Lecture 5 - Screening - Basics and Practice Applications

Screening – Basics and
practice applications
Dr. Beesan Maraqa , MD,MPH , PBFM, Family Medicine specialist
beesanm@hebron.com
10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 1

Natural History of Disease
Detectable subclinical disease
Susceptible Subclinical Clinical Stage of Recovery,

Host Disease Disease Disability, or Death
Diagnosis
Point of required
Exposure
Onset of
symptoms
Screening
Screening
Screening is the process to
detect among healthy
people disorders or risk
factors of which they are
unaware

Types of Screening
• Mass screening
• aims to screen the whole population (or subset);
• Targeted screening (risky groups)
• groups with specific exposures, e.g. workers in lead battery factories
• Case-finding or opportunistic screening
• aimed at patients who consult a health practitioner for some other purpose.
• Multiple or multiphasic screening
• uses several screening tests at the same time

Appropriate Diseases for screening
 Important Health Problem  Long latent period
 High Prevalence  Early detection improves prognosis
 Natural History understood  Available and meaningful treatment
 It is not cost or time effective to screen for rare conditions.

 The incidence of ocular melanoma is 6-8 cases per million people per year. Clearly, population
screening is not reasonable.
 Breast cancer affects as many as 1 in 8 women and is aggressively screened
 The condition should have high morbidity.

 Amblyopia in adults is generally not burdensome. Patients adapted to the condition during
childhood and it does not usually limit health quality.
 Uncorrected refractive error is burdensome since it may prevent driving, holding a job, and reading

Appropriate Screening Test
• Feasibility
• Reliability (repeatability, precision)
• Validity (Sensitivity, Specificity)
• Yield (performance): Predictive values of the

test.
• Effectiveness

Feasibility
• Quick, easy, safe
• Acceptable
• Affordable
• Cost effective

Reliability
• Reliability (Reproducibility) Precision):
• The extent to which the screening test will produce the same or very similar
results each time it is administered (repeated).
• --- A test must be reliable before it can be valid.
• Sources of variability that can affect the reproducibility of results of a screening

test:
1. Biological variation (e.g. blood pressure)
2. Reliability of the instrument itself
3. Intra-observer variability (differences in repeated measurement by the same screener)
4. Inter-observer variability (inconsistency in the way different screeners apply or
interpret test results)

Validity
• Test validity is the ability of a screening test to accurately identify diseased and
non-disease individuals
• is based on its accuracy in identifying diseased and non-diseased persons,
• this can only be determined if the accuracy of the screening test can be compared to some "gold
standard" that establishes the true disease status.
• The gold standard might be a very accurate, but more expensive diagnostic test.
 Sensitivity
 Probability to test positive among truly affected
 Specificity
 Probability to test negative among truly unaffected

Validity
• A 2 x 2 table, or contingency table, is also used when testing the validity of a
screening test,
• Different from contingency for epidemiological studies,
• The 2 x 2 table below shows the results of the evaluation of a
screening test for breast cancer among 64,810 subjects.
Diseased Not Diseased Total
Test Positive 132 (TP) 983 (FP) 1,115

Test Negative 45 (FN) 63,650 (TN) 63,695
Column Totals 177 64,633 64,810

Validity
Test Positive 132 983 1,115

Test Negative 45 63,650 63,695
Column Totals 177 64,633 64,810
What was the probability that the screening test would correctly indicate disease in this
subset?
The probability is simply the percentage of diseased people who had a positive
screening test, i.e., 132/177 = 74.6%.
I could interpret this by saying, "The probability of the screening test correctly
identifying diseased subjects was 74.6%."
SENSITIVITY: The probability of testing positive if the disease is truly present

Validity

Column Totals 177 64,633 64,810
What was the probability that the screening test would correctly indicate free of disease
in this subset?
The probability is simply the percentage of non diseased people who had a negative
screening test, i.e., 63,650/64,633 = 98.5%.
I could interpret this by saying, "The probability of the screening test correctly
identifying non-diseased subjects was 98.5%."
SPECIFICITY: The probability of screening negative if the disease is truly

absent

Positive and Negative Predictive Value: Yield
(Performance)
 Positive predictive value is the probability that subjects with a positive

screening test truly have the disease.
 Negative predictive value is the probability that subjects with a
10/17/2023 negative screening test- Basics
Screening truly anddon't have
application, theMaraqa
Dr Beesan disease. 15
Positive Predictive Value

Column Totals 177 64,633 64,810
• If a test subject has an abnormal screening test (i.e., it's positive), what is the
probability that the subject really has the disease?
• In the example we have been using there were 1,115 subjects whose screening test
was positive, but only 132 of these actually had the disease, according to the gold
standard diagnosis.
• Therefore, if a subject's screening test was positive, the probability of disease was
132/1,115 = 11.8%.
Here, the positive predictive value is 132/1,115 = 0.118, or 11.8%.
Interpretation: Among those who had a positive screening test, the
probability of disease was 11.8%.
Negative Predictive Value

Column Totals 177 64,633 64,810
• Negative predictive value: If a test subject has a negative screening test, what is the
probability that the subject really does not have the disease?
• In the same example, there were 63,895 subjects whose screening test was negative,
and 63,650 of these were, in fact, free of disease.
• Consequently, the negative predictive value of the test was 63,650/63,695 = 99.9%.
Here, the negative predictive values is 63,650/63,950=0.999, or 99.9%.
Interpretation: Among those who had a negative screening test, the

probability of being disease-free was 99.9%.

Adverse Effects of Screening
• Although screening may lead to an earlier diagnosis, not all screening tests
have been shown to benefit the screened person
• There are two important down sides to screening:
• false positives, people who test positive even though they don't have disease
• false negatives, people who test negative even though they really have disease.
 Adverse effects of screening procedure (e.g. stress and anxiety, discomfort,

radiation exposure, chemical exposure).
 Stress and anxiety caused by prolonging knowledge of an illness without any
improvement in outcome (over-diagnosis).
 Stress and anxiety caused by a false positive screening result.
 Unnecessary investigation and treatment of false positive results (misdiagnosis).
 A false sense of security caused by false negatives

Effectiveness
• Outcome measures
• Morbidity
• Disability
• Mortality
• Bias :
• There are three possible sources of bias when evaluating a screening program
that may result in a false picture of its efficacy:
• Self selection bias
• Lead time
• Length bias

Biases when evaluating a screening program
Volunteer bias:
People who choose to participate in the screening program may be healthier or at higher
risk of developing the disease than those that don’t participate
Lead-time bias
Lead-time is the amount of time by which the diagnosis was advanced due to screening.
• Lead time bias means that survival may erroneously appear to be increased among
screen-detected cases simply because the diagnosis was made earlier in the course of
the disease

Biases when evaluating a screening program
Length-biased sampling
• Screening over-represents less aggressive disease
• Example
• Aggressive disease has a short asymptomatic period
• Screening is unlikely to detect these patients early
• Less aggressive disease has longer asymptomatic period
• Disease often detected by screening
• Over-represented in screening cohort
• Screening program falsely appears to improve survival
• Less aggressive disease common in screening group
• Screening cohort has a better prognosis by definition

Screening in Practice
Periodic health exam

Periodic health exam
• Evaluation of apparently health individuals in certain time periods, of their life using a
number of standard procedures such history, physical examination, laboratory
investigations or imaging with the purpose to find those probably diseased.
• Periodicity is determined by the age and risk factors of each patient

Goals of Periodic Health Exam
• To evaluate health status.

• To screen for risk factors and disease.
• Provide preventive counseling interventions in an appropriate Age manner.
• for health promotion disease
• To prevent morbidity and mortality by identifying modifiable risk factors and early
signs of treatable disease

overview of USPSTF
recommendations Adults
• Cardiovascular , endocine disease

Hypertension Screening
• USPSTF and SHMS
• Adults 18 years and older without known hypertension
How often ?
- Screening for hypertension annually in adults 40 years or older and in adults at increased risk for hypertension
- Screening less frequently (every 3 to 5 years) as appropriate for adults aged 18 to 39 years not at increased risk
for hypertension and with a prior normal blood pressure reading.
Grade A

Prediabetes and Type 2 Diabetes: Screening
USPSTF recommend screen

• Adults aged 35 to 70 years who overweight or obese: (Grade B)
• Consider screening earlier in patients with higher risk (i.e., one of the following): family history of diabetes; members of
certain racial and ethnic groups (i.e., blacks, American Indians, Asian Americans, Latinos) , personal history of gestational
diabetes or polycystic ovary syndrome …
• offer or refer patients with prediabetes to effective preventive interventions.
• How often ?
• Screening every 3 years may be a reasonable approach The American Diabetes Association
Recommend screen all adults 45 years or older
for adults with normal blood glucose levels for, regardless of risk factors, and screening adults who have
overweight or obese with risk factors

• cancer

• You are discussing cancer screening with a patient. Her father was diagnosed with colorectal
cancer at age 62. When should you recommend she begins colorectal cancer screening?
• A- 40 years
• B- 45 years
• C- 52 years
• D- 60 years
• E- 62 year

Colorectal Cancer: Screening The American College of
Gastroenterology (ACG)
2021 guidelines also
• US Preventive Services Task Force (USPSTF) recommend recommend initiating
screening at age 45 in all
adults at average risk
• initiate screening at age 45 years in adults at average risk. (Grade B)
• while maintaining for initiating at age 50 (its strongest recommendation (Grade A)
Recommended screening strategies and intervals include:

-
FOBT--- > Every year
-Flexible sigmoidoscopy--- > Every 5 years
-CT colonography ---> every 5 years
-Colonoscopy ---> Every 10 years

Breast Cancer: Screening
• USPSTF recommend screening the Ministry of Health of
Palestine guideline panel
suggests screening with
• Women aged 50 to 74 years mammography in women aged
• biennial screening mammography 40–49 years every 1 to 2 years
And women 50 years and older
• Grade B biannulay (every two years)
• Women aged 40 to 49 years

• The decision to start screening mammography in women
prior to age 50 years should be an individual one.
• Grade C

• According to USPSTF current guidelines for cervical cancer screening
when should HPV DNA first be performed along with Papanicolaou testing (cotesting)?
• A) At age 21
• B) At age 25
• C) At age 30
• D) At age 35

Cervical Cancer: Screening
USPSTF screening
Women aged 21 to 29 years

• Screen for cervical cancer every 3 years with cytology alone.
Women aged 30 to 65 years

• Screen for cervical cancer every 3 years with cytology alone,
• every 5 years with high-risk human papillomavirus (hrHPV) testing alone,
• or every 5 years with cotesting.
• Grade: A

Lung Cancer: Screening
• The USPSTF recommend

• Adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit
within the past 15 years
• How often?
• Annual Screen for lung cancer with low-dose computed tomography (CT)
• Stop screening once a person has not smoked for 15 years or has a health problem that limits life expectancy
or the ability to have lung surgery.
• Grade: B

• Infectious disease

• A 22-year-old female has recently been hired to work at your clinic. She is going through the orientation and
screening process and you are asked to screen her for tuberculosis. She tells you that she received the bacille
Calmette-Guérin (BCG) vaccine as a child.
• Which one of the following would be the recommended screening for this patient?
• A) No screening
• B) A tuberculin skin test (TST)
• C) An interferon-gamma release assay (IGRA)
• D) A chest radiograph

Latent Tuberculosis Infection: Screening

• Asymptomatic adults at increased risk for infection
• Screening Intervals
• screening frequency could range from 1-time only screening among persons who are at low risk for
future tuberculosis exposure to
• annual screening among those who are at continued risk of exposure.
• Grade B

Hepatitis B and Hepatitis C Virus Infection: Screening
USPSTF
Hep B Hep C
For adolescents and adults including pregnent: For adults aged 18 to 79 years:
(including pregnant persons)
Screen adolescents and adults at increased risk for hepatitis B
virus (HBV) infection.
How often?
Periodically screen persons with continued risk for infection

Human Immunodeficiency Virus (HIV) Infection: Screening
• Adolescents and adults aged 15 to 65 years

• Younger adolescents and older adults who are at increased risk of infection should also be screened.
• Pregnant women including those who present in labor or at delivery whose HIV status is unknown.
• Screening Intervals
• The USPSTF found insufficient evidence to determine appropriate or optimal time intervals or strategies for
repeat HIV screening. However, repeat screening is reasonable for persons known to be at increased risk of
HIV infection,
• Grade: A

Chlamydia and Gonorrhea: Screening
USPSTF recommend
For sexually active women, including pregnant :
• Screen for chlamydia and gonorrhea if they are

• 24 years or younger
• 25 years or older and at increased risk for infection
Screening Intervals
In the absence of studies on screening intervals, a reasonable approach would
be to screen patients whose sexual history reveals new or persistent risk
• Grade: B factors since the last negative test result.

• antenatal

Folic Acid for the Prevention of Neural Tube Defects
• USPSTF recommend
• Women who are planning or capable of pregnancy

• Take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid.
• Women at high risk of Neural Tube Defects such as epileptic, dm , or previous hx of baby with NTD should
take 4 mg
Grade: A

Asymptomatic Bacteriuria : Screening
• USPSTF recommend
• screening for asymptomatic bacteriuria using urine culture in pregnancy

at the first prenatal visit or at 12 to 16 weeks of gestation
• Grade B

• USPSTF and ADA recommend
• Gestational Diabetes: Screening
One-time screening should be performed at 24 weeks of gestation or after (Grade: B)
Preeclampsia: USPSTF Screening
• Blood pressure measurements should be obtained during each prenatal care visit throughout pregnancy
•10/17/2023
(Grade: B) Screening - Basics and application, Dr Beesan Maraqa 48
Counselling
• USPSTF recommend screening

• Tobacco Smoking Cessation
• ask all adults including pregnents about tobacco use, advise them to stop using tobacco, and provide behavioral
interventions and pharmacotherapy for cessation
• Unhealthy Drug Use : Screening
screening by asking questions about unhealthy drug use in adults age 18 years or older.
• Unhealthy drug use includes using illegal drugs, such as heroin,
• And provide interventions

Depression :
USPSTF recommend
- Screening for depression in the general adult population, including pregnant and postpartum women.
- screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years.
- Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective
- Grade B

Weight Loss to Prevent Obesity
• The USPSTF recommends that clinicians offer or refer adults with a body mass index
(BMI) of 30 or higher to intensive, multicomponent behavioral interventions.
• Effective intensive behavioral interventions were designed to help participants achieve or

maintain a ≥5% weight loss through a combination of dietary changes and increased
physical activity
• Grade: B

• elderly

• A 72-year-old male comes to your office for an annual health maintenance visit. He mentions that
some of his friends recently underwent health screenings and he asks if there are any cardiovascular
screening tests recommended for him. His blood pressure is well controlled and he does not have any
shortness of breath or chest pain. He exercises regularly. He started smoking cigarettes while he
attended college but quit at age 25. He does not have a significant family history of cardiovascular
disease.
• Which one of the following tests is recommended by the U.S. Preventive Services Task Force for
patients such as this?
• A) An ankle-brachial index
• B) A high-sensitivity C-reactive protein level
• C) A coronary artery calcium score
• D) Abdominal aortic aneurysm screening with ultrasonography
• E) Echocardiography

Abdominal Aortic Aneurysm: Screening
• For men aged 65 to 75 years who have ever smoked
• Perform 1-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men who have
a history of smoking.
• Grade B

Osteoporosis : Screening
• USPSTF and National Osteoporosis Foundation (NOF)recommend
• Women 65 years and older
• Postmenopausal women younger than 65 years at increased risk of osteoporosis
These include parental history of hip fracture, smoking, excessive alcohol consumption, and low body weight.
(Grade B)
• T-score of -2.00 to -2.49 →repeat testing every two years

• T-score of -1.50 to -1.99 → DXA) in three to five years.
• with normal or slightly Osteopenia (T-score -1.01 to -1.49) → DXA in 10 to 15 years
• How often ?
10/17/2023 Screening - Basics and application, Dr Beesan Maraqa uptodate

55
Falls Prevention
Screen 65 years and older at increased risk for falls, without osteoporosis or vitamin D deficiency
The initial assessment a multidisciplinary comprehensive geriatric assessment or an assessment using

a combination of various components, such as balance, gait, vision, medication, environment,
cognition, and psychological health.
• Recommend exercise interventions such as gait balance, and resistance training , aerobic
exercises as well as muscle-strengthening activities twice per week to prevent falls.
• Grade: B

• Pediatrics

• The U.S.Preventive Services Task Force recommends vision screening to detect amblyopia:
• A) at 2 years of age
• B) at 3–5 years of age
• C) the summer before the child enters first grade
• D) once at 4–5 years of age and once at 8–9 years of age

For more information :
https://www.mhqp.org/wp-
content/uploads/2020/12/MHQP-
Pediatric-Preventative-Care-Guidelines-
2021.pdf
•You should master this
•Best luck

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Screening – Basics and

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 1

Susceptible Subclinical Clinical Stage of Recovery,

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 4

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 5

 It is not cost or time effective to screen for rare conditions.

 The condition should have high morbidity.

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 7

• Reliability (repeatability, precision)

• Validity (Sensitivity, Specificity)

• Yield (performance): Predictive values of the

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 8

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 9

• Sources of variability that can affect the reproducibility of results of a screening

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 10

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 11

Test Positive 132 (TP) 983 (FP) 1,115

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 12

Test Positive 132 983 1,115

SENSITIVITY: The probability of testing positive if the disease is truly present

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 13

Test Positive 132 983 1,115

SPECIFICITY: The probability of screening negative if the disease is truly

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 14

 Positive predictive value is the probability that subjects with a positive

Test Positive 132 983 1,115

Test Positive 132 983 1,115

Interpretation: Among those who had a negative screening test, the

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 17

 Adverse effects of screening procedure (e.g. stress and anxiety, discomfort,

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10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 19

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• Periodicity is determined by the age and risk factors of each patient

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 25

• To evaluate health status.

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 26

• Cardiovascular , endocine disease

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 27

• USPSTF and SHMS

• Adults 18 years and older without known hypertension

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 28

USPSTF recommend screen

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 29

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• while maintaining for initiating at age 50 (its strongest recommendation (Grade A)

Recommended screening strategies and intervals include:

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 34

• Women aged 40 to 49 years

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 35

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 36

Women aged 21 to 29 years

Women aged 30 to 65 years

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• The USPSTF recommend

10/17/2023 Screening - Basics and application, Dr Beesan Maraqa 38

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• The USPSTF recommend