusion:Community colorectal cancer Chinese medicine chronic disease management information system with B/S model design, is easy to install and maintain. Information collaboration platform may share medical data center, eliminating the traditional model of medical information silos. Community population of anti-cancer information resources are effectively shared. It also ensure that anti-cancer information is authoritative, accurate and continuous. Community medical staff were trained In the working process. It resolved the problem of community medical staff lack of the cancer prevention and treatment knowledge. This system also realizes the function of two-way referral medical appointment.the utilization of medical resources is maximized, rational distributed. At the same time the community colorectal cancer TCM for chronic disease management information system link with the medical management departments, medical insurance agencies, cancer registration agency, to provide data support for diagnosis and treatment performance analysis, the rational allocation of medical resources.
引文
[1]李华才.区域信息网络是构建医疗卫生信息资源共享的平台[J].中国数字医学,2007,2(7)：1.
[2]杨钰晨.数字卫生信息化建设浅谈[J].科技前沿,2011,7(上)：39-40.
[3]杨宏桥,卜海兵等.基于本体的区域医疗信息系统设计[J].计算机工程,2009,35(11)：283-285.
[4]Gartner.区域卫生信息化分析报告,2005.
[5]申一帆,张琨,李包罗.区域卫生信息化——信息技术铺就通向”健康中国2020"愿景的
现实之路[J].中国数字医学,2009,4(12)：51-54.
[6]Adler-Milstein J, McAfee AP, Bates DW, et al. The State of Regional Health Information Organizations:Current Activities and Financing[J].Health Aff((Millwood), 2008,27(1):w60-69
[7]Julia Adler-Milstein, David W. Bates, and Ashish K. Jha. U. S. Regional Health Information Organizations:progress and challenges[J]. Health Affairs,2009,28(2): 483-492.
[8]卫生部信息化工作领导小组办公室.基于健康档案的区域卫生信息平台建设技术解决方案(试行)业务部分.2009,121-2.
[9]许怀湘美国区域卫生信息组织的发展和启示[J].电子政务2008(8)：119-125.
[10]苏锦梅,郭平等区域医疗网络案例研究——美国佛罗里达州健康信息网络素[J].中国数字医学2007,2(7)：21-24.
[11]张俊平,李凯,李秀莉美国利用卫生信息化成功支农——路易斯安那州乡村医疗信息交换项目被ADVANCE杂志评为"2009年度IT项目”[J].中国数字医学,2009,4(9)：86-87.
[12]Jha AK, DesRoches CM.Campbell EG Use of electronic health records in U.S. hospitals[J]. N Engl J Med.2009,360(16):1628-1638.
[13]Http://wwww.washingtonpost.com/wp-dyn/content/Article/2008/12/21/AR20081221014 48.html
[14]David W Hollar. Progress along developmental tracks for electronic health records implementation in the United States[J]. Health Research Policy and Systems 2009,7:3 doi:10.1186/1478-4505-7-3 http://www.health-policy-systems.dom/content/7/1/3
[15]中国医院协会信息管理专业委员会,埃森哲咨询公司.中国医院信息化发展研究报 告(白皮书)[J].中国数字医学,2008,3(8)：8-17.
[16]Protti D. US regional health Information Organizations and the Nationwide Health Information Network:any lession for Canadians [J]? Healthcare Quarterly,2008,11(2): 96-101.
[17]华永良,段楠.加拿大区域医疗信息系统的研发与应用[J].中国数字医学,2010,5(1)：84-85.
[18]中共中央国务院关于深化医药卫生体制改革的意见(全文).2009-03-17.http://www.gov.cn/jrzg/2009—04/06/content_1278721.htm.
[19]卫生部信息化工作领导小组办公室.基于健康档案的区域卫生信息平台建设指南.http://www.moh.gov.cn
[20]于广军,高解春,王锦福.大型城市医疗信息共享及协同服务系统的探索与实践[J].中国数字医学,2010,5(1)：40-42.
[21]陈晓红,陈运奇,赵军平.”区域协同医疗服务示范工程”对医疗卫生服务模式的影响[J].中国数字医学,2009,4(7)：11-13.
[22]宋炎,席修明,张进生.医院与社区互动的卫生服务综合信息系统的建立与研究[J].中国数字医学,2010,5(2)：20-22.
[23]张跃红,刘丽红,刘帆.区域医疗卫生服务共同体创新模式下社区与综合医院双向转诊示范应用研究[J].中国全科医学,2009,12(7)：561-563.
[24]马丽明,苏晞,刘海平.区域卫生信息资源规划下的新生儿疾病筛查质量监测及控制管理平台的设计与实现[J].现代医院,2009,9(3)140-145.
[25]孟晓阳,孙国强,许燕.基于SOA与HL7的医院信息系统的研究与实践[J].中国数字医学,2009,4(8)：80-82
[26]Hsin Hsin Chang, Ching Sheng Chang. An assessment of technology-based service encounters & network security on the e-health care systems of medical centers in Taiwan[J]. BMC Health Services Research 2008,8:87.
[27]Fallberg, Lars H. Patients Rights in the Nordic Countries[J]; 7 Eur. J. Health L:123-143, (2000)
[28]Hanoa R.Vascular surgical patients and patient rights legislation [J].Tidsskr Nor Laegeforen,2002,122(3):290-292.
[29]Syse A.LI Norway:valid (as opposed to informed) consent [J].The Lancet,2000, 356:1347-1348.
[30]朱长元,万莹.区域卫生信息化人才需求与培养途径[J].医学信息学杂志,2012,33(1)：8-11.
[31]李包罗,董军,李军.感受台湾医院信息化建设[J].中国数字医学,2009,4(4)：88-89.
[32]Adler-Milstein J, McAfee AP, Bates DW. The State of Regional Health Information Organizations:current activities and financing[J].Health Aff(Millwood),2008,27(1):w60-69.
[33]李华才区域卫生信息化建设任重道远——访中国医院协会信息管理专业委员会常务副主任委员李包罗[J].中国数字医学,2008,3(1)：13-14.
[34]龚怀宇,魏咏兰,贾勇.国内外慢病监测管理信息化的现状与发展趋势[J].中国数字医学,2009,4(12)37-39.
[1]Jemal A, Bray F,Center MM,et al. Global Cancer Statistics. CA Cancer J Clin,2011,61 (2):69-90
[2]Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study[J]. N Engl J Med.1993,328(19): 1365-1371.
[3]Center MM, Jemal A, Ward E. International trends in colorectal cancer incidence rates [J]. Cancer Epidemiol Biomarkers Prev.2009,18(6):1688-1694.
[4]Center MM, Jemal A, Smith RA, Ward E. Worldwide variations in colorectal cancer[J]. CA Cancer J Clin.2009,59(6):366-378.
[5]Garcia-Alvarez A, Serra-Majem L, Ribas-Barba L,et al. Obesity and overweighttrends in Catalonia, Spain (1992-2003):gender and socio-economic determinants[J]. Public Health Nutr. 2007,10(11A):1368-1378.
[6]de Kok IM, Wong CS, Chia KS, et al. Gender differences in the trend of colorectal cancer incidence in Singapore,1968-2002[J]. Int J Colorectal Dis.2008,23(5):461-467.
[7]Edwards BK, Ward E, Kohler BA, et al. Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates[J]. Cancer.2010,116(3):544-573.
[8]Chu KC, Tarone RE, Chow WH, Hankey BF, Ries LA. Temporal patterns in colorectal cancer incidence, survival, and mortality from 1950 through 1990[J]. J Natl Cancer Inst.1994,86:997-1006.
[9]Sant M, Capocaccia R, Coleman MP, et al. Cancer survival increases in Europe, but international differences remain wide[J]. Eur J Cancer.2001,37(13):1659-1667.
[10]赵平,陈万清.2009中国肿瘤登记年报.北京：军事医学科学出版社,2010：170-175.
[11]李德錄,吴春晓,郑莹.上海市2003-2007年大肠癌发病率和死亡率分析[J].中国肿瘤,2011,20(6)：413-418.
[12]Smith RA,Cokkinides V,Browley OW. Cancer screeing in the United State,2009:a review of current American Cancer Society guidelines and issues in cancer screening[J]. CA Cancer J Clin,2009,59(1):27-41.
[13]Zauber AG, Lansdorp-Vogelaar I, Knudsen AB,et al. Evaluating test strategies for colorectal cancer screening:a decision analysis for the U.S. Preventive Services Task Force[J]. Ann Intern Med. 2008,149(9):659-669.
[14]Muller AD, Sonnenberg A. Prevention of colorectal cancer by flexible endoscopy and polypectomy.A case-control study of 32,702 veterans[J]. Ann Intern Med.1995,123(12):904-910.
[15]董志伟,乔友林,等.大肠癌的筛查及早诊早治技术方案.中国癌症筛查及早诊早治技术方案 (试行)[M].北京：人民卫生出版社,2009：123-153.
[16]郑树.我国的结直肠癌筛查方案[J].医学研究杂志,2006,35(2)：8-9.
[17]黄彦钦,蔡善荣,张苏展.中国结直肠癌人群筛查方案的应用价值初探[J].中华预防医学杂志,2011,45(7)：601-604.
[18]李军,徐朝,郭志强,等.免疫数值化法和免疫胶体金法粪便潜血试验临床应用比较[J].标记免疫分析与临床,2011,18(6)：425-426.
[19]Scales C D, Fein S, Muir A J, et al. Clinical utilization of digital rectal examination and fecal occult blood testing upon hospital admission[J]. J Clin Castro,2006,40(10):913-918.
[20]Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood.Minnesota Colon Cancer Contro Study[J].N Engl J Med,1993,328(19): 1365-1371.
[21]Mandel JS, Church TR, Ederer F, et al. Colorectal cancer mortality:effectiveness of biennial screening for fecal oc-cult blood[J].J Natl Cancer Inst,l999,91(5):434-437.
[22]Hard castle JD, Cham berlain JO, Robinson MH, et al. Ran-domised controlled trial of feacal-occult-blood screening for colorectal cancer[J]. Lancet,1996,348(9040):1472-1477.
[23]Jorgenson OD, Kronborg O, Fenger C. A randomised study of screening for colorectal cancer using faecal occult blood testing:results after 13 years and seven biennial screening rounds[J].Gut, 2002,50(1):29-32.
[24]AIHW. Cancer in Australia 2010:an overview[R].Report No.Cat.no CAN 56.Canberra,Australia. [25]Pignone MP, Flitcroft KL, Howard K, et al. Costs and cost-effectiveness of full implementation of a biennial faecal occult blood test screening program for bowel cancer in Australia[J].Med J Aust, 2011,194(4):180-185.
[26]Levin B, Lieberman DA, McFarland B, et al. Screening and surveil lance for the early detection of colorectal cancer and adenomatous polyps,2008:a joint guideline from th American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology [J]. CA Cancer J Clin,2008,58(3):130-160.
[27]IyengarV, Albaugh GP, LohaniA, et al. Human stools as a source ofviable colonic epithelial cells [J]. FASEB J,1991,5 (13):2856-2859.
[28]SidranskyD,TokinoT,Hamilton SR,et al. Identification of ras on-cogenemutations in the stool of patients with curable colorectaltumors[J]. Science,1992,256(5053):102-105.
[29]汤东,薛彦俊,傅文杰,等.探讨SFRP2基因甲基化在大肠癌筛查中的作用[J].中国现代普通外科进展,2009,12(5)：378-382.
[30]Glockner SC, Dhir M, Yi JM, et al. Methylation of TFPI2 in stool DNA:a potential novel biomarker for the detection of colorectal cancer[J]. Cancer Res.2009,1;69(11):4691-4699.
[31]Itzkowitz SH, Jandorf, Brand T, et al. Improved fecal DNA test for colorectal cancer screening [J]. Clin Gastroenterol Hepatol 2007,5(1):111-117.
[32]ParekhM, Fendrick AM, Ladabaum U. As tests evolveand costs of cancer care rise:reappraising stool-based screeningfor colorectal neoplasia[J]. Alimentary Pharmacology& Therapeutics,2008, 27(8):697.
[33]王颢,傅传刚,孟荣贵.软乙状结肠镜初筛法在大肠癌普查中的应用[J].第二军医大学学报,2005,26(11)：1297.
[34]Schoen RE. The case for population-based screening for colorectal cancer[J]. NatRev Cancer, 2002,2(1):65.
[35]Pignone M, Rich M, Teutsch SM, et al. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force [J]. Agency for Health Care Research and Quality,2002,137(2):132-141.
[36]Atkin WS, Edwards R, Kralj-Hans I, et al.Once-only flexible sigmoidoscopy screeningin prevention of colorectal cancer:a multicentre randomised controlled trial [J]. Lancet,2010,375(9726): 1624-1633.
[37]Hol L, van Leerdam ME, van Ballegooijen M, et al. Screening for colorectal cancer:randomised trial comparing guaiac-based and immunochemical faecal occult blood testing and flexible sigmoidoscopy[J]. Gut.2010,59(1):62-68.
[38]许岸高,姜泊,钟旭辉,等.广东地区近20年大肠癌临床特征的变化趋势[J].中华医学杂志,2006,86(4)：272-275.
[39]罗程,余志金,许岸高,等.乙状结肠镜检查对大肠肿瘤的漏诊研究[J].胃肠病学和肝病学杂志,2010,19(2)：126-129.
[40]Rabeneck L,Davila JA, El-Serag H. Is there a true"shift" to the right colon in the incidence of colorectal cancer[J]?Am J Gastroenterol,2003,98(6):1400-1409.
[41]Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomo-graphic virtual colonoscopy to screen for colorectal neoplasia in a-symptomatic adults [J]. N Engl JMed,2003,349(23):2191.
[42]Thiis-Evensen E,Hoff GS, Sauar J, et al. Population-based surveil-lance by colonoscopy:effect on the incidence of colorectal cancer. Telemark Polyp Study I[J]. Scand JGastroentero,l 1999,34(4): 414-420.
[43]Citarda F, Tomaselli G, Capocaccia R, et al. Italian Multicentre StudyGroup. Efficacy in standard clinical practice of colonoscopic polypectomy in reducing colorectal cancer incidence [J]. Gut,2001,48(6):812-815.
[44]Johnson CD,Chen MH,Toledano AY, et al. Accuracy of CT colonography for detection of large adenomas and cancers[J].N Eng1 J Med,2008,359(12):1207-1217.
[45]Kahi CJ, Imperiale TF, Juliar BE, et al. Effect of screening colonoscopy on colorectal cancer incidence and mortality[J].Clin Gastroenterol Hepatol,2009,7(7):770-775.
[46]Niv Y, Hazazi R, Levi Z, et al. Screening colonoscopy for colorectal cancer in asymptomatic people:a meta-analysis [J]. Dig Dis Sci,2008,53(12):3049-3054.
[47]BrennerH, HoffmeisterM, BrennerG, et al. Expected reduction of colorectal cancer incidencewithin 8 years after introduction of the Ger-man screening colonoscopy programme: Estimates based on 1,875,708 screening colonoscopies [J]. Eur J Cancer,2009,45 (11):2027-2033.
[48]Levin B, Lieberman DA, McFarland B, et al. Screening and surveil-lance for the early detection of colorectal cancer and adenomatous pol-yps,2008:a jointguideline from theAmerican Cancer Society, theUS Multi-SocietyTask Force on Colorectal Cancer, and the American Col-lege of Radiology [J]. CA Cancer JClin,2008,58(3):130-160.
[49]Yaron Niv, Rachel Hazazi, Zohar Levi. Screening Colonoscopy for Colorectal Cancer in asymptomatic People:a Meta-Analysis[J]. Dig Dis Sci,2008,53(12):3049-3054.
[50]NCCN Guidelines Panel. Colorectal Cancer Screening.NCCN Practice Guidelines, in Oncology-v.1.2010, CSCR2.
[51]Forde K A. Colonoscopic screening for colon cancer[J]. Sur-gical Endoscopy,2006,20:471.
[52]Lieberman DA, Weiss DG, Bond JH, et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer[J]. N Engl J Med,2000,343(3):162.
[53]Trifan A,Stanciu C, Toader E, et al. Role of video capsule endoscopy in Crohn's d isease [J]. Rev Med Chir Soc Med Nat lasi,2006,110(2):275-281.
[54]Spada C, Hassan C, Munoz-Navas M, et al. Second-generation colon capsule endoscopy compared with colonoscopy[J]. Gastrointest Endosc,2011,74(3):581-589.
[55]Mulhall BP,Veerappan GR, Jackson JL. Meta-analysis:compu-ted tomographic colonograpy[J]. Ann Intern Med,2005,142(l):75-76.
[56]Mulhall BP, Veerappan GR, Jackson JL. Meta-analysis:computed tomographic colonography [J]. Ann Intern Med,2005,142 (8):635-650.
[57]Halligan S, Altman DG, Taylor SA, et al. CT colonography in the detection of colorectal polyps and cancer:systematic review, meta-a-nalysis, and proposedminimum data set for study level reporting [J].Radiology,2005,237(3):893-904.
[58]Lancet Oncol.2011 Nov.15 [doi:10.1016/S1470-2045(11)70297-2]
[59]吴方,魏旭倩,孙璟,等.肠癌患者外周血中肿瘤标志物联合检测的临床研究[J].中国癌症杂志,2009,19(5)：353-357.
[60]陈恺杰.3种血清肿瘤标志物在诊断大肠癌中的价值[J].广东医学院学报,2005,23(4)：384-385.
[61]杜雅菊,刘晓珺,金英敏,曲波,李宝杰.RT-PCR寻找大肠癌患者外周血早期分子标记物的研究[J].世界华人消化杂志,2006,14(3)：280-286.
[1]陈竺.全国第三次死因回顾抽样调查报告[M].北京：中国协和医科大学出版社,2008：18-28.
[2]Jemal A, Bray F,Center MM, et al. Global Cancer Statistics. CA Cancer J Clin,2011,61 (2):69-90
[3]章滨云,郝超.文献论证我国农村三级医疗预防保健网存在的焦点问题[J].中国卫生资源,2000,3(6)：268-270.
[4]朱荣,李士雪,滕芬.以社区为平台在慢性病综合防治中开展健康促进活动[J].实用全科医学,2007,5(12)：1035.
[5]王建辉,张选,禹震.网格化管理信息化支撑建立城市社区慢性病管理新模式[J].中国初级卫生保健,2009,23(2)：23-24.
[6]中国互联网络信息中心.中国互联网络发展状况统计报告,2012,1-2.
[7]程志舫,王广平.我国医疗卫生信息化服务模式的发展趋势[J].现代中西医结合杂志,2007,16(13)：1880-1881.
[8]贝品联,李水静,王志明.发挥健康教育在社区慢性病防治工作中的作用[J].实用全科医学,2006,4(2)：209.
[9]Henley SJ, King JB, German RR, et al. Surveillance of screening-detected cancers (colon and rectum, breast, and cervix)-United-States,2004-2006[J].MMWR Surveill Summ 2010,59(9):1-25.
[10]杨秉辉.全科医生应积极投身于肿瘤防治工作[J].中华全科医师杂志,2005,4(6)：325.
[11]赵建军.结直肠癌误诊原因分析[J].临床肿瘤学杂志,2006,11(2),142.
[1]赵平,陈万清.2009中国肿瘤登记年报[M].北匕京：军事医学科学出版社,2010：170-175.
[2]李德録,吴春晓,郑莹.上海市2003-2007年大肠癌发病率和死亡率分析[J].中国肿瘤,2011,20(6)：413-418.
[3]Edwards BK, Ward E, Kohler BA, et al. Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates[J]. Cancer,2010,116:544-573.
[4]蔡善荣,郑树,周伦,等.杭州城市社区自然人群大肠癌筛查实践[J].实用肿瘤杂志,2006,21(2)：177-178.
[5]董志伟,乔友林,等.大肠癌的筛查及早诊早治技术方案.中国癌症筛查及早诊早治技术方案(试行)[M].北京：人民卫生出版社,2009：123-153.
[6]NCCN Guidelines Panel. Colorectal Cancer Screening.NCCN Practice Guidelines.in Oncology-v.1.2011, CSCR2.
[7]万德森.随诊的原则.结直肠癌NCCN临床实践指南特刊[J],2011,42,COL-G2-1-2.
[8]曾楚华,张光建,杨基然,等.立足于社区的肿瘤防治[J].中国初级卫生保健,2000,14(10)：28-29.
[9]徐连根,周晶.214例结直肠癌误诊原因分析[J].武汉大学学报(医学版)2006,(6)812-814.
[10]郑树,蔡善荣,张苏展.重视结直肠癌高危人群的筛查[J].中华消化杂志,2006,26(6)：361-363.
[11]许岸高,余志金,钟旭辉,等.大肠癌高危人群筛查研究[J].中华医学杂志,2010,90(2)：116-118.
[1]黄彦钦,蔡善荣,张苏展.中国结直肠癌人群筛查方案的应用价值初探[J].中华预防医学杂志,2011,45(7)：601-604.
[2]张思维,雷正龙,李光琳等.中国肿瘤登记地区2005年发病死亡资料分析[J].中国肿瘤,2009,18(12)：973-979.
[3]赵平,陈万清.2009中国肿瘤登记年报[J].北京：军事医学科学出版社,2010,170-175.
[4]章滨云,郝超.文献论证我国农村三级医疗预防保健网存在的焦点问题[J].中国卫生资源,2000,3(6)：268-270.
[5]中国互联网络信息中心.中国互联网络发展状况统计报告,2012.
[6]陈先波,金盾,金新政.区域卫生信息化建设探究[J].中国卫生质量管理,2011,18(3).
[7]杨怀中,杨宇飞,吴寅莹.肿瘤患者就诊流向调查及建立三级肿瘤防控网络可行性研究[J]中国肿瘤,2011,20(9)：654-658.