1. Comunicación y Gerencia
بسم الله الرحمن الرحيم
5/1/2011

2. Family and Community Medicine Department
Screening
Dr. Salwa Tayel
Family and Community Medicine Department
King Saud University
5/1/2011

3. Define screening and mention its purpose.
Learning Objectives:
Define screening and mention its purpose.
List WHO criteria for effective screening
Calculate and interpret measures of the validity of a screening test:
--- Sensitivity
--- Specificity
Calculate and interpret measures of the performance (yield) of a screening test:
--- Predictive value positive (PV+)
--- Predictive value negative (PV-)
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4. Screening
Screening: The application of a disease-detection test in asymptomatic apparently healthy individuals.
Purpose: To classify individuals with respect to their likelihood of having a particular disease.
Screening procedure itself does NOT formally diagnose illness.
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5. Screening Vs. diagnosis Tests
The purpose of screening is to segregate those who may have the condition. It is an initial step, as it needs further confirmation.
On the other hand, diagnosis is a procedure to confirm or disprove the existence of a disease or abnormality.
Both screening and diagnosis can be achieved by obtaining medical history, performing physical examination and the application of laboratory or non-laboratory test.
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6. Comparison between screening and diagnostic tests
Screening tests
Done to those with suggestive signs or symptoms
Done to those who are apparently healthy or asymptomatic
Applied to a single person
Applied to a group of individuals
Results are based on the evaluation of a number of symptoms, signs and investigations
Results are based on one criterion
Results are conclusive and final
Results are not conclusive
More accurate
Less accurate
More expensive
Less expensive
Basis for treatment
Not a basis for treatment
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7. Types of screening programs
Mass screening
Application of the screening program to the whole population or population subgroups as adults, school children, industrial workers.
High risk or selective screening
The screening program will be applied to a selective group of population who are at a high risk e.g. cancer cervix in low social class.
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8. Early Intervention in the Natural History of Disease
HEALTH OUTCOMES Cure
Control
Disability
Death
Good Health
Disease Onset
Care Seeking
Symptoms
Diagnosis
Therapy
Population disease screening programs are important countermeasures for reducing the epidemiologic impact of latency by testing for the presence of a disease before symptoms would motivate an individual to visit a physician for diagnosis and treatment. Disease screening is secondary prevention, since it aims to minimize damage associated with the disease process.
Early detection through Screening
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9. 5/1/2011

10. Flow diagram for a screening program
Population
Screening test
Test -ve
Test +ve
Diagnostic procedures
Unaffected
Affected
Re-screen
Intervention
Re-screen
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11. Screening for Disease Control
Screening Objective:
To lower morbidity and mortality of the disease in a population (control, rather than elimination of disease).
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12. Cervical cancer screening
- Screening test: Pap smear
Diagnostic test: Biopsy and pathological examination
Types of screening
Mass screening: Married females/ sexual activity
Selective screening: Married female of the lower social class, Multiple sexual partners, Repeated viral infection (human papilloma virus) Genital warts
- Value: Early detection and treatment/ reduces human suffering and mortality
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13. WHO criteria for effective screening:
The disease should be important public health problem (relates to cost effectiveness, and prognosis).
There should be an effective and acceptable treatment for the condition if identified in an early stage.
Facilities for the confirmation of the diagnosis and treatment should be available.
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14. WHO criteria for effective screening:
4) There should be a latent stage of the disease (long and detectable pre-symptomatic stage).
5) There should be a suitable screening test or examination that can detect the condition
6) The test should be acceptable to the population.
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15. 7) Natural history of disease should be adequately understood.
8) There should be an agreed upon policy on whom to treat.
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16. 9) The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
10) Case finding should be a continuous process, not just a “once and for all” project.
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17. Diseases for which screening has been recommended
Cervical cancer
Breast cancer
Ovarian cancer
Colorectal cancer
Skin cancer
Diabetes
Hypertension
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18. Characteristics of a screening test:
• Validity (Sensitivity, Specificity)
• Reliability (repeatability/precision)
• Yield (performance): Predictive values of the test.
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19. Validity of Screening Tests
How good is the screening test compared
with the confirmatory diagnostic test
(Gold Standard test)?
The test will correctly classify a diseased person as likely to have the condition (“sensitivity”).
The test will correctly classify a non- diseased person as unlikely to have the condition (“specificity”).
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20. Results of screening test compared to gold standard
Total
Gold standard
Screening test
Negative
Positive PS
(FP)
(TP) NS
(TN)
(FN) GT TH TD
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21. Validity of Screening Tests
True Disease Status
Results of
Screening Test + - + a b - c d
a = true positive
b = false positive
c = false negative
d = true negative
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22. Validity of Screening Tests
True Disease Status
Results of
Screening Test + - + a b - c d
Sensitivity: The probability of testing positive if the disease is truly present
Sensitivity = a / (a + c)
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23. Validity of Screening Tests
True Disease Status
Results of
Screening Test + - + a b - c d
Specificity: The probability of screening negative if the disease is truly absent
Specificity = d / (b + d)
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24. Results of screening 100 men for prostate cancer using (PSA)
Total
Gold standard
(Prostatic biopsy)
Screening test (PSA)
No cancer
Cancer 10
7 (FP)
3 (TP)
Positive 90
88 (TN)
2 (FN)
Negative
100 95 5
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25. Adverse effects of screening
Stress and anxiety caused by a false positive screening results.
Unnecessary investigation and treatment of false positive results
Prolonging knowledge of an illness if nothing can be done about it.
A false sense of security caused by false negatives, which may even delay final diagnosis.
Overuse/waste of medical resources.
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26. Prevalence of disease =(a+c)/(a+b+c+d) =100/200=50%
Sensitivity: a / (a + c)
Sensitivity = 90%
Specificity: d / (b + d)
Specificity = 95%
Prevalence of disease =(a+c)/(a+b+c+d)
=100/200=50%
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27. Number of false positives=b False Positive Rate=b/b+d
Number of false negatives=c
False Positive Rate=c/a+c
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28. Sensitivity: a / (a + c) = 90% Specificity: d / (b + d) 95%
False Positive Rate=b/b+d=5/100=5%
False negative Rate=c/a+c=10/100=10%
Prevalence of disease = (a+c)/ (a+b+c+d) 100/200= 50%
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29. Reliability of Screening Tests
RELIABILITY (Reproducibility) Precision:
The extent to which the screening test will produce the same or very similar results each time it is administered (repeated).
It can be assessed by repeating the test using the same or different observers.
--- A test must be reliable before it can be valid.
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30. Validity vs. reliability
If you measure blood pressure in an obese patient and use a cuff that is too small you are likely to get a falsely high reading.
The reading maybe reliable (you get the same blood pressure if you do it again) but it lacks validity.
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31. Reliability of Screening Tests
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)
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32. Website http://faculty.ksu.edu.sa/73234/default.aspx
Bibliotheca Alexandrina
Thank you
End of the course
Website
5/1/2011