Screening

MBBS Public Health Year 1

Max Bachmann
By the end of this lecture you should be able to:
• Define screening
• State the purpose of screening
• List some NHS national screening programmes
• Describe the screening process
• Describe the components of a screening programme
• Describe harms that screening can cause
• Identify sources of evidence about screening effectiveness
• Identify common biases in evaluations of effectiveness
Definition and purpose of screening
• Testing people who do not suspect they have a health problem
(without symptoms), so as to:

• Reduce risk of future ill health

• by earlier detection and treatment

• Provide information
• to help make choices
NHS national screening programmes
• Cervical cancer
• Breast cancer
• Bowel cancer
• Abdominal aortic aneurysms
• Antenatal and neonatal testing
• Diabetic eye disease
Screening within other NHS programmes
• Health Check: screening adults aged 40-74 forearly signs of stroke,
kidney disease, heart disease, type 2 diabetes or dementia
• Eg Cardiovascular risk factors
• Blood pressure, cholesterol, obesity (BMI), glucose (or HbA1c), smoking
• => GP management of risk factors

• National Diabetes Prevention Programme

• Based on glucose (or HbA1c) testing in Health Check
• Diagnosis of prediabetes => lifestyle interventions
• Diagnosis of diabetes => GP
Eg: screening for diabetic eye disease
Time

No retinal disease Non- and pre- Proliferative Visual loss Blindness

proliferactive retinopathy and
retinopathy maculopathy

-------Screening: retinal photos------------------    

    Referral and    
Treatment
Stages and outcomes of the screening process
Components of a screening programme
• Register of eligible people
• System of invitation and recall
• Screening tests
• Confirmation of diagnosis
• Treatment or other interventions
• Information and support for patients
• Staff training
• Standards and quality assurance
Screening can cause harm too
• Over diagnosis
• False positive tests
• Further testing can lead to more false positive tests
• False negative tests
• False sense of security
• Unnecessary treatment
• Might never have progressed to severe disease or death
• Costs of screening, further testing and treatment
=> There are always trade-offs between possible harms and benefits
 True and false test results
(Brief introduction to diagnostic test accuracy
covered later in Research Methods)

Has disease Does not have disease

Screening test positive A = true positive B = false positive

Screening test negative C = false negative C = true negative

 Sensitivity = A / (A+C) i.e. % of people with disease who test positive

Specificity = C / (B+C) i.e. % of people without disease who test negative

Has disease Does not have disease

Screening test positive A = true positive B = false positive

Screening test negative C = false negative C = true negative

Evidence about effectiveness of screening
• Randomised controlled trials (best)
• Time trends in disease incidence and outcomes
• Compared to countries or regions without screening
• Case control studies
• Is % screened lower in cases with disease than in controls without disease?
• Often biased by confounding

• Systematic reviews of evidence

• Modelling (combining a variety of evidence)
Common sources of bias in screening evaluation
• Healthy screening effect
• People who take part tend to be healthier than those who don’t

• Length time bias

• Disease is more likely to be detected in people with longer lasting and slowly
progressive types of the disease => have better outcomes anyway

• Lead time bias

• Earlier detection makes duration of survival after diagnosis longer, even if
treatment is ineffective
Summary
• Screening is a common and important part of medical practice
in general practice and many specialities
• It is an important part of public health

• Screening programmes are much more than just tests

• Screening is imperfect and can cause harm as well as benefits
Learn more
Online videos: Raffle A, Screening
https://www.healthknowledge.org.uk/interactive-learning/screening/introduction

Online textbooks through UEA Library:

UEA Portal => Library => Search for books => Click on “UEA Access”
• Book chapter: Raffle A et al. Chapter 3.6. Assuring screening programmes. In Guest C et al, eds, Oxford
Handbook of Public Health 2013
• Book chapter : Chapter 9. Diagnosis. In Ben Schlomo et al, eds, Lecture Notes: Epidemiology, Evidence
Based Medicine and Public Health
• Book: Raffle AE, Muir Gray JA. Screening: Evidence and Practice

NHS and NICE screening programme web sites:

https://www.evidence.nhs.uk/search?q=screening+programmes&sp=on