1. Screening and its future……………………

2. A definition of screening. Any medical investigation that does not arise from a patient’s request for advice for a specific complaint Any medical investigation that does not arise from a patient’s request for advice for a specific complaint

3. Current Screening Cancers screened for are Cancers screened for are Breast Breast Cervical Cervical Just rolling out Bowel Just rolling out Bowel

4. Cervical Cancer testing Hot topic thanks to Jade and HPV Hot topic thanks to Jade and HPV Currently in England 1st invite at 25 brush cytology every 3 yrs until 49. Some worry re age but more false +ves under 25 and based on paper ‘benefits of cerv screening at different ages’ BJC July ‘03 Currently in England 1st invite at 25 brush cytology every 3 yrs until 49. Some worry re age but more false +ves under 25 and based on paper ‘benefits of cerv screening at different ages’ BJC July ‘03 50-64 5 yrly, none over 65 50-64 5 yrly, none over 65 Advise to continue despite HPV vaccn. as long lag time to effect. Advise to continue despite HPV vaccn. as long lag time to effect. Costs £157 million a year decreased cancer incidence of 41% 20-39, 69% 40-54, 73% 55-69. Costs £157 million a year decreased cancer incidence of 41% 20-39, 69% 40-54, 73% 55-69.

5. Breast Cancer testing Again in the news as some concerns over over treatment. Again in the news as some concerns over over treatment. Currently mammogram every 3 years over 50 (so could get 1st call at 53) to 70 can request over 70 but not rountine. Works as breast more fat than gland so sensitive post menopause. Currently mammogram every 3 years over 50 (so could get 1st call at 53) to 70 can request over 70 but not rountine. Works as breast more fat than gland so sensitive post menopause. Costs 52 million a year Costs 52 million a year 117, 000 cancers from 19 million people screened. 117, 000 cancers from 19 million people screened. ?overdiagnosis of DCIS Cancer UK say 1 in 3 DCIS detected may not become invasive so about 1 in 20 of cancers detected- still worth it! ?overdiagnosis of DCIS Cancer UK say 1 in 3 DCIS detected may not become invasive so about 1 in 20 of cancers detected- still worth it!

6. Bowel Cancer Screening Lifetime prevalence 1 in 20 people Lifetime prevalence 1 in 20 people Screening reduces risk of dying by 16% Screening reduces risk of dying by 16% Screening is FOB every 2 yrs 60-69 Screening is FOB every 2 yrs 60-69 Cost so far £55 M 08-9 Cost so far £55 M 08-9 Likely 2% colonscopy. Likely 2% colonscopy.

7. Other Screening -Pregnancy since NICE Anaemia at 12, 28 and 34 weeks Anaemia at 12, 28 and 34 weeks MSU at booking and sunsequent dips MSU at booking and sunsequent dips Blood group and Rh at booking Blood group and Rh at booking Hep B and HIV at booking Hep B and HIV at booking Rubella and Syphillis at booking Rubella and Syphillis at booking Downs screening available to all should all be combined/integrated test now. Downs screening available to all should all be combined/integrated test now. Fetal anomaly scan at 18-21 weeks. Fetal anomaly scan at 18-21 weeks. NOT placenta/ vasa previa but if over os at 20 weeks repeat at 36. NOT placenta/ vasa previa but if over os at 20 weeks repeat at 36.

8. GU / Vascular Chlamydia voluntary screening (opportunistic). Chlamydia voluntary screening (opportunistic). Controversy re vascular screening, NSF recommends need to identify high risk and in ‘06 there was no recommenation for whole popln screening. There is the handbook for vascular risk assmt anamagement. We are expected to do more but needs whole teaching session to discuss. Currently guided by QOF targets but huge subject. Controversy re vascular screening, NSF recommends need to identify high risk and in ‘06 there was no recommenation for whole popln screening. There is the handbook for vascular risk assmt anamagement. We are expected to do more but needs whole teaching session to discuss. Currently guided by QOF targets but huge subject.

9. How do we decide whether to introduce a screening programme?

10. Group work Split into groups of 3, what do you need for a screening programme to work? Split into groups of 3, what do you need for a screening programme to work?

11. Wilson’s criteria the condition should be an important health problem the condition should be an important health problem the natural history of the condition should be understood the natural history of the condition should be understood there should be a recognisable latent or early symptomatic stage there should be a recognisable latent or early symptomatic stage there should be a test that is easy to perform and interpret, acceptable, accurate, reliable, sensitive and specific there should be a test that is easy to perform and interpret, acceptable, accurate, reliable, sensitive and specific there should be an accepted treatment recognised for the disease there should be an accepted treatment recognised for the disease treatment should be more effective if started early treatment should be more effective if started early there should be a policy on who should be treated there should be a policy on who should be treated diagnosis and treatment should be cost-effective diagnosis and treatment should be cost-effective case-finding should be a continuous process case-finding should be a continuous process

12. Criteria by the National Screening Committee (2003) The condition Should be an important health problem Should be an important health problem The epidemiology and natural history should be well understood The epidemiology and natural history should be well understood There should be a detectable risk factor and early latent stage There should be a detectable risk factor and early latent stage The test Should be simple, safe, precise and validated The distribution of test values in the population should be known Should be acceptable to the population

13. Criteria by the National Screening Committee (2003) The treatment There should be an effective intervention There should be an effective intervention There should be evidence of early treatment leading to better outcomes than later treatment There should be evidence of early treatment leading to better outcomes than later treatment There should be agreed evidence based policies on treatment policy There should be agreed evidence based policies on treatment policy The programme There should be evidence from high quality RCT that the screening programme reduces morbidity and mortality There should be evidence that the programme is clinically, socially and ethically acceptable

14. Criteria by the National Screening Committee (2003) The programme (cont.) The benefit from the programme should outweigh physical and psychological harm The benefit from the programme should outweigh physical and psychological harm ‘The opportunity cost’ should be ‘economically balanced’ ie ‘value for money’ ‘The opportunity cost’ should be ‘economically balanced’ ie ‘value for money’ Adequate staffing and facilities should be in place before its commencement Adequate staffing and facilities should be in place before its commencement There should be a plan for managing and monitoring the programme There should be a plan for managing and monitoring the programme Evidence based information should be available to allow participants to make fully informed choices Evidence based information should be available to allow participants to make fully informed choices

15. Role play time! Split into twos Split into twos One of you is the patient, other the doctor, One of you is the patient, other the doctor, Scenario – the patient is a 25 year old university graduate, she has been sexually active for 8 years and had a friend who has recently had treatment for an abnormal smear- she wonders if she should have a smear and wants to discuss it with you. Scenario – the patient is a 25 year old university graduate, she has been sexually active for 8 years and had a friend who has recently had treatment for an abnormal smear- she wonders if she should have a smear and wants to discuss it with you.

16. Feedback

17. Review article by Muir Gray BJGP April 2004 New Concepts in Screening : All screening programmes do harm; some do good as well All screening programmes do harm; some do good as well Screening is a programme; not a test Screening is a programme; not a test False negatives and positives are an inevitable part of any screening programme False negatives and positives are an inevitable part of any screening programme

18. Ethical issues to consider Is screening different to care? Is screening different to care? Informed consent Informed consent Who owns genetic material Who owns genetic material What do you do with the knowledge (eg carrier of the CF gene) What do you do with the knowledge (eg carrier of the CF gene) Parents’ Vs infants’/children’s rights Parents’ Vs infants’/children’s rights

19. Consent Consent for National Screening Programmes is taken for granted by many, as they are led to believe that there is an obvious benefit of any intervention that may take place. True understanding is not easy for many doctors, let alone patients. Consent for National Screening Programmes is taken for granted by many, as they are led to believe that there is an obvious benefit of any intervention that may take place. True understanding is not easy for many doctors, let alone patients.

20. Consent (an example) Let’s take a look at regular breast self- examination, and start from the patient’s point of view : Let’s take a look at regular breast self- examination, and start from the patient’s point of view : “Regular examination of my own breasts is a good idea because it will stop me from dying of breast cancer” “Regular examination of my own breasts is a good idea because it will stop me from dying of breast cancer”

21. Consent (an example) Well, the bad news is that it won’t, or not on present evidence(recent Cochrane r/v). Well, the bad news is that it won’t, or not on present evidence(recent Cochrane r/v). “If I find a lump it will mean I will stay healthy because I will have caught it in time.” “If I find a lump it will mean I will stay healthy because I will have caught it in time.”

22. Consent (an example) Not true, or if it is, the difference is not great. Operating on some lumps very early may even make the prognosis worse. Some lumps metastasise early, some don’t. At present we cannot tell the difference. Not true, or if it is, the difference is not great. Operating on some lumps very early may even make the prognosis worse. Some lumps metastasise early, some don’t. At present we cannot tell the difference. “There must be a useful thing to do because the doctor/nurse/magazine told me to do it.” “There must be a useful thing to do because the doctor/nurse/magazine told me to do it.”

23. Consent (an example) Really. The Chief Medical Officer did change his mind recently, but was howled down and succumbed to encouraging breast awareness instead, whatever that is. Really. The Chief Medical Officer did change his mind recently, but was howled down and succumbed to encouraging breast awareness instead, whatever that is. “It stands to reason I must be a good idea.” “It stands to reason I must be a good idea.”

24. Consent (an example) It doesn’t. It doesn’t. “It makes me worry about cancer, but prevention is better than cure, isn’t it?” “It makes me worry about cancer, but prevention is better than cure, isn’t it?” Not when the premise is a fallacy. Not when the premise is a fallacy.

25. Consent (an example) Now try it from the doctor’s point of view : “It stands to reason it must be a good idea.” “It stands to reason it must be a good idea.” Have you looked long and hard at Wilson’s criteria for screening recently? Have you looked long and hard at Wilson’s criteria for screening recently?

26. Consent (an example) “It can’t do any harm.” “It can’t do any harm.” It can, not least in creating false expectations and contributing to the overvaluing of medical competence. It can, not least in creating false expectations and contributing to the overvaluing of medical competence. “I can’t really tell her the truth, she wouldn’t believe me.” “I can’t really tell her the truth, she wouldn’t believe me.”

27. Consent (an example) It would take time, but she might. Honesty should be the best policy. It would take time, but she might. Honesty should be the best policy. “But she will think I am an uncaring nihilist and that it does not worry me what happens to her.” “But she will think I am an uncaring nihilist and that it does not worry me what happens to her.” If that is the case, you have not achieved any degree of shared understanding and it is still not worth perpetuating a dubious quarter-truth. If that is the case, you have not achieved any degree of shared understanding and it is still not worth perpetuating a dubious quarter-truth.

28. Ponder for thought…….. There is a major ethical divide between your patient coming to see you for your opinion and help with their agenda, and you imposing your screening agenda on them. There is a major ethical divide between your patient coming to see you for your opinion and help with their agenda, and you imposing your screening agenda on them. If you do initiate such a procedure, you should have conclusive evidence that the test is likely to alter favourably the outlook for that individual and that it is unlikely to do any physical or psychological harm. Face the issues honestly and help your patients to ask searching questions. If you do initiate such a procedure, you should have conclusive evidence that the test is likely to alter favourably the outlook for that individual and that it is unlikely to do any physical or psychological harm. Face the issues honestly and help your patients to ask searching questions.

29. Ponder for thought…… However, giving patients more honest information about potential risks and benefits of screening may lead to people being discouraged from attending for screening, with a subsequent associated increase in mortality of a preventable disease at population level. However, giving patients more honest information about potential risks and benefits of screening may lead to people being discouraged from attending for screening, with a subsequent associated increase in mortality of a preventable disease at population level.

30. Group work Are the current screening programmes for cervical Ca and Breast Ca justified in your eyes? Why? Are the current screening programmes for cervical Ca and Breast Ca justified in your eyes? Why? Split into 2 groups and discuss. Split into 2 groups and discuss.