1. Ann Jolly1 Screening “...the identification of unrecognized disease or defect by the application of tests, examinations or other procedures...” “...sort out apparently well persons who probably have disease from those who probably do not.” “...not intended to be diagnostic...”

2. Ann Jolly2 Different kinds of testing in medicine “Diagnostic” - specifically looking for a suspected condition which is tested for and confirmed or excluded “Case-finding” - usually in an investigation of exposed people, to sort the exposed and ill from the exposed and well. (E.g., test people who were in contact with a case of tuberculosis, or check b.p. of patient who is overweight) “ Screening” - usually no specific exposure or indication that the individual has disease. (E.g., routine PSA testing in middle-aged males)

3. Ann Jolly3 Types of screening Mass screening, no selection of population (e.g., checking all infants for hearing problems) Selective screening (e.g., by age and sex: mammograms for women aged over 40) Multiphased screening (a series of tests, as family doctors do at annual health exams)

4. Ann Jolly4 Logic of screening Apparently well population Screening test Negative results Positive results: Diagnostic test DiseaseNo diseaseDiseaseNo disease (False negative)(True negative) (True positive)(False positive)

5. Ann Jolly5 How good is the test? Disease present? Yes No Positive Negative Test result True positive False negative False positive True negative Sensitivity = True positive True positive + False negatives Specificity = True negative True negative + False positives

6. Ann Jolly6 Characteristics of a good screening test Valid (e.g., sensitive and specific) Reliable (gives consistent results; no random errors) Yield (number of cases identified per thousand screened) Cost – benefit (compare costs avoided due to early detection of the disease against cost of the screening. Does the test merely uncover more disease that is expensive to treat without appreciable advantage?) Acceptable (discomfort, hassle, cost of obtaining test) Follow-up services (plan needed to deal with positive results)

7. Ann Jolly7 When should we screen? Screen when: It is an important health problem (think about how to define ‘important’?) There is an accepted and effective treatment Disease has a recognizable latent or early symptomatic stage There are adequate facilities for diagnosis and treatment There is an accurate screening test There is agreement as whom to consider as cases

8. Ann Jolly8 Ethics of medical care Remember the basic ethical principles:ethical principles Autonomy Non-maleficence Beneficence Justice

9. Ann Jolly9 Ethics in screening Informed consent obtained? Implications of positive result? Number and implications of false positives? Ditto for false negatives? Labeling and stigmatization

10. Ann Jolly10 Periodic health examination Canadian Task Force Levels of evidence for interventions –I-1 Randomized controlled trials –II-1 Well-designed trial but not randomized –II-2Cohort or case-control studies in more than one centre –II-3“Natural experiments” –IIIExpert opinion

11. Ann Jolly11 Example of Periodic Health Exam: Women and men aged 16 - 44 Immunizations Polio Tetanus and diphtheria Travel - related Rubella Screening Hypertension CA cervix Tuberculosis STD