NATIONAL SCREENING CONTROL

POLICIES
• A policy is a course of action adopted and
pursued by an individual or organisation.
 PRINCIPLES OF SCREENING
• Screening refers to the application of a test to
a population which has no overt signs or
symptoms of the disease in question, to
detect disease at a stage when treatment is
more effective.
• The screening test is used to identify people
who require further investigation to
determine the presence or absence of disease
and is not primarily a diagnostic test.
• The purpose of screening an asymptomatic
individual is to detect early evidence of an
abnormality or abnormalities such as pre-
malignant changes (e.g. by Pap test) or early
invasive malignancy (e.g. by mammography) in
order to recommend preventive strategies or
treatment that will provide a better health
outcome than if the disease were diagnosed
at a later stage.
• The potential benefits of organised population
screening program for cancer must outweigh
any potential harms that may result in the use
of a screening test in people who are
otherwise well.
• There must be strong evidence, preferably
from randomised trials, that a screening
program is effective in reducing mortality from
cancer.
 Principles for introduction of population
screening
• the condition should be an important health problem
• there should be a recognisable latent or early
symptomatic stage
• the natural history of the condition, including
development from latent to declared disease, should
be adequately understood
• there should be an accepted treatment for patients
with recognised disease
• there should be a suitable test or examination that has
a high level of accuracy
• the test should be acceptable to the population.
• there should be an agreed policy on whom to treat as
patients.
• facilities for diagnosis and treatment should be available
• the cost of screening (including diagnosis and treatment
of patients diagnosed) should be economically balanced
in relation to possible expenditure on medical care as a
whole, and
• screening should be a continuing process and not a
‘once and for all’ project.
 The condition
• For the disease to be amenable to screening,
there must be a latent stage or ‘window’
during which it would be possible to detect
the disease before it reaches an advanced
stage.
• If detection of cancer at an early stage is
possible, it is crucial that appropriate
intervention at that time has the potential to
alter the course of the disease.
 The screening test
• The screening test must be sufficiently
accurate to detect the condition earlier than in
the absence of screening.
• Accuracy is measured by considering
sensitivity and specificity of the screening test
• Finally, the screening test must be acceptable
to the population and cause minimal
discomfort, or participation in the screening
program will be low.
 Ethical issues in population screening: balance of benefits and
harms

• Participants in screening programs are

ostensibly healthy people, so a program should,
at the very least, be able to demonstrate
evidence of an overall benefit to the community
and a minimum of risk that certain individuals
may be disadvantaged by the program.
• Not only is it important that information on the
effectiveness of screening programs be
available, it should also be disseminated widely
• Regular monitoring and evaluation of
screening programs is also vital to ensure that
effectiveness is maintained and improved
where possible.
 Ethical principles
• Respect for dignity and autonomy.
• Non-maleficence and beneficence. Non-
maleficence means doing no harm to people;
beneficence aims to do good for people.
• Justice and equity. Prudence and precaution.
• Honesty and transparency.
 Potential harms from screening
• It is essential to recognise that an organised population
approach to screening, which ultimately achieves a net
health benefit to a community, can result in adverse
outcomes for some individuals.
• There is a risk that people who receive false negative
results may experience delays in diagnosis and treatment.
• Some may develop a false sense of security and ignore
warning symptoms.
• Increasingly, false negative results can give rise to legal
action by people whose cancers appear to have been
missed.
• A false positive result can mean that people
without the disease undergo follow-up testing
that may be uncomfortable, expensive, and, in
some cases, potentially harmful.
• Rarely, this can lead to unnecessary
treatment.
• There may be psychological consequences
such as anxiety for both the patient and their
family.
 Informed consent
• As screening is initiated by ‘the health system’,
individuals invited to participate must be
informed, prior to any testing, of potential
adverse effects as well as the potential
benefits.
 Economic issues in screening
• Determining the costs of screening involves the
costs of the test and subsequent diagnostic tests
and the costs associated with any hazard of the test
as well as the costs of over-treatment.
balanced against
• reduced costs of therapy for the primary condition,
reduced costs associated with less expenditure on
the treatment of the advanced disease, and the
economic value of the additional years of life
gained.
• Screening policy covers: planning, designing,
implementation, monitoring and evaluating
screening programmes.
 Aims of screening programs
• to reduce mortality by early detection and early
treatment of a condition;
• to reduce the incidence of a condition by identifying
and treating its precursors;
• to reduce the severity of a condition by identifying
people with the condition and offering effective
treatment; and
• to increase choice by identifying conditions or risk
factors at an early stage in a life-course when more
options are available
 Steps in a simplified screening pathway

1.Identify the population eligible for screening

2. Invitation and information
3. Testing
4. Referral of screen positives and reporting of
screen-negative results
5. Diagnosis
6. Intervention, treatment and follow-up
7. Reporting of outcomes
 Deciding whether to start or stop a
screening program
• Map stake holders and engage them in the
process
• Establish a group to lead the process
• Conduct a situational analysis.
 Piloting the screening project
• Once a decision is made in principle that a
screening program is the right intervention,
the program should be tested in practice to
determine whether it will deliver the
anticipated benefits.
• Pilot projects aim to test the feasibility,
resource implications and optimal delivery of
a large-scale screening program.
 Dimensions of screening
• 1. Is the test carried out in isolation or is the test part
of a pathway of care?
• 2. Who is eligible for screening?
• 3. How is the test offered?
• 4. Is the pathway governed by protocols and
guidelines?
• 5. Are there quality standards based on evidence that
are followed by screening providers?
• 6. Is the screening supported by an information
system?
 Operational readiness
• Leadership, coordination and management.
At all levels of the screening process.
• Constructing a pathway from: how they are
identified, invited, screened and referred and
what further investigations and treatment or
intervention they will receive. It should also
describe how individuals are given information
and receive results from their screening.
• Trained personnel
• Information systems
• Funding
• Health system capacity
• Information and communication
Operating a screening programme
• At the outset, every screening program needs to
set the parameters for how it will operate. These
should be based on the best evidence, feasibility
and cost–effectiveness.
• These parameters include: who should be invited;
how often; what information people should be
given to make an informed choice; the threshold
for the test and its sensitivity, specificity and
positive predictive value; and what diagnostic
procedures and treatments should be used.
 Quality assurance systems
Quality assurance systems have various components:
• standards based on the parameters of the
program;
• a system to check that standards are being met;
• guidance and operational policies;
• mechanisms to ensure the quality of the testing;
• failsafe systems; and
• quality improvement initiatives to support services
to improve their quality.
 Improving participation
• Ensure that the target group is screen not only
those that are socioeconomically advantaged
• Focus on increasing uptake and coverage
• Encourage individual invitations rather than
just public invitations
• Others can include reminders by making
phone calls.
 Monitoring and evaluation
• Monitoring and evaluating screening programs
is essential.
Measure performance of screening program
• Measuring using incidence of cancer
• Mortality from cancer
 Challenges to evaluating outcomes of a
screening program
• Poor quality data
• Numbers too small to notice a change
• Detecting many cases when screening starts
• Comparing number of deaths before and after
screening starts
• Measuring survival time from diagnosis