To Screen or Not to Screen: Reconciling Individual and Population Perspectives on Screening

Abstract

Screening is the early detection of a latent disorder by a test to allow early intervention with the aim of improving prognosis. Individual and population perspectives on screening are perceived as opposing interests of patients and the population. In this article, we try to reconcile these perspectives. The individual perspective is based on the clinical experience of a better prognosis at early stages and patients with missed opportunities. In the population perspective, screening is based on a population-oriented, evidence-based model and addresses the acceptability and possible negative effects, including for people without the disorder. Known possible obstacles to a positive effect of screening include a short latent stage, lead time, overdiagnosis, lack of acceptability, poor performance of tests, and misclassification of outcome. Randomized trials of screening are challenging and need an adaptation of standards such as the Consolidated Standards of Reporting Trials (CONSORT). Simulating the effects of screening can allow the consideration of complex screening strategies and other options to help avoid biases related to treatment improvement and prevention success. Reconciling both perspectives is possible by considering that hypotheses underlying the former are prerequisites for the latter. From an evidence-based medicine and policy perspective, we suggest that recommending screening or prescribing a test is unethical if all possible obstacles are not documented by providing the best available evidence.