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PubMed1992

A case-control evaluation of the effect of breast cancer screening in the United Kingdom trial of early detection of breast cancer.

OBJECTIVE: The aim was to assess the extent to which selection bias affects a case-control study of breast cancer screening in which attenders and non-attenders for screening are compared. DESIGN: There were two retrospective case-control studies, one estimating the risk of death from breast cancer in women in the screening district relative to those in the comparison district (study A), the second estimating the relative risk for women who had ever been screened compared with women who had never been screened in the screening district alone (study B). For cases and controls in study B, the women's screening history was summarised for the time period from date of entry to diagnosis of the case, or the equivalent time from date of entry for the matched controls. For cases detected by screening, the screen at which cancer was detected was included in the screening history. SUBJECTS: Cases were deaths from breast cancer in women with disease diagnosed after entry to the trial, up to 31 December 1986 or a maximum of seven years from date of entry, in one of the screening districts (Guildford) and one of the comparison districts (Stoke) participating in the UK Trial of Early Detection of Breast Cancer: study A: 198 deaths in Guildford and Stoke; study B: 51 deaths in Guildford only. There were five age matched controls for each case, with length of follow up at least as great as the time from entry to death of the case. MAIN RESULTS: The estimate of the risk of death from breast cancer in the screening district relative to the comparison district from study A was 0.76, thus implying a reduction of 24% in the screening district, similar to that obtained from a cohort analysis of data from the two districts. In contrast, the relative risk in study B for ever v never screened women was 0.51, which, taking the 72% compliance into account, would result in a relative risk of 0.65 for the screening district if there were no selection bias. The risk of breast cancer mortality in the never screened relative to the comparison district was 1.13, despite the fact that incidence rates in the two populations were similar. This suggested that cancers in the never screened group had a particularly poor prognosis, contributing to selection bias. CONCLUSIONS: The possible existence of selection bias should lead to caution in interpretation of the results of case-control studies of the effect of breast cancer screening on mortality.

Breast Neoplasms↗
PubMed2003

False-positive result and reattendance in the Ontario Breast Screening Program.

OBJECTIVE: To determine the association between initial screen result and returning for a second screen in an organised breast screening programme for women with a biennial screening recommendation. SETTING: Women who attended the Ontario Breast Screening Program (OBSP). METHODS: A retrospective cohort study was conducted of 140723 Ontario women aged 50 years and older who had an initial screen at the OBSP between 1 July 1990 and 31 December 1995 and were followed until 30 June 1998. Rescreening rates at 36 months and risk ratio estimates were calculated using survival methods. Age of women, year of screen, region (within Ontario) and initial screen result were compared. For initial screen results, returning for a second screen was examined by integration of screening centre with an assessment programme and by modality of referral. RESULTS: Women with a false-positive result were less likely to return for a second screen as were women aged 70 and older and those living in regions of Ontario with fewer OBSP screening centres. However, there were minimal differences in reattendance behaviour by initial screen result for women screened at the OBSP centre with an assessment programme. CONCLUSIONS: Integration of breast screening and assessment services improved reattendance of women with false-positive screen results within an organised screening programme.

Aged↗
PubMed2006

The clinical effectiveness and cost-effectiveness of computed tomography screening for lung cancer: systematic reviews.

OBJECTIVES: The aim of this review is to examine the clinical and cost-effectiveness of screening for lung cancer using computed tomography (CT) to assist policy making and to clarify research needs. DATA SOURCES: Electronic databases and Internet resources. REVIEW METHODS: A systematic review was undertaken and selected studies were assessed using the checklists and methods described in NHS Centre for Reviews and Dissemination (CRD) Report 4. Separate narrative summaries were performed for clinical effectiveness and cost-effectiveness. Cost-effectiveness analysis resulting in a cost per quality-adjusted life-year was not feasible, therefore the main elements of such an appraisal were summarised and the key issues relating to the existing evidence base were discussed. RESULTS: Twelve studies of CT screening for lung cancer were identified, including two randomised controlled trials (RCTs) and ten studies of screening without comparator groups. The quality of reporting of these studies was variable, but the overall quality was adequate. The two RCTs were of short duration (1 year) and therefore there was currently no evidence that screening improves survival or reduces mortality. The proportion of people with abnormal CT findings varied widely between studies (5-51%). The prevalence of lung cancer detected was between 0.4% and 3.2% (number need to screen to detect one lung cancer = 31-249). Incidence rates of lung cancer were lower (0.1-1% per year). Detection of stage I and resectable tumours was high, 100% in some studies. Adverse events, as a result of investigation or surgery, or the screening process per se were poorly reported. Incidental findings of other abnormalities requiring medical follow-up were reported to be as high as 49%. Six full economic evaluations of population CT screening programmes for lung cancer were included in the review. The magnitude of cost-effectiveness ratios reported varied widely. None was set in the UK and generalisation was complicated by wide variation in the data used in different countries and a paucity of UK data for comparison. All six made the fundamental assumption that screening with CT for lung cancer reduced mortality. At the current time, there is no evidence to support that assumption. In the absence of evidence of health gains from screening for lung cancer, in terms of either quantity or quality of life, and faced with a range of uncertainties, from the frequency of abnormal screening findings within a population to the natural history of screening detected lung cancers, it is not feasible at the current time to develop accurately and meaningfully an economic argument for CT screening for lung cancer in the UK. For subgroups, in particular certain occupational groups, there is evidence of increased risk of lung cancer, but the role of screening has not been demonstrated by the current studies. CONCLUSIONS: The accepted National Screening Committee criteria are not currently met, with no RCTs, no evidence to support clinical effectiveness and no evidence of cost-effectiveness. RCTs are needed to examine the effect of CT screening on mortality, either with whole-population screening or for particular subgroups; to determine the rate of positive screening and detected lung cancers. Research is also needed to understand better the natural history and epidemiology of screening-detected lung cancers, particularly small, well-differentiated adenocarcinomas; as well as the impacts on quality of life. Increased collection is needed of UK health service data regarding resource use and safety data for lung cancer management and services. Research is also needed into the feasibility and logistics of tracing people who have in the past worked in industry where there was exposure to lung carcinogens.

Adult↗
PubMed1997

Mammographic screening: results from the 1996 National Breast Health Survey.

OBJECTIVE: To establish the extent of women's knowledge of mammographic screening, particularly in relation to the national screening program, BreastScreen Australia, and to estimate the proportion of women who are participating in screening both within and outside BreastScreen Australia. DESIGN AND SETTING: Validated prospective telephone survey of women aged 30-69 years selected at random from across Australia. PARTICIPANTS: 2935 women with no previous breast cancer diagnosis. RESULTS: The adjusted response rate was 64%. Almost 90% of women had heard of the national program; only 1% correctly stated that screening is for asymptomatic women. 60% correctly identified the current recommended age of starting screening is about 50 years of age; 26% thought screening should begin at about 40 years of age. Approximately 60% correctly reported that the recommended screening interval is every two years; 27% thought screening should be done annually. 55% reported ever having had a mammogram, and 37% reported having had at least one screening mammogram. Among women in the target age group (50-69 years) about 70% reported ever having had a screening mammogram, and about 50% reported having had a screening mammogram within the national program in the last two years. Among women aged 40-49 years, 29% reported ever having had a screening mammogram, and 22% reported having been screened in the last two years. CONCLUSIONS: Awareness of the national screening program is high, but some women do not know the purpose of screening, the target age group and the recommended screening interval. Compliance with screening is good among women in the target age group; many women in their 40s are also participating in screening.

Adult↗
PubMed2001

The cost-utility of screening for depression in primary care.

BACKGROUND: Depressive disorders are common in primary care and cause substantial disability, but they often remain undiagnosed. Screening is a frequently proposed strategy for increasing detection of depression. OBJECTIVE: To examine the cost-utility of screening for depression compared with no screening. DESIGN: Nonstationary Markov model. DATA SOURCES: The published literature. TARGET POPULATION: Hypothetical cohort of 40-year-old primary care patients. TIME HORIZON: Lifetime. PERSPECTIVE: Health care payer and societal. INTERVENTIONS: Self-administered questionnaire followed by provider assessment. OUTCOME MEASURES: Costs and quality-adjusted life-years (QALYs). RESULTS OF BASE-CASE ANALYSIS: Compared with no screening, the cost to society of annual screening for depression in primary care patients is $192 444/QALY. Screening every 5 years and one-time screening cost $50 988/QALY and $32 053/QALY, respectively, compared with no screening. From the payer perspective, the cost of annual screening is $225 467. RESULTS OF SENSITIVITY ANALYSES: Cost-utility ratios are most sensitive to the prevalence of major depression, the costs of screening, rates of treatment initiation, and remission rates with treatment. In Monte Carlo sensitivity analyses, the cost-utility of annual screening is less than $50 000/QALY only 2.2% of the time. In multiway analyses, four model variables must be changed to extreme values for the cost-utility of annual screening to fall below $50 000/QALY, but a change in only one variable increases the cost-utility of one-time screening to more than $50 000/QALY. One-time screening is more robustly cost-effective if screening costs are low and effective treatments are being given. CONCLUSIONS: Annual and periodic screening for depression cost more than $50 000/QALY, but one-time screening is cost-effective. The cost-effectiveness of screening is likely to improve if treatment becomes more effective.

Adult↗
PubMed2000

Screening for hypercholesterolaemia versus case finding for familial hypercholesterolaemia: a systematic review and cost-effectiveness analysis.

BACKGROUND: In the majority of people with familial hypercholesterolaemia (FH) the disorder is caused by a mutation of the low-density lipoprotein receptor gene that impairs its proper function, resulting in very high levels of plasma cholesterol. Such levels result in early and severe atherosclerosis, and hence substantial excess mortality from coronary heart disease. Most people with FH are undiagnosed or only diagnosed after their first coronary event, but early detection and treatment with hydroxymethylglutaryl-coenzyme (HMG CoA) reductase inhibitors (statins) can reduce morbidity and mortality. The prevalence of FH in the UK population is estimated to be 1 in 500, which means that approximately 110,000 people are affected. OBJECTIVES: To evaluate whether screening for FH is appropriate. To determine which system of screening is most acceptable and cost-effective. To assess the deleterious psychosocial effects of genetic and clinical screening for an asymptomatic treatable inherited condition. To assess whether the risks of screening outweigh potential benefits. METHODS DATA SOURCES: Relevant papers were identified through a search of the electronic databases. Additional papers referenced in the search material were identified and collected. Known researchers in the field were contacted and asked to supply information on unpublished or ongoing studies. INCLUSION/EXCLUSION CRITERIA: SCREENING AND TREATMENT: The review included studies of the mortality and morbidity associated with FH, the effectiveness and cost of treatment (ignoring pre-statin therapies in adults), and of the effectiveness or cost of possible screening strategies for FH. PSYCHOSOCIAL EFFECTS OF SCREENING: The search for papers on the psychological and social effects of screening for a treatable inherited condition was limited to the last 5 years because recent developments in genetic testing have changed the nature and implications of such screening tests. Papers focusing on genetic testing for FH and breast cancer were included. Papers relating to the risk of coronary heart disease with similarly modifiable outcome (non-FH) were also included. DATA EXTRACTION AND ASSESSMENT OF VALIDITY: A data assessment tool was designed to assess the quality and validity of the papers which reported primary data for the social and psychological effects of screening. Available guidelines for systematically reviewing papers concentrated on quantitative methods, and were of limited relevance. An algorithm was developed which could be used for both the qualitative and quantitative literature. MODELLING METHODS: A model was constructed to investigate the relative cost and effectiveness of various forms of population screening (universal or opportunistic) and case-finding screening (screening relatives of known FH cases). All strategies involved a two-stage process: first, identifying those people with cholesterol levels sufficiently elevated to be compatible with a diagnosis of FH, and then either making the diagnosis based on clinical signs and a family history of coronary disease or carrying out genetic tests. Cost-effectiveness has been measured in terms of incremental cost per year of life gained. RESULTS: MODELLING COST-EFFECTIVENESS: FH is a life-threatening condition with a long presymptomatic state. Diagnostic tests are reasonably reliable and acceptable, and treatment with statins substantially improves prognosis. Therefore, it is appropriate to consider systematic screening for this condition. Case finding amongst relatives of FH cases was the most cost-effective strategy, and universal systematic screening the least cost-effective. However, when targeted at young people (16 year olds) universal screening was also cost-effective. Screening patients admitted to hospital with premature myocardial infarction was also relatively cost-effective. Screening is least cost-effective in men aged over 35 years, because the gains in life expectancy are small. (ABSTRACT TRUNCA

Adult↗
PubMed2002

Colorectal cancer screening: physician attitudes and practices.

PURPOSE: The American Cancer Society (ACS) set a nationwide goal to increase to 75% by 2015 the proportion of people aged 50 and older who have colorectal cancer (CRC) screening consistent with ACS guidelines. Little is known about current physician screening practices and attitudes. The purpose of this study was to document current physician attitudes and practices regarding CRC screening, and to formulate appropriate interventions to meet the ACS screening goal. METHODS: Questionnaires were sent to a random sample of 600 primary care physicians in Wisconsin. The survey measured 1) screening preferences; 2) estimates of patients screened by each method; 3) agreement to statements regarding screening guidelines and practices, patient compliance, effectiveness in reducing mortality, factors regarding colonoscopy as a screening tool; 4) use of reminder systems; 5) demographics. RESULTS: Physicians prefer combining fecal occult blood testing (FOBT) with flexible sigmoidoscopy for CRC screening, while they believe patients prefer FOBT alone. Only 1.5% view colonoscopy as their preferred method of screening. There is discrepancy between physicians' beliefs that patients should be screened and estimated numbers they screen. Only 38.2% of respondents would screen a moderate-risk patient at the ACS recommended age. Physicians perceive screening compliance to be low. Cost, availability, risks, and lack of proof of effectiveness influence physician decisions. Fewer than half have any reminder system for CRC screening. CONCLUSIONS: CRC screening rates are currently lower than the 2015 ACS goal. Influential factors include physician attitudes and beliefs about effectiveness, familiarity with guidelines, perception of patient preferences and compliance, and lack of adequate reminder systems. Targeting interventions to these factors may increase the rate of CRC screening. Despite increased consensus from professional societies on colonoscopy as the best choice for screening, few primary care physicians would choose this option.

Colonoscopy↗
PubMed2005

Quality assessment of the mammographic screening programme in the Azienda Sanitaria locale Provincia Milano 1 -- analysis of interval cancers and discussion of possible causes of diagnostic error.

PURPOSE: To evaluate the sensitivity of the mammographic screening programme and the causes of diagnostic fault in cases surfacing as interval cancers. MATERIALS AND METHODS: Interval cancers (CI) were identified by linkage of the screening database for the years 2000-2002 to the database of hospital discharge records (HDR) for breast cancer during 2000-2002. Linkage between screening attenders during 2000-2001 and HDR (biennial follow-up for year 2000, one year follow-up for year 2001) was used to calculate the proportional rate of observed/expected IC. The observed/ expected rate was compared with international standards and literature data. Screening mammograms followed by IC, randomly admixtured with negative controls, underwent blind review by an independent radiologist, using the recommended classification criteria to evaluate causes of error (occult, minimal signs, screening error). RESULTS: The analysis of HDR during 2000-2002 allowed us to identify 31 out of 89 expected IC. Proportional observed/expected IC rate in the first or second year of screening interval was 26 or 67%, respectively. Screening mammograms for radiological review were available in 38 of 61 total IC: 20 cases (52.6%) were classified as occult, whereas minimal signs or screening errors were 2 (5.2%) or 16 (42.1%), respectively. Diagnostic suspicion had been reported at screening in 7 of 16 cases classified as screening error, but were not diagnosed at the subsequent diagnostic assessment. CONCLUSIONS: Proportional IC rate was higher than reported in the literature or currently recommended (<30% in the 1st, <50% in the 2nd year). The analysis of error causes shows an excess of screening errors with respect to current recommendations (<20% of IC should be classified as screening error at review), but also an excess of IC suspected at screening but misdiagnosed at assessment (7/38=18.4 %). Overall the analysis revealed a reduced sensitivity of the screening programme, as often observed in service screening as compared to excellence centres, and suggests proper action to improve diagnostic accuracy. Analysis and critical review of IC is an early indicator of screening efficacy which is not currently used in Italian screening programmes. Using HDR for this purpose may have limited drawbacks, but gives the advantage of earlier identification of IC as compared to cancer registries and is the most reliable source of information in areas lacking a cancer registry. The present study methodology might be currently applied in screening programmes.

Aged↗
PubMed1992

Update of the Swedish two-county program of mammographic screening for breast cancer.

The results of the Swedish two-county trial of mammographic screening for breast cancer are presented, updated to December 31, 1990, which is an average of 10.8 years follow-up per person. The main result of the trial in terms of breast cancer mortality remained the same: compared with the control group, the group invited to screening had a relative breast cancer mortality of 0.70 (P = 0.0002) with 95% confidence interval (0.58, 0.85). Analysis of survival showed that relative to the control group, the cancers detected at prevalence screen, incidence screens, and in the interval between screens had a good prognosis, whereas cancers detected in those who had refused screening had a very poor prognosis. When adjusted for tumor size, lymph node status, and tumor grade (differentiation), the better survival associated with incidence screen and interval detection was largely accounted for, indicating that the benefit of incidence screening is largely achieved through the effect of screening on the three prognostic variables, notably size of the tumor. Results indicate that to achieve a substantial mortality reduction, 50% of screen-detected invasive cancers should be less than 15 mm in diameter, at least 30% of screen-detected grade 3 tumors should be less than 15 mm, and at least 70% of screen-detected tumors should not have lymph node metastases. The percentage of grade 3 tumors of a given size should be the same in screen-detected cancers as in clinically detected, and breast cancer prevalence at first screen should be at least three times the expected incidence rate in the absence of screening. This should be achieved without the recall rate for further examination exceeding 9%, and procedures including further imaging techniques and fine needle aspiration or core biopsy should be used before resorting to surgical biopsy. These aims can be achieved in specialist screening centers if particular attention is paid to resources for screening and diagnostic evaluation, specialist training of clinical and technologic screening staff, and ongoing monitoring of mammographic quality, recall rates, and the attributes of the tumors detected.

Adult↗
PubMed2005

Behavioral associations between prostate and colon cancer screening.

BACKGROUND: Despite the controversy over the utility of routine prostate-specific antigen (PSA) screening in reducing prostate cancer-specific mortality, it has gained widespread use throughout the United States. Although colorectal cancer (CRC) screening reduces CRC mortality and appears to be cost effective, CRC screening adherence is suboptimal. To better understand screening behaviors among men, the Behavioral Risk Factors Surveillance Survey was used to identify potential relationships that would allow interventions to enhance CRC screening. STUDY DESIGN: We included in our analysis 22,304 men, 50 years and older, who participated in the 2002 Behavioral Risk Factors Surveillance Survey. Chi-square and multivariate analyses were performed to determine the independent correlates of adherence to CRC screening. Independent variables evaluated were age, race, educational level, employment status, income, health insurance, the presence of a personal physician, self-reported general health, current smoking status, and receiving a PSA test. RESULTS: Men were more adherent with PSA screening than CRC screening (50.4% versus 47.6%;p < 0.002). In multivariate analysis, adherence to PSA screening (adjusted odds ratio [OR] 3.24, p < 0.001) exerted the largest independent effect on CRC screening adherence. Other positive correlates of adherence to CRC screening were having health insurance (adjusted OR 1.39, p < 0.01) and a personal physician (adjusted OR 2.01, p < 0.01). Age predicted CRC screening with an inverse-U correlation. Failure to adhere to CRC screening was associated with self-reported good health (adjusted OR 0.87, p < 0.01) and being a current smoker (adjusted OR 0.65, p < 0.01). Even in men who were compliant with PSA testing, CRC screening remained suboptimal (65%). CONCLUSIONS: More men received PSA testing than CRC screening. Men who received PSA testing were more likely to adhere to CRC screening. Taken together, PSA testing may represent a "teachable moment" for a behavior-related intervention aimed at reducing the risk of colon cancer. Targeting men who already accept one form of cancer screening can potentially increase CRC screening adherence.

Aged↗
PubMed1994

Screening for non-insulin-dependent diabetes mellitus (NIDDM): how often should it be performed?

OBJECTIVES: To examine whether a screening programme for diabetes repeated after an interval of 30 months is worthwhile both in terms of yield of new cases and continued high response rate. METHODS: Self testing for postprandial glycosuria was used as it has been shown to have a good response rate, a good yield of cases of diabetes, and a sensitivity and specificity which compares favourably with more expensive and invasive screening methods. A total of 3231 subjects aged 45-70 years in one practice were screened on two occasions 30 months apart. Eighty seven subjects known to have diabetes were excluded. This number included five new patients who had presented since the initial screen; two of whom had moved into the practice, one who screened positive at the initial screen but failed to attend for the oral glucose tolerance test (OGTT), and two subjects who had screened negative, the first presenting 24 months after screening. RESULTS: At repeat screening the return rate was lower than at the first screening (72.5% v 79.2%, P < 0.0001). Glycosuria was detected in 52 subjects (2.3%), at the repeat screening, similar to that at the initial screen. Attendance for the OGTT after a positive screening test was 93.2%. Only six subjects of the 24 with glycosuria but normal glucose tolerance at initial screen were found to have glycosuria again; repeat OGTTs were all normal. Of the remaining 46 subjects, 10 had non-insulin-dependent diabetes mellitus (NIDDM) and five impaired glucose tolerance (IGT). The number of subjects with diabetes was not significantly different from that at the initial screening (0.44% v 0.72%, P = 0.2). CONCLUSIONS: Repeat screening after 30 months has a high response rate, similar rate of detection of glycosuria, and a further yield of 0.44% of newly diagnosed cases of diabetes. A screening programme detecting postprandial glycosuria identifies additional diabetic subjects 30 months after a previous screening programme.

Age Factors↗
PubMed2006

Reduction in breast cancer mortality from organized service screening with mammography: 1. Further confirmation with extended data.

BACKGROUND: In an earlier publication, our evaluation of data from breast cancer screening programs in seven Swedish counties suggested a 40% reduction in incidence-based breast cancer mortality among women actually screened. In the current study, we expand the previous analysis from seven counties to 13 large areas within nine counties, including six of the original counties and seven additional areas, examine a longer period of follow-up (20-44 years), apply new analytic methods for the evaluation of incidence-based breast cancer mortality, and estimate the number needed to screen to save one life. METHODS: Data from six of the original counties (one being excluded as it does not yet have 10 years of follow-up after the initiation of screening), with increased follow-up, and seven additional large areas, within three counties, representing approximately 45% of Swedish women, provide information about age at diagnosis, age at death, and screening history for 542,187 women in the prescreening and 566,423 women in the screening epochs. Regardless of year of diagnosis, there were a total of 6,231 deaths due to breast cancer in the period of study as a whole. Of these, 4,778 were incidence-based deaths in the two epochs, i.e., death among cases diagnosed within either the prescreening or screening period. Data were analyzed using Poisson regression and adjusted, when necessary, for self-selection bias, contemporaneous changes in incidence, and changes in mortality independent of screening. RESULTS: Attendance was uniformly high, averaging 75% in the screening epochs. Recall rates for assessment varied from 4% to 5% at the first round of screening and approximately 3% at later rounds. Detection rates averaged five breast cancers per 1,000 women screened in the first round, and four breast cancers per 1,000 women screened in subsequent rounds. There was a significant 45% reduction in incidence-based breast cancer mortality among screened women in the screening epoch relative to incidence-based breast cancer mortality in the prescreening epoch (relative risk, 0.55; 95% confidence intervals, 0.51-0.59). After adjusting for self-selection bias, there still was a significant 43% reduction in incidence-based breast cancer mortality associated with screening (relative risk, 0.57; 95% confidence intervals, 0.53-0.62). CONCLUSIONS: These results indicate a reduction in breast cancer mortality of between 40% and 45% in association with screening, after adjustment for self-selection bias. These results were obtained with modest human costs: the number needed to screen to save one life was estimated as 472.

Adult↗
PubMed2003

Potential health and economic impact of adding a human papillomavirus vaccine to screening programs.

CONTEXT: Recently published results suggest that effective vaccines against cervical cancer-associated human papillomavirus (HPV) may become available within the next decade. OBJECTIVE: To examine the potential health and economic effects of an HPV vaccine in a setting of existing screening. DESIGN, SETTING, AND POPULATION: A Markov model was used to estimate the lifetime (age 12-85 years) costs and life expectancy of a hypothetical cohort of women screened for cervical cancer in the United States. Three strategies were compared: (1) vaccination only; (2) conventional cytological screening only; and (3) vaccination followed by screening. Two of the strategies incorporated a vaccine targeted against a defined proportion of high-risk (oncogenic) HPV types. Screening intervals of 1, 2, 3, and 5 years and starting ages for screening of 18, 22, 24, 26, and 30 years were chosen for 2 of the strategies (conventional cytological screening only and vaccination followed by screening). MAIN OUTCOME MEASURES: Incremental cost per life-year gained. RESULTS: Vaccination only or adding vaccination to screening conducted every 3 and 5 years was not cost-effective. However, at more frequent screening intervals, strategies combining vaccination and screening were preferred. Vaccination plus biennial screening delayed until age 24 years had the most attractive cost-effectiveness ratio (44 889 dollars) compared with screening only beginning at age 18 years and conducted every 3 years. However, the strategy of vaccination with annual screening beginning at age 18 years had the largest overall reduction in cancer incidence and mortality at a cost of 236 250 dollars per life-year gained compared with vaccination and annual screening beginning at age 22 years. The cost-effectiveness of vaccination plus delayed screening was highly sensitive to age of vaccination, duration of vaccine efficacy, and cost of vaccination. CONCLUSIONS: Vaccination for HPV in combination with screening can be a cost-effective health intervention, but it depends on maintaining effectiveness during the ages of peak oncogenic HPV incidence. Identifying the optimal age for vaccination should be a top research priority.

Adolescent↗
PubMed2003

Results from an ultrasound-based familial ovarian cancer screening clinic: a 10-year observational study.

OBJECTIVES: To assess the use of transvaginal sonography as a screening test for familial ovarian cancer and, secondarily, to determine the value of a family history of malignant disease and the potential role of serum CA 125 levels in the screening procedure. METHODS: Two thousand five hundred self-referred women were studied at the Ovarian Screening Clinic at King's College Hospital, London. These symptom-free women with at least one close relative who had developed ovarian cancer were studied prospectively. Each woman was scanned for the presence of a persistent ovarian lesion and a sample of peripheral blood was taken for the retrospective analysis of serum CA 125. Women with a positive screen result were referred for surgical investigations; those with a negative result but considered to be at high risk were rescreened. The main outcome measures were findings at surgery, the histological classification of ovarian lesions, and cancer reported at follow-up. RESULTS: The women were aged 17 to 78 (mean, 48) years; 65% were premenopausal, 26% were postmenopausal and 9% had undergone hysterectomy. Seven hundred and thirty-eight women (29.5%) had a family history of multiple site cancers and 279 (11.2%) reported cancer specific to the ovary. There were 4231 screenings (2500 first screens, 998 second screens and 733 third or higher order screens). One hundred and four screens gave a positive result (2.5%); 11 cancers were detected (seven (64%) at stage I, four of which were of borderline malignancy). One additional cancer was reported within 12 months of the last scan and classified as a false-negative screen result. Eight cancers (including two peritoneal) were reported at follow-up (> 1-9 years after the last scan). All these women presented at an advanced stage (stage III). Fifteen of 20 cancers occurred in premenopausal women. The overall sensitivity of ultrasound screening was 92% (95% confidence interval, 76-100); the specificity was 97.8%. The prior odds of any woman having a screen-detectable ovarian malignancy during the study period were 1 : 207. The posterior odds subsequent to a positive screen result were 1 : 8.5 (1 : 12.7 at Screen 1; 1 : 3.7 at Screen 2; 1 : 3.0 at subsequent screens); the value was 1 : 11.4 for women with one family relative with ovarian cancer and 1 : 5.0 for women with the site-specific ovarian cancer syndrome. The prior use of a decision level for serum CA 125 >or= 20 U/mL would have reduced the number of women undergoing sonography by 78%; seven of the 12 cancers (58%) would have been detected (63% of all stage I disease, 75% of invasive stage I disease). An alternative cut-off value of 35 U/mL would have resulted in a detection rate of 33%. CONCLUSIONS: Transvaginal sonography can effectively detect intraovarian cancer and tumors of borderline malignancy in women with a family history of the disease. Screening efficacy is related to the type of family history. The level of serum CA 125 can be used to select women for sonography, but the detection rate for early cancers would be reduced.

Adolescent↗
PubMedDate not supplied

Screening for type 2 diabetes mellitus in children and adolescents: attitudes, barriers, and practices among pediatric clinicians.

OBJECTIVE: The American Diabetes Association (ADA) recommends screening children at risk for type 2 diabetes with a fasting plasma glucose test or an oral glucose tolerance test. The purpose of this study was to describe attitudes, barriers, and practices related to type 2 diabetes screening in children among pediatric clinicians. METHODS: Pediatricians, nurse practitioners and physician assistants from a multispecialty, group practice in Eastern Massachusetts completed a mailed survey. To assess screening practice, three vignettes were presented representing pediatric patients with low, moderately high, and high risk for type 2 diabetes. The moderately high-risk and high-risk patients met ADA criteria for screening. ADA-consistent practice was defined as only screening the moderately high-risk and high-risk patients; lower-threshold practice was defined as also screening the low-risk patient; and higher threshold practice was screening only the high-risk patient. RESULTS: Sixty-two of 90 clinicians responded (69%). Based on intent to screen in the 3 vignettes, 21% of respondents reported ADA-consistent screening practice, 39% lower-threshold, and 35% higher-threshold screening practice. Five percent had incomplete or nonclassifiable responses. Many clinicians ordered screening tests other than those recommended by the ADA; few (< or =8% in any vignette) ordered only an ADA-recommended test. Preferences for nonfasting tests were influenced by nonmedical factors such as access to or cost of transportation. Inadequate patient education materials and unclear recommendations for appropriate screening methods were the most frequently reported moderate/strong barriers to screening. CONCLUSIONS: Most respondents reported type 2 diabetes screening practices that differed from current ADA recommendations. Our findings suggest that type 2 diabetes screening tests must be practical for clinicians and patients if they are to be used in pediatric practice. Further study of the benefits and cost-effectiveness of type 2 diabetes screening in children is warranted to clarify the role and optimal methods for screening in pediatric primary care.

Adolescent↗
PubMed2005

Screening of colorectal cancer.

Cost-effectiveness analyses have shown that the cost per year of life saved by screening with any of the tests recommended is reasonable by US standards. Although the specific results vary among analyses, in general the marginal cost-effectiveness of this screening is less than $25,000 per year of life saved. Screening for CRC was among the highest ranked services in an analysis of the value of preventive services based on the burden of disease prevented and cost-effectiveness. Although the up-front costs vary by screening modality, the long-term cost-effectiveness is similar across screening tests, so that decisions about which options to include--in the long run and from the perspective of society--do not need to be affected heavily by costs. Costs increase out of proportion to benefits with shorter intervals between screening examinations. Screening has provided great opportunities. Screening can prevent CRC by polypectomy and find early-stage cancers for treatment with less morbidity. Screening can reduce the burden of treating advanced cancers and can identify families at increased risk. Screening also has provided a better understanding of the biology of CRC. Screening for CRC should be part of a complete prevention program that includes a healthy lifestyle and familial risk assessment. Individuals with increased familial risk require special screening approaches, whereas individuals with average risk can have more standard screening. The average-risk individuals can be stratified further into persons who require intensive follow-up and persons who require less intensive or no follow-up at all. We are beginning to learn how to apply screening and surveillance approaches based on risk stratification for a more cost-effective approach to conserve resources and reduce complications and costs. Chemoprevention can be added to the program when substantial benefit of agents has been demonstrated. We have a better understanding of the biology of CRC and the technology to intervene in that biology to make a difference in the lives of many people. We have the concepts and technology to reduce substantially the mortality for CRC and even prevent it entirely. Newer screening tests or others yet to be developed may, with time, replace the modern options. Screening should take place with the tests currently available and not wait until something better comes along. In this way, needless suffering and loss of life can be avoided for this leading cause of cancer death. Screening may become even more successful if the promise of new technologies is confirmed and they enter clinical practice. In the last analysis, the best test is the one that gets done and gets done immediately.

Adenoma↗
PubMed2004

Factors associated with colorectal cancer screening in a population-based study: the impact of gender, health care source, and time.

INTRODUCTION: The effectiveness of colorectal cancer screening in reducing incident colorectal cancer and the risk of death has been shown. Despite campaigns to promote the benefits of and use of colorectal cancer screening, most people are not participating in screening. In this paper, we examine factors associated with screening behavior over time, by health care provider, and by gender and report associations between screening and development of colorectal cancer after adjusting for diet and lifestyle factors. METHODS: Data from two population-based case-control studies of colorectal cancer were used to examine risk associations with nonparticipation in colorectal cancer screening. Study participants were identified for the first study between 1991 and 1994 (N = 1,346 cases and 1,544 controls) and for the second between 1997 and 2001 (N = 952 cases and 1,205 controls) and were asked to complete a detailed in-person interviewer-administered diet and lifestyle questionnaire. The control population is used to examine changes in screening behavior and associations with screening over time. RESULTS: Significantly, fewer people reported fecal occult blood test (FOBT) in 1997-2001 than in 1991-1994 (62.5% in 1991-1994 vs. 47.2% in 1997-2001); a slight nonsignificant increase in sigmoidoscopy screening was reported for these periods among controls (33.9% vs. 36.6%). In the control population, during these periods, there was a statistically significant increase in the number of people who reported having had a sigmoidoscopy for screening rather than for problems (72.6% in 1997-2001 vs. 63.8% in 1991-1994). There were differences in factors associated with screening behavior by time, by sex, and by health care provider, although having a family history of colorectal cancer, having more education, and being male was associated with more screening in all settings. After adjusting for diet and lifestyle factors, we observed that non-sigmoidoscopy screening significantly influenced risk of incident cancer (rectal OR: 2.9; 95% CI, 2.3-3.7; distal tumor OR: 1.8; 95% CI, 1.4-2.3); proximal tumor: 1.4; 95% CI, 1.1-1.8). Nonuse of FOBT also was associated significantly with tumors in the rectal (OR: 1.6; 95% CI, 1.3-1.9) and distal (OR: 1.4; 95% CI, 1.1-1.8) sites. SUMMARY: These data reinforce the importance of screening to reduce risk of colorectal cancer development. However, flexible sigmoidoscopy screening is increasing only modestly over time, and primarily in settings where a significant investment in screening has been made. FOBT screening, which is effective for rectal cancer prevention, is actually decreasing.

Aged↗
PubMed2000

Universal versus targeted screening of infants for sickle cell disease: a cost-effectiveness analysis.

OBJECTIVE: To compare the health outcomes, costs, and incremental cost-effectiveness of universal neonatal screening for sickle cell disease (SCD) with screening targeted to African Americans. STUDY DESIGN: A cost-effectiveness analysis was done by using a Markov simulation model that considered the costs and outcomes associated with the prevention and treatment of sepsis in those with sickle cell anemia and sickle beta(0)-thalassemia. Three strategies were compared: (1) no screening, (2) targeted screening of African Americans, and (3) universal screening for SCD. RESULTS: In the base case analysis, targeted screening of African Americans compared with no screening cost $6709 per additional year of life saved, and universal screening compared with targeted screening cost $30,760 per additional year of life saved. In a sensitivity analysis, the cost per additional year of life saved with universal screening compared with targeted screening was positively correlated with the delivery rate of targeted screening and was inversely related to the proportion of African Americans in the population. CONCLUSIONS: Targeted screening of African American newborns for SCD compared with no screening is always cost-effective. Universal screening compared with targeted screening always identifies more infants with disease, prevents more deaths, and is cost-effective given certain delivery rates for targeted screening and proportions of African Americans in the population.

Anemia, Sickle Cell↗