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PubMed2005

Diagnostic precision and accuracy in interpretation of specimens from cancer screening programs.

Few areas in modern medicine provide a better example of evidence-based data than the anatomic pathologists' classification of fully developed malignancies. Beginning with the Papanicolaou (Pap) smear, morphologic tools also were applied to specimens obtained in cancer screening programs directed at large, asymptomatic patient populations. The Papanicolaou test was quickly responsible for a reduction in the incidence of invasive squamous cell carcinoma of the cervix, proving the concept that screening could interdict the development of advanced malignancy. Other screening programs followed the Papanicolaou test initiative, producing a revolutionary change in the specimens submitted to pathologists. Cancer screening generates specimens containing morphologic deviations from normal that are thought to put currently healthy patients at risk of future malignancy. However, translating morphologic findings in such samples into risk estimates raises a number of statistical and ethical problems. When diagnostic thresholds are set to favor specificity, unwanted false-negative results accrue. Conversely, aiming at sensitivity over specificity is associated with biologically false-positive results, which are likewise undesirable. Pathologists interpreting these specimens find themselves facing a screening paradox. These screening programs attempt to discover the very earliest changes of neoplastic transformation, but these same earliest changes are inherently the most difficult to identify with precision and accuracy. This paper discusses these challenges.

Data Interpretation, Statistical↗

PubMed1990

Results of a repeat television-advertised mass screening program for colorectal cancer using fecal occult blood tests.

The results of a 1987 television-advertised colorectal screening program using fecal occult blood tests (FOBT) are compared with the initial 1986 program (results in parentheses). In the 1987 program, 73,508 fecal occult blood test (FOBT) kits were distributed free of charge, of which 63% were returned for analysis (57,000, 53%). Twenty-five percent of persons from the initial screening participated again in the 1987 program: 1,303 or 2.8% of persons had a positive screen (1,165, 3.9%). The predictive value of a positive screen was 23% for an adenomatous polyp and 8% for colorectal cancer (22%, 8%). Seventy-nine percent of the cancers detected were Dukes A or B or carcinoma in situ (78%). In order to promote a more thorough diagnostic work-up in positive screenes, a suggested diagnostic algorithm for the work-up of a positive FOBT was sent to participating physicians. Despite this, 35% of positive screenees had a diagnostic work-up limited to a repeat FOBT, and/or sigmoidoscopy only (32%). In conclusion, television-advertised mass screening programs consistently enroll large numbers of participants. The rate of compliance (percent of kits returned) and the limited diagnostic evaluation of persons with a positive screen appear to be the major factors limiting the success of our screening program.

Adenocarcinoma↗

PubMed2003

The Norwegian Breast Cancer Screening Program: re-attendance related to the women's experiences, intentions and previous screening result.

OBJECTIVE: To survey factors of importance for attendance in the Norwegian Breast Cancer Screening Program (NBCSP). METHODS: Simple forced choice questionnaires were sent to 1221 women, in four categories: not attended, screened negative, false positive, and breast cancer cases. The response rate was 80.7%. RESULTS: Women who were invited to the NBCSP reported positive opinions about being invited and the provided information. This response was independent of attendance and screening result. An experience of pain during screening examination was reported in the same proportion among women who were screened negative and false positive (p = 0.27). Unsatisfactory care was reported in a significantly lower rate among women who were screened negative, compared to the false positive (p = 0.02) and breast cancer cases (p < 0.01). Re-attendance was significantly higher among women who were screened negative (91.8%), compared to the false positive (83.9%, p < 0.01). Experienced pain seemed to influence re-attendance among the false positive, while care seemed to influence re-attendance among women who were screened negative. Intention to re-attend was significantly associated with the rate of re-attendance (p < 0.01) and it was the only significant predictor for re-attendance (OR = 5.4, 95% CI: 1.8-16.7) in a multiple logistic regression analysis with intention, age, experienced pain, experienced care and waiting time included in the model. Age did not have much influence on results. CONCLUSION: Women, who were invited to the NBCSP, reported positive opinions about the program. Re-attendance was related to previous screening results, partly by, experienced pain and care.

Aged↗

PubMed2005

Volume of screening mammography and performance in the Quebec population-based Breast Cancer Screening Program.

BACKGROUND: In the Quebec Breast Cancer Screening Program (Programme quebecois de depistage du cancer du sein [PQDCS]), radiologists' and facilities' volumes of screening mammography vary considerably. We examined the relation of screening-mammography volume to rates of breast cancer detection and false-positive readings in the PQDCS. METHODS: The study population included 307,314 asymptomatic women aged 50-69 years screened during 1998-2000. Breast cancer detection rates were analyzed by comparing all women with screening-detected breast cancer (n = 1709) and a 10% random sample of those without (n = 30,560). False-positive rates were analyzed by comparing the 3159 women with false-positive readings and the 27,401 others in the 10% random sample. Characteristics of participants, radiologists and facilities were obtained from the PQDCS information system. Data were analyzed by means of logistic regression. RESULTS: The rate of breast cancer detection appeared to be unrelated to the radiologist's screening-mammography volume but increased with the facility's screening-mammography volume. The breast cancer detection rate ratio for facilities performing 4000 or more screenings per year, compared with those performing fewer than 2000, was 1.28 (95% confidence interval [CI] 1.07-1.52). In contrast, the frequency of false-positive readings was unrelated to the facility's screening volume but was inversely related to the radiologist's screening volume: the rate ratio for readers of 1500 or more screenings per year compared with those reading fewer than 250 was 0.53 (95% CI 0.35-0.79). INTERPRETATION: Radiologists' and facilities' caseloads showed independent and complementary associations with performance of screening mammography in the PQDCS. Radiologists who worked in larger facilities and read more screening mammograms had higher breast cancer detection rates while maintaining lower false-positive rates.

Aged↗

PubMed2002

Dyslipidemia prevalence in a laboratory initiated screening program.

OBJECTIVE: Evaluate utilization and diagnosis rates in a self-pay, self-referred screening program for dyslipidemia. DESIGN: 301 patients self-referred to the clinical laboratory for lipid testing in a two-year period. The patient population that participated was characterized in terms of insurance status, gender, age, and known cardiovascular risk factors. Lipid profiles were characterized as measured by total cholesterol, triglycerides (TGs), low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), and total cholesterol to HDL risk factor. SETTING: Clinical laboratory in an academic medical center. PATIENTS: Data from all patients that self-selected for screening were included. INTERVENTIONS: Immediate laboratory results with both verbal and written interpretations and recommendations were provided to the patients. MAIN OUTCOME MEASURES: Age, gender, insurance status, number of known risk factors, and lipid profiles in the subject group. RESULTS: The mean age of participants was 57 years. Men (197) outnumbered women (104) by almost 2:1; most (94%) had health insurance. At presentation, 44% of the patients had more than one risk factor for coronary heart disease (CHD). 151 individuals (50%) had lipid findings that would require at least dietary intervention by NCEP guidelines. CONCLUSION: A self-pay, self-referred screening program for lipid disorders is an effective means of improving screening and diagnosis rates. Patients with insurance were willing to pay for the convenience offered and men in particular were more likely to self-refer than women, independent of previous knowledge of risk factors or lipid disorders.

Adult↗

PubMed1988

Screening programs for congenital hypothyroidism. How can they be improved?

High-sensitivity neonatal hypothyroid screening tests are used throughout the country. Because of low specificity, primary care physicians are faced with an abundance of false-positive results that challenge the interpreting physician with clinical, economic, and medicolegal considerations. We surveyed 154 physicians caring for Wisconsin-born infants with the highest newborn-screen thyrotropin values in a two-year period. Our results indicated that (1) confirmation of thyroid normalcy is often delayed beyond 6 weeks of age; (2) there is wide variation among physicians regarding therapeutic goals if hypothyroidism is confirmed; and (3) physicians prefer autonomy in the management of congenital hypothyroidism. Modifications in hypothyroid screening programs may include confirmatory tests by a central laboratory (that distributes filter paper with all abnormal results), provision of a management decision tree for primary care physicians, and a one-time subsidy for a visit to a pediatric endocrinologist. We suggest that these modifications may improve the long-term outcome of hypothyroid infants identified by the screening program.

Attitude of Health Personnel↗

PubMed2005

[Bavarian mammography screening program].

In Bavaria since the 1st April 2003 we have been conducting a high quality mammography-screening carried out in individual practises (BMS). We have used the European and the S 3 guidelines. The best diagnosis is an early diagnosis of the breast carcinoma to save human life. Because of this and the high mortality rate due to this disease it is essential to have a mammogram screening program. There is no single one ideal way of constructing a screening program, it is always based on compromise within the particular health care-systems. Arising problems cannot be avoided, it is only possible when all parties work closely together that the BMS works properly.

Breast Neoplasms↗

PubMedDate not supplied

[Neonatal cystic fibrosis screening program in the state of Paraná: evaluation 30 months after implementation].

OBJECTIVES: To present and analyze the results of the National Neonatal Cystic Fibrosis Screening Program in Paraná, 30 months after its implementation. METHODS: This is a descriptive study, with an analysis of the data from the screening of around 98% of all neonates in the period from September 2001 to April 2004, undertaken at the Neonatal Screening Program laboratory of the Fundação Ecumênica de Proteção ao Excepcional do Paraná. Blood samples for the Guthrie test were collected on hospital discharge, ideally between the second and sixth days postpartum, and filter papers were sent for immunoreactive trypsin assay by the immunofluorometric method. Children whose immunoreactive trypsin assay results were > or = 70 ng/ml for two distinct samples during the first 30 days of life, were referred for sweat conductivity testing by the Wescor method. In cases when the result was greater than 50 mMol/l quantitative chlorine and/or sodium in sweat was assayed (iontophoresis with pilocarpine). RESULTS: From a total of 456,982 tests, 4,028 (0.9%) children presented a first immunoreactive trypsin assay above the cutoff point set. Four hundred and seventy-eight of these (12.5%) also had a second blood sample assayed with immunoreactive trypsin above 70 ng/ml and 56 (11.7%) of these were referred to specialized clinics after their sweat conductivity test results were above 50 mMol/l and 48 (0.01% of the total number of children screened) had a diagnosis of cystic fibrosis confirmed. The incidence for the state of Paraná was 1:9,520, although some children have not yet been fully investigated. CONCLUSIONS: Neonatal screening for cystic fibrosis in the State of Paraná, in accordance with Health Ministry directives, was a pioneering initiative for Brazil. Many patients were diagnosed early, even asymptomatic ones, which is a challenge to improving prognosis with this fatal disease.

Biomarkers↗

PubMed2005

Use of risk projection models to estimate mortality and incidence from radiation-induced breast cancer in screening programs.

The authors report on a method to calculate radiological risks, applicable to breast screening programs and other controlled medical exposures to ionizing radiation. In particular, it has been applied to make a risk assessment in the Valencian Breast Cancer Early Detection Program (VBCEDP) in Spain. This method is based on a parametric approach, through Markov processes, of hazard functions for radio-induced breast cancer incidence and mortality, with mean glandular breast dose, attained age and age-at-exposure as covariates. Excess relative risk functions of breast cancer mortality have been obtained from two different case-control studies exposed to ionizing radiation, with different follow-up time: the Canadian Fluoroscopy Cohort Study (1950--1987) and the Life Span Study (1950--1985 and 1950--1990), whereas relative risk functions for incidence have been obtained from the Life Span Study (1958--1993), the Massachusetts tuberculosis cohorts (1926--1985 and 1970--1985), the New York post-partum mastitis patients (1930--1981) and the Swedish benign breast disease cohort (1958--1987). Relative risks from these cohorts have been transported to the target population undergoing screening in the Valencian Community, a region in Spain with about four and a half million inhabitants. The SCREENRISK software has been developed to estimate radiological detriments in breast screening. Some hypotheses corresponding to different screening conditions have been considered in order to estimate the total risk associated with a woman who takes part in all screening rounds. In the case of the VBCEDP, the total radio-induced risk probability for fatal breast cancer is in a range between [5 x 10(-6), 6 x 10(-4)] versus the natural rate of dying from breast cancer in the Valencian Community which is 9.2 x 10(-3). The results show that these indicators could be included in quality control tests and could be adequate for making comparisons between several screening programs.

Adult↗

PubMed1984

Results and benefits of a maternal serum alpha-fetoprotein screening program.

Maternal serum alpha-fetoprotein (MSAFP) screening was offered in a private suburban practice to 21,000 nondiabetic and 442 diabetic women with apparently normal pregnancies. Using 2.5 or greater multiples of the median as the normal upper limit, 249 (1.2%) had a raised MSAFP level. There were 25 neural tube defects (NTDs) (1.2/1,000 births); 18 were detected by screening and two by ultrasound scanning. Three had closed spina bifida lesions. Two had anencephaly with normal MSAFP levels, but were studied at more than 24 weeks' gestation. An additional 13 with raised MSAFP levels had other congenital defects. One in 400 women screened had a recommended amniocentesis; 26.4% of them had a fetus with an NTD or major malformation. Our detection efficiency before 24 weeks' gestation for anencephaly was 85.7% (12/14), 62.5% (5/8) for open and closed spina bifida, and 1/1 for encephalocele. A raised MSAFP level occurred in ten (2.3%) of the 442 diabetic women, four (0.9%) of whom had a fetus with an open NTS. A screening program should be established only where there is linked excellent interdisciplinary support among obstetrician, laboratory, clinical geneticist, ultrasonographer, and an identified program coordinator.

Congenital Abnormalities↗

PubMed2005

[Participation rate and related socio-demographic factors in the national cancer screening program].

BACKGROUND: Cancer is the leading cause of death and one of the largest burdens of disease in Korea. In 1996, the 'Ten year Plan for Cancer Control' was formulated and the government then adopted the plan as a national policy. As part of this plan, the National Cancer Screening Program (NCSP) for Medicaid recipients was formulated, and the government adapted this in 1999. For low-income beneficiaries of the National Health Insurance Corporation (NHIC), the screening program has been in place since 2002. In 2002, the target cancers of NCSP were stomach, breast and cervical cancer. This study was conducted to examine the relationships between the participation rate, the abnormal screening rate and the socio-demographic factors associated with participation in the screening program. METHODS: To analyze the participation rate and abnormal rate for the NCSP, we used the 2002 NCSP records. The information on the socio-demographic factors was available from the database of the beneficiaries in the NHIC and Medicaid. RESULTS: The participation rate of the Medicaid beneficiaries for the stomach, breast and cervical cancer screening were 9.2%, 15.5% and 15.0%, respectively, and 11.3% and 12.5%, except cervical cancer which wasn't be included in the NCSP, for the beneficiaries of the NHIC. The abnormal rate of stomach, breast and cervical cancer screening were 25.7%, 11.2% and 21.0%, respectively, for the beneficiaries of Medicaid and 42.6% and 19.4% for the beneficiaries of the NHIC. On the multiple logistic regression analysis, gender, age and place of residence were significantly associated with participation rates of the NCSP. For stomach cancer, women participated in the NCSP more than men. The participation rate was higher among people in their fifties and sixties than for those people in their forties and those people over seventy years in age. For the breast and cervical cancer, people in their fifties were more likely to participate in the NCSP than people in their forties and people over sixty. For the place of residence, people in the rural areas participated more than those people in any other places. CONCLUSIONS: The above results show that the participation rate and abnormal rate were significantly associated with the socio-demographic factors. To improve the participation rate for the NCSP, more attention should be given to the underserved groups.

Adult↗

PubMed2006

Organized breast screening programs in Canada: effect of radiologist reading volumes on outcomes.

PURPOSE: To examine retrospectively the relationship between radiologist screening program reading volumes and interpretation results. MATERIALS AND METHODS: This research project was reviewed by the University of British Columbia Research Ethics Board. Informed patient consent was not required. Data were requested from Canadian provincial screening programs for the period 1988-2000. Cancer detection rates, abnormal interpretation rates, and positive predictive values (PPVs) were calculated for individual radiologists in those programs. Multivariate Poisson mixed regression models were used to examine the effect of patient age, screening examination sequence (first or subsequent screening examination), province, radiologist reading volume, and interradiologist differences on cancer detection rate, abnormal interpretation rate, and PPV. RESULTS: The results of the interpretation of 1406678 screening mammograms by 304 radiologists from seven provincial programs were analyzed. Cancer detection rate, abnormal interpretation rate, and PPV all varied according to age of woman screened and screening sequence and across the sample of radiologists. None of the rates varied by province. Neither the cancer detection rate nor the abnormal interpretation rate varied by reading volume, but the average PPV was increased by 34% for volumes over 2000 mammograms versus volumes of 480-699 mammograms per year. There was no evidence that the magnitude of variability around the average, for radiologists reading the same volume of mammograms, varied across different volume groups for any of the outcome measures. CONCLUSION: Cancer detection did not vary with reading volume. The average PPV for individual radiologists increased as reading volume rose up to 2000 mammograms per year; it stabilized at higher volumes.

Adult↗

PubMed2004

[Mass screening programs running in Podlaski region based on standards existing in European Union-- actual status and future perspectives].

High mortality rates caused by breast cancer and cervical cancer are still an actual and enormous problem in our country. Such unfavorable epidemiological situation lasts for many years, in spite of availability of diagnostic procedures, which permits secondary prevention of these diseases. Successes of mass screening programs conducted in several European Countries are the best proof for this statement. For the last years the number of mammography and cytology tests systematically have been been going up in our country, unfortunately without any effects on women's mortality rates. The question arises: what is the reason for that situation and if could it be useful to adopt European experiences into the Polish conditions? This could be done by appropriate staff training and increase of effectiveness of diagnostic and therapeutic procedures. One more core element of mass screening programs is logistic background--coordinating center ensuring good functioning of the screening program.

Breast Neoplasms↗

PubMedDate not supplied

Eight-year prospective targeted ultrasound screening program for instability and at-risk hip joints in developmental dysplasia of the hip.

The use of targeted ultrasound screening for at-risk hips to reduce the rate of surgery in developmental dysplasia of the hip is unproven. A prospective trial was undertaken in an attempt to clarify this matter. This study was undertaken between May 1992 and April 2000. There were 28,676 live births. Unstable and at-risk hips were routinely targeted for ultrasound examination. One thousand eight hundred six infants underwent ultrasound examination (6.3% of the birth population). Twenty-five children (18 with dislocations, 7 with dysplasia) required surgical intervention in the form of open reduction of the hip or pelvic or femoral osteotomy (0.87 per 1,000 births for dysplasia, 0.63 per 1,000 births for dislocation). Targeted ultrasound screening does not reduce the overall rate of surgery compared with the best conventional clinical screening programs. The development of a national targeted ultrasound screening program for at-risk hips cannot be justified on a cost or result basis.

Breech Presentation↗

PubMed1985

The use of lay readers of chest roentgenograms in industrial screening programs.

A study was conducted to test the feasibility of training lay persons to screen chest x-ray films for professional readers in an industrial screening program and to use the International Labor Office classification of the pneumoconioses for silicosis. With minimal training the lay readers agreed with the professional readers on the presence or absence of silicosis in 72.6% of the films and missed only 3.2% of the silicosis identified by the professional readers. The lay readers were able to identify only 17.1% of the pathology other than silicosis; however, it appeared that they identified some of these conditions as silicosis. Considering this, the lay readers missed only 27.0% of the other pathologies. It was concluded that, with more extensive training, lay persons could be taught to screen chest X-ray films for professional readers in an industrial screening program.

Allied Health Personnel↗

PubMed2005

Evaluation of automated lung nodule detection on low-dose computed tomography scans from a lung cancer screening program(1).

RATIONALE AND OBJECTIVES: The purpose of this study was to evaluate the performance of a fully automated lung nodule detection method in a large database of low-dose computed tomography (CT) scans from a lung cancer screening program. Because nodules demonstrate a spectrum of radiologic appearances, the performance of the automated method was evaluated on the basis of nodule malignancy status, size, subtlety, and radiographic opacity. MATERIALS AND METHODS: A database of 393 thick-section (10 mm) low-dose CT scans was collected. Automated lung nodule detection proceeds in two phases: gray-level thresholding for the initial identification of nodule candidates, followed by the application of a rule-based classifier and linear discriminant analysis to distinguish between candidates that correspond to actual lung nodules and candidates that correspond to non-nodules. Free-response receiver operating characteristic analysis was used to evaluate the performance of the method based on a jackknife training/testing approach. RESULTS: An overall nodule detection sensitivity of 70% (330 of 470) was attained with an average of 1.6 false-positive detections per section. At the same false-positive rate, 83% (57 of 69) of the malignant lung nodules in the database were detected. When the method was trained specifically for malignant nodules, a sensitivity of 80% (55 of 69) was attained with 0.85 false-positives per section. CONCLUSION: We have evaluated an automated lung nodule detection method with a large number of low-dose CT scans from a lung cancer screening program. An overall sensitivity of 80% for malignant nodules was achieved with 0.85 false-positive detections per section. Such a computerized lung nodule detection method is expected to become an important part of CT-based lung cancer screening programs.

Adult↗

PubMed2005

Screening program for prostate cancer at a university hospital in eastern Saudi Arabia.

OBJECTIVE: Implementation of a pilot screening program for prostate cancer among Saudi patients that would serve as a nucleus for a Kingdom-wide screening program. METHODS: A prospective study on 1,213 Saudi males between 50-80 years of age who attended the Outpatient Department at King Fahd Hospital of King Faisal University, Al-Khobar, Kingdom of Saudi Arabia during a period of 18 months (April 2001-October 2002). They were included at random from different clinics including the urology clinic. Free and total prostate specific antigen (PSA), and digital rectal examination (DRE) of the prostate were performed in all patients. Patients with abnormal DRE or PSA were scheduled for transrectal ultrasound (TRUS) and ultrasound guided biopsy of the prostate. RESULTS: Abnormal DRE or PSA were present in 84 out of 1,213 patients. Only 63 patients agreed to have TRUS and ultrasound guided biopsies. Prostate cancer was confirmed in 14 out of 1,192 patients who completed the study (1.17%). CONCLUSION: The incidence of prostate cancer among Saudi men in this hospital based study is low. A population based screening for prostate cancer may reveal the incidence of this disease.

Aged↗

PubMed1989

Results of a television-advertised public screening program for colorectal cancer.

We report the results of a free, television-advertised mass screening program for colorectal cancer using stool guaiac kits. A total of 57,000 test kits were picked up and 29,619 (53%) were returned; 3.9% (1165) of the tests were positive. Ninety-three percent of persons with a positive screen sought medical evaluation after screening. Detailed follow-up was available on 744 persons. Fifty-eight persons had large-bowel carcinomas diagnosed, 80% of which were localized. One hundred sixty persons had adenomatous polyps removed. Forty percent of cancers and 58% of polyps were detected in persons with only one or two positive test slides out of a total of six. In 33% of persons with a positive screen, the diagnostic workup consisted of a repeated stool guaiac test and/or sigmoidoscopy only. A major drawback to improving the results of mass screening programs for colorectal cancer is the limited gastrointestinal workup conducted by physicians in many persons with a positive fecal occult blood test.

Adult↗