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PubMed2003

The influence of cost-effectiveness information on physicians' cancer screening recommendations.

Physicians are increasingly faced with choices in which one screening strategy is both more effective and more expensive than another. One way to make such choices is to examine the cost-effectiveness of the more costly strategy over the less costly one. However, little is known about how cost-effectiveness information influences physicians' screening decisions. We surveyed 900 primary care US physicians, and presented each with a hypothetical cancer-screening scenario. We created three familiar screening scenarios, involving cervical, colon, and breast cancer. We also created three unfamiliar screening scenarios. Physicians were randomized to receive one of nine questionnaires, each containing one screening scenario. Three questionnaires posed one of the familiar screening scenarios without cost-effectiveness information, three posed one of the familiar scenarios with cost-effectiveness information, and three posed one of the unfamiliar scenarios with cost-effectiveness information. The cost-effectiveness information for familiar scenarios was drawn from the medical literature. The cost-effectiveness information for unfamiliar scenarios was fabricated to match that of a corresponding familiar scenario. In all questionnaires, physicians were asked what screening alternative they would recommend. A total of 560 physicians responded (65%). For familiar scenarios, providing cost-effectiveness information had at most a small influence on physicians' screening recommendations; it reduced the proportion of physicians recommending annual Pap smears (p=0.003), but did not significantly alter the aggressiveness of colon cancer and breast cancer screening (both p's<0.1). For all three unfamiliar scenarios, physicians were significantly less likely to recommend expensive screening strategies than in corresponding familiar scenarios (all p's<0.001). Physicians' written explanations revealed a number of factors that moderated the influence of cost-effectiveness information on their screening recommendations. Providing physicians with cost-effectiveness information had only a moderate influence on their screening recommendations for cervical, colon, and breast cancer. Significantly, fewer physicians recommended aggressive screening for unfamiliar cancers than for familiar ones, despite similar cost-effectiveness. Physicians are relatively reluctant to abandon common screening strategies, even when they learn that they are expensive, and are hesitant to adopt unfamiliar screening strategies, even when they learn that they are inexpensive.

Adult↗
PubMed2003

Annual screening for oral cancer detection.

Most oral cancer and oral mucosal screening programs initiated in the past 20 years have been limited to a single examination of the population under study. Age specific, annual oral mucosal screening examination as a part of general health screening has been in operation in Tokonama city, Japan, from 1986. From 1996 the same target population aged 40 years and older has been invited for screening. The program coverage extended to 26% of the city population. During 1995-1998, out of 9536 attendees who participated in a general health and oral mucosal screening program in Tokoname city 6340 subjects (66.5%) re-attended at least for one further screening examination. There was no difference in the attendance for two annual mucosal examinations between male (67.0%) and female (66.2%) subjects. Three thousand nine hundred thirty-five subjects attended oral screening all 3 years (1996-1999) and the overall show-up rate for three consecutive examinations was 61%. During September-October 1996, 42 volunteer dentists carried out 6705 mouth examinations among those aged 40 years and older at the Municipal Center. One oral cancer was detected in 1996, in a subject free of any mucosal disease in the previous year. Among the screen-negative cases in 1996, 78% re-attended for screening in 1997 and 79% re-attended in the subsequent year. In the cohort that re-attended screening (1996-1998), oral mucosal pathology detected in three consecutive screenings included 18 leukoplakias, 24 with oral lichen planus and 343 other benign mucosal lesions. The number of subjects who complied to return and who remained disease-free over the 3-year period amounted to 3860, 59% of the disease-free subjects seen in 1996. A regular smoker was less likely to attend oral cancer screening in the three consecutive years of follow-up (odds ratio: 0.832, 95% CI 0.701-0.988). Satisfactory participation can be obtained for annual oral mucosal screening in Japan: this allows detection of new lesions, including oral cancer and leukoplakia (a surrogate marker of cancer risk). The number of new oral cancers detected in the program was too low to determine the optimal frequency for oral cancer screening but new oral leukoplakias were found on annual re-screening: the data indicate that the interval between two screens for this population should not be greater than 12 months.

Adult↗
PubMed2001

Newborn screening for congenital adrenal hyperplasia.

Classic CAH (salt-wasting and simple virilizing) meets all of the recommended criteria for newborn screening. There are reliable and efficient newborn screening tests, the disorder results in high morbidity and mortality if left undetected, there is effective treatment that reduces negative outcomes, and there is a relatively high incidence. When compared with the case findings without the benefit of screening, the data from screening programs show reduced adrenal crises, reduced incorrect sex assignments, and reduced deaths. Racial/ethnic prevalence differences are present in newborn screening program data. The Texas data indicate a lower disease frequency in African-Americans when compared with Caucasians, and international data indicate higher frequencies in native Yupik Eskimos, Brazilians, residents of La Reunion, and Filipinos. When worldwide clinical ascertainment data are compared with newborn screenng data, it is clear that newborns with CAH (especially males) die when screening is not done. To be effective in reducing mortality, newborn screening must be performed soon after birth, and the results must be available quickly so that early salt-wasting crises can be averted. It is preferable that newborn screening laboratiories be operational 7 days a week, and that sample delivery from the collection site to testing laboratory be as efficient as possible, including weekends and holidays, so that undue testing delays are not encountered. These two requirements pose major challenges for most programs, but they are critical to optimal screening outcome. Based on the studies in Texas, with second screening samples collected at approximately 2 weeks of age, some newborns with simple virilizing CAH are missed on initial screening using current testing protocols. There is need to set a screening cut-off such that the false-positive rate does not oversaturate the follow-up system, in part owing to the insensitivity of current kit methodologies and the biochemical manifestations of CAH. With advances in genetic testing procedures and improved automation techniques, it may soon be possible for CAH screening programs to include genotyping as a second-tier confirmation as a part of the newborn screening protocol. Despite the fact that CAH is a continuum of disorders, the correlation between genotype and phenotype is fairly consistent in most cases. For the purpose of screening, genotyping will likely be useful only for differential diagnoses of non-salt wasters, given the necessary time constraints and expense of obtaining genotypes and the need for immediate diagnosis/treatment of salt wasters. It is hoped that newborn screening programs will begin to provide answers to some of these question in addition to their primary function of reducing the morbidity and mortality resulting from CAH.

17-alpha-Hydroxyprogesterone↗
PubMed1998

Selective opportunistic screening for hypercholesterolemia in primary care practice.

OBJECTIVES: To assess the performance of selective opportunistic screening in a primary care group practice. DESIGN: Cross-sectional survey of coronary heart disease risk factors and retrospective chart audit of cholesterol testing. SETTING: Capitation-funded primary care group practice in Ontario, Canada. SUBJECTS: 7785 enrolled patients between the ages of 20 and 69 years. INTERVENTION: Protocol-based selective opportunistic screening program for hypercholesterolemia of 45 months duration. MAIN OUTCOME MEASURES: Targeting (proportion of screening tests that were appropriate), coverage (proportion of those meeting screening criteria who had a screening test performed), over-screening (proportion of those not meeting screening criteria who had a screening test performed), and screening ratio (likelihood that a screening test was performed on an individual who met screening criteria rather than one who failed to meet screening criteria). RESULTS: 64.7% of patients tested met the practice criteria for screening. 37.7% of patients who met the practice screening criteria were tested and 24.9% of those not meeting practice screening criteria had a cholesterol test performed. The screening ratio was 1.52. CONCLUSION: Our findings bring into question the effectiveness of opportunistic approaches to preventive care.

Adult↗
PubMedDate not supplied

Evaluating post-treatment screening in women with breast cancer.

PURPOSE: The objective of this study was to evaluate the 5-year post-treatment use rate for screening mammography and clinical breast examination (CBE) among women treated for atypical hyperplasia (AH) or carcinoma in situ (CIS). DESCRIPTION OF STUDY: A total of 103 women, who had received diagnoses and had been treated for primary AH or CIS, were observed for 5 years through a review of medical records and electronic databases. Adequate screening use was defined as the patient undergoing one mammography examination and at least one CBE per year. RESULTS: Multivariate logistic regression showed that screening activity declined significantly with time. During the first year, 83.5% and 80.6%, respectively, of women were screened by CBE and mammography. By year 2, CBE screening had dropped by 25.2% (P <.01) and mammography screening by 9.7% (P =.08). Attrition in CBE and mammography screening continued for each consecutive year and was significant (P <.01). During the first year, 70.9% of women received both methods of screening, which declined to 9.7% by year 5. Women who had received diagnoses of CIS and those married with children were more likely to use post-treatment screening, while fee-for-service insurance was negatively associated with screening. CLINICAL IMPLICATIONS: The reasons for the observed decline in the annual post-treatment screening are not known. Negative findings from follow-up screenings might have lowered the perception of cancer susceptibility and promoted the decline in screening use. A communication gap between physicians and patients might have reinforced this perception. The importance of annual screening may be verbally emphasized at each clinic visit, and reminder notes and telephone calls may be used to remind patients of upcoming screenings. Additional studies are planned to evaluate the effect of various intervention strategies in improving post-treatment screening use.

Adult↗
PubMed2003

Combined first-trimester versus second-trimester serum screening for Down syndrome: a cost analysis.

OBJECTIVE: The purpose of this study was to compare the cost-effectiveness of combined first-trimester screening for fetal Down syndrome with second-trimester maternal serum triple screening. STUDY DESIGN: A first-trimester screening approach that used nuchal translucency measurement and maternal serum screening was evaluated against second-trimester maternal serum triple screening in a hypothetic population. Screening sensitivities and screen-positive rates were 91% and 5% for the first-trimester approach and 70% and 7.5% for the second-trimester approach, respectively. The costs of fetal Down syndrome, live-born Down syndrome cost, and total costs (screening plus live-born costs) were calculated for each screening program. RESULTS: First-trimester screening was associated with lower screening and live-born Down syndrome costs versus second-trimester serum screening. Total Down syndrome screening costs were 29.1% lower with first-trimester screening. CONCLUSION: In this hypothetic model, combined first-trimester screening for fetal Down syndrome was more cost-effective than universal second-trimester triple serum screening.

Adult↗
PubMed2003

Options for screening for colorectal cancer.

Unlike other types of cancer, there are several options for screening for colorectal cancer (CRC). The most extensively examined method, faecal occult blood testing (FOBT), has been shown, in three large randomized trials, to reduce mortality from CRC by up to 20% if offered biennally and possibly more if offered every year. Recently published data from the US trial suggest that CRC incidence rates are also reduced by up to 20%, but only after 18 years. In this study, the number of positive slides was associated with the positive predictive value both for CRC and adenomas larger than 1 cm, suggesting that the reduction in CRC incidence was caused by the identification and removal of large adenomas. In this respect, this study supports the concept that removing adenomas prevents CRC. More efficient methods of detecting adenomas include the use of colonoscopy or flexible sigmoidoscopy (FS). Considerable evidence exists from case-control and uncontrolled cohort studies to suggest that endoscopic screening by sigmoidoscopy reduces incidence of distal colorectal cancer. However, in the absence of evidence from a randomized trial, several countries have been reluctant to introduce endoscopic screening. Three trialsare currently in progress (in the UK, Italy and the US) to address this issue. Two of these trials are examining the hypothesis that a single FS screen at around age 55-64 might be a cost-effective and acceptable method for reducing CRC incidence rates. Recruitment and screening are now complete in both studies and the first analysis of results on incidence rates is expected in 2004. Colonoscopy screening at 10-year intervals has recently been endorsed in the US on the basis that the reductions in incidence observed with distal CRC screening can be extrapolated to the proximal colon. However, data are lacking and a pilot study for a trial of the acceptability and efficacy of colonoscopy screening is in progress in the US. It has also been suggested that FOBT testing should be used to detect proximal CRC missed by sigmoidoscopy screening, but the small amount of published data suggest that supplementing FS with FOBT offers very little advantage over FS alone. Other forms of CRC screening are under investigation and represent exciting options for the future. Extraction of DNA from stool is now feasible and a number of research groups have shown high sensitivity for CRC using a panel of DNA markers including mutations in k-ras, APC, p53 and BAT26. Data so far indicate that, with the exception of k-ras, these markers are highly specific and therefore represent a significant improvement over FOBT. Whether these tests will replace or supplement existing methods of screening has yet to be determined. It has been suggested that BAT26, which is a marker of microsatellite instability, a feature of proximal sporadic CRC, might be a useful adjunct to sigmoidoscopy screening. Others have suggested that a test for occult blood should be included with the DNA markers to further increase sensitivity. It is not yet known how sensitive these markers are for adenomas--it is only by detecting adenomas that CRC incidence rates can be reduced. A final exciting new option for screening is virtual colonoscopy (VC), which by screening out people without neoplasia allows colonoscopy to be reserved for patients requiring a therapeutic intervention. The sensitivity of VC for large adenomas and CRC appears to be high, although results vary by centre and there is a steep learning curve. Sensitivity for small adenomas is low, but perhaps it is less essential to find such lesions. Some groups have suggested that virtual colonoscopy might be a useful option for investigating patients who test positive with stool-based screening tests. Whichever CRC screening method is finally chosen (and there is no reason why several methods should not ultimately be available), high quality endoscopy resources will always be required to investigate and treat neoplastic lesions detected.

Adenoma↗
PubMed1999

The Transtheoretical Model and cervical screening: its application among culturally diverse communities in Queensland, Australia.

OBJECTIVES: To apply the Transtheoretical Model of Behaviour Change (TTM) to cervical cancer screening to determine and report on the level of support required by different language and cultural groups in Queensland to enhance participation. The model consists of six stages: Pre-contemplation (no intention to be screened, no past action), Contemplation (intention to be screened, no past action), Action (intention to be screened, initial screening), Maintenance (intention to be screened, regular screening), Relapse (no intention to be screened, initial screening) and Relapse Risk (no intention to be screened, regular screening). DESIGN: Focus groups and structured interviews were used to classify women in terms of the model and collect information regarding knowledge, health service contact barriers and enhancing factors and sources of information in relation to cervical cancer screening. The sample was recruited by bi-cultural workers for each community using snowball techniques. RESULTS: The interview sample consisted of Australian South Sea Islanders, Chinese, German, Greek and Moslem women. There was no evidence of significant differences in TTM stage according to ethnicity. Women who intended to be screened in the future were more likely to have positive decisional balance scores and higher knowledge scores than women who did not. Women who had had Pap tests were significantly more likely to have received information from their general practitioner (GP) than women who had not had Pap tests. Women in Action and Maintenance were also more likely to have had their last Pap test by a female GP compared to women in relapse categories. Women in Pre-contemplation were more likely than women who had Pap tests to agree that they would travel a long way to see a practitioner who spoke their own language. CONCLUSION: Classification based on the model was supported both by the decisional balance scale and measures of knowledge. Women in earlier stages of the model were more likely to express preferences for the provision of services in their own language and by a female. Cervical cancer screening among women in Action and Maintenance appeared to be better supported by GPs. Cervical cancer screening promotion for women of diverse cultures and ethnicities has tended to focus on Pre-contemplation and Contemplation stages, however, as most women in this sample were in Action or Maintenance, as are most Australian-born women, structuring cervical cancer screening promotion in terms of the TTM may significantly improve the effectiveness of interventions for women of diverse cultures and ethnicities.

Adult↗
PubMed1995

Quantitative interpretation of age-specific mortality reductions from the Swedish breast cancer-screening trials.

BACKGROUND: Results from five Swedish randomized trials may provide the most conclusive evidence on the effect of mammographic screening and have been used to forecast the expected reduction in breast cancer mortality in other programs. However, those trials demonstrated different degrees of reduction. The interpretation of observed mortality reduction after long follow-up for women aged 40-49 years at trial entry is both important and controversial. PURPOSE: We estimated what percentage of the observed mortality reduction for women aged 40-49 years at entry into the five Swedish screening trials might be attributable to screening these women at 50 years of age or older. Moreover, we calculated the most likely percentage mortality reduction for specific screening programs if the Swedish results were generalized and analyzed whether characteristics of each trial might at least partly explain the observed differences in reductions among the trials. METHODS: Each Swedish trial was simulated with one underlying computer simulation model (MISCAN--MIcrosimulation SCreening ANalysis) of the natural history of the disease and the performance of screening, taking into account nine important trial characteristics. Improvement in prognosis for screen-detected case patients was estimated with age-specific reduction for all trials and each trial design as a reference. RESULTS: An expected 7% reduction in breast cancer mortality for women aged 40-49 years at trial entry (relative risk [RR] = 0.93) was determined by computer modeling, assuming no improvement in prognosis for cancers that are screen detected before 50 years of age. This result indicates that, of the overall 10% observed reduction (RR = 0.90) in the five Swedish trials analyzed, most (70%) of this reduction might be attributable to screening these women in later rounds after their 50th birthday. Using additional trial information, predictions of breast cancer mortality reduction in women 50 years or older might be 11% larger than previously expected, assuming that high-quality mammographic screening can be achieved in nationwide programs. For women aged 50-69 years at trial entry, the differences in expected versus observed mortality reduction among the trials are estimated to be relatively small. (Expected mortality reductions range from 24% to 32%). CONCLUSIONS: Results from the Swedish randomized breast cancer-screening trials should be seen as more favorable regarding the effect of mammographic screening in reducing breast cancer mortality for women aged 50-69 years than was estimated earlier. Our analyses also suggest that the improvement in prognosis due to screening for women aged 40-49 years is much smaller than that for women aged 50 years or older. Approximately, 70% of the 10% observed reduction in breast cancer mortality (i.e., 7%) for women aged 40-49 years at trial entry might be attributable to a reduction due to screening these women after they reach age 50. IMPLICATIONS: Detailed screening data for the 40- to 49-year age group of all Swedish trials should be analyzed to specifically estimate the natural history and performance of screening in this age group.

Adult↗
PubMed1995

Mammography screening: an incremental cost effectiveness analysis of two view versus one view procedures in London.

STUDY OBJECTIVE: To compare the costs and effects of routine mammography screening by a single mediolateral-oblique view and two views (mediolateral-oblique plus craniocaudal) of each breast. DESIGN: A cost effectiveness analysis of a prospective non-randomised trial comparing one and two view mammography screening was carried out at St Margaret's Hospital, Epping. All women in the study had two view mammography. The mediolateral-oblique view was always the first image read by the radiologist. After reading the films for a clinic session, the same radiologist then went back and read both the mediolateral-oblique and craniocaudal views together. Each set of films was read by two radiologists. The main outcome measures were recall rates, number of cancers detected, screening and assessment costs, and cost effectiveness ratios. SUBJECTS: A total of 26,430 women who attended for breast screening using both one and two view mammography participated. A sample of 132 women attending for assessment provided data on the private costs incurred in attending for assessment. RESULTS: There was a reduction in the recall rate from 9.1% (2404 of 26,430) after one view screening to 6.7% (1760 of 26,430) after two view screening. The results also suggest that for every 10,000 women screened an additional five cancers would be detected earlier with two view screening. The additional health service screening cost associated with two view screening was estimated to be 3.63 pounds: the costs associated with one and two view screening policies were estimated to be 41.49 pounds and 32.99 pounds respectively. Private costs incurred were estimated to be 0.35 pounds per woman screened and 32.75 pounds per woman assessed. Two cost effectiveness ratios were calculated: an incremental health service cost per additional cancer detected of 4129 pounds and an incremental health service plus private cost per additional cancer detected of 2742 pounds. The sensitivity analysis suggested that the results were sensitive to relatively large changes in a number of parameters. These included screening costs, assessment costs, equipment life, and recall rates. CONCLUSIONS: Use of two view screening increased early cancer detection and also costs. The reduction in the recall rate with two views was not sufficiently large to make the cost of two view screening neutral. While these results are not completely generalisable, a framework is provided to allow other centres to estimate the cost effectiveness of two view screening in their locality.

Breast Neoplasms↗
PubMed1996

Long term breast cancer screening in Nijmegen, The Netherlands: the nine rounds from 1975-92.

STUDY OBJECTIVE: To assess the performance of breast cancer screening in different age categories over two decades. DESIGN: Important determinants of reduced breast cancer mortality such as attendance, mammography performance, cancer detection, and disease stage were recorded. SETTING: Nijmegen, The Netherlands, 1975-92. SUBJECTS: Since 1975 more than 40,000 women aged 35 years and older have been invited biennially for breast screening in a population based project in Nijmegen. MAIN RESULTS: Rates of attendance, referral, detection, and disease stage were calculated, as well as the specificity of screening mammography and the predictive value of referral and biopsy. From round 3 onwards, the attendance rate of women younger than 50 years stabilised at 70%, in women of 50-69 years it was 62%, and in women aged 70 and over it was 22%. In these three age categories, the referral rates of a positive screening mammography per 1000 screened women were 4.9, 6.2, and 11.8, respectively. Specificity rates were between 99% and 100%. Current predictive values of referral were high: in the specific age categories 39%, 59%, and 68% of the referred women had cancer. Detection rates remained fairly stable over the rounds 4-9, at 1.9, 3.6, and 8.0 cancers per 1000 screened women. In the two year period between screening the numbers of interval cancers per 1000 screened women were 2.2, 2.2, and 2.9, for the three age categories respectively. With regard to invasive cancers detected during screening, the percentage of small tumours (< or = 20 mm on the mammogram) was 84% in each age category. For women younger than 50 years, the proportion of intraductal carcinoma in all the cancers detected at screening was 40%, while it was 15% in the other age categories. CONCLUSION: Throughout the nine rounds, the screening outcomes were found to be adequate, particularly considering the high specificity rate and the predictive value of referral without the interference of a low detection rate. Although the occurrence of interval cancers seemed high, it was similar to other screening programmes. Despite a relatively low referral rate, the ratios of screen detected versus interval cancer cases were favourable. Well organised screening programmes can achieve good mammography results without too many false positives. It is important that women continue to participate in a screening programme because cancer can still be detected even after several successive negative screening examinations.

Adult↗
PubMed2004

History of medical screening: from concepts to action.

The objective of medical screening is to identify disease in its preclinical, and therefore hopefully still curable, phase. This may have been an old quest in medicine but it became historically possible when at least four conditions were met: the availability of simple, valid and acceptable forms of tests, the discovery of effective treatments, the establishment of a theory of screening, and the wide access to health care. Five selected examples that illustrate the history of medical screening are reviewed: screening for psychiatric disorders in the United States army as it is one of the oldest screening programmes; screening for syphilis as it used one of the earliest screening tests; screening for diabetes as one of the first modern forms of mass screening; screening for cervical cancer using the Pap test as one of the greatest successes of screening; and screening for breast cancer by mammography as this offers a good opportunity to discuss the development of modern evaluation of screening programmes. The evaluation of the impact of screening on human health slowly progressed, from obvious changes in the vital statistics such as the decline in incidence of syphilis, to less obvious changes such as the decline in mortality of cancer of the uterus, to finally more subtle changes, such as the impact of mammographic screening on breast cancer mortality. Methods of evaluation had therefore to adapt, evolving from simple surveys to case-control studies and randomised trials. The history of screening is short, but very rich and mostly still to be written.

Breast Neoplasms↗
PubMedDate not supplied

Results of a mammographic and clinical screening in a health district (USSL) of Brescia, Italy.

AIMS AND BACKGROUND: Screening by mammography has been shown to be effective in reducing breast cancer mortality. We present the results of a mammographic and clinical screening program carried out in an Italian health district. METHODS: The first screening round started in June 1987 and ended in July 1990, and 25,100 women between the age of 50 and 60 years were invited. The second screening round invited 34,332 women between the age of 50 and 64 years and was carried out from September 1990 to September 1993. Women with positive or equivocal results at palpation or mammography were referred for immediate diagnostic assessment followed by surgery, when required. RESULTS: The attendance rate was 67.3% at the first and 62.1% at the repeat screening. At the first screening, 206 biopsies were advised and 197 were performed; 129 of the 197 were found to be malignant. At repeat screening, 248 biopsies were recommended, 208 were performed, and 125 were found to be malignant. The cancer detection rate was 7.7 per thousand at the first and 5.9 per thousand at repeat screening. Of 129 cancers, 107 (83.0%) were T1 at first screening; 6.2% were in situ carcinomas. Axillary lymph nodes were histologically positive in 24% of cases. At repeat screening, 77.6% (97/125) of cancers were T1; 11.2% were in situ carcinomas. Positive axillary lymph nodes were found in 16.8% of cases. CONCLUSIONS: The attendance to screening was satisfactory. A higher frequency of small tumors (83.0%) was found at first screening than before the introduction of screening (56.6%). A marked difference in lymph node positivity (24.0% vs 40.6% in the pre-screening era) was also observed. Such a difference was even more evident at repeat screening. Quality standards of the screening in our study proved to be higher than those currently recommended. The reported results are encouraging, also considering the greater chance for conservative treatment.

Axilla↗
PubMed1994

Feasibility study of a randomised trial of ovarian cancer screening among the general population.

OBJECTIVE: To determine the feasibility of a randomised trial of ovarian cancer screening among women attending a breast cancer screening centre. DESIGN: Randomised controlled trial of ovarian cancer screening using transvaginal ultrasonography as a primary screening test and colour Doppler imaging as a secondary screening test in the screened group and no intervention in the control group. SETTING: Reading breast cancer screening centre (United Kingdom). SUBJECTS: 8678 women, without a bilateral oophorectomy or hysterectomy, aged between 50 and 64 attending for NHS breast cancer screening between September 1989 and February 1993. MAIN OUTCOME MEASURES: Uptake of ovarian cancer screening among eligible women and the screening false positive rate (considered as the referral rate to a gynaecologist for surgical intervention). RESULTS: 82% (7124/8678) of eligible women agreed to join the trial and were randomly allocated in equal numbers to each arm of the trial. 3280 women had an initial scan. The false positive rate after ultrasonography alone was 2.9% (86/2952), but this dropped to 0.5% after colour Doppler as a secondary screening test. One stage I primary ovarian cancer was detected at screening in a 58 year old women. CONCLUSIONS: A randomised trial of ovarian cancer screening using ultrasonography and colour Doppler imaging is feasible and acceptable among women attending a breast cancer screening centre. The results indicate that the expected odds of being affected given a positive result in the general population would be about 1:12. A full randomised trial of ovarian cancer screening with mortality as the end point is needed to assess whether screening reduces mortality from this disease. A multicentre European trial is currently in progress.

Costs and Cost Analysis↗
PubMed1997

UK breast screening programme: how does it reflect the Forrest recommendations?

OBJECTIVE: To compare the UK breast screening programme with the Forrest Report recommendations of 1986. SETTING: The UK breast screening programme. METHODS: A postal survey of 97 local breast screening programmes in the United Kingdom. The main outcome measures were the frequency of screening, the use of two view screening on incident screens, reading of screening mammograms, assessment procedures and visits, staffing levels, and the use of building and equipment. RESULTS: Eighty two (85%) of the questionnaires were completed and returned. All programmes screen every three years, as Forrest intended, with the exception of one health region which screens more often. The national policy is to use two views on incident screens where there is a clinical indication. None the less, 14% of programmes are using, or intending to use, two views on all women. Double reading of mammograms is not recommended in the United Kingdom outside Scotland, but is used by 88% of programmes. All programmes have access to the equipment required for the assessment techniques recommended by Forrest. Variation exists between programmes in the procedures women can expect to receive at their initial assessment visit and in the total number of assessment visits. Sixty eight per cent of programmes' breast screening budgets cover the staff required for a multidisciplinary team as defined by the Forrest Report. Ninety three per cent of screening programmes are organised around static sites, with 86% of these also using mobile vans. CONCLUSIONS: The national programme is following recommendations about the frequency of screening, but there seems to be some divergence from policy as regards the use of double reading, two views at incident screening, and the multidisciplinary team covered by the programmes' breast screening budget. Further research is needed on the effectiveness and cost effectiveness of two view incidence screening, double reading, and non-radiologists as readers. Investigation is also needed of the costs and effects of the variation between programmes in the number of assessment visits a woman may have.

Breast Neoplasms↗
PubMed2006

Knowledge, attitudes and practices on cervical cancer screening among the medical workers of Mulago Hospital, Uganda.

BACKGROUND: Cervical cancer is the commonest cancer of women in Uganda. Over 80% of women diagnosed in Mulago national referral and teaching hospital, the biggest hospital in Uganda, have advanced disease. Pap smear screening, on opportunistic rather than systematic basis, is offered free in the gynaecological outpatients clinic and the postnatal/family planning clinics. Medical students in the third and final clerkships are expected to learn the techniques of screening. Objectives of this study were to describe knowledge on cervical cancer, attitudes and practices towards cervical cancer screening among the medical workers of Mulago hospital. METHODS: In a descriptive cross-sectional study, a weighted sample of 310 medical workers including nurses, doctors and final year medical students were interviewed using a self-administered questionnaire. We measured knowledge about cervical cancer: (risk factors, eligibility for screening and screening techniques), attitudes towards cervical cancer screening and practices regarding screening. RESULTS: Response rate was 92% (285). Of these, 93% considered cancer of the cervix a public health problem and knowledge about Pap smear was 83% among respondents. Less than 40% knew risk factors for cervical cancer, eligibility for and screening interval. Of the female respondents, 65% didn't feel susceptible to cervical cancer and 81% had never been screened. Of the male respondents, only 26% had partners who had ever been screened. Only 14% of the final year medical students felt skilled enough to use a vaginal speculum and 87% had never performed a pap smear. CONCLUSION: Despite knowledge of the gravity of cervical cancer and prevention by screening using a Pap smear, attitudes and practices towards screening were negative. The medical workers who should be responsible for opportunistic screening of women they care for are not keen on getting screened themselves. There is need to explain/understand the cause of these attitudes and practices and identify possible interventions to change them. Medical students leave medical school without adequate skills to be able to effectively screen women for cervical cancer wherever they go to practice. Medical students and nurses training curricula needs review to incorporate practical skills on cervical cancer screening.

Adult↗
PubMed2001

Barriers to domestic violence screening in the pediatric setting.

OBJECTIVE: By surveying practitioners in our community, we hoped to determine what pediatricians and family physicians (FPs) perceive as barriers to the American Academy of Pediatrics (AAP) Recommendation on Domestic Violence Screening. BACKGROUND: When screened in the pediatric setting, as many as 40% of mothers will disclose domestic violence (DV) by their partner. Recognizing the profound effects of DV on children, the AAP recently recommended that all practitioners incorporate DV screening as a part of routine anticipatory guidance. Yet, there is little information about whether pediatricians have the training, the time to screen, or understand the magnitude of this problem. DESIGN/METHODS: A 22-question survey about attitudes, training, and current DV screening practice was sent to all general pediatricians and FPs with admitting privileges to Children's Hospital Medical Center in Cincinnati, Ohio. A copy of the AAP recommendation on screening was included. The vast majority of practitioners with an appreciable pediatric practice in the surrounding tri-state area of 1.8 million people have privileges at the institution. RESULTS: After 2 mailings, 310 (57%) of 547 of questionnaires were returned. The majority of practitioners (64%) were unaware of the AAP recommendation, but 51% of practitioners screened at least high-risk families for DV and 49% had identified a case of DV in their practice. Still, only 8.5% routinely screened for DV and 74% had received no specific DV training. Fifty-eight percent of practitioners estimated the incidence of DV to be <5% in their practice. The most commonly perceived barriers to screening were lack of education (61%), office protocol (60%), time (59%), and support staff (55%). FPs were significantly more likely to have DV training (64% vs 21%), more likely to screen at least high-risk women (79% vs 56%), and more likely to have identified a case of DV (92% vs 40%) than pediatricians. FPs were less likely to cite lack of education (46% vs 65%) and lack of time (50% vs 61%) than pediatricians. Physicians licensed in Ohio were less likely to have specific domestic violence training (23% vs 60%) as compared with Kentucky physicians, where domestic violence education is required for licensing. Kentucky physicians were less likely to cite lack of education as barrier to DV screening (20% vs 62%). When comparing the characteristics of those who screen to those who do not, those with DV training were 10.9 times (odds adjusted ratio) more likely to screen. CONCLUSIONS: Practitioners grossly underestimate the incidence of DV in their practices. Lack of education including knowledge of screening recommendations is a barrier to DV screening by pediatricians. Greater efforts are needed to educate pediatricians on DV for the AAP recommendations to be accepted.domestic violence, child abuse, screening, physician attitude.

Adult↗
PubMed2006

Brief maternal depression screening at well-child visits.

OBJECTIVES: The goals were (1) to determine the feasibility and yield of maternal depression screening during all well-child visits, (2) to understand how pediatricians and mothers respond to depression screening information, and (3) to assess the time required for discussion of screening results. METHODS: Implementation of brief depression screening of mothers at well-child visits for children of all ages was studied in 3 rural pediatric practices. Two screening trials introduced screening (1 month) and then determined whether screening could be sustained (6 months). Screening used the 2-question Patient Health Questionnaire. Practices tracked the proportions of visits screened and provided data about the screening process. RESULTS: Practices were able to screen in the majority of well-child visits (74% in trial 1 and 67% in trial 2). Of 1398 mothers screened, 17% had 1 of the depressive symptoms and 6% (n = 88) scored as being at risk for a major depressive disorder. During discussion, 5.7% of all mothers thought they might be depressed and 4.7% thought they were stressed but not depressed. Pediatric clinicians intervened with 62.4% of mothers who screened positive and 38.2% of mothers with lesser symptoms. Pediatrician actions included discussion of the impact on the child, a follow-up visit or call, and referral to an adult primary care provider, a mental health clinician, or community supports. Pediatrician time needed to discuss screening results decreased in the second trial. Prolonged discussion time was uncommon (5-10 minutes in 3% of all well-child visits and >10 minutes in 2%). CONCLUSIONS: Routine, brief, maternal depression screening conducted during well-child visits was feasible and detected mothers who were willing to discuss depression and stress issues with their pediatrician. The discussion after screening revealed additional mothers who felt depressed among those with lesser symptoms. The additional discussion time was usually brief and resulted in specific pediatrician actions.

Adult↗