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PubMed2005

Cost-effectiveness of computerized tomographic colonography versus colonoscopy for colorectal cancer screening.

BACKGROUND: Computerized tomographic (CT) colonography is a potential alternative to colonoscopy for colorectal cancer screening. Its main advantage, a better safety profile, may be offset by its limitations: lower sensitivity, need for colonoscopy in cases where results are positive, and expense. METHODS: We performed an economic evaluation, using decision analysis, to compare CT colonography with colonoscopy for colorectal cancer screening in patients over 50 years of age. Three-year outcomes included number of colonoscopies, perforations and adenomas removed; deaths from perforation and from colorectal cancer from missed adenomas; and direct health care costs. The expected prevalence of adenomas, test performance characteristics of CT colonography and colonoscopy, and probability of colonoscopy complications and cancer from missed adenomas were derived from the literature. Costs were determined in detail locally. RESULTS: Using the base-case assumptions, a strategy of CT colonography for colorectal cancer screening would cost 2.27 million dollars extra per 100,000 patients screened; 3.78 perforation-related deaths would be avoided, but 4.11 extra deaths would occur from missed adenomas. Because screening with CT colonography would cost more and result in more deaths overall compared with colonoscopy, the latter remained the dominant strategy. Our results were sensitive to CT colonography's test performance characteristics, the malignant risk of missed adenomas, the risk of perforation and related death, the procedural costs and differences in screening adherence. INTERPRETATION: At present, CT colonography cannot be recommended as a primary means of population-based colorectal cancer screening in Canada.

Aged↗

PubMed2002

Breast cancer screening. First Nations communities in New Brunswick.

OBJECTIVE: To determine use of breast cancer screening and barriers to screening among women in First Nations communities (FNCs). DESIGN: Structured, administered survey. SETTING: Five FNCs in New Brunswick. PARTICIPANTS: One hundred thirty-three (96%) of 138 eligible women between the ages of 50 and 69 years. INTERVENTIONS: After project objectives, methods, and expected outcomes were discussed with community health representatives, we administered a 32-item questionnaire on many aspects of breast cancer screening. MAIN OUTCOME MEASURES: Rate of use of mammography and other breast cancer screening methods, and barriers to screening. RESULTS: Some 65% of participants had had mammography screening within the previous 2 years. Having mammography at recommended intervals and clinical breast examinations (CBEs) yearly were significantly associated with having had a physician recommend the procedures (P < .001). A family history of breast cancer increased the odds of having a mammogram 2.6-fold (P < .05, 95% confidence interval [CI] 1.03 to 6.54). Rates of screening differed sharply by whether a family physician was physically practising in the community or not (P < .05, odds ratio 2.68, 95% CI 1.14 to 6.29). CONCLUSION: Women in FNCs in one health region in New Brunswick have mammography with the same frequency as off-reserve women. A family physician practising part time in the FNCs was instrumental in encouraging women to participate in breast cancer screening.

Aged↗

PubMed2004

Mammography screening in the Netherlands: delay in the diagnosis of breast cancer after breast cancer screening.

In a prospective study we determined the frequency and causes of delay in the diagnosis of breast cancer after suspicious screening mammography. We included all women aged 50-75 years who underwent biennial screening mammography in the southern breast cancer screening region of the Netherlands between 1 January 1996 and 1 January 2002. Clinical data, breast imaging reports, biopsy results and breast surgery reports were collected of all women with a positive screening result with a minimum of 2-year follow-up. Of 153 969 mammographic screening examinations, 1615 (1.05%) were positive screens. Breast cancer was diagnosed in 770 (47.9%) of 1607 women for whom follow-up information was available, yielding a cancer detection rate of 5.0 per 1000 women screened. Breast cancer was diagnosed within 3 months following a positive screen in 722 cases (93.8%). The diagnostic delay was 4-6, 7-12 and 13-24 months, respectively, in 11 (1.4%), 24 (3.1%) and nine (1.2%) patients. In four other patients (0.5%), breast cancer was diagnosed after a repeat positive screen, resulting in a diagnostic delay of 25-27 months. Reasons for a diagnostic delay >3 months were erroneous mammographic interpretation of suspicious lesions as benign or probably benign lesions (33 cases), benign biopsies from a malignant lesion (10), and omission to biopsy or remove a lesion that was suspicious at breast imaging (4) or core biopsy (1). We conclude that there is room for improvement in the workup of patients with a positive screening mammography, as seen from data in this screening region. To improve the workup, we suggest that other breast cancer screening programmes also identify delay in breast cancer diagnosis after a positive screen.

Aged↗

PubMed2001

Cost-effectiveness of colorectal cancer screening.

PURPOSE: To determine the most cost-effective colorectal cancer screening strategy costing less than $100,000 per life-year saved and to determine how available strategies compare with each other. MATERIALS AND METHODS: Standardized methods were used to calculate incremental cost-effectiveness ratios (ICERs) from published estimates of cost and effectiveness of colorectal cancer screening strategies, and the direction and magnitude of any effect on the ratio from parameter estimate adjustments based on literature values were estimated. RESULTS: Strategies in which double-contrast barium enema examination was performed emerged as optimal from all studies included. In average-risk individuals, screening with double-contrast barium enema examination every 3 years, or every 5 years with annual fecal occult blood testing, had an ICER of less than $55,600 per life-year saved. However, double-contrast barium enema examination screening every 3 years plus annual fecal occult blood testing had an ICER of more than $100,000 per life-year saved. Colonoscopic screening had an ICER of more than $100,000 per life-year saved, was dominated by other screening strategies, and offered less benefit than did double-contrast barium enema examination screening. CONCLUSION: Double-contrast barium enema examination can be a cost-effective component of colorectal cancer screening, but further modeling efforts are necessary.

Barium Sulfate↗

PubMed1998

Inner city primary care providers' breast cancer screening knowledge: implications for intervention.

Low income and minority women continue to have relatively low breast cancer screening rates. Since physician recommendation is one of the most important determinants of mammography participation, we aimed to characterize the breast cancer screening knowledge of primary care providers serving a socially disadvantaged population. The study was conducted at the Adult Medicine Clinic of Seattle's county hospital. All attending physicians, resident physicians, and mid-level practitioners were asked to complete a questionnaire in the spring of 1995. Forty-nine of 52 (94%) eligible providers completed the survey. The respondents generally agreed with published guidelines for screening mammography use. In contrast, they had relatively low levels of knowledge about breast cancer risk factors and the effectiveness of other breast cancer screening methods. Additionally, providers tended to over-estimate their breast cancer screening knowledge and skills. For example, 69% believed that they could answer patients' questions about mammography, but only 23% were aware of Medicaid's reimbursement policy for the procedure. For some variables, attending physicians were no more knowledgeable than resident physicians. Our results reinforce the need for increased preventive care training in medical schools and primary care residency programs. Educational programs for providers serving disadvantaged populations might usefully focus on pragmatic issues such as institutional costs and public payer reimbursement policies.

Adult↗

PubMed2002

Sociodemographic variations in breast cancer screening behavior among Australian women: results from the 1995 National Health Survey.

BACKGROUND: Knowledge of sociodemographic variations in breast cancer screening can help identify population groups that are at risk of underutilization of breast cancer screening procedures and practices. We examined sociodemographic variations in breast cancer screening behavior among Australian women. METHODS: We used a subsample of women aged 18 years and older (n = 10,179) from the 1995 National Health Survey. We examined the association of sociodemographic variables with mammography, clinical breast examination, and breast self-examination. RESULTS: Being in the oldest age group, never being or previously being married, living in rural regions (except in the case of breast self-examination), residing in more disadvantaged areas (except in the case of breast self-examination), and having lower levels of education were all associated with a smaller likelihood of screening. Ethnicity was also significantly associated with screening. CONCLUSION: Strategies to promote breast cancer screening practices should pay particular attention to the underserved groups and should be part of a more comprehensive policy that ensures the accessibility to regular health care of these population groups.

Adolescent↗

PubMed2005

HPV testing and cervical cancer screening: recommendations and practice patterns.

In summary, guidelines for cervical cancer screening continue to evolve, as knowledge of the pathogenesis of the disease as well as the role of HPV expands. Oncogenic HPV typing has proven effective in cancer screening and follow-up in certain situations, and its uses will undoubtedly increase. Patients and providers may be reassured with negative HPV testing, but long term management of positive HPV testing (especially in conjunction with negative cytology) is unclear. At present, however, numerous worldwide, prospective studies involving HPV testing and cervical cancer screening will, we hope, provide some of the answers regarding optimal management of women who remain persistently HPV positive.

DNA, Viral↗

PubMed2007

Update on ovarian cancer screening.

PURPOSE OF REVIEW: Epithelial ovarian cancer is usually diagnosed in the advanced stage and carries a poor prognosis. When detected at an early stage, the 5-year survival rate is 90%. Despite the availability of various diagnostic tools for ovarian cancer screening, high levels of sensitivity and specificity are not achievable. There is therefore an ongoing need to identify new screening tests and strategies that should be readily available, relatively noninvasive, and achieve high sensitivity, specificity, and positive and negative predictive values. RECENT FINDINGS: Our review focuses on various screening technologies including serum biomarkers, transvaginal ultrasonography as well as multimodality screening that can be used for early detection of ovarian cancer. The efficacy of different screening tools is discussed along with the efforts made to improve sensitivity, specificity and positive predictive value. The initial results of two large population-based screening studies are presented. SUMMARY: An optimal screening test with high levels of sensitivity and specificity is indispensable for early detection of ovarian cancer. Serological screening with serum biomarkers (serum proteins and autoantibodies) can be used as a first-line screening test. In combination with TVS or color-flow Doppler imaging, this may prove very effective in early detection of ovarian cancer.

Biomarkers, Tumor↗

PubMed1998

Use of a mathematical model to evaluate breast cancer screening policy.

A model of breast cancer screening was developed, in which the processes of tumour origination and growth, detection of tumours at screening, presentation of women with cancers to their GP, and of survival after diagnosis were modelled parametrically. The model was fitted to data from the North-West of the UK, for 413 women who screened positive, and for 761 women who developed interval cancers. Model validation comprised verification that the final model fitted the data adequately, together with the comparison of model predictions with findings by other workers. The mathematical model was used to assess different screening policies, and to ask "what if" questions. Taking the cost of breast cancer to be the sum of the cost of screening and the cost of PYLL (person years of life lost due to cancer), the optimal screening policy was calculated. The costs of the current policy and of other possible screening policies were found, together with their effects on life lost and on mortality. The tentative conclusion was that if monies can be found to extend the screening programme, for example to carry out one more screen per woman, most benefit would be obtained by reducing the start age of screening by 3 years.

Aged↗

PubMed1995

An epidemiological perspective on cancer screening.

OBJECTIVE: To provide an epidemiological perspective on cancer screening. METHODS AND RESULTS: For screening to be applicable as public health policy, the disease has to be an important health problem, there has to be evidence that early detection results in improved outcome, that adequate facilities for diagnosis, therapy, and subsequent management of true and false positives are available, that screening is acceptable to the target groups, and that programs are cost effective in the population. Although it is relatively easy to demonstrate that screening results in earlier detection of cancer, survival is a biassed measure of its effectiveness. The only valid design to study the efficacy of screening is the randomized trial. Cervical cancer screening was introduced before these requirements were recognized. There is, however, good evidence of its effectiveness; the challenge is to make programs cost effective. For breast cancer, studies show little or no evidence of effectiveness of mammography screening in women age 40-49. For women age 50-69, there is good evidence of effectiveness in trials comparing screening with no screening. These support the introduction of population-based programs for this age group. The challenge is to put the research results into practice to ensure cost-effective programs. For colo-rectal cancer, there is some evidence that both screening sigmoidoscopy and the fecal occult blood test will reduce mortality. It is not clear, however, whether programs using either or both these tests will be cost effective. For lung cancer, there is good evidence of no benefit for screening. For ovarian, prostate, mouth, and skin cancer, although early detection has been demonstrated, there is no evidence of reduction in mortality in the target groups; indeed, prostate screening could result in lowering the overall quality of life. CONCLUSION: Screening, which offers a fairly rapid return from appropriate investment, should remain part of our armamentarium for cancer control.

Epidemiologic Methods↗

PubMed1990

Breast cancer screening in women over age 50. A critical appraisal.

Breast cancer screening with mammography is strongly advocated by some and rejected by others. Discussions in the medical literature focus on the beneficial and unfavourable effects of breast cancer screening. Among the latter are the suggested excess mortality rate of screen-detected breast cancer patients, the high number of unnecessary biopsies, the possibility of overdiagnosis and subsequent unnecessary treatment, and the occurrence of interval breast cancer cases. It is concluded that screening can to a certain extent prevent women from dying of breast cancer but some negative effects are unavoidable. However, adequate training of the screening team can minimize the number of unnecessary biopsies and the occurrence of interval cancers. Research is needed to evaluate the natural course of so-called 'minimal' lesions, and to optimize screening tests. The search for new (imaging) techniques is needed to detect lobular cancers in dense breasts.

Biopsy↗

PubMed2001

Fecal occult blood testing for colorectal cancer screening: use the finger.

OBJECTIVE: Fecal occult blood testing (FOBT) has been widely underused as a means of colorectal cancer screening. Less than 35% of Americans have had the recommended FOBT in the last 5 yr. Guidelines suggest FOBT of three spontaneously passed stools (SPS) on a prescribed diet. Testing stool obtained by digital rectal exam (DRE) is discouraged because its yield in colorectal cancer screening is unknown. The aim of this study is to compare the positive predictive value of FOBT for the detection of colorectal neoplasia done by SPS versus DRE in asymptomatic outpatients. METHODS: Medical records and endoscopic reports of all patients who underwent colonoscopy between 1984-1999 for a positive FOBT were reviewed. Only asymptomatic outpatients whose indication was colorectal cancer screening were included. The method of FOBT was confirmed as either SPS or DRE. Chi2 was used to compare the yield of detecting colorectal neoplasia between SPS and DRE. RESULTS: A total of 165 patients with a mean age of 61 yr (range 33-85) were included (84 patients were women). Neoplasia was detected in 29 of 80 (36%) with SPS and 28 of 85 (33%) with DRE (p = 0.18). CONCLUSIONS: The positive predictive value of FOBT on DRE for detecting neoplasia is similar to that of SPS in asymptomatic outpatients undergoing colorectal cancer screening. Positive FOBT on DRE warrants colonoscopic evaluation. Hemoccult testing by DRE may be performed in the office to increase patient compliance with colorectal cancer screening. A negative FOBT on DRE should be followed up with FOBT of SPS.

Adenoma↗

PubMed1997

Prevalence and correlates of breast and cervical cancer screening among older women.

OBJECTIVE: To identify and assess differences in cancer screening patterns among women 55-64, 65-74, 75-84, and over 84 years of age. METHODS: Nationally representative data reported in the 1990 Health promotion and Disease Prevention Supplement to the National Health Interview Survey of 28,584,574 women were analyzed secondarily. The dependent variables were a knowledge of breast self-examination, over having had a mammogram, and a Papanicolaou smear within the last 3 years. Independent variables were age and various sociodemographic, health-status, and health-belief measures. RESULTS: More than half (58%) of the women had ever had a mammogram, and of these, 91% had had between one and five mammograms. Over a third (35%) of those who had not had a mammogram attributed the omission to a lack of a recommendation by a physician. Almost half (45%) had had a breast examination by a physician within the last year, and 84% knew how to examine their own breasts. Approximately 87% had a Papanicolaou smear with the last 3 years. Age, race, education, and living in a large city were significantly associated with all three screening measures, but prevalent health beliefs were significantly associated only with breast-cancer screening. CONCLUSION: Lack of mammogram screening in a substantial number of women, attributed to lack of physician recommendation, decreased screening in the older age groups, and the negative association of three screening tests with race and residence in a large city suggest that new interventions are needed by health care providers and the public health community to increase older women's use of effective cancer screening techniques.

Aged↗

PubMed1990

[Participation of regional inhabitants in cancer screening].

As part of the strategic planning for increasing participation by community residents in cancer screening, a survey about life style and attitudes toward cancer screening was carried out in Samukawa town, Kanagawa Prefecture. Subjects were males 40 years old or over, and females 30 years old or over selected by random sampling from residents. Number of subjects was 1,916 (822 males, 1,094 females). Self administered anonymous questionnaires were sent and returned by mail. The response rate was 73%. The results were as follows: (1) The reported participation rates for cancer screening under "the Health and Medical Services Law for the Aged" did not reflect the actual participation rate of residents. (2) The major reason for not participation in screening was lack of interest in cancer prevention. (3) Socio-economic status of regular participants in screening was different from persons who did not participate. (4) Persons who did not participate in screening were more passive with regard to obtaining knowledge of cancer than regular participants. (5) Results of this study show that cancer prevention education at various levels such as by clinical offices, TV and radio programs, and newspapers may be effective. In order to increase participation in screening programs, health education that considers the life style characteristics of persons who do not participate in the screening programs is vitally important.

Adult↗

PubMed1997

Use of a stochastic simulation model to identify an efficient protocol for ovarian cancer screening.

The intervention protocol for an ovarian cancer screening trial should be efficient as well as effective, because it may become the standard of care if the trial demonstrates mortality reduction. To identify an efficient ovarian cancer screening protocol, the effectiveness and cost-effectiveness of selected single modality and multimodal screening strategies were estimated using a stochastic simulation model. Screening was simulated over a 30-year period in a hypothetical cohort of 1 million women aged 50 at the beginning of the period. The net present value of the cost per year of life saved was estimated for six protocols involving transvaginal sonography (TVS) and/or the tumor antigen CA 125. Internal and external validation was performed, and sensitivity analyses were conducted to assess the robustness of the ranking of the strategies. A multimodal strategy involving CA 125 with a threshold for positivity of either elevation above 35 U/ml or doubling since the previous screen, followed by TVS only if CA 125 is positive, was found to be efficient in the sense that no other strategies saved as many years of life at lower cost per year of life saved. Used annually, this strategy cost under $100,000 per year of life saved over a range of assumptions. The model's predictions are consistent with results reported in the literature regarding the performance of TVS and CA 125. The multimodal strategy used annually or every six months was efficient compared to either ultrasound or CA 125 used alone, over a range of assumptions. Simulation of screening may be useful in selecting a screening protocol to be tested in a randomized controlled trial.

Aged↗

PubMedDate not supplied

[Breast cancer screening 1988].

Recent state of investigations concerning the efficacy of breast cancer screening is presented. Opinions expressed in different conferences and symposia supporting the necessity of introducing in adequately organized societies the breast cancer screening on population scale is presented. The problem of screening methods and models is discussed. Some objections concerning the problem of breast cancer screening on national scale are also discussed.

Breast Neoplasms↗

PubMed1997

The Gothenburg Breast Cancer Screening Trial: preliminary results on breast cancer mortality for women aged 39-49.

We carried out a randomized trial of invitation to screening mammography in the city of Gothenburg, Sweden, to estimate the effect of screening on breast cancer mortality in women under age 50 years. A total of 11,724 women aged 39-49 were randomized to the study group, which was invited to mammographic screening every 18 months; 14,217 women in the same age range were randomized to a control group, which was not invited to screening until the fifth screen of the study group. Breast cancers diagnosed in both groups between randomization and immediately after the first screen of the control group were followed up for death from breast cancer to the end of December 1994. There was a significant 44% reduction in mortality from breast cancer in the study group compared to the control group (relative risk [RR] = 0.56, P = 0.042, 95% confidence interval [CI]: 0.32-0.98). A conservative estimate based on removal of the cancers detected at the first screen of the control group gave an RR = 0.59 (P = 0.069, 95% CI: 0.33-1.05). The true answer is likely to lie between the two estimates. These data suggest that mammographic screening can reduce breast cancer mortality in women under age 50, particularly if high-quality mammography is used and a short interscreening interval is adhered to.

Adult↗

PubMed2001

Evaluation of preventive technologies in Germany: case studies of mammography, prostate cancer screening, and fetal ultrasound.

OBJECTIVE: In this article, three preventive strategies-mammography screening for breast cancer, PSA screening for prostate cancer, and routine ultrasound in normal pregnancy-are discussed in the context of German health care. METHODS: Epidemiologic data and German studies evaluating different aspects of these preventive measures were identified and analyzed. RESULTS: Only a few studies could be identified that investigate these preventive measures. Despite sufficient evidence, in part derived from a German study, there is not yet a mammography screening program. In contrast, ultrasound in pregnancy is offered routinely, although there are controversies regarding the benefit of this practice. PSA screening is not offered as part of the screening program for prostate cancer. However, PSA tests as well as mammographies are done in large numbers in German ambulatory care-a practice that could be considered wild or opportunistic screening. CONCLUSIONS: These case studies show that preventive programs and practices in Germany are not sufficiently based on sound evidence. The paucity of evaluation activities related to prevention in Germany is probably due to the low threshold to introduce new preventive programs into the German healthcare system in the past.

Adult↗