以循证医学为基础的健康体检课程大纲案例讨论周期性健康检查的概念以李先生为例：李先生54岁，从事后勤管理工作。有30年吸烟史，每天一包。他知道戒烟的害处，确感到戒烟很难。他现在没有不适的感觉，但担心长期吸烟史是否会使他患肺癌。他问医生是否应该进行CT或胸片检查？他既往曾患胃食道反流疾病，父亲65岁时死于肺癌。你计划给李先生安排什么体检项目？要给他做胸部X线片吗？为什么？以证据为基础的医学方法循证医学（EvidenceBaseMedicine）Patient=healthy,asymptomaticmalesmoker病人=健康，无症状男性吸烟者Intervention=lungcancerscreening干预=肺癌筛查Comparison=notest对比=不检查Outcome=prolongedsurvival结局=延长生存期Focusedclinicalquestion:临床关注的问题IdealScreeningProgram:理想的筛查项目PrinciplesofScreening筛查原则A.—TheUSPSTFstronglyrecommendsthatcliniciansprovide[theservice]toeligiblepatients.TheUSPSTFfoundgoodevidencethat[theservice]improvesimportanthealthoutcomesandconcludesthatbenefitssubstantiallyoutweighharms.B.—TheUSPSTFrecommendsthatcliniciansprovide[thisservice]toeligiblepatients.TheUSPSTFfoundatleastfairevidencethat[theservice]improvesimportanthealthoutcomesandconcludesthatbenefitsoutweighharms.C.—TheUSPSTFmakesnorecommendationfororagainstroutineprovisionof[theservice].TheUSPSTFfoundatleastfairevidencethat[theservice]canimprovehealthoutcomesbutconcludesthatthebalanceofbenefitsandharmsistooclosetojustifyageneralrecommendation.D.—TheUSPSTFrecommendsagainstroutinelyproviding[theservice]toasymptomaticpatients.TheUSPSTFfoundatleastfairevidencethat[theservice]isineffectiveorthatharmsoutweighbenefits.I.—TheUSPSTFconcludesthattheevidenceisinsufficienttorecommendfororagainstroutinelyproviding[theservice].Evidencethatthe[service]iseffectiveislacking,ofpoorquality,orconflictingandthebalanceofbenefitsandharmscannotbedetermined.U.S.PreventiveServicesTaskForceRatings:StrengthofRecommendationsandQualityofEvidence.GuidetoClinicalPreventiveServices,ThirdEdition:PeriodicUpdates,2000-2003.AgencyforHealthcareResearchandQuality,Rockville,MD.http://www.ahrq.gov/clinic/3rduspstf/ratings.htm没有足够的证据说明用胸片、痰细胞学检查等方法筛查肺癌能延长寿命USPSTF2004:insufficientevidencefororagainstLDCT,CXR,sputumcytologyorcombinationoftestsAmericanCollegeofChestPhysicians2003:LDCTonlyincontextofwell-designedclinicaltrialsAmericanCancer