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1 전립샘암발견율에대한역학적특성 Epidemiologic Characteristics of Prostate Cancer Detection Kyung Soo Choi, Jong Kwan Park From the Departments of Urology, Chonbuk National University Medical School, Institute for Medical Sciences of Chonbuk National University Medical School, and Research Institute of Clinical Medicine and Clinical Trial Center of Chonbuk National University Hospital, Jeonju, Korea Purpose: The prevalence of prostate cancer is increasing in the general population. This study aimed to evaluate the epidemiologic characteristics of the prostate cancer detection rate. Materials and Methods: We analyzed data from patients who underwent transrectal ultrasound-guided prostate biopsy and who were newly diagnosed with prostate cancer from 2005 to 2006 in Korea. These data were based on National Health Insurance statistics. We also analyzed the data of patients who underwent transrectal ultrasound-guided prostate biopsy and were newly diagnosed with prostate cancer in our institution from 2005 to Results: According to the data of the National Health Insurance, the detection rates of prostate cancer were 45.8% in 2005 and 43.1% in These results were not actual cancer detection rates. According to the data from our institution, the cancer detection rate ranged from 24.8% to 25.9% compared with the 15.5% to 23% cancer detection rate reported by other Korean studies. We analyzed the reasons for this difference in detection rates and suggest that the difference is because a suggestive diagnosis is useful and is unchanged until the diagnosis is confirmed. Conclusions: The prevalence of prostate cancer is increasing more rapidly than that of other major cancers. The detection rate of prostate cancer in Korean patients who underwent transrectal ultrasound-guided prostate biopsy was inferior to that in Caucasians. Also, some patients were detected without proper screening or biopsy and were thus diagnosed as having advanced or metastatic prostatic cancer. We need a good corelationship between National Health Insurance and the cancer registration project for real detection of prostate cancer. (Korean J Urol 2009;50: ) Key Words: Prostatic neoplasms, Early detection of cancer, Biopsy, National health programs Korean Journal of Urology Vol. 50 No. 11: , November 2009 DOI: /kju 전북대학교의학전문대학원비뇨기과학교실, 전북대학교병원임상연구소, 전북대학교의과학연구소, 전북대학교병원지역임상시험센터 최경수ㆍ박종관 Received:October 13, 2009 Accepted:October 23, 2009 Correspondence to: Jong Kwan Park Department of Urology, Chonbuk National University Hospital, , Geumam-dong, Deokjin-gu, Jeonju , Korea TEL: FAX: rain@chonbuk.ac.kr C The Korean Urological Association, 2009 서론최근우리나라는평균수명의연장으로인한노령인구의증가, 진단방법의발달, 전립샘암에대한인식의증가및서구화된식생활의영향으로전립샘암환자가증가추세에있다. 대한비뇨기과학회와대한비뇨기과종양학회는 블루리본캠페인을시행하여 대한민국전립샘암지도만들기프로젝트 를위한전립샘암선별검사를시행하였으며, 이조사에서추정전립샘암발견율이 3.17% 였고, 이는다른아시아국가들보다높은수치라하였다. 실제국민건강보험공단이발표한 2006년암환자분석결과 에따르면최근 6년사이전립샘암환자가가장큰폭으로증가하였으며, 그수치는 2000년 1,457명에서 2006년 1054

2 Kyung Soo Choi and Jong Kwan Park:Epidemiology of Detection of Prostate Cancer ,436명으로 236% 가량늘어나증가율 1위를차지했다고하였다. 또한건강보험공단의자료에의하면 2005년, 2006 년에 40세이상에서전립샘비대증의일차추정진단하에전립샘조직검사를받은환자수는각각 5,623명과 7,966명이었으며, 2005년, 2006년등록된전립샘암신규환자는 2,579 명과 3,436명으로전립샘암뿐아니라전립샘암을진단하기위한전립샘조직검사의빈도도높은것을알수있다. 이에대하여저자들은건강보험공단의자료와본원의자료를기초로하여전립샘암의증가추이및전립샘조직검사를통한전립샘암의추정발견율을예상해보고, 그역학적특성을분석하고자하였다. 대상및방법 2005년과 2006년의건강보험공단에서발표한건강보험주요통계자료중건강보험암환자분석결과와 2005, 2006, 2007년본원에서전립샘암으로새롭게등록된 60, 90, 117명의환자와본원에서혈청전립샘특이항원치 (prostatespecific antigen; PSA) 가 4 ng/ml 이상이거나직장수지검사 (digital rectal examination) 에서결절이촉지되어임상적으로전립샘암의심하에경직장초음파 (model 2102, B&K medical, Denmark) 유도전립샘조직검사를시행받은 201, 315, 408명의환자를대상으로하였다. 전립샘조직검사를시행한환자의정의는전립샘비대증일차추정진단하에조직검사를시행한환자와전립샘암일차추정진단하에조직검사를시행한환자의합계이며, 일차추정진단은최종진단과다를수있음을고려하였다. 본원의자료분석은후향적으로환자기록을검토하여분석하였으며, 본원에서새롭게전립샘암으로진단된환자들에대해서는암으로진단된경로즉본원에서조직검사를통해진단되었는지와그렇지않다면어떠한경로로진단되었는지환자들의병력을추적해보았고, 2005, 2006, 2007년에새롭게암으로등록된환자들의평균 PSA와나이, 그리고경직장초음파를통해측정된전립샘용적을분석하였다. 또한본원조직검사없이암으로등록된환자들은치료경과를통해분석하였다. 건강보험공단의전립샘암을포함한주요암종별환자추이를분석하여 2000년기준으로 2005, 2006년건강보험신규암환자추이와증가율을조사하였다. 건강보험공단에 40세이상남성에서일차추정진단이전립샘비대증으로등록된환자중전립샘조직검사를받은환자수를조사하였으며, 건강보험공단에따르면일차추정진단은최종진단과다를수있다고하였다. 총전립샘조직검사를받은환자에대한신규전립샘암환자의비율을조사하고이를본원의자료와비교분석하였다. 결과건강보험공단에서발표한건강보험주요통계에따르면 2000년전체암환자는 218,735명에서 2006년에는 425,281명으로 206,546명이증가하여 6년간 1.94배가증가하였으며, 전립샘암을비롯한주요한암이 2000년에비해증가추세를보이고있다. 특히전립샘암이연평균 26.1%, 유방암은 18.1%, 대장암은 16.1% 로크게증가하였고, 자궁경부암이 4.9% 증가에그쳐다른암종에비해증가율이낮았다 (Fig. 1). 또한건강보험신규암환자추이를보면 2000년신규암환자는 101,781명에서 2006년에는 131,604명으로 29,823명이증가하여 6년간 1.29배가증가하였다. 2000년을기준으로 2006년신규암환자진료인원에서 5년간크게증가추세를보이는암종은전립샘암연평균 15.4%, 유방암 9.6%, 대장암 8.3% 였고, 폐암과간암은 2000년과비교하여큰변화가 Fig. 1. Total number of patients by cancer type of Health Insurance. Fig. 2. Number of patients by newly detected cancer type and year.

3 1056 Korean Journal of Urology vol. 50, , November 2009 없었으며, 자궁경부암은연평균 2.7% 감소를보였다 (Fig. 2). 건강보험공단자료에의하면 40세이상에서일차추정진단을전립샘비대증으로청구한환자중전립샘조직검사를받은환자수는 2005년 5,623명이고 2006년에는 7,966명이었다. 또한신규전립샘암환자수는 2005년 2,579명이고 2006년에는 3,436명으로보고되었으며, 위의자료를토대로하여전립샘조직검사를시행받은환자에대한신규전립샘암환자의백분율을계산해보면 2005년에는 45.8%, 2006 년에는 43.1% 였다. 본원에서전립샘조직검사를시행받은환자는 2005년 201명, 2006년 315명, 2007년 408명이었으며, 이중에는전립샘암을일차추정진단으로조직검사를시행한환자수는 2005년 21명, 2006년 42명, 2007년 40명으로전체조직검사환자수의약 10% 의비율을차지하고있었다. 신규전립샘암으로등록된환자는 2005년 60명, 2006년 90명, 2007년 117명으로나타났으며, 이환자들의평균 PSA는 2005년 ng/ml, 2006년 ng/ml, 2007년 ng/ml로나타났다 (Table 1). 전립샘조직검사를시행받은환자에대한신규전립샘암환자의백분율을계산해보면 2005년 29.9%, 2006년 28.6%, 2007년 28.7% 를보였지만실제적으로본원에서전립샘조직검사를통해서신규암으로등록된환자는 2005년 50명, 2006년 82명, 2007년 106명으로전립샘조직검사를통한암발견율은 2005년 24.8%, 2006년 26.0%, 2007년 25.9% 로조사되었다. 2005년본원에서전립샘조직검사를받지않고신규암으로등록된환자는 10명이었고, 이중 5명은다른병원에서조직검사를받고암으로진단된후본원에서암등록과치료를같이받았으며, 5명의환자에선조직검사없이영상의학검사 (MRI, bone scan) 에서진행된암과뼈전이소견을보여조직검사없이호르몬치료를받았다. 또한 2006년에도 8명의환자가본원의조직검사없이신규암으로등록되었는데이중 5명은다른병원에서조직검사를시행받아암으로진단된후본원에서암등록과치료를 같이받았고, 1명은요도경유전립샘절제술후조직검사에서암으로진단되었으며, 또다른 1명은영상검사에서진행된암의소견을보여호르몬치료를받았고, 나머지 1명의환자는정확한정보를얻을수없었다. 또한 2007년에는 6 명의환자가다른병원에서조직검사를받고암으로진단된후본원에서암등록후치료를받았고, 2명의환자는요도경유전립샘절제술과개복전립샘절제술후의병리소견에서암으로진단되었다. 고찰전립샘암은 1984년이래미국에서발생하는가장흔한악성종양으로, 전체암의 1/3을차지하고있으며 [1], 2002 년전세계남자인구의 6.1% 인 1,100만명에발생한두번째로흔한암으로알려져있다 [2]. 한국에서도인구의고령화식생활의서구화, 진단방법의발달, 건강에대한관심의증가와인식의변화로인하여전립샘암환자가꾸준히증가하는추세이다. 건강보험공단에서발표한건강보험주요통계에따르면 2000년전체건강보험암환자는 218,735명에서 2006년에는 425,281명으로 206,546명이증가하여 6년간 1.94배가증가하였으며, 이중전립샘암은연평균 26.1% 로크게증가하였다. 2004년에는전체암중 8번째로빈번하였으며, 2005년에는 7번째, 2006년에는 6번째빈번한암으로보고되었다. 또한신규암환자추이를살펴볼때전립샘암은연평균 15.4% 로 5년간가장크게증가추세를보였다. 대한비뇨기과학회와대한비뇨기종양학회에서실시한블루리본캠페인에서 대한민국전립샘암지도만들기프로젝트 를위한전립샘암선별검사를시행하였고, 전립샘암발견율을 3.17% 로보고하였으며, 이는가까운중국 ( 장춘 1.3%) 과일본 ( 오사카 2.3%) 보다높은수치라하였다. 다른보고에의하면, 전립샘암의발생률은 년과 년사이에 28.2% 까지증가했으며 [3], 5년상대생존율은 1993년의 59.1% 에서 2002년 70.6% 로증가했다고하였다 [4]. Table 1. Patients characteristics No. of patients Mean age (years) Mean total PV d (g) Mean total PSA (ng/ml) 2005 a 2006 b 2007 c ± ± ± ± ± ± ± ± ±84.12 PV: prostate volume, PSA: prostate-specific antigen, a : patients who detected newly prostate cancer in 2005, b : patients who detected newly prostate cancer in 2006, c : patients who detected newly prostate cancer in 2007, d : PV was measured by transrectal ultrasonography (B-K Medical, Denmark)

4 Kyung Soo Choi and Jong Kwan Park:Epidemiology of Detection of Prostate Cancer 1057 전립샘암은잠복암에서임상암으로매우느리게진행되고조기진단후적절한치료방법이있어서선별검사에매우적합한질환이므로미국을포함한서구에서는전립샘암의선별검사체계가거의확립되어있으며, 일본에서도선별검사가보편화되어있는실정이다. Kwon 등은한국에서의전립샘특이항원선별검사도입에따른전립샘암의임상병리학적특성의변화에대하여보고하였으며, PSA 도입으로인해전립샘암의조직학적분화도의감소는관찰되었지만, 진단당시연령및임상병기의변화는관찰되지않았고, 그결과전체적인암특이생존율의차이는없었다고하였다 [5]. 또한 Song 등에의한전립샘암환자의진단시기에따른임상적요소들의변화에대한보고에따르면, 전립샘암으로진단되는환자수는꾸준히증가추세를보여, 서구인에서의결과와동일하지만, 진단시환자의평균연령은차이를보이지않았다 [6]. 국소전립샘암은증가하는추세를보였으며, 림프절이나원격전이가있는환자는감소하였다고했다. 또한 T1c 환자의비율이증가하는추세를보여, 31.6% 에달하였지만, 서구인의 75% 에비해서는현저하게낮다고하였다. 따라서광범위한선별검사와적극적인치료가필요하다고하였다 [6]. Seong 등은전립샘특이항원치가 ng/ml인한국남성에서나이와전립샘용적이전립샘암발견율에미치는영향에대한다기관후향적연구를발표하였다 [7]. 이연구에서 1993년부터 2002년까지 10년동안국내 12개병원에서직장수지검사나경직장초음파의소견과연령별참고치에관계없이혈청 PSA치가 ng/ml의진단적회색지대에있어전립샘생검을받은 791명의분석결과에서전립샘암으로확진된환자는 123명으로 15.5% 의전립샘암발견율을보였다 [7]. 하지만서양인들의전립샘암발견율은 % 에이르며 [8-11], 일본의경우는 % 로보고되었다 [12,13]. 또다른국내의연구에서는 % 로비교적낮게보고되었다 [14-16]. 저자들의연구에는전립샘암발견율이 % 로나타났으며, 이는국내의다른보고들보다높았지만대상환자수가적고또한 PSA치가 4.0 ng/ml 이상이거나임상적으로암이의심된경우에서조직검사가이루어져높을수있을거라생각한다. 또한대한비뇨기종양학회의블루리본캠페인 2008년보고에서는전립샘암발견율이 27.7% 를나타내, 이전에비해높은결과를보였다. 2005년과 2006년에건강보험공단에전립샘암으로신규등록된환자수는 2,579명과 3,436명이었고, 전립샘조직검사가동일해에이루어진환자수는 5,623명과 7,966명으로발표되었다. 이를전립샘조직검사를받은환자에대한신규암환자등록환자수의백분율즉전립샘암발견율로 다시분석해보면 2005년 45.8%, 2006년 43.1% 로나타난다. 전립샘조직검사를받은환자는실제적으로일차추정진단을전립샘비대증으로하여조직검사를시행한환자와일차추정진단을전립샘암으로하여검사를시행한환자의합계로봐야하지만, 건강보험공단의자료는일차추정진단을전립샘비대증으로하여검사를시행한환자수였다. 하지만국내에보고된전립샘조직검사를통한암발견율이 20% 내외임을볼때이수치는너무높다고볼수있다. 따라서본저자들은본원의자료를분석해보았다. 본원의자료에서는전립샘조직검사를받은환자에대한신규암환자등록건수의백분율은 2005년 29.9%, 2006년 28.6%, 2007년 28.7% 로나타났으며, 이중실제본원에서조직검사를받고암으로등록된경우는 2005년 24.8%, 2006년 26.0%, 2007년 25.9% 로나타나차이가있었다. 본원에서조직검사를받지않고암등록이된환자를분석해보았을때, 조직검사없이영상의학검사 (MRI, bone scan) 에서국소진행성암또는뼈전이소견을보인전이성암으로진단되어이후호르몬치료를받았던경우, 요도경유전립샘절제술과개복전립샘절제술후의병리소견에서암으로진단된경우였다. 이런환자들은적절한선별검사와조직검사를통해분화도가좋은암으로진단되었다면예후에있어서도좋을거라생각한다. 실제국내다른보고들에서 PSA 의선별검사의확대이후암의발견율이좋아지고, T1c 환자의비율이증가하고있다고하지만서구에비해그비율이매우낮으며, 아직도더많은환자들이적극적인전립샘암선별검사를통해조직검사가이루어져야하며, 이로인해전체암에대한생존율의향상을도모할수있을거라생각한다. 대한비뇨기과학회의보고에의하면국내중년남성들은대부분전립샘암및검진방법에대해잘모르고있었고, 설문조사응답자의 80% 가전립샘암에대해막연히알고있었다고하였다. 이에본저자들은국내전립샘암에대한적극적인홍보와선별검사가필요할거라생각하고, 이를통해적절한시기에조직검사를통하지않고진단되는전립샘암환자들을조기에발견하여적절한치료를시행해야한다고생각한다. 본연구는비록건강보험공단의수치적자료만을분석하여정확한역학적조사가이루어지지않았다는단점이있어이를보완하기위해본원의자료를조사하였으나, 이또한대상환자수가적어앞으로더많은환자군에대한대규모조사가필요할거라생각한다. 더욱정확한통계를위해서는암환자의진단및치료와관련된보험공단의통계와암등록사업의통계가연동되어연구자들이쉽게이용할수있는체계가갖추어져야된다고생각한다.

5 1058 Korean Journal of Urology vol. 50, , November 2009 결 전립샘암은다른주요암종에비하여가장빠른증가추세를보이고있으며, PSA의선별검사확대이후암의발견율이좋아지고있다. 또한일부환자들에서적절한선별검사또는조직검사를통해암이진단되지않고진행성또는전이성암으로발견되는경우가있어, 광범위한선별검사와적절한조직검사그리고전립샘암에대한적극적인홍보가이루어져야한다고생각한다. 정확한통계를위하여국민보험공단과암등록사업이잘연계되어야암과관련된역학적연구에도움이되리라생각한다. 론 REFERENCES 1. Jemal A, Tiwari RC, Murray T, Ghafoor A, Samuels A, Ward E, et al. Cancer statistics, CA Cancer J Clin 2004; 54: Pu YS, Fujimoto H, Kakizoe T, Myers R. The 18th international symposium: controversies in prostate cancer diagnosis and treatment. Jpn J Clin Oncol 2005;35: Park SK, Sakoda LC, Kang D, Chokkalingam AP, Lee E, Shin HR, et al. Rising prostate cancer rates in South Korea. Prostate 2006;66: Jung KW, Yim SH, Kong HJ, Hwang SY, Won YJ, Lee JK, et al. Cancer survival in Korea : a population-based study. J Korean Med Sci 2007;22(Suppl):S Kwon JK, Chang IH, Kim TH, Myung SC. Changes in prostate cancer pattern according to prostate-specific antigen screening test. Korean J Urol 2009;50: Song K, Song C, Ahn H. Continuing trends of the clinical parameter migration in patients with prostate cancer in Korea. Korean J Urol 2007;48: Seong DH, Cho JS, Hong SJ, Chung BH, Choi YD, Kim SJ, et al. The influence of age and prostate volume on the cancer detection rate in Korean men with PSA levels of 4.0 to 10.0 ng/ml: a multicenter, retrospective study. Korean J Urol 2006; 47: Catalona WJ, Richie JP, Ahmann FR, Hudson MA, Scardino PT, Flanigan RC, et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men. J Urol 1994;151: Meshref AW, Bazinet M, Trudel C, Aronson S, Peloquin F, Nachabe M, et al. Role of prostate-specific antigen density after applying age-specific prostate-specific antigen reference ranges. Urology 1995;45: Schröder FH, Van der Cruijsen-Koeter I, de Koning HJ, Vis AN, Hoedemaeker RF, Kranse R. Prostate cancer detection at low prostate specific antigen. J Urol 2000;163: Morote J, Raventos CX, Lorente JA, Lopez-Pacios MA, Encabo G, de Torres I, et al. Comparison of percent free prostate specific antigen and prostate specific antigen density as methods to enhance prostate specific antigen specificity in early prostate cancer detection in men with normal rectal examination and prostate specific antigen between 4.1 and 10 ng/ml. J Urol 1997;158: Kobayashi T, Nishizawa K, Ogura K, Mitsumori K, Ide Y. Detection of prostate cancer in men with prostate-specific antigen levels of 2.0 to 4.0 ng/ml equivalent to that in men with 4.1 to 10.0 ng/ml in a Japanese population. Urology 2004;63: Yamamoto S, Ito T, Aizawa T, Noda K, Umezu K, Ohtsuru N, et al. Dose transrectal ultrasound guided eight-core prostate biopsy improve cancer detection rates in patients with prostatespecific antigen levels of ng/ml? Int J Urol 2004;11: Jung JY, Jeong H, Chung J, Lee SB, Lee SE, Kim SH. The outcome of TRUS-guided sextant biopsy according to prostate volume. Korean J Urol 2000;41: Jung BC, Kim TH, Jeong SJ, Kwak C, Lee SE. The clinical usefulness of the prostate-specific antigen, prostate-specific antigen density, digital rectal examination, and transrectal ultrasonography in the screening test of prostate cancer in Koreans. Korean J Urol 2002;43: Lee SC, Lee SC, Kim WJ. Value of PSA density, PSA velocity and percent free PSA for detection of prostate cancer in patients with serum PSA 4-10 ng/ml patients. Korean J Urol 2004;45:

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