Screening is generally not diagnostic.

It is the application of a test to an

asymptomatic population to determine who is likely to have the disease
and who is not likely to have the disease.

Screening is therefore a two phase process since those who have a
positive screening test must undergo a diagnostic procedure to
determine if they actually have the disease.

Synonymous with secondary prevention.

Earlier therapeutic intervention is possible through screening an
asymptomatic population to identify cancer at an earlier stage than it
would have been diagnosed in the absence of screening.

Expectation is that early diagnosis and treatment lead to a reduction in
mortality from the disease and/or a reduction in the severity of the
disease.

Distinguished from case detection or case finding, which occurs when the
patient presents to a physician with symptomatic disease.


There are circumstances in which screening can contribute to primary
prevention, for example, when colorectal cancer screening leads to the
identification and removal of an adenoma, which subsequently reduces
the incidence of colorectal cancer


Screening for cancer began with the Pap smear, a test developed by
George Papanicolaou who in 1941 published his seminal paper The
diagnostic value of vaginal smears in carcinoma of the uterus in the
American Journal of Obstetrics and Gynecology.

He initially presented his research at the Third Race Betterment
Conference in Battle Creek, Michigan, in 1928, but his colleagues were
sufficiently discouraging of his ideas about detecting cancer through
exfoliative cytology that Papanicolaou abandoned the work for many
years.
He returned to it more than a decade later and eventually established the
correlation between cells scraped from the surface of the cervix and the
detection of cervical carcinoma, which he published in 1941. In 1942, he
published Diagnosis of uterine cancer by the vaginal smear
Cervical cytology followed by biopsy of a positive test is still the principal
method for cervical cancer screening in the world.
Although most cancers have a better prognosis if diagnosed earlier in
their natural history, this basic observation is not in itself sufficient to
justify screening an asymptomatic population for cancer.

A number of criteria should be met before initiating cancer screening,
these having been first outlined by Wilson and Junger in 1968 for the
World Health Organization.
The disease should be an important public health problem in terms of its
frequency and/or severity.

Today some of the cancer sites considered for screening are not
particularly common diseases, but, nevertheless, early detection and
subsequent reduction of mortality can result in a significant benefit in
life-years saved.
The natural history of the disease presents a window of opportunity for
early detection.

For cancer this generally refers to a detectable preclinical phase (DPCP),
and it represents the interface between characteristics of the disease and
the screening technology. It is during this period that screening is
considered optimal to detect the disease early and prior to the
development of symptoms.

For screening to be effective, the recommended screening interval must
be shorter than the estimate of the DPCP.
An effective treatment should be available that favorably alters the
natural history of the disease. Usually for cancer this means a reduction
in cause-specific mortality.

The treatment should be more effective if initiated during the
presymptomatic (or earlier) stage than during the symptomatic (or later)
stage; that is, if treating early (presymptomatic) has no advantage over
treating late (symptomatic) then the cost and the risk of screening
cannot be justified.

A suitable screening test should be available, that is, one that is accurate,
acceptable to the population, fairly easy to administer, safe, and
relatively inexpensive.


The screening guidelines should be based on good scientific evidence
(usually based on results of a RCT) and economically feasible.

Screening program should have the following characteristics:

Should high rates of participation from the eligible population.
Should take into account specific resources available for screening, diagnosis,
and treatment so that countries can focus on optimal recommendations
based on available resources.
Should be sensitive to patient and provider concerns.
Should ensure prompt follow-up of positive tests with a diagnostic
examination and prompt treatment of cases.
Screening programs should be cost-effective.
Screening programs should be monitored and regularly evaluated.

The accuracy or validity of a screening test, that is, its ability to distinguish
between diseased and non-diseased people, is measured by sensitivity and
specificity

Sensitivity
Refers to the ability of the screening test to correctly identify people with the
disease among the screened population.
Defined as the number of people screened with a positive test divided by
those who actually have the disease.
Specificity
Refers to the ability of the test to correctly identify people without the disease
among the screened population
Defined as the number of people with a negative test divided by the number
of people who do not have the disease.
Ideally, sensitivity and specificity would be 100% accurate, but
unfortunately there is no cancer screening test that performs this well.
Some people with a positive screening test will eventually be found not to
have the disease following the diagnostic work-up (false positives)
Some with the disease will be labeled negative by the screening test and thus
are missed cases or false negatives.

Sensitivity and specificity are inversely related, ultimately increasing one
results in a decrease in the other after a certain threshold of accuracy is
reached.
Balancing Sensitivity and Specificity:

For a quantitative test (e.g., a quantitative immunochemical test for colorectal
cancer), the cutoff level to designate a test positive can be adjusted to the
extent that all potential cases can be identified (sensitivity equals 100%).
However, to do so would sacrifice specificity, resulting in a large number of
individuals who would be unnecessarily subjected to a costly and sometimes
risky diagnostic procedure.
Thus, balancing sensitivity and specificity (when possible) is important in
determining the outcome of a screening program.
Diseased Not Diseased Total
Positive
screening test
True positives
(a)
False positives
(b)
Test positives
(a + b)
Negative
screening test
False negatives
(c)
True negatives
(d)
Test negatives
(c + d)
Total Total with
disease (a + c)
Total without
disease (b + d)
Total screened
(a + b + c + d)
Sensitivity = a/(a + c)
Specificity = d/(b + d)
Positive predictive value = a/(a + b)
Negative predictive value = d/(c + d)
Positive predictive value (PPV):
Which is the proportion of individuals with a positive screening test who
actually have the disease.
The PPV can only be computed after the diagnostic examinations of those
who test positive had been completed.
A PPV of 10% means that only one in ten of the test positives truly had the
disease.
The PPV is influenced by three factors: sensitivity and specificity of the test
and the prevalence of disease. Specificity has a bigger effect on PPV since
most people who are screened for cancer do not have the disease. If the
specificity is increased to improve PPV, the sensitivity will likely decrease
(since sensitivity and specificity are inversely related) and the number of false
negatives will increase.


Lead time bias: Diagnosing the disease earlier however having the same
mortality as without screening

Length time bias: Slow growing tumors have the better prognoses than fast
growing tumors, and screening tests more likely to detect these tumors
that are more treatable anyway

Selection bias: If patients with higher risk of disease are more likely to be
screened, screening test results will look worse than they are

Over-diagnosis bias: Test may diagnose abnormalities that would never
cause a problem in a persons lifetime (i.e. prostate cancer)

Avoid bias by using Randomized Control Trials (RCTs)


Breast Cancer poses a serious health risk for women throughout the world.

More than one million women world wide are diagnosed with breast cancer
every year.

It is estimated that 1 in 9 Pakistani women will develop breast cancer at
some stage of their life.

In developed countries there are national cancer registries where every newly
diagnosed cancer patient is registered. This is very helpful to understand the
epidemiology and causative factors of cancer.

In Pakistan we do not have such a registry at national level. Several studies
and reports suggest that among Asian population, Pakistani women have
the highest risk of breast cancer (after non-Arab Israeli women).
With the improving knowledge of molecular pathophysiology of breast
cancer, therapies are coming onto the market, which have given a new
lease of life to these patients.

Since the early 1990s death rates from breast cancer have decreased by
approximately 25% in the USA and Europe.

This has been possible mostly due to screening mammography and
continuously improving treatment strategies utilizing chemotherapy,
hormone therapy and more recently targeted therapy.
Yearly mammograms are recommended starting at age 40 and
continuing for as long as a woman is in good health

Clinical breast exam (CBE) about every 3 years for women in their 20s and
30s and every year for women 40 and over

Women should know how their breasts normally look and feel and report
any breast change promptly to their health care provider. Breast self-
exam (BSE) is an option for women starting in their 20s.

The American Cancer Society recommends that some women -- because
of their family history, a genetic tendency, or certain other factors -- be
screened with MRI in addition to mammograms. (The number of women
who fall into this category is small: less than 2% of all the women

Beginning at age 50, both men and women should follow one of these testing
schedules:
Tests that find polyps and cancer
Flexible sigmoidoscopy every 5 years*, or
Colonoscopy every 10 years, or
Double-contrast barium enema every 5 years*, or
CT colonography (virtual colonoscopy) every 5 years*
Tests that primarily find cancer
Yearly fecal occult blood test (gFOBT)**, or
Yearly fecal immunochemical test (FIT) every year**, or
Stool DNA test (sDNA), interval uncertain**
* If the test is positive, a colonoscopy should be done.
** The multiple stool take-home test should be used. One test done by the doctor in
the office is not adequate for testing. A colonoscopy should be done if the test is
positive.
The tests that are designed to find both early cancer and polyps are preferred
if these tests are available and the individual is willing to have one of these
more invasive tests.
All women should begin cervical cancer screening about 3 years after
they begin having vaginal intercourse, but no later than 21 years old.
Screening should be done every year with the regular Pap test or every 2
years using the newer liquid-based Pap test.

Beginning at age 30, women who have had 3 normal Pap test results in a
row may get screened every 2 to 3 years. Women older than 30 may also
get screened every 3 years with either the conventional or liquid-based
Pap test, plus the human papilloma virus (HPV) test.


Women 70 years of age or older who have had 3 or more normal Pap
tests in a row and no abnormal Pap test results in the last 10 years may
choose to stop having Pap tests.

Women who have had a total hysterectomy (removal of the uterus and
cervix) may also choose to stop having Pap tests, unless the surgery was
done as a treatment for cervical cancer or pre-cancer. Women who have
had a hysterectomy without removal of the cervix should continue to
have Pap tests.

The American Cancer Society recommends that men make an informed
decision with their doctor about whether to be tested for prostate
cancer.

Research has not yet proven that the potential benefits of testing
outweigh the harms of testing and treatment.

Starting at age 50, after the pros and cons of testing have been
explained, individual can decide if testing is the right choice.

If the individual decides to be tested, he should have the PSA blood test
with or without a rectal exam.
Stay away from tobacco.
Stay at a healthy weight.
Get moving with regular physical activity.
Eat healthy with plenty of fruits and vegetables.
Limit how much alcohol you drink (if you drink at all).
Protect your skin.
Know yourself, your family history, and your risks.
Have regular check-ups and cancer screening tests.