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Editorial
Breast screening in Britain.
L Tabar. J Med Screen 1995 2: 179.

Journal Articles
Monitoring interval cancers in breast screening programmes: the east Anglian experience. Quality Assurance Management Group of the East Anglian Breast Screening Programme.
N Day, J McCann, C Camilleri-Ferrante, P Britton, G Hurst, S Cush, and S Duffy. J Med Screen 1995 2: 180-185.
Interval cancer rates are a major determinant of the success of a screening programme. In the Swedish two county study, on which the United Kingdom programme is based, a 39% reduction in mortality was observed in screened women aged 50-64. Using data from the Swedish study, the relationship between interval cancer incidence and the likely future effect on breast cancer mortality was quantified. In East Anglia, as elsewhere in the United Kingdom, interval cancers rates are nearly double those obtained in Sweden: interval cancer rates in the first, second, and third years respectively, after a negative screen were 24%, 59%, and 79% of the expected underlying incidence in the absence of screening. The corresponding figures from the two county study were 17%, 30%, and 56%. From these it was estimated that the mortality reduction in East Anglia will be 21%, which is lower than the 35% observed in invited women in this age group in the Swedish two county study and the 25% specified in the Health of the Nation target. In a rereading exercise, using screening mammograms from women who were screen normal, who had screen detected cancers, or who subsequently developed interval cancers, four out of five radiologists recommended recall for around 70% of the original mammograms (classed as screen normal at time of screening) from 33 interval cancers. This suggests that sensitivity is a contributory factor to the higher interval cancer rates in East Anglia.

Results from the NHS breast screening programme 1990-1993.
SM Moss, M Michel, J Patnick, L Johns, R Blanks, and J Chamberlain. J Med Screen 1995 2: 186-190.
OBJECTIVE: To present results from the NHS breast screening programme (NHSBSP) for the three year period 1990 to 1993, and to examine the extent to which interim targets are being met.
METHODS: Data have been collated from all screening programmes in the United Kingdom on standard "Korner" returns, supplemented for the year 1991/92 by data from the radiology quality assurance programme. Most of the data refer to the prevalent screening round, but some data on rescreening are also available.
RESULTS: The total cancer detection rate at prevalent screens was 6.0/1000, 18% being in situ cancers; the detection rate of invasive cancers < or = 10 mm in diameter was 1.3/1000, but data on size were missing for 12% of cancers. Referral rates were significantly lower for programmes using two view mammography at the prevalent screen than for those using single view, and cancer detection rates were significantly higher. For prevalent screens over the three year period, 70% of programmes had a referral rate of < or = 7%, 87% had a benign biopsy rate of < or = 5/1000, and 79% had a cancer detection rate of > or = 5/1000. By contrast, only 30% of programmes appeared to meet the target detection rate of > 1.5/1000 for invasive cancers < or = 10 mm in diameter.
CONCLUSIONS: While the majority of interim targets are being met by the NHSBSP, the rate of detection of small invasive cancers requires careful monitoring. Collection of more accurate data on size of cancers and interval cancer rates will give a better indication of progress towards the target mortality reduction.

Measurement of the costs in two mammographic screening programmes in the province of Florence, Italy.
M Zappa, G Spagnolo, S Ciatto, D Giorgi, E Paci, and M Rosseli del Turco. J Med Screen 1995 2: 191-194.
OBJECTIVES: To estimate and to compare the cost per woman examined and per breast cancer detected in two mammographic screening programmes in the province of Florence.
SETTING: Two ongoing, population based, mammographic screening programmes in the province of Florence. The first (district project) was started in the seventies in a rural area, whereas the second (city project) was started in the city at the end of 1990.
METHODS: All relevant resources consumed by the programmes (costs) were listed and measured. The costs are related to 1993. The unit cost for each phase (recruitment, screening, assessment) of the screening process was estimated by dividing the total cost of the phase by the number of women examined. The cost per cancer detected was obtained by dividing the total cost of the programme by the number of cancers detected at screening.
RESULTS: The costs per woman examined were $38.1 and $41.1 in the district and city programmes respectively. The cost per breast cancer detected was $7424 in the district programme and $5180 in the city programme. Staff accounted for more than 50% of the total cost. The unit cost in the screening phase was higher in the district programme, whereas it was lower in the assessment phase.
CONCLUSIONS: Our results are consistent with, although slightly lower than, published estimates of the cost per woman screened. Important parameters for determining the efficiency of a mammographic screening programme are the compliance rate and the recall rate.

Compliance after 17 years of breast cancer screening.
W Scaf-Klomp, FL van Sonderen, R Stewart, JA van Dijck, and WJ van den Heuvel. J Med Screen 1995 2: 195-199.
OBJECTIVE: To investigate changes in attendance over the course of a population based breast screening programme.
DESIGN: Longitudinal; analysis of registered data over nine screening rounds.
SETTING: Subjects belong to the screening population of the Nijmegen experimental breast screening programme (1975-1990).
SUBJECTS: A cohort of 6898 women who were enrolled in 1975 at the age of 50-69 years and who were invited to nine subsequent screening rounds, irrespective of their attendance at previous rounds.
RESULTS: Attendance of women aged 50-53 years at entry was high at the initial screening (88%), decreased in the course of the programme, but remained well over 60% until round 8; 39% completed nine rounds and 24% completed seven to eight rounds. Attendance of women who were older at entry was somewhat lower at the initial screening (87%-82%) and declined more strongly. Regular compliance was also lower. Specific compliance patterns are found that can be relevant for further research.
CONCLUSIONS: A substantial proportion of eligible women can be committed to mammography every two years, possibly even after reaching the age of 70, if the age at entry is around 50 and the screening programme is well established in the community. Starting a screening programme in older women seems ineffective.

Evaluating the national screening programme for congenital dislocation of the hip.
C Dezateux and S Godward. J Med Screen 1995 2: 200-202.
In 1969 universal clinical screening for neonatal hip instability was formally adopted in the United Kingdom with the aim of detecting and treating children considered to be at high risk of congenital dislocation of the hip (CDH). However, clinical screening is associated with both false positive and false negative diagnoses and has never been evaluated in a randomised trial. The emergence of hip ultrasound provides renewed impetus to reconsider and formally evaluate screening for CDH. Ultrasound imaging of the newborn hip may be used as a screening test and to assess and manage infants with clinically detected hip instability. Universal primary ultrasound screening has been adopted in some European countries, but enthusiasm for this new technology has been tempered by the subsequent large increases in treatment and follow up. This paper reviews the existing evidence to support the different approaches to screening and describes the research agenda of the MRC working party on congenital dislocation of the hip. A randomised trial of screening is required to evaluate the policy options before ultrasound screening becomes widely adopted within the United Kingdom. The feasibility and acceptability of a trial need to be explored and key issues relating to trial design addressed.

Screening for Down's syndrome: the first two years experience in Bristol.
DJ Goldie, JP Astley, JM Beaman, DA Bickley, A Gunneberg, and SR Jones. J Med Screen 1995 2: 207-210.
OBJECTIVES: To evaluate the effectiveness of a programme for antenatal screening for Down's syndrome using alpha fetoprotein and total human chorionic gonadotrophin as maternal serum markers.
SETTING: A district general hospital providing a screening service to a local purchasing authority and (under contract) to another purchasing authority in the same region.
METHODS: Patients were counselled and screened between 15 and 20 weeks gestation and Down's risk estimates calculated using the maternal serum marker results as modifiers of the age related risk. Outcome was determined in collaboration with the Regional Cytogenetics Unit.
OUTCOME MEASURES: Detection rate for Down's syndrome, false positive rate, uptake of screening, and uptake of amniocentesis.
RESULTS: In two years 22816 women were screened (approximately 84% of population); 32 Down's pregnancies were identified, 19 (59.4%) had a reported risk of > or = 1:250 and 20 (62.5%) a reported risk of > or = 1:300. Of those screened before 17 weeks, 16/20 (80%) had a reported risk of > or = 1: 300 compared with 4/12 (33%) of those screened later (P = 0.008); 4.64% of patients screened had reported risks > or = 1: 250 and 5.87% reported risks of > or = 1:300. Amniocentesis uptake was 70% in patients with reported risks of > or = 1:300.
CONCLUSIONS: Overall the screening programme was effective but screening before 17 weeks was very much more effective than screening later.

Problems in assessing screening experience in observational studies of screening efficacy: example of urinalysis screening for bladder cancer.
GD Friedman, RA Hiatt, CP Quesenberry, Jr, JV Selby, and NS Weiss. J Med Screen 1995 2: 219-223.
OBJECTIVE: To evaluate screening urinalysis for its efficacy in preventing fatal bladder cancer.
METHODS: A case-control study of 290 case subjects with fatal bladder cancer upsilon 290 age and sex matched control subjects, with ascertainment of urinalyses by medical record review.
RESULTS: In the five years before the symptoms that led to the detection of bladder cancer, case subjects had significantly fewer routine (screening) urinalyses than controls (matched odds ratio for one or more urinalyses upsilon none = 0.60 [95% confidence interval (CI) 0.41 to 0.87], adjusted for cigarette smoking and occupational bladder cancer risk). However urinalyses for urinary symptoms and problems before those that led to bladder cancer diagnosis were more frequent in the cases; hence there was only a small statistically non-significant deficit in cases of urinalyses for all reasons combined (corresponding adjusted odds ratio 0.94, 95% CI 0.61 to 1.46). Since urinalyses for symptoms and problems could have led to the detection of bladder cancer, the latter finding appears more applicable. Methodological problems included: difficulty in assigning the reason for urinalysis; the possibility that clinically indicated urinalyses led to a reduction in screening urinalyses; and difficulty in identifying the detectable and curable preclinical phase for targeting ascertainment of urinalyses. Reducing potential efficacy, haematuria on urinalysis, particularly transient or mild asymptomatic microhaematuria, was often not followed up by cystoscopy.
CONCLUSIONS: This study did not show that ordinary urinalysis was effective in preventing fatal bladder cancer but because of methodological problems a clear answer may require a randomised controlled trial.

Public understanding of medical screening.
J Cockburn, S Redman, D Hill, and E Henry. J Med Screen 1995 2: 224-227.
AIM: To estimate the extent of public understanding of mass screening for disease and of the benefits and limitations of screening.
METHODS: Telephone interviews were conducted with a national sample of 835 Australians.
RESULTS: Of total respondents, 68% claimed to have heard of screening tests, but only 21% correctly understood that screening tests are for asymptomatic people. This understanding was related to education. The most frequently named tests were mammography (51%) and Pap tests (33%), and for all age groups these were mentioned by more women than men. Around 27% of respondents thought that the Pap test would detect 95% or more of case, 45% thought the test would detect 90% or more, while 60% of respondents thought the test would detect 80% or more of cases. Around 29% of respondents thought that mammography would detect 95% or more of cases, 49% thought the test would detect 90% or more, while 65% of respondents thought the test would detect 80% or more of cases. Of all respondents, 33% favoured compensation when cases were "missed" by screening provided people were warned beforehand, 58% were not in favour, and 9% were unsure.
CONCLUSIONS: There are misconceptions among the public concerning the purpose of screening and the accuracy of screening tests. However, most people accept that some cases of disease will be missed by screening and that if people are adequately informed beforehand compensation should not automatically follow for those whose disease is missed.

Detection of pregnancies with trisomy 18 in screening programmes for Down's syndrome.
AK Hackshaw, A Kennard, and NJ Wald. J Med Screen 1995 2: 228-229.

Clinical Trial
A randomised controlled trial of strategies to prompt attendance for a Pap smear.
J Bowman, R Sanson-Fisher, C Boyle, S Pope, and S Redman. J Med Screen 1995 2: 211-218.
OBJECTIVE: To assess the comparative efficacy, by randomised controlled trial, of three interventions designed to encourage "at risk" women to have a Pap smear: an educational pamphlet; letters inviting attendance at a women's health clinic; and letters from physicians.
METHODS: Subjects at risk for cervical cancer who had not been adequately screened were identified by a random community survey and randomly allocated to one of the intervention groups or a control group. Six months after intervention implementation, a follow up survey assessed subsequent screening attendance. Self report was validated by comparison with a national screening data base.
RESULTS: A significantly greater proportion of women (36.9%) within the group receiving a physician letter reported screening at follow up than in any other group (P = 0.012). The variables most strongly predicting screening attendance were: age, perceived frequency of screening required, use of oral contraceptives, and allocation to receive the physician letter intervention. CONCLUSIONS: The relative efficacy of the GP letter in prompting screening attendance shows that this strategy is worthy of further investigation. There remains a need to examine the barriers to screening for older women, and to develop tailored strategies for this population.

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