臺灣博碩士論文加值系統

本研究分析台灣地區1979-1998年子宮頸癌發生率及子宮頸原位癌發生率。 本研究採用了衛生署台閩地區癌症登記檔資料針對台灣地區子宮頸癌及原位癌發生率變遷作長期趨勢之探討，年齡曲線改變及組織型態的改變加以分析。另外，本研究採用了衛生署台閩地區死亡檔資料做了長期趨勢的探討。針對年齡，組織型態加以分析。此外，利用台灣地區子宮頸抹片篩檢檔加以分析死亡趨勢。 為了不同期別之存活分析，本研究分析了臺大醫院1979-1995年2333子宮頸癌病例，分析不同期別，年齡，組織型態及診斷年份對存活之影響。因為大部分子宮頸癌病患處於較早的期別，本研究更加已針對所有再臺大醫院因子宮頸癌而接受手術的病患做預後因子的分析。
研究結果顯示，台灣的子宮頸癌發生率並沒有明顯的下降，但子宮頸原位癌有明顯的上升，特別在年輕女性而且在全民健保實施後更加明顯。子宮頸癌死亡率逐年下降，但是在70歲以上的病患還是呈上升的趨勢。影響死亡的因子包括期別，組織型態，及年齡。分析早期子宮頸癌而接受子宮根除術的病患顯示，影響疾病復發的因子包括淋巴腺是否轉移、子宮體本身是否被侵犯、侵犯的深度、血管及淋巴管是否有被侵犯等等。研究顯示，術前的評估如血清Squamous-cell carcinoma antigen是預防病患產生併發症的好方法。

This study analyzed incidence rates of invasive cervical cancer and carcinoma in sit in Taiwan from 1979-1998. It retrieved data from Cancer Registry of Department of Health and analyzed changing trends in incidence of invasive cervical cancer and incidence of carcioma in situ along with changing patterns of age and histologic type. In addition, this study used data according to death certificate to analyze the trend in incidence of mortality and factors associated with mortality. In order the stratified the cases into different stages in order for survival analysis, we acquired data from National Taiwan University Hospital to analyze survival of patients with cervical cancer. Since most patients are at early stage of cervical according at time of diagnosis, we further retrieved individual medical charts of patients operated at National Taiwan University Hospital for further analysis on prognostic factors.
Study shows that the incidence rate of invasive cervical cancer remained relatively steady. However, incidence of carcinoma in situ increased particular for women at younger age groups and after time of national funded Pap screening initiated in 1995. Mortality decreased in a secular fashion but it still increased for those aged 70 years and over. Further analysis showed that factors associated with survival included staging, histology and age. Analysis of patients operated at National Taiwan University Hospital shows that factors associate with recurrence include lymph node status, depth of stromal invasion, lymphovascular space invasion and etc. Clinicians should be prudent in selecting patients for the most appropriate treatment and pretreatment SCC-antigen level could provide clues to identification of patient that may require adjuvant radiotherapy.

Absract ………………………………………………………………….II
Contents……………………………………………………………….....V
Table Contents.………………………………………………………. VIII
Figure Contents…………..…………………………………………….. X
Chapter 1: Introduction ……. ……………………………………………1
Section 1-1: Background ……………………………………….…...1
Section 1-2: Objectives ………………………………………….….2
Chapter 2: Review of literature ……………………………………….….3
Section 2-1: Anatomy of the human cervix …………………….…..3
Section 2-2: Etiologies of cervical cancer ………………………….5
2-2.1: Human papilloma virus …………………………………...5
2-2.2: Male factors………………………………………………..5
2-2.3:. Menstrual and reproductive factors ………………………6
2-2.4: Cigarette smoking …………………………………….…...6
2-2.5: Oral contraceptives ………………………………………..7
2-2.6: Dietary factors …………………………………………….7
2-2.7: Host factors ……………………………………………….8
2-2.8: Carcinogenesis ……………………………………………8
2-2.9: Difficulties in ascertainment of the disease ………………9
Section 2-3: Pap screening and cervical cancer …………………...10
Section 2-4: Clinical management of cervical cancer …………….18
2-4.1: Role of SCC-antigen in the management of cervical cancer patients …………………………………………………23
Chapter 3: Incidence of cervical cancer ………………………………..29
Section 3-1: Introduction ………………………………………….29
Section 3-2: Materials and methods…………………………….…31
Section3-3: Results ………………………………………………..32
3-3.1: Incidence of cervical cancer 1979-1998 ………………...32
3-3.2:Effect of screening by pap smear …..……………………33
3-3.3: Changes in pattern of histologic type ……………………36
Section 3-4: Discussion …………………………………………...39
Chapter 4: Mortality of cervical cancer and survival analysis …...…….43
Section 4-1: Introduction ………………………………………….43
Section 4-2: Materials and methods ………………………………43
4-2.1: Data source…..…………………………………………..43
4-2.2: Statistical analyses ………………………………………46
Section 4-3.Results ………………………………………………..47
4-3.1: Analysis of cervical cancer mortality in Taiwan………….47
4-3.2: Hospital based analysis of cervical cancer mortality …….51
Section 4-4: Discussion …………………………………………..60
Chapter 5: Investigation on prognostic factors ……………………….. 67
Section 5-1: Introduction ………………………………………….67
Section 5-2: Materials and methods ………………………………69
5-2.1: Data source ………………………………………………..69
5-2.2: Statistical analyses ………………………………………..69
Section 5-3: Results …………………………………………….71
Section 5-4: Discussion …………………………………………..94
Chapter 6: Conclusions………………..………………………………102
Reference ……………………………………………………………...104
Tables
Table 2-3.1: Comparison of Papanicolaou, WHO, and Bethesda cervical cytology terminology …………………………………..13
Table 2-4.1: Staging of carcinoma of the uterine cervix according to International Federation of Gynecology and Obstetrics (FIGO) ………………………………………………..18
Table 3-3.1: Percent change in age-specific incidence rate of invasive cancer between 1994 and 1998 ………….…………..… 33
Table 4-3.1: Percent change in cervical cancer mortality rate by age, between 1971-1995……………………………………..48
Table 4-3.2: Percentage change in rate of mortality before and after Pap screening, by age ..…………………………………..…50
Table 4-3.3: Age and stage distribution of patients in National Taiwan University Hospital (1979-1995) ………………………51
Table 4-3.4: Diagnosis period and stage distribution of patients …….52
Table 4-3.5: Histology and stage of patients …………………………52
Table 4-3.6: Univariate analysis of factors related to survival by stage, age, and histologic type …………………….…….…….56
Table 4-3.7: Multivariate analysis of factors related to survival …..58
Table 5-3.1: Clinical baseline data and difference between groups ….71
Table 5-3.2: Pathologic baseline data and difference between groups .72
Table 5-3.3: Difference in recurrence rate among different clinical and pathological factors in Stage I patients …………………74
Table 5-3.4: Difference in recurrence rate among different clinical and pathological factors in stage II patients ………………..76
Table 5-3.5: Univariate analysis of clinical factors related to recurrence ………………………………………………87
Table 5-3.6: Univariate analysis of pathological factors related to recurrence……………………………………………….87
Table 5-3.7: Difference in recurrence with differences in lymph node status and whether Radiotherapy was given in stage I patients ………………………………………………….90
Table 5-3.8: Difference in recurrence with differences in lymph node status and whether Radiotherapy was given in stage II patients ………………………………………………….90
Table 5-3.9: Factors that associate with lymph node involvement …...92
Table 5-3.10: Association of pretreatment SCC-antigen levels and pathologic prognostic factor ………………………..……92
Figures
Figure 3-3.1: Secular patterns of age-adjusted incidence rates of invasive cancer and carcinoma in situ 1978-1998 ……………….32
Figure 3-3.2: Secular patterns of ratio of Carcinoma in situ to invasive cancer … ……………………………………………..34
Figure 3-3.3: Trends of age-specific ratio of carcinoma in situ to invasive cancer……………………………………….35
Figure3-3.4: Trends of age-adjusted rates of incidence of squamous cell carcinoma and adenocarcinoma by diagnosis period .…35
Figure 3-3.5: Trends of age-specific incidence rate of squamous cell carcinoma of the cervix by age, 1979-1998 ……………37
Figure 3-3.6: Trends of age-specific incidence rate of adenocarcinoma of the cervix by age, 1979-1998 …………………..……...38
Figure 4-3.1:Trends of age-adjusted mortality rate of cervical cancer in Taiwan 1971-1998 ……………………………………...47
Figure 4-3.2: Trends of cervical cancer mortality by age, 1971-1998 ....48
Figure 4-3.3: Effects of pap smear screening on mortality of cervical cancer …………………………………………………...49
Figure 4-3.4: Survival curves of cervical cancer by stage ……………...54
Figure 4-3.5: Survival curves of cervical cancer by histology ……….54
Figure 4-3.6: Survival curves of cervical cancer by different age groups.…………………………………………………55
Figure 4-3.7: Survival curves of cervical cancer by diagnosis period...55
Figure 5-3.1: Recurrence-free curves of cervical cancer by stage ...…79
Figure 5-3.2: Recurrence-free curves of stage I patients by histology .80
Figure 5-3.3: Recurrence-free curves of stage II patients by histology.80
Figure 5-3.4: Recurrence-free curves of stage I patients by age group …………………………………………………...81
Figure 5-3.5: Recurrence-free curves of stage II patients by age group …………………………………………………...81
Figure 5-3.6: Recurrence-free curves of stage I patients by lymph node invasion ………………………………………………...82
Figure 5-3.7: Survival curves of stage II patients by lymph node invasion ………………………………………….……...82
Figure 5-3.8: Recurrence-free curves of stage I patients by LVSI ….….83
Figure 5-3.9: Recurrence-free curves of stage II patients by LVSI …….83
Figure 5-3.10: Recurrence-free curves of stage I patients by depth of stromal invasion ……………….………………...…...84
Figure 5-3.11: Recurrence-free curves of stage II patients by depth of stromal invasion ……………………………………...84
Figure 5-3.12: Recurrence-free curves of stage I patients by number of lymph nodes involved.……………………………….85
Figure 5-3.13: Recurrence-free curves of stage II patients by number of lymph nodes involved ……………………………….85
Figure 5-3.14. Recurrence-free curves of stage I patients by status of lymph node and radiotherapy …………………………..86
Figure 5-3.15: Recurrence-free curves of stage II patients by status of lymph node and radiotherapy …………………...……..86
　

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