Abstract: Objective　To construct a complete，standardized and patient-centered breast cancer prevention and control process based on general hospital-community collaboration model with clear division of labor at all levels of medical institutions through integrating and optimizing the commonly used breast cancer screening tools and based on the foundation of regional family doctor contracted service.Methods　Through literature review，the current guidelines for breast cancer prevention and control at home and aboard were summarized.And then expert consultation method，brainstorming method and flow chart method were used to build the breast cancer prevention and control process.Results　The prevention and control process of breast cancer mainly consisted of three steps.Step 1：To build residents' awareness of cancer prevention through the health education from community general practitioners.Step 2：Gail-2 risk assessment and clinical breast examination were carried out by community general practitioners to screen out high-risk groups of breast cancer，and these high-risk residents were transferred to higher level of medical institutions.Step 3：Breast cancer was diagnosed and treated through mammography and other breast-related examination performed by specialists in general hospitals，and a rehabilitation prescription was issued.Conclusion　The establishment of breast cancer prevention and control process could enable the implementation of clinical guidelines for breast cancer and form a practical and feasible plan of breast cancer focusing on patient as the center with the reasonable division of labor among general hospital specialists and community general practitioners.It also completed the entire process from the early detection and early diagnosis to early treatment of breast cancer，avoiding the waste of medical resources because of multiple examinations and visits.At the same time，it could improve the ability of general practitioners in the clinical examination and control of breast cancer.

Key words: Breast neoplasms, Prevention and treatment, Screening, Process

摘要： 目的　以区域家庭医生签约服务为基础，通过整合优化国内外常用乳腺癌防治筛查工具，构建一套完整的、规范的基于综合医院-社区协作模式的乳腺癌防治流程，实现以患者为中心、各层级医疗机构分工明确的乳腺癌防治流程。方法　通过文献回顾性研究汇总当前国内外乳腺癌防治相关指南，并采用专家咨询法、头脑风暴法及流程图法构建基于综合医院-社区协作模式的乳腺癌防治流程。结果　乳腺癌防治流程主要包括3个步骤。第1步，通过社区全科医生对社区居民进行健康宣教，提高社区居民的防癌意识；第2步，由社区全科医生进行Gail-2风险评估和临床乳腺检查，筛选出社区乳腺癌高危人群，并将乳腺癌高危人群向上转诊；第3步，通过综合医院专科医生进行乳腺X线检查或其他乳腺相关检查，进行乳腺癌的初步诊断与治疗，并开具康复处方进行癌后康复。结论　乳腺癌防治流程的建立，实现了乳腺癌临床指南的落地实施，形成了切实可用的执行方案，实现了以患者为中心、社区全科医生与综合医院专科医生的合理分工，完成了乳腺癌从早发现、早诊断到早治疗的全过程，避免了多次检查、多次就诊的医疗资源浪费情况。同时，也有助于提高全科医生乳腺癌临床防治检查能力。

关键词: 乳腺肿瘤, 防治, 筛查, 流程