Jump to Volume 1, Issue 1, March 1994
Jump to Volume 1, Issue 2, June 1994
Jump to Volume 1, Issue 3, September 1994

Editorials
What are we screening for?
NJ Wald. J Med Screen 1994 1: 205.

Is screening for ovarian cancer worthwhile?
J Philip. J Med Screen 1994 1: 206-207.

"Opportunistic" screening.
M Law. J Med Screen 1994 1: 208.

Clinical Trials
Feasibility study of a randomised trial of ovarian cancer screening among the general population.
CA Parkes, D Smith, NJ Wald, and TH Bourne. J Med Screen 1994 1: 209-214.
OBJECTIVE: To determine the feasibility of a randomised trial of ovarian cancer screening among women attending a breast cancer screening centre.
DESIGN: Randomised controlled trial of ovarian cancer screening using transvaginal ultrasonography as a primary screening test and colour Doppler imaging as a secondary screening test in the screened group and no intervention in the control group.
SETTING: Reading breast cancer screening centre (United Kingdom).
SUBJECTS: 8678 women, without a bilateral oophorectomy or hysterectomy, aged between 50 and 64 attending for NHS breast cancer screening between September 1989 and February 1993.
MAIN OUTCOME MEASURES: Uptake of ovarian cancer screening among eligible women and the screening false positive rate (considered as the referral rate to a gynaecologist for surgical intervention).
RESULTS: 82% (7124/8678) of eligible women agreed to join the trial and were randomly allocated in equal numbers to each arm of the trial. 3280 women had an initial scan. The false positive rate after ultrasonography alone was 2.9% (86/2952), but this dropped to 0.5% after colour Doppler as a secondary screening test. One stage I primary ovarian cancer was detected at screening in a 58 year old women.
CONCLUSIONS: A randomised trial of ovarian cancer screening using ultrasonography and colour Doppler imaging is feasible and acceptable among women attending a breast cancer screening centre. The results indicate that the expected odds of being affected given a positive result in the general population would be about 1:12. A full randomised trial of ovarian cancer screening with mortality as the end point is needed to assess whether screening reduces mortality from this disease. A multicentre European trial is currently in progress.

Feasibility study of a randomised trial of ovarian cancer screening.
A Tabor, FR Jensen, JE Bock, and CK Hogdall. J Med Screen 1994 1: 215-219.
OBJECTIVES: To assess the feasibility of a randomised trial of ovarian cancer screening by vaginal ultrasonography.
SETTING: A population based study, recruiting a random sample of the female population aged 46 to 65 years living in Copenhagen, Denmark.
DESIGN: Randomised controlled trial allocating 50% to the study group having vaginal ultrasonography, and 50% to the control group having no examination. (a) Acceptability of the study was evaluated by the proportion of eligible women willing to participate in the study. (b) The false positive rate was evaluated as the proportion of women without ovarian cancer referred for an operation because of abnormal ovaries detected by ultrasonography.
RESULTS: 950 (64.3%) of the 1477 eligible women participated in the study. At the first scan abnormal ovaries were detected in 54 of 435 women (12%), significantly more frequently among younger women. Nine women were referred for an operation because of abnormal findings in the ovaries, giving a false positive rate of 2%. Ovarian size and morphology found at operation corresponded with those at ultrasonography; none of them was malignant.
CONCLUSIONS: A randomised controlled trial of ovarian cancer screening using vaginal ultrasonography seems acceptable in the general population. The rate of abnormal ovaries at ultrasonography with the cut offs used in this study was quite high. Such a study is, therefore, feasible, but it is proposed that it is carried out in an older age group (50-64 years) and that the cut offs used for ovarian size and morphology are re-evaluated. Second line tests, such as colour Doppler flow, should be considered in order to reduce the false positive rate.

Tailored written invitations for second round breast cancer screening: a randomised controlled trial.
P Meldrum, D Turnbull, HM Dobson, C Colquhoun, WH Gilmour, and GM McIlwaine. J Med Screen 1994 1: 245-248.
OBJECTIVES: Firstly, to determine if attendance for second round mammography screening in those sent a tailored letter (that is, making reference to their screening history) is increased compared with those sent a standard letter; secondly, to investigate the acceptability of tailored letters.
SETTING: North West Glasgow Breast Screening Centre.
METHODS: A randomised controlled trial.
RESULTS: Overall attendance was unrelated to whether the women were sent a tailored or standard letter; 60% of those sent the standard letter attended (922/1531) compared with 62% of those sent the tailored letter (956/1552) (chi 2 = 0.61, P = 0.4) (difference 2%; 95% confidence interval -2% to 5%). There were no significant differences in percentage attendance within each of the study subgroups: women who attended previously and received an all clear result, women who attended previously and received a false positive result, women who were invited previously and failed to attend, and women who were previously too young to be invited for screening. However, there was a statistically significant difference in percentage attendance between these four groups, independent of letter type (chi 2 = 510, P < 0.00001). Although women found the letters acceptable and understandable, they did not seem to pay close attention to the content.
CONCLUSIONS: Tailoring invitation letters does not have a significant effect on uptake rates for breast screening and does not justify the additional workload required.

Journal Articles
Opportunistic screening for abdominal aortic aneurysm.
ND Derbyshire, DR Lindsell, J Collin, and TS Creasy. J Med Screen 1994 1: 220-222.
OBJECTIVE: To contribute to the current debate on screening for abdominal aortic aneurysm (AAA).
SETTING: Radiology department of the John Radcliffe Hospital, Oxford.
METHODS: The prevalence of AAA in 317 clinically referred male patients aged 65-74 undergoing abdominal ultrasonography with no clinical suspicion of an AAA was investigated over a period of one year.
RESULTS: Over the year 15/317 (5%) patients were found to have an aneurysm (defined as aortic diameter (> or = 30 mm), with eight (3%) patients having an aortic diameter of > or = 40 mm. Six months later appropriate management for the AAA had been started for only four patients. A knowledge assessment questionnaire sent to 245 hospital clinicians and general practitioners showed that 17 (12%) of the 139 respondents would initiate no review of patients found to have an aneurysm of 30-39 mm and two would take no action with aneurysms of 40-49 mm. Thirty two (23%) respondents would seek advice on management for all categories of aneurysm, 14% from the radiologist.
CONCLUSIONS: Opportunistic screening for AAA in men undergoing clinically indicated abdominal ultrasonography is easy, productive, without discernible cost, and discloses a prevalence of AAA comparable with that of population screening programmes. Routine opportunistic measurement of aortic diameter during abdominal ultrasonography in the at risk group would allow 12-15% of men aged 65-74 to be screened for AAA within five years without the need for any additional resources.

Is screening once at age 65 an effective method for detection of abdominal aortic aneurysms?
DE Khoo, H Ashton, and RA Scott. J Med Screen 1994 1: 223-225.
OBJECTIVE: To evaluate whether a single screening at 65 or screening at 65 and 70 are the methods of choice to detect the majority of abdominal aortic aneurysms (AAA) suitable for treatment.
SETTING: District general hospital, district general practice and community.
METHODS: Data were collated from four studies (a pilot, a control trial, and two cohorts) of abdominal ultrasound screening of an invited group of 11 666 men and women aged 65-80 to derive age related prevalence, invitation acceptance rates, and operative mortality. Deaths from AAA rupture were obtained from district registrars' returns.
RESULTS: The prevalence of AAA increased with age being greater overall in men (6.8%) than in women (1.2%). From ages 65 to 80 the prevalence in men increased from 5.4% to 10.4%, and in women from 0.6% to 2.1%. In men and women 4% of patients dying from AAA rupture were aged 65 or under and 85% of deaths occurred over the age of 70. Acceptance rates for screening decreased between 65 and 80 from 80.5% to 66.2% in men and from 72.7% to 58.3% in women. In elective or symptomatic patients operative mortality was zero up to the age of 70, increasing to 7.1% in older patients.
CONCLUSIONS: Men should be screened at age 65 to obtain a high acceptance rate and to identify those with AAA most likely to benefit from treatment. The prevalence is relatively low at this age so an additional screen at age 70 is recommended, which would pick up a further 3.7% of patients with AAA, at which age intervention is likely to be of benefit.

Prevalence of abdominal aortic aneurysm associated with hypertension in an urban population.
GM Grimshaw, JM Thompson, and JD Hamer. J Med Screen 1994 1: 226-228.
SETTING AND METHOD: Since 1989 13,000 invitations to screening for abdominal aortic aneurysm have been offered to men aged 60 to 75 living within the Birmingham conurbation.
RESULTS: The overall attendance was 76.1% (52-99%). The prevalence of aneurysms greater than 29 mm in the whole male population aged 60 to 75 was 7.2%. For those aged 60 to 64 the prevalence was 3.8%. For those aged between 60 and 64 with hypertension, however, the prevalence of abdominal aortic aneurysm was 7.7%. The relative risk of hypertension associated with aneurysm disease is 2.7.
CONCLUSIONS: This paper suggests that all men over 65 should be screened for aortic aneurysm, but that those men over 60 with hypertension should be added to the screened cohort.

Neonatal screening for sickle cell disease in a metropolitan university hospital: efficacy and problems.
SK Ballas, D Park, and RJ Wapner. J Med Screen 1994 1: 229-232.
OBJECTIVE: To determine the effectiveness of a screening programme to identify infants with sickle cell anaemia.
SETTING: A metropolitan university hospital.
METHOD: 4845 (73.3%) newborn cord blood samples from 6271 infants born in the Thomas Jefferson University Hospital over a two year period were tested for the presence of haemoglobinopathies. The patient group comprised approximately 44% white Americans and 51% African Americans. Diagnoses of haemoglobinopathies were established by cellulose acetate (pH 8.6) and citrate agar (pH 6.2) electrophoresis, and thin layer isoelectric focusing.
RESULTS: 17 African American infants were suspected of having sickle cell anaemia and their families were notified and called for retesting to confirm the diagnosis. Fourteen of these families responded; retesting confirmed the diagnosis of sickle cell anaemia in 12 (86%), and the remaining two (14%) had sickle cell trait. The other three families never responded and all efforts to reach them were unsuccessful so the diagnosis could not be confirmed. The infants for whom the diagnosis of sickle cell anaemia was confirmed were treated prophylactically with penicillin and enrolled in sickle cell programmes. Of 398 infants with an abnormal haemoglobin (Hb), 170 (3.5% of all infants tested) showed sickle trait, 63 (1.3%) showed Hb C trait, and 165 samples (3.4%) showed Hb Bart's. Letters of notification were sent to those families whose infants had sickle trait or Hb C trait. Thirty three (16%) families responded and asked for additional information, counselling, or testing of other family members. Three of these families (about 0.1% of all white subjects tested) were white subjects of Italian, English, and Polish ancestry, and all of their infants had sickle trait. Additional testing on other family members showed that one black parent had Hb SC disease that had not previously been diagnosed as the subject was asymptomatic.
CONCLUSIONS: A screening programme for newborns in a metropolitan hospital (a) was effective in identifying and treating infants with sickle cell anaemia with prophylactic penicillin, (b) was associated with difficulties in tracking infants and their families in about 30% of suspected cases of sickle cell disease, (c) found that sickle trait is not uncommon in white subjects, and (d) found that "silent" sickle cell disorders to occur among American black subjects.

Monitoring trends in prenatal diagnosis of Down's syndrome in England and Wales, 1989-92.
JK Morris, DE Mutton, R Ide, E Alberman, and M Bobrow. J Med Screen 1994 1: 233-237.
The national register of chromosomal anomalies that lead to Down's syndrome has enabled the monitoring of change in prenatal diagnosis for this condition, and the factors which affect the change. The proportion of cases of cytogenetically diagnosed Down's syndrome in England and Wales detected prenatally rose to 46% in 1991-2 from 31% in 1988-9, a 1.5-fold increase (95% confidence interval 1.3 to 1.7). The increase was confined to mothers under 40 years and was due to the introduction of screening by maternal serum analysis and ultrasound. Over a quarter of affected pregnancies in women aged 25-29 were detected prenatally in 1991-2 compared with less than 10% in 1988-9. Analysis of the data showed regional differences in prenatal diagnosis rates, and in the length of time elapsing between the diagnostic test and termination of an affected pregnancy. An inexplicable finding was that this period varied with the sex of the fetus, being on average a day longer for females than for males.

Written information needs of women who are recalled for further investigation of breast screening: results of a multicentre study.
J Austoker and G Ong. J Med Screen 1994 1: 238-244.
OBJECTIVE: To assess the written information needs of women who are recalled for further investigation of breast screening.
METHODS: Women from eight breast screening centres in England, Scotland, and Wales who had been recalled for further investigation were invited to complete a structured questionnaire about aspects of recall. Four hundred and eighty four consecutive women were invited to be interviewed immediately before assessment. Two weeks after attendance for assessment 2132 consecutive women (including all women who had been interviewed) were sent a postal questionnaire. No reminder was sent. Subjects from four of the centres received an information leaflet with their recall letter, the remainder did not. Letters/ leaflets used by the centres differed markedly.
RESULTS: The response rate was 95% for the interview questionnaires and 70% for the postal questionnaires. Women who were prepared in advance for a possible recall were less likely to feel distressed/ very distressed when receiving a recall letter. The more aspects of the recall process included in the recall literature, the more women were likely to think that assessment had been explained (89% of women (544/ 609) receiving six or more items of information compared with 73% of women (269/370) receiving four or fewer items (P < 0.0001). Women who received a leaflet with their recall letter were significantly more likely to find some aspect of the information about recall reassuring than women who did not (61% (313/510) v 50% (278/557); P < 0.0001). Distressed/very distressed women were significantly more likely than somewhat/not distressed women to want further information about the reasons for recall (48% (403/834) v 26% (157/598); P < 0.0001 and how to get more information (29% (237/811) v 19% (116/ 616); P < 0.0001).
CONCLUSIONS: Information can increase satisfaction and reduce distress. The amount of information women needed about recall was consistently underestimated. Inclusion of a leaflet improved satisfaction. Sensitive topics, words, and phrases should be carefully expressed.

UK cervical cancer screening programme: setting a research agenda.
C Davies and J Brown. J Med Screen 1994 1: 249-254.
The UK national cervical cancer screening programme aims at reducing the incidence of and mortality from carcinoma of the cervix. It is generally agreed that high grade cervical intraepithelial neoplasia should be treated aggressively, but the appropriate management strategies for women with lesser degrees of abnormality are uncertain because of the inability to distinguish lesions that are likely to progress to invasive disease from those that will regress spontaneously. The role of human papillomavirus (HPV) and the possible usefulness of HPV testing as a secondary screening tool in women with borderline or mild dyskaryosis is also unknown. This paper proposes an agenda for research into the uncertainties within the UK screening programme, suggesting that priority should be given to determining the most appropriate referral and management policies and the use of HPV DNA assay for women with borderline and mild dyskaryosis, so that those women at highest risk of developing invasive disease are treated. A randomised controlled trial is needed. The practical and methodological difficulties which would need to be considered and the need to convene a multidisciplinary research team to develop and implement the trial are highlighted.

Jump to Top