screening and its future……………………. a definition of screening. any medical...

ScreeningScreening

and its future……………………and its future……………………

A definition of screening.A definition of screening.

Any medical investigation that does Any medical investigation that does not arise from a patient’s request for not arise from a patient’s request for advice for a specific complaintadvice for a specific complaint

Current Screening Current Screening

Cancers screened for areCancers screened for are BreastBreast CervicalCervical Just rolling out BowelJust rolling out Bowel

Cervical Cancer testingCervical Cancer testing Hot topic thanks to Jade and HPVHot topic thanks to Jade and HPV Currently in England 1st invite at 25 brush Currently in England 1st invite at 25 brush

cytology every 3 yrs until 49. Some worry re cytology every 3 yrs until 49. Some worry re age but more false +ves under 25 and based age but more false +ves under 25 and based on paper ‘benefits of cerv screening at on paper ‘benefits of cerv screening at different ages’ BJC July ‘03different ages’ BJC July ‘03

50-64 5 yrly , none over 6550-64 5 yrly , none over 65 Advise to continue despite HPV vaccn. as long Advise to continue despite HPV vaccn. as long

lag time to effect.lag time to effect. Costs £157 million a year decreased cancer Costs £157 million a year decreased cancer

incidence of 41% 20-39, 69% 40-54, 73% 55-incidence of 41% 20-39, 69% 40-54, 73% 55-69.69.

Breast Cancer testingBreast Cancer testing Again in the news as some concerns over over Again in the news as some concerns over over

treatment.treatment. Currently mammogram every 3 years over 50 Currently mammogram every 3 years over 50

(so could get 1st call at 53) to 70 can request (so could get 1st call at 53) to 70 can request over 70 but not rountine. Works as breast more over 70 but not rountine. Works as breast more fat than gland so sensitive post menopause.fat than gland so sensitive post menopause.

Costs 52 million a yearCosts 52 million a year 117, 000 cancers from 19 million people 117, 000 cancers from 19 million people

screened.screened. ?overdiagnosis of DCIS Cancer UK say 1 in 3 ?overdiagnosis of DCIS Cancer UK say 1 in 3

DCIS detected may not become invasive so DCIS detected may not become invasive so about 1 in 20 of cancers detected- still worth it!about 1 in 20 of cancers detected- still worth it!

Bowel Cancer ScreeningBowel Cancer Screening

Lifetime prevalence 1 in 20 people Lifetime prevalence 1 in 20 people Screening reduces risk of dying by Screening reduces risk of dying by

16%16% Screening is FOB every 2 yrs 60-69Screening is FOB every 2 yrs 60-69 Cost so far £55 M 08-9Cost so far £55 M 08-9 Likely 2% colonscopy.Likely 2% colonscopy.

Other ScreeningOther Screening-Pregnancy since NICE-Pregnancy since NICE

Anaemia at 12, 28 and 34 weeksAnaemia at 12, 28 and 34 weeks MSU at booking and sunsequent dipsMSU at booking and sunsequent dips Blood group and Rh at bookingBlood group and Rh at booking Hep B and HIV at bookingHep B and HIV at booking Rubella and Syphillis at booking Rubella and Syphillis at booking Downs screening available to all should Downs screening available to all should

all be combined/integrated test now.all be combined/integrated test now. Fetal anomaly scan at 18-21 weeks.Fetal anomaly scan at 18-21 weeks. NOT placenta/ vasa previa but if over os NOT placenta/ vasa previa but if over os

at 20 weeks repeat at 36.at 20 weeks repeat at 36.

GU / VascularGU / Vascular Chlamydia voluntary screening Chlamydia voluntary screening

(opportunistic).(opportunistic). Controversy re vascular screening, NSF Controversy re vascular screening, NSF

recommends need to identify high risk recommends need to identify high risk and in ‘06 there was no recommenation and in ‘06 there was no recommenation for whole popln screening. There is the for whole popln screening. There is the handbook for vascular risk assmt handbook for vascular risk assmt anamagement. We are expected to do anamagement. We are expected to do more but needs whole teaching session more but needs whole teaching session to discuss. Currently guided by QOF to discuss. Currently guided by QOF targets but huge subject.targets but huge subject.

How do we decide How do we decide whether to whether to introduce a introduce a screening screening

programme? programme?

Group workGroup work

Split into groups of 3, what do you Split into groups of 3, what do you need for a screening programme to need for a screening programme to work?work?

Wilson’s criteriaWilson’s criteria the condition should be an important health problem the condition should be an important health problem the natural history of the condition should be the natural history of the condition should be

understood understood there should be a recognisable latent or early there should be a recognisable latent or early

symptomatic stage symptomatic stage there should be a test that is easy to perform and there should be a test that is easy to perform and

interpret, acceptable, accurate, reliable, sensitive and interpret, acceptable, accurate, reliable, sensitive and specific specific

there should be an accepted treatment recognised for there should be an accepted treatment recognised for the disease the disease

treatment should be more effective if started early treatment should be more effective if started early there should be a policy on who should be treated there should be a policy on who should be treated diagnosis and treatment should be cost-effective diagnosis and treatment should be cost-effective case-finding should be a continuous process case-finding should be a continuous process

Criteria by the National Criteria by the National Screening Committee Screening Committee

(2003)(2003)The conditionThe condition Should be an Should be an

important health important health problemproblem

The epidemiology and The epidemiology and natural history should natural history should be well understoodbe well understood

There should be a There should be a detectable risk factor detectable risk factor and early latent stageand early latent stage

The testThe test Should be simple, Should be simple,

safe, precise and safe, precise and validatedvalidated

The distribution of The distribution of test values in the test values in the population should be population should be knownknown

Should be Should be acceptable to the acceptable to the populationpopulation


(2003)(2003)The treatmentThe treatment There should be an There should be an

effective interventioneffective intervention There should be There should be

evidence of early evidence of early treatment leading to treatment leading to better outcomes than better outcomes than later treatmentlater treatment

There should be There should be agreed evidence based agreed evidence based policies on treatment policies on treatment policypolicy

The programmeThe programme There should be There should be

evidence from high evidence from high quality RCT that the quality RCT that the screening programme screening programme reduces morbidity and reduces morbidity and mortalitymortality

There should be There should be evidence that the evidence that the programme is programme is clinically, socially and clinically, socially and ethically acceptableethically acceptable


(2003)(2003)The programme (cont.)The programme (cont.) The benefit from the programme should The benefit from the programme should

outweigh physical and psychological harmoutweigh physical and psychological harm ‘‘The opportunity cost’ should be The opportunity cost’ should be

‘economically balanced’ ie ‘value for money’‘economically balanced’ ie ‘value for money’ Adequate staffing and facilities should be in Adequate staffing and facilities should be in

place before its commencementplace before its commencement There should be a plan for managing and There should be a plan for managing and

monitoring the programmemonitoring the programme Evidence based information should be Evidence based information should be

available to allow participants to make fully available to allow participants to make fully informed choicesinformed choices

Role play time!Role play time!

Split into twosSplit into twos One of you is the patient, other the One of you is the patient, other the

doctor, doctor, Scenario – the patient is a 25 year old Scenario – the patient is a 25 year old

university graduate, she has been university graduate, she has been sexually active for 8 years and had a sexually active for 8 years and had a friend who has recently had treatment friend who has recently had treatment for an abnormal smear- she wonders if for an abnormal smear- she wonders if she should have a smear and wants to she should have a smear and wants to discuss it with you.discuss it with you.

FeedbackFeedback

Review article by Muir Gray Review article by Muir Gray BJGP April 2004BJGP April 2004

New Concepts in Screening :New Concepts in Screening : All screening programmes do harm; All screening programmes do harm;

some do good as wellsome do good as well Screening is a programme; not a testScreening is a programme; not a test False negatives and positives are an False negatives and positives are an

inevitable part of any screening inevitable part of any screening programmeprogramme

Ethical issues to considerEthical issues to consider

Is screening different to care?Is screening different to care? Informed consentInformed consent Who owns genetic materialWho owns genetic material What do you do with the knowledge What do you do with the knowledge

(eg carrier of the CF gene)(eg carrier of the CF gene) Parents’ Vs infants’/children’s rightsParents’ Vs infants’/children’s rights

ConsentConsent

Consent for National Screening Consent for National Screening Programmes is taken for granted by Programmes is taken for granted by many, as they are led to believe that many, as they are led to believe that there is an obvious benefit of any there is an obvious benefit of any intervention that may take place. intervention that may take place. True understanding is not easy for True understanding is not easy for many doctors, let alone patients.many doctors, let alone patients.

Consent (an example)Consent (an example)

Let’s take a look at regular breast Let’s take a look at regular breast self-examination, and start from the self-examination, and start from the patient’s point of view :patient’s point of view :

““Regular examination of my own Regular examination of my own breasts is a good idea because it will breasts is a good idea because it will stop me from dying of breast stop me from dying of breast cancer”cancer”


Well, the bad news is that it won’t, Well, the bad news is that it won’t, or not on present evidence(recent or not on present evidence(recent Cochrane r/v).Cochrane r/v).

““If I find a lump it will mean I will If I find a lump it will mean I will stay healthy because I will have stay healthy because I will have caught it in time.”caught it in time.”


Not true, or if it is, the difference is not Not true, or if it is, the difference is not great. Operating on some lumps very great. Operating on some lumps very early may even make the prognosis worse. early may even make the prognosis worse. Some lumps metastasise early, some Some lumps metastasise early, some don’t. At present we cannot tell the don’t. At present we cannot tell the difference.difference.

“ “There must be a useful thing to do There must be a useful thing to do because the doctor/nurse/magazine told because the doctor/nurse/magazine told me to do it.”me to do it.”


Really. The Chief Medical Officer did Really. The Chief Medical Officer did change his mind recently, but was change his mind recently, but was howled down and succumbed to howled down and succumbed to encouraging breast awareness encouraging breast awareness instead, whatever that is.instead, whatever that is.

“ “It stands to reason I must be a good It stands to reason I must be a good idea.”idea.”


It doesn’t.It doesn’t.

“ “It makes me worry about cancer, It makes me worry about cancer, but prevention is better than cure, but prevention is better than cure, isn’t it?isn’t it?””

Not when the premise is a fallacy.Not when the premise is a fallacy.


Now try it from the doctor’s point of Now try it from the doctor’s point of view :view :

“ “It stands to reason it must be a good It stands to reason it must be a good idea.”idea.”

Have you looked long and hard at Have you looked long and hard at Wilson’s criteria for screening Wilson’s criteria for screening recently?recently?


“ “It can’t do any harm.”It can’t do any harm.”

It can, not least in creating false It can, not least in creating false expectations and contributing to the expectations and contributing to the overvaluing of medical competence.overvaluing of medical competence.

“ “I can’t really tell her the truth, she I can’t really tell her the truth, she wouldn’t believe me.”wouldn’t believe me.”


It would take time, but she might. It would take time, but she might. Honesty should be the best policy.Honesty should be the best policy.

“ “But she will think I am an uncaring But she will think I am an uncaring nihilist and that it does not worry me what nihilist and that it does not worry me what happens to her.”happens to her.”

If that is the case, you have not achieved If that is the case, you have not achieved any degree of shared understanding and it any degree of shared understanding and it is still not worth perpetuating a dubious is still not worth perpetuating a dubious quarter-truth.quarter-truth.

Ponder for thought……..Ponder for thought…….. There is a major ethical divide between your There is a major ethical divide between your

patient coming to see you for your opinion patient coming to see you for your opinion and help with their agenda, and you imposing and help with their agenda, and you imposing your screening agenda on them.your screening agenda on them.

If you do initiate such a procedure, you If you do initiate such a procedure, you should have conclusive evidence that the test should have conclusive evidence that the test is likely to alter favourably the outlook for is likely to alter favourably the outlook for that individual and that it is unlikely to do any that individual and that it is unlikely to do any physical or psychological harm. Face the physical or psychological harm. Face the issues honestly and help your patients to ask issues honestly and help your patients to ask searching questions.searching questions.

Ponder for thought……Ponder for thought……

However, giving patients more However, giving patients more honest information about potential honest information about potential risks and benefits of screening may risks and benefits of screening may lead to people being discouraged lead to people being discouraged from attending for screening, with a from attending for screening, with a subsequent associated increase in subsequent associated increase in mortality of a preventable disease at mortality of a preventable disease at population level.population level.

Group workGroup work

Are the current screening Are the current screening programmes for cervical Ca and programmes for cervical Ca and Breast Ca justified in your eyes? Breast Ca justified in your eyes? Why? Why?

Split into 2 groups and discuss.Split into 2 groups and discuss.

screening and its future……………………. a definition of screening. any medical...

Documents

vascular screening

screening programme

popln screening

national screening committee

cancer incidence

breast cancer testingagain

disease treatment

accepted treatment