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PubMed2003

[Health economics analysis of cervical cancer screening].

INTRODUCTION: To reduce the high mortality rate of cervical cancer there are organized, nation-wide mass-screening programmes. AIM: To assess the screening rate, the cost of screening and treatment and to calculate the expected epidemiological and economic gain and cost-effectiveness of mass-screening programme. METHODS: The data derive from the financial database of the National Health Insurance Fund of Hungary from 2001. To assess the screening rate the authors used the code "No. 29601 cytological examination for screening" of out-patient care. The cost of treatment includes the cost of out-patient care, the acute and chronic inpatient care, the subsidies of medicines' prices and the expenditure on disability to work (including sickness-pay). The expected benefits of the screening programme were modelled with changing the screening interval. RESULTS: The screening rates for 1999, 2000 and 2001 were 14.5%, 16.2% and 15.6% respectively, while the 3 year screening rate for 1999-2001 were 35.7%. The cost of treatment of cervical cancer were around 1 billion Hungarian forint in 2001. The cost of one life saved according to the current screening strategy was 16.6 million Hungarian forints (57.792 USD) with a successful screening programme, while with a less successful program it was 33.8 million Hungarian forint (118.093 USD). The cost of one life year gained according to the current screening strategy was 0.7 million Hungarian forints (2.513 USD) with a successful screening programme, while with a less successful program it was 1.5 million Hungarian forint (5.134 USD). CONCLUSION: It is important to increase the screening rate. With increasing the screening interval for women aged between 25-65 from 1 year to 2 or 3 years, it improves the cost-effectiveness of screening programme.

Adult↗
PubMed2006

Rates and predictors of colorectal cancer screening.

INTRODUCTION: Despite widespread recommendations for colorectal cancer screening, the U.S. screening rate is low. The objectives of this study were to describe the rates and predictors of colorectal cancer screening use by examining groups in two categories--1) those who have ever been screened and 2) those with up-to-date screening--and to assess whether trends and predictors change over time. METHODS: We analyzed data from the 2000 and 2003 National Health Interview Surveys about the use of fecal occult blood tests, sigmoidoscopies, and colonoscopies for adults aged 50 years and older and without a history of colorectal cancer (N = 11,574 in 2000 and N = 11,779 in 2003). RESULTS: Rates in the 2000 study population of those who have ever been screened for colorectal cancer (53%) had increased in the 2003 study population (55%) as had the rates in the 2003 study population of those with up-to-date colorectal screening (53%) compared with the rates in the 2000 study population (38%). Among those who were ever screened, 76% were up-to-date with screening in 2003, compared with 68% in 2000. There was increased use of colonoscopies but decreased use of fecal occult blood tests and sigmoidoscopies. Individuals were more likely to be up-to-date with screening if they had higher income, higher education, insurance coverage, a usual source of care, and a dental visit in the last year than if these predictors were not evident. Since 2000, these predictors of colorectal cancer screening use have remained stable. CONCLUSION: Although there has been relatively limited success in increasing overall screening, it is encouraging that most people in the group of those who have ever been screened are up-to-date with colorectal cancer screening. Predictors for colorectal screening were stable over time despite changes in screening policies and rates. Further research is needed to uncover barriers to colorectal cancer screening.

Adult↗
PubMed2006

Knowledge, barriers, and predictors of colorectal cancer screening in an Appalachian church population.

INTRODUCTION: This study examined knowledge about and barriers to colorectal cancer screening and predictors of screening adherence among members from 16 Appalachian churches as part of a larger study on the prevention and early detection of colorectal cancer. METHODS: Baseline data were collected on 839 respondents aged 50 years and older through a self-administered survey, and 23 focus groups were conducted with 205 church members RESULTS: Survey results showed that older age, male sex, being current for other cancer screening, being physically active, having perceived support from others for screening, better provider communication, knowledge about screening guidelines, greater perceived susceptibility to colorectal cancer, and a family history of the disease were predictors of screening adherence. Major barriers to screening in both surveys and focus groups were failure of providers to recommend screening, lack of knowledge about the need for screening, and the belief that screening was not necessary without symptoms. Fear of cancer, lack of knowledge about screening methods other than colonoscopy, reliance on physicians for screening information, and the need for people to feel at risk for screening to occur were other findings from the focus groups. Focus groups supported survey findings and provided further insights. CONCLUSION: Several factors predictive of colorectal cancer screening in this study can be modified through educational interventions. Recognizing and changing risk factors for colorectal cancer, raising awareness of screening guidelines, and encouraging adults aged 50 years and older to discuss screening with their health care provider could increase colorectal cancer screening.

Aged↗
PubMed1987

The control of breast cancer through mammography screening. What is the evidence?

There are few forms of cancer that can be effectively controlled. Now that there is sufficient evidence demonstrating that mortality from breast cancer can be reduced with the help of mammography screening, we are faced with the challenge of applying this method on a large scale. What are the major practical problems? The medical profession and decision makers must be made familiar with nature of the recent achievements and with their practical implications. The personnel who will be responsible for undertaking screening have to be adequately trained before screening gets under way. Women should understand the benefits that they can gain from mammography screening so that they will be sufficiently motivated to attend. This can be achieved by sincere, periodic information through the mass media. It is important that every woman eligible for screening understand that her risk of dying from breast cancer will be half as much if she participates in screening as it would be if she fails to participate. She should also be aware that the smaller cancers detected at screening can often be removed by breast conserving surgery without the need for mastectomy. Because mammography does not prevent breast cancer, women must be aware of the fact that mammography has to be repeated at regular intervals if the benefits of screening are to be maintained. Additionally, breast self-examination should be practiced in the interval between screens. Finally, decision makers will have to realize that screening with mammography can, in the long run, lead to reduction of health service costs. It is obvious that the expenses involved in taking care of a patient with advanced breast carcinoma can be very high. As it has been clearly demonstrated that properly performed screening will significantly decrease the number of advanced, costly breast carcinomas, a large proportion of these expenses will be saved in the population invited to screening. Because screening itself drains economic resources, the costs of screening outweigh the savings until the number of advanced cancers decreases; however, after this occurs the expenses of screening will be far less than the savings. The savings arise from the smaller number of advanced, costly cases. The results to date are convincing enough to justify recommending large-scale mammographic screening. The Swedish government has recommended screening with mammography for all women aged 40-74. This recommendation repeatedly emphasizes the necessity of high quality examinations interpreted by well-trained radiologists.

Breast Neoplasms↗
PubMedDate not supplied

School-based screening for tuberculous infection. A cost-benefit analysis.

OBJECTIVE: To compare tuberculin screening of all kindergartners and high school entrants (screen-all strategy) vs screening limited to high-risk children (targeted screening). DESIGN: Decision, cost-effectiveness, and cost-benefit analyses. SETTING AND SUBJECTS: Students in a large urban and rural county. DEFINITIONS: High risk of tuberculosis infection was defined as birth in a county with a high prevalence of tuberculosis. Low risk was defined as birth in the United States. OUTCOME MEASURES: Tuberculosis cases prevented for 10, 000 children screened. Net costs, net cost per case prevented, benefit-cost ratio, and incremental cost-effectiveness. RESULTS: The screen-all strategy would prevent 14.9 cases per 10,000 children screened; targeted screening would prevent 84.9 cases per 10,000 children screened. The screen-all strategy is more costly than no screening; the benefit-cost ratio is 0.58. Targeted screening would result in a net savings; the benefit-cost ratio is 1.2. Screening all children is cost saving only if the reactor rate is 20% or greater. The cost per additional case prevented for screening all children compared with targeted screening (+34 666) is more than twice as high as treatment and contact tracing for a case of tuberculosis (+16 392). CONCLUSIONS: Targeted screening of schoolchildren is much less costly than mass screening and is more efficient in prevention of tuberculosis.

Adolescent↗
PubMed1997

Newborn screening for inborn errors of metabolism: a systematic review.

OBJECTIVES. To establish a database of literature and other evidence on neonatal screening programmes and technologies for inborn errors of metabolism. To undertake a systematic review of the data as a basis for evaluation of newborn screening for inborn errors of metabolism. To prepare an objective summary of the evidence on the appropriateness and need for various existing and possible neonatal screening programmes for inborn errors of metabolism in relation to the natural history of these diseases. To identify gaps in existing knowledge and make recommendations for required primary research. To make recommendations for the future development and organisation of neonatal screening for inborn errors of metabolism in the UK. HOW THE RESEARCH WAS CONDUCTED. There were three parts to the research. A systematic review of the literature on inborn errors of metabolism, neonatal screening programmes, new technologies for screening and economic factors. Inclusion and exclusion criteria were applied, and a working database of relevant papers was established. All selected papers were read by two or three experts and were critically appraised using a standard format. Seven criteria for a screening programme, based on the principles formulated by Wilson and Jungner (WHO, 1968), were used to summarise the evidence. These were as follows. Clinically and biochemically well-defined disorder. Known incidence in populations relevant to the UK. Disorder associated with significant morbidity or mortality. Effective treatment available. Period before onset during which intervention improves outcome. Ethical, safe, simple and robust screening test. Cost-effectiveness of screening. A questionnaire which was sent to all newborn screening laboratories in the UK. Site visits to assess new methodologies for newborn screening. The classical definition of an inborn error of metabolism was used (i.e., a monogenic disease resulting in deficient activity in a single enzyme in a pathway of intermediary metabolism). RESEARCH FINDINGS. INBORN ERRORS OF METABOLISM. Phenylketonuria (PKU) (incidence 1:12,000) fulfilled all the screening criteria and could be used as the 'gold standard' against which to review other disorders despite significant variation in methodologies, sample collection and timing of screening and inadequacies in the infrastructure for notification and continued care of identified patients. Of the many disorders of organic acid and fatty acid metabolism, a case can only be made for the introduction of newborn screening for glutaric aciduria type 1 (GA1; estimated incidence 1:40,000) and medium-chain acyl CoA dehydrogenase (MCAD) deficiency (estimated incidence 1:8000-1:15,000). Therapeutic advances for GA1 offer prevention of neurological damage but further investigation is required into the costs and benefits of screening for this disorder. MCAD deficiency is simply and cheaply treatable, preventing possible early death and neurological handicap. Neonatal screening for these diseases is dependent upon the introduction of tandem mass spectrometry (tandem MS). This screening could however also simultaneously detect some other commonly-encountered disorders of organic acid metabolism with a collective incidence of 1:15,000.(ABSTRACT TRUNCATED)

Cost-Benefit Analysis↗
PubMed1998

Once is enough--why some women do not continue to participate in a breast cancer screening programme.

AIM: To assess the reasons why many women who have been screened once in a breast screening programme decline an invitation for further screening. METHODS: Telephone interview survey of a sample of such women; for questions relating to their experience of previous mammography, comparison to data on a representative sample of first screen attendees. The subjects were women who had attended the first round of the Otago-Southland breast cancer screening programme in 1991-1994, who were eligible for re-screening but had been rescreened; age range 50-62. RESULTS: From programme records, 86% of women who were eligible for a second screen accepted it. Of the women not recorded as having had a second screen, some had attended for a second screen; some had not been invited until they had become age ineligible and some had received no invitation for re-screening. Of women who had received and declined an invitation for re-screening (n = 81), the major reason (46%) was their previous mammogram being painful. Other factors contributing were illness in themselves or their spouse, practical difficulties arranging time and negative experiences with staff in the previous mammography, although these related to relatively few women. A few women thought mammography would be of no benefit, and a few thought re-screening was unnecessary because their first mammography had been normal, or because they practise self-examination. CONCLUSIONS: Ensuring that all women eligible for further screening do get invited could substantially increase the re-screening rate. Even women who have declined previous invitations should be offered further invitations, as a substantial proportion with to be screened. Flexible and convenient appointment times are the main modifiable logistic issue. The major factor influencing non-participation with further screening is a painful experience of mammography. Innovative approaches, either to reduce the pain or to reduce the impact of the pain on the woman's attitude to re-screening, should be trialed.

Attitude↗
PubMed1999

Reasons why trauma surgeons fail to screen for alcohol problems.

BACKGROUND: Alcohol screening and intervention have been recommended as routine components of trauma care but are rarely performed. HYPOTHESIS: An association exists between current screening and counseling practices and the trauma surgeon's knowledge, attitude, and perceived role and responsibility toward alcohol problems. PARTICIPANTS: Random-sample survey (n = 241) of members of the American Association for the Surgery of Trauma. MAIN OUTCOME MEASURES: Reported screening and counseling practices. RESULTS: Fifty-four percent of respondents screened 25% or fewer patients, while only 29% screened most patients. The most common reason for not screening was "lack of time." Most (76%) were not familiar with the most common clinically used screening questionnaires, and 83% reported no training in alcohol screening. Screening was more likely if attending physicians perceived a major responsibility for screening (P<.001). Nonscreeners were twice as likely to state screening was "not what I was trained to do" and more frequently believed screening offends patients (P =.001). Independent predictors of screening were perceived major role responsibility (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.38-4.01) and confidence in screening ability (OR, 1.96; 95% CI, 1.05-3.67) and counseling ability (OR, 2.27; 95% CI, 1.34-3.85). Eighty-eight percent of respondents would be willing to devote time to training if shown that counseling is effective. CONCLUSIONS: Lack of screening and counseling appears to be due to cognitive factors, not lack of motivation. Skills on how to screen and counsel for alcohol abuse should be taught to trauma surgeons, because a strong correlation exists between screening and confidence in skills. There is a need for education regarding results of effective intervention trials in medical settings.

Alcohol-Related Disorders↗
PubMed2006

Mammography as a screening tool for peripheral vascular disease.

BACKGROUND: Peripheral vascular disease (PVD) is a progressive and debilitating disease often diagnosed only when patients become symptomatic. Currently there are no widespread screening tests available for the early detection of PVD. Patients with diabetes and coronary artery disease are known to have a higher incidence of PVD. Prior studies have indicated that benign vascular calcifications seen on routine screening mammogram are more prevalent in women with diabetes and coronary artery disease. The same association has not been shown for women with PVD. The purpose of this study was to identify an association between benign vascular calcifications identified on mammography and PVD. If such an association exists then screening mammography, already widely used as a screening tool for breast cancer, may identify women at high risk for PVD. METHODS: To determine the incidence of vascular calcifications in our general screening population we prospectively evaluated consecutive routine screening mammograms for the presence of benign vascular calcifications. We then identified a population of women with PVD by using a computerized database maintained by the Division of Vascular Surgery. The population of women identified with PVD was categorized further to identify those women who had received routine screening mammogram within our hospital system. These mammograms were reviewed retrospectively with particular attention to the presence of vascular calcifications. All mammograms were reviewed by our dedicated mammographers. Statistical analysis of the study group using the chi-square test was performed to determine the association of PVD and mammographic vascular calcifications. RESULTS: Prospective evaluation of 645 women undergoing consecutive routine screening mammography identified 123 (19%) with benign vascular calcifications. By using our PVD computerized database between the years 2002 and 2004 we identified 763 women with PVD. Of this group only 121 (15%) had undergone a routine screening mammogram in our hospital system. These mammograms were reviewed retrospectively by the same group evaluating the screening mammograms. On evaluation vascular calcifications were identified in 42% (51 of 121) of these women with PVD. Statistical analysis was performed using the chi-square test, odds ratio, and relative risk. A highly significant association was identified between PVD and the presence of mammographic vascular calcifications (P > .001). With a confidence interval of 95% the presence of benign vascular microcalcifications on routine screening mammogram identifies a significant risk for PVD with an odds ratio of 3.06. We showed through our analysis that women with calcifications are 2.19 times more likely to have PVD if microcalcifications are present. By using vascular calcifications identified on screening mammography as a means to identify women with PVD the sensitivity and specificity are 42% and 80%, respectively. The positive predictive value and the negative predictive value are 29% and 88%, respectively, with an accuracy of 75%. CONCLUSIONS: This initial study indicates that the presence of vascular calcifications identified on routine screening mammogram is significantly higher in women with PVD and the lack of vascular calcifications on screening mammography correlates well with a negative history of PVD. We have identified a significant association with PVD and vascular calcifications in our patient population. Further studies are indicated to determine if screening mammography may become a widespread inexpensive screening tool to identify women at risk for PVD. Additional studies are underway at our institution to evaluate the association of PVD, diabetes and coronary artery disease, and vascular calcifications identified on routine screening mammography.

Adult↗
PubMed2005

CT screening for lung cancer: past and ongoing studies.

It has been widely recognized that the oft-quoted randomized clinical trials (RCTs) of lung cancer screening by chest radiography--studies that were interpreted as showing no benefit--were seriously flawed. We begin by describing the shortcomings of these trials and presenting an analysis of the problems typically encountered in performing RCTs in this area. Screening for lung cancer using computed tomography (CT) has shown that CT offers great superiority over chest radiography in diagnosing small lung cancers in the three studies that performed both CT and chest radiography on all patients. The Early Lung Cancer Action Project (ELCAP), showed that false-positive results can be kept reasonably low and are much less common on repeat screening, and that CT screening can be managed with no notable excess of percutaneous or surgical biopsies when following a well-defined regimen of screening. This regimen details the parameters of the initial CT, the definition of a positive result, and the subsequent work-up of positive results. Following the updated International (I)-ELCAP protocol, it has been further found that (1) the frequency of positive results is low: 15% for the baseline cycle of screening and 6% for the subsequent cycles. (2) The frequency of screen-diagnoses as compared with all diagnoses is 97% or higher. (3) The relative frequency of presurgical Stage I is well over 80%; the median diameter of the screen-diagnosed cases on repeat screening is 8 mm (versus 15 mm at baseline screening). (4) A high percentage of the screen-diagnosed cases were genuine cancers which led to death if not treated. (5) The estimated 8-year cure rate for resected baseline screen-diagnosed lung cancers without evidence of lymph node metastases is 95% and for resected annual repeat cancers is 98%. (6) CT screening appears to be highly cost-effective. These preliminary results of CT screening suggests that the cure rate of screen-diagnosed lung cancer, using the I-ELCAP regimen of screening, may be over 70% as compared with that of usual care of 10% and that of chest radiographic screening of 20%.

Adenocarcinoma↗
PubMed1997

A role for otoacoustic emissions in screening for hearing impairment and middle ear disorders in school-age children.

OBJECTIVE: The primary purpose of this study was to investigate the potential role of transient-evoked otoacoustic emissions (TEOAEs) for screening for hearing impairment and middle ear disorders in school-age children. Because TEOAEs are present in ears with normal cochlear and middle ear function and typically are absent or reduced in ears with cochlear and/or middle ear disorders of even mild degree, TEOAE screening could serve as a first-stage screening to separate from the general population of school-age children those at greater risk for hearing impairment and/or middle ear disorder. There were two secondary objectives. First, the relationship between TEOAE measurement variables and measures of middle ear immittance in ears declared clinically normal was investigated. Second, the performance of TEOAEs in screening was compared with the performance of the pure-tone hearing and tympanometric screening protocol commonly used in the schools. DESIGN: Sixty-six children (ages 5 to 10 yr) participated. TEOAEs, pure-tone hearing screening, acoustic immittance (single-frequency and multi-frequency tympanometry), and an otoscopic exam by a pediatrician, who previously had been "validated" for identification of middle ear effusion, were done on each child under typical school hearing screening conditions. Performance of the TEOAE screening was determined based on the pediatrician's determination of middle ear status and the pure-tone hearing screening as the gold standards. RESULTS: Of the 66 subjects, 61 completed the study. Fifty-six children passed the hearing and otoscopic screenings bilaterally, and five children did not pass either or both the hearing screenings or otoscopic examination in at least one ear. A variety of TEOAE criteria were examined with respect to their ability to identify ears with either hearing impairment and/or middle ear disease. Several different otoacoustic emission criteria performed well according to our diagnostic criteria. Correlations between TEOAE variables and immittance measures of middle ear function were all low. In addition, tympenometric data were used to compare the TEOAE screening with the American Speech-Language-Hearing Association's (ASHA) recommended protocol for the same ears. The ASHA protocol, as recommended, did not do as well as the TEOAE screening. Using slightly modified criteria, the ASHA protocol did as well as TEOAEs. CONCLUSION: There were some screening criteria based on TEOAE measurement that produced good sensitivity and specificity. A TEOAE screening for hearing impairment and middle ear disease performed as well as or better than the ASHA-recommended protocol, which requires a minimum of two different tests, even when the ASHA protocol was modified to optimize performance. The results suggest that the TEOAE test has the potential to be incorporated successfully into hearing screening programs for school-age children and may have advantages over current screening protocols. Finally, no relationship between TEOAEs and middle ear function, as measured using single-frequency and multifrequency tympanometry, could be determined in ears with normal hearing and normal middle ear function.

Acoustic Impedance Tests↗
PubMed2002

A prospective, controlled assessment of factors influencing acceptance of screening colonoscopy.

OBJECTIVES: Medicare beneficiaries now have access to screening colonoscopy (SC). For colon cancer screening to be fruitful, SC must become more acceptable to a broad segment of this population. However, we currently lack knowledge of which aspects of SC have an impact on patient acceptance. The aims of this study were: 1) to identify the features of SC that are most important in deterring participation, and 2) to prioritize and to compare the perceptions of never-screened individuals with those of individuals previously screened for colon cancer. METHODS: Questionnaires were distributed to 300 outpatients at Mayo Clinic, Rochester (150 never-screened patients; 150 previously screened patients). The survey instrument addressed domains of the Health Belief Model and colon cancer risk perception. Patients ranked the three most important barriers to SC and answered general knowledge questions on colon cancer. RESULTS: Response rates of never-screened (84%) and screened (88%) patients were similar. Never-screened patients were less likely to have a regular primary physician (80% vs 95%, p = 0.0003) and were less likely to have undergone a prior screening mammography (87% vs 96% of women, p = 0.02) compared with screened patients. The four most reported deterrents to SC ("volume of bowel preparation," "adequate analgesia," "no recommendation from primary physician," and "embarrassment") were ranked similarly by both groups. Never-screened patients had less understanding of the incidence and treatment outcomes of colon cancer. CONCLUSION: Colon cancer screening behavior seems to be associated with having a regular primary physician, as well as other cancer screening behaviors. Knowledge of colon cancer is the most reliable discriminator of prior screening status. There does not seem to be any difference in the preferences expressed by never-screened and screened patients with respect to the aspects of colonoscopy that they find objectionable.

Aged↗
PubMed2005

Lung cancer screening: simulations of effects of imperfect detection on temporal dynamics.

PURPOSE: To use a mathematic model to demonstrate effects of imperfect detection on temporal dynamics of radiologic lung cancer screening. MATERIALS AND METHODS: Monte Carlo simulations of lung cancer screening programs were performed in subjects at high risk for developing cancer. The effects of detection probabilities, symptomatic presentation of tumors, tumor volume doubling time, and time between screenings were examined. Computed tomography (CT) and chest radiography models were used. RESULTS: For imperfect detection probabilities, the percentage of subjects with cancers detected with repeated screenings decreased to a steady-state value. The transition period was the period during which screenings were performed and detection rates decreased. At steady-state repeat screening, the proportion of subjects with cancers diagnosed at screening or by means of symptomatic presentation was determined by the annual probability of developing cancer and not by the sensitivity of the screening modality. The sensitivity of the screening technique did affect detected cancer size, number of interval cancers, and total number of cancers observed. CT was used to detect more total cancers over the course of the screening program and cancers with a smaller average size; moreover, fewer interval cancers were observed with CT screening than with chest radiography screening. CONCLUSION: Lung cancer screening with imperfect detection has a transition period between baseline screening and steady-state behavior of annual screenings. Advantages of CT screening include a decrease in the average cancer size at detection, a decrease in the number of observed interval cancers, and an increase in the total number of cancers observed. Steady-state behavior indicates that long-term trials of screening may not be necessary.

Humans↗
PubMed1997

Antenatal screening for Down's syndrome.

BACKGROUND: In 1968 the first antenatal diagnosis of Down's syndrome was made and screening on the basis of selecting women of advanced maternal age for amniocentesis was gradually introduced into medical practice. In 1983 it was shown that low maternal serum alpha fetoprotein (AFP) was associated with Down's syndrome. Later, raised maternal serum human chorionic gonadotrophin (hCG), and low unconjugated oestriol (uE3) were found to be markers of Down's syndrome. In 1988 the three biochemical markers were used together with maternal age as a method of screening, and this has been widely adopted. PRINCIPLES OF ANTENATAL SCREENING FOR DOWN'S SYNDROME: Methods of screening need to be fully evaluated before being introduced into routine clinical practice. This included choosing markers for which there is sufficient scientific evidence of efficacy, quantifying performance in terms of detection and false positive rates, and establishing methods of monitoring performance. Screening needs to be provided as an integrated service, coordinating and managing the separate aspects of the screening process. SERUM MARKERS AT 15-22 WEEKS OF PREGNANCY: A large number of serum markers have been found to be associated with Down's syndrome between 15 and 22 weeks of pregnancy. The principal markers are AFP, hCG or its individual subunits (free alpha- and free beta-hCG), uE3, and inhibin A. Screening performance varies according to the choice of markers used and whether ultrasound is used to estimate gestational age (table 1). When an ultrasound scan is used to estimate gestational age the detection rate for a 5% false positive rate is estimated to be 59% using the double test (AFP and hCG), 69% using the triple test (AFP, hCG, uE3), and 76% using the quadruple test (AFP, hCG, uE3, inhibin A), all in combination with maternal age. Other factors that can usefully be taken into account in screening are maternal weight, the presence of insulin dependent diabetes mellitus, multiple pregnancy, ethnic origin, previous Down's syndrome pregnancy, and whether the test is the first one in a pregnancy or a repeat. Factors such as parity and smoking are associated with one or more of the serum markers, but the effect is too small to justify adjusting for these factors in interpreting a screening test. URINARY MARKERS AND FETAL CELLS IN MATERNAL BLOOD: Urinary beta-core hCG has been investigated in a number of studies and shown to be raised in pregnancies with Down's syndrome. This area is currently the subject of active research and the use of urine in future screening programmes may be a practical possibility. Other urinary markers, such as total oestriol and free beta-hCG may also be of value. Fetal cells can be identified in the maternal circulation and techniques such as fluorescent in situ hybridisation can be used to identify aneuploidies, including Down's syndrome and trisomy 18. This approach may, in the future, be of value in screening or diagnosis. Currently, the techniques available do not have the performance, simplicity, or economy needed to replace existing methods. DEMONSTRATION PROJECTS: Demonstration projects are valuable in determining the feasibility of screening and in refining the practical application of screening. They are of less value in determining the performance of different screening methods. Several demonstration projects have been conducted using the triple and double tests. In general, the uptake of screening was about 80%. The screen positive rates were about 5-6%. About 80% of women with positive screening results had an invasive diagnostic test, and of those found to have a pregnancy with Down's syndrome, about 90% chose to have a termination of pregnancy. ULTRASOUND MARKERS AT 15-22 WEEKS OF PREGNANCY: There are a number of ultrasound markers of Down's syndrome at 15-22 weeks, including nuchal fold thickness, cardiac abnormalities, duodenal atresia, femur length, humerus length, pyelectasis, and hyperechogenic bowel. (ABSTRA

Biomarkers↗
PubMed1994

[Comparison of two types of mass screening for lung cancer in terms of cost-effectiveness: indirect chest X-ray vs LSCT].

Mass screening for lung cancer is widely performed in Japan, with the photofluoroscopic examination and sputum cytology used as the screening methods. However the clinical efficacy of these screening methods is considered to be inadequate in terms of the survival rate of the screened population. In the previous report we proposed that a specially designed CT technique, called lung cancer screening CT (LSCT), may be useful in screening for lung cancer. In this paper a preliminary comparison is made between the present and future methods of lung cancer screening in terms of cost-effectiveness. A model for cost-effectiveness analysis estimates the net life-years saved by screening and then determines the direct cost of screening including cost of therapy. Various factors are taken into account such as sensitivity of the screening methods, rate of participation in detailed examination, 5-year survival rate of the screened population, cost of the screening method, and average cost of therapy for screen-detected patients and outpatients. An example of the results is as follows: for a population with a lung cancer incidence of 200 x 10(-5) person/year and life expectancy of 30 years, the net person years saved are 672 x 10(-5) for the present screening method and 2376 x 10(-5) for LSCT screening. The cost required to save one person year are 1.46 x 10(5) yen for the present screening method and 2.03 x 10(5) yen for LSCT screening.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-Benefit Analysis↗
PubMedDate not supplied

Universal newborn hearing screening: summary of evidence.

CONTEXT: Each year, approximately 5000 infants are born in the United States with moderate-to-profound, bilateral permanent hearing loss (PHL). Universal newborn hearing screening (UNHS) has been proposed as a means to speed diagnosis and treatment and thereby improve language outcomes in these children. OBJECTIVES: To identify strengths, weaknesses, and gaps in the evidence supporting UNHS and to compare the additional benefits and harms of UNHS with those of selective screening of high-risk newborns. DATA SOURCES: We searched the MEDLINE, CINAHL, and PsychINFO databases for relevant articles published from 1994 to August 2001, using terms for hearing disorders, infants or newborns, screening, and relevant treatments. We contacted experts and reviewed reference lists to identify additional articles, including those published before 1994. STUDY SELECTION: We included controlled and observational studies of (1) the accuracy, yield, and harms of screening using otoacoustic emissions (OAEs), auditory brainstem response (ABR), or both in the general newborn population and (2) the effects of screening or early identification and treatment on language outcomes. Of an original 340 articles identified, 19 articles, including 1 controlled trial, met these inclusion criteria. DATA EXTRACTION: Data on population, test performance, outcomes, and methodological quality were extracted by 2 authors (D.C.T., H.M.) using prespecified criteria developed by the US Preventive Services Task Force. We queried authors when information needed to assess study quality was missing. DATA SYNTHESIS: Good-quality studies show that from 2041 to 2794 low-risk and 86 to 208 high-risk newborns were screened to find 1 case of moderate-to-profound PHL. The best estimate of positive predictive value was 6.7%. Six percent to 15% of infants who are missed by the screening tests are subsequently diagnosed with bilateral PHL. In a trial of UNHS vs clinical screening at age 8 months, UNHS increased the proportion of infants with moderate-to-severe hearing loss diagnosed by age 10 months (57% vs 14%) but did not reduce the rate of diagnosis after age 18 months. No good-quality controlled study has compared UNHS with selective screening of high-risk newborns. In fair- to poor-quality cohort studies, intervention before age 6 months was associated with improved language and communication skills by ages 2 to 5 years. These studies had unclear criteria for selecting subjects, and none compared an inception cohort of low-risk newborns identified by screening with those identified in usual care, making it impossible to exclude selection bias as an explanation for the results. In a mathematical model based on the literature review, we estimated that extending screening to low-risk infants would detect 1 additional case before age 10 months for every 1441 low-risk infants screened, and result in treatment before 10 months of 1 additional case for every 2401 low-risk infants screened. With UNHS, 254 newborns would be referred for audiological evaluation because of false-positive second-stage screening test results vs 48 for selective screening. CONCLUSIONS: Modern screening tests for hearing impairment can improve identification of newborns with PHL, but the efficacy of UNHS to improve long-term language outcomes remains uncertain.

Evidence-Based Medicine↗
PubMed2003

Effect of expanded newborn screening for biochemical genetic disorders on child outcomes and parental stress.

CONTEXT: Tandem mass spectrometry now allows newborn screening for more than 20 biochemical genetic disorders. Questions about the effectiveness and risks of expanded newborn screening for biochemical genetic disorders need to be answered prior to its widespread acceptance as a state-mandated program. OBJECTIVES: To compare newborn identification by expanded screening with clinical identification of biochemical genetic disorders and to assess the impact on families of a false-positive screening result compared with a normal result in the expanded newborn screening program. DESIGN: Prospective study involving an inception cohort of newly diagnosed children. SETTING: Massachusetts, Maine, and a private laboratory in Pennsylvania with expanded newborn screening; other New England states with limited screening. PARTICIPANTS: Families of 50 affected children identified through expanded newborn screening (82% of eligible cases); 33 affected children identified clinically (97% of eligible cases); 94 screened children with false-positive results (75% of eligible cases); and 81 screened children with normal results (63% of eligible cases). MAIN OUTCOME MEASURES: Child's health and development and the Parental Stress Index. RESULTS: Within the first 6 months of life, 28% of children identified by newborn screening compared with 55% of clinically identified children required hospitalization (P =.02). One child identified by newborn screening compared with 8 (42%) identified clinically performed in the range of mental retardation (P<.001). Mothers in the screened group reported lower overall stress on the Parental Stress Index than mothers in the clinically identified group (z = 3.38, P<.001). Children with false-positive results compared with children with normal results were twice as likely to experience hospitalization (21% [n = 20] vs 10% [n = 8], respectively; P =.06). Mothers of children in the false-positive group compared with mothers of children with normal screening results attained higher scores on the Parental Stress Index (z = 4.25, P<.001) and the Parent-Child Dysfunction subscale (z = 5.30, P<.001). CONCLUSIONS: Expanded newborn screening may lead to improved health outcomes for affected children and lower stress for their parents. However, false-positive screening results may place families at risk for increased stress and parent-child dysfunction.

Adult↗
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Intention to screen for colorectal cancer among white male employees.

BACKGROUND: This study identifies factors associated with employee intention to participate in a company-sponsored program of continuous screening for colorectal cancer. Automobile industry pattern and model makers who had been offered screening for over a decade were included in the study. METHODS: Data were collected at the outset of a randomized trial of screening and nutrition interventions. A baseline survey was mailed to 4,490 white men without a history of colorectal cancer. This mailing generated complete responses from 2,693 (60%) individuals. Survey data obtained for these men, including measures of cognitive and psychological representations related to colorectal screening, social influence, and intention to screen, were supplemented by background information gathered from employment records of these men. Workplace screening services were documented via a survey of plant health care professionals. RESULTS: Fifty-eight percent of respondents reported a high level of intention to screen. Multivariate analyses showed that intention to screen was positively associated with employee past participation in screening, belief in the salience and coherence of screening, belief in screening efficacy, perceived self-efficacy, belief that polyp removal prevents colorectal cancer, perceived personal susceptibility to colorectal cancer or polyps, receptivity to family member support for screening, and workplace scheduling of screening examinations. CONCLUSIONS: Factors associated with intention to screen may contribute to participation in continuous screening programs. Research is needed to assess the impact of interventions that facilitate appointment scheduling, provide tailored education about screening, and encourage lay support.

Adult↗