Efficacy Of Screening Programs Research Articles

Non-participation of asymptomatic candidates in screening protocols reduces early diagnosis and worsens prognosis of colorectal cancer.

The Agatsuma et al's study shows that despite the evidence of the benefits of an early colorectal cancer (CRC) diagnosis, through screening in asymptomatic subjects, up to 50% of candidates reject this option and many of those affected are diagnosed later, in advanced stages. The efficacy of screening programs has been well-established for several years, which reduces the risk of CRC morbidity and mortality, without taking into account the test used for screening, or other tools. Nevertheless, a significant proportion of patients remain unscreened, so understanding the factors involved, as well as the barriers of the population to adherence is the first step to possibly modify the participation rate. These barriers could include a full range of social and political aspects, especially the type of financial provision of each health service. In Japan, health services are universal, and this advantageous situation makes it easier for citizens to access to these services, contributing to the detection of various diseases, including CRC. Interestingly, the symptomatic CRC group had a lower early-stage diagnosis rate than the patients detected during follow-up for other comorbidities, and symptomatic and cancer screening groups showed similar early-stage diagnosis.

The contribution of endoscopy quality measures to the development of interval colorectal cancers in the screening population: a systematic review.

Colon cancer is the second most common cause of cancer-related death and an important cause of morbidity. The natural history of carcinogenesis, via the adenoma-carcinoma sequence, permits screening, which reduces the relative risk of mortality by up to 16%. The efficacy of a screening programme is limited by the growth of interval colorectal cancers between screening examinations. Quantifying the rate of interval cancers and delineating contributing endoscopic factors are crucial to maximise the benefit of a screening program. A systematic review was performed in accordance with PRISMA principles. Electronic databases were interrogated with a considered search strategy, and reference lists of retrieved papers were surveyed. For inclusion, studies included the rate of interval cancer (stated or calculated) and reported at least one of a predefined list of endoscopy characteristics. The primary outcome was to establish the rate of interval cancers. The secondary outcome was to determine the association between endoscopy quality measures and interval cancers. The search yielded 2067 papers. Seventy-six full text papers were reviewed. Fifteen papers met the inclusion criteria. In total, there were 117,793 colon cancers, 7281 of which were interval lesions, giving an overall rate of 6.2%. The adenoma detection rate (ADR) of the endoscopist performing the index operation was the most consistent endoscopy factor associated with development of interval cancers. The impact of setting, volume and bowel preparation varied between papers. Interval cancers reduce the efficacy of colorectal screening programmes. Ensuring the quality of the endoscopy process, specifically by increasing the ADR of practitioners, is crucial to the reduction of the rate of interval cancers.

Acceptability of two colorectal cancer screening tests: pain as a key determinant in sigmoidoscopy.

Background Participants' experience with a screening test can influence adherence, and therefore the efficacy of screening programs. We compared screening with unsedated flexible sigmoidoscopy and fecal immunochemical testing (FIT) for participants' satisfaction with the decision and for willingness to repeat colorectal cancer screening. Methods In a prospective, randomized trial 3257 individuals (50 - 74 years) were invited to either flexible sigmoidoscopy or FIT (1:1), of whom 1650 took up the offer (52.6 %). In total, 1497 screening participants completed at least one questionnaire, either before screening, and/or at three time points in the following year, that measured willingness to repeat screening, willingness to recommend screening, and satisfaction with decision to attend. There were 769 and 728 responders in the flexible sigmoidoscopy and FIT group, respectively. Additionally, 581 flexible sigmoidoscopy participants also completed a pain questionnaire. Results 1 year later, 10 % of the flexible sigmoidoscopy participants were not willing to repeat screening, compared to 5 % of FIT participants. A higher percentage of women compared to men would not repeat flexible sigmoidoscopy screening (adjusted odds ratio [OR] 2.52, 95 % confidence interval [95 %CI] 1.48 to 4.28). Notably, 22 % of women reported pain during flexible sigmoidoscopy compared to 5 % of men. When we added pain to the statistical model, pain was significantly associated with unwillingness to repeat flexible sigmoidoscopy (OR 3.15, 95 %CI 1.68 to 5.87), while gender was no longer associated (OR 1.53, 95 %CI 0.82 to 2.88). Conclusion Acceptability for flexible sigmoidoscopy and for FIT was high among Norwegian screening participants, though FIT participants were more willing to repeat screening. Women were less willing to repeat screening with flexible sigmoidoscopy compared to men. This gender difference seemed partly due to pain, and therefore preventable.This study is registered at ClinicalTrials.gov: NCT01538550.

Stages of Change for Mammography Among Mexican Women and a Decisional Balance Comparison Across Countries.

An analysis of the adoption of secondary preventive behaviors is significant in regions with disparities in mammography use and breast cancer survival. Therefore, we determined the cognitive factors and the degree to which they differentiate stages of change in mammography among Mexican women. We also compared the decisional balance performance at Mexico, Switzerland, South Korea, and the USA. A cross-sectional study was designed for women in the stages of precontemplation (n=240), contemplation (n=243), action (n=205), maintenance (n=311), and relapse (n=348). We only considered those ≥40years with no cancer history. We measured the pros, cons, and self-efficacy, among other components. The decisional balance was estimated, and the result was transformed into T-scores. Odds ratios (OR) and 95% confidence intervals (CI) were estimated with multinomial logistic regression using precontemplation as the reference group. The decisional balance distinguished stages partially: in contemplation, the OR was 1.26 (95%CI 1.08, 1.47) and in maintenance, 1.34 (95%CI 1.13, 1.59); in action and relapse, the statistical significance was marginal (p<0.10). The decisional balance T-score performance registered variations among countries. Additionally, the effect of self-efficacy progressively ascended from contemplation to action and maintenance (OR=1.29 [95%CI 1.05, 1.58], 1.53 [95%CI 1.20, 1.96], and 2.48 [95%CI 1.82, 3.39], respectively). Furthermore, risk perception and severity did not have an effect on stages of change among Mexican women. Recognition of what provokes action in a population is a key factor in the efficacy of screening programs. Variations among countries highlight the necessity for importance of investigating cognitive determinants for mammography in specific areas.

Abstract SY14-01: Preventable exposures associated with human cancer.

Abstract SY14-01: Preventable exposures associated with human cancer.

Interferon-γ releasing assay versus tuberculin skin testing for latent tuberculosis infection in targeted screening programs for high risk immigrants

Recent immigrants from developing countries (<2 years since immigration) are at very high risk of active TB disease due to reactivation of latent infections acquired in the country of origin. In industrialized low-incidence TB countries targeted testing programs for high risk groups could allow the detection of latently infected persons who would likely benefit from a course of preventive treatment. In this study we evaluated the tuberculin skin test (TST) and interferon-gamma enzyme-linked immunosorbent assay (QuantiFERON TB-gold in tube, QFT-IT) strategies for TB infection screening programs in recent immigrants from highly endemic countries. This is a prospective cross-sectional study. Paired tests performed in 1,130 immigrants attending an outpatient ward, between 2005 and 2007 for any health problem were evaluated by intention-to-treat (ITT) and per-protocol (PP) analysis for efficiency and efficacy of screening program. Positive TST and QFT-IT were observed in 36.04 versus 29.82% (ITT) and in 45.27 versus 30.22% (PP) respectively. A higher drop-out rate was observed for TST (20.35 vs. 1.33%) (p < 0.0001). Second level assessment was accepted by half of the TST positive patients. Overall agreement rate between 887 paired tests was fair (k = 0.38). Higher k values were observed for higher TB prevalence rate in the country of origin (k = 0.43), for TST induration diameters >20 mM (k = 0.47), in subjects aged 40-50 years (k = 0.41) and in unvaccinated persons (k = 0.40). In a multiple logistic regression model continent of origin, class of TB prevalence in the country of origin and contacts with TB patients were found to be significantly associated with the probability of TST and QFT-IT positive result. Low education levels were associated only to an increased risk of TST positive results. The drawback of the TST screening strategy in recent immigrants from highly endemic countries is due to low sensitivity/specificity of the test and to high drop-out rate with an overall significant lowering in strategy efficacy/efficiency. The higher QFT-IT specificity prevents unnecessary overload of the health care system and, although more expensive, might represent a cost-effective alternative to TST in targeted screening programs directed to high risk populations.

Efficacy of Disease Management Profiles. The Mammographic Screening Program of Lazio

Screening programs are considered disease management profiles. The aim of the present study was to evaluate the efficacy of screening programs compared to regularly offered health care services, using early outcomes and process indicators. In the study period (1/7/99-30/6/01), six breast cancer screening programs were active in 12 health districts in the Lazio region of Italy. Screening histories of all the incident cases of women surgically treated for a breast neoplasm were reconstructed (not contacted, contacted, non-participants, participants). The subpopulations were then compared for the appropriateness of treatments received. We identified 3251 women who were treated for malignant neoplasms of the breast and 1562 treated for benign neoplasms. The incidence of malignant neoplasms was higher in the women contacted for screening (incidence rate ratio, 1.45; 95% CI, 1.32-1.60), and the incidence of treatment for non-malignancies was similar in the two populations (incidence rate ratio, 1.00: 95% CI, 0.86-1.16). The percentage of surgery for non-malignancies detected by screening was 16.7%, whereas among the cases diagnosed outside a screening program it was 33.8%. Of malignancies detected outside of screening, 16.6% had a surgical treatment that was too invasive, among the screen-detected malignancies the percentage fell to 11% (prevalence rate ratio, 0.66; 95% CI, 0.48-0.91). Women contacted for screening showed a higher incidence of localized and in situ tumors, whereas the incidence of non-localized and metastatic tumors was basically the same in the two groups. The first round of screening programs led to more surgical interventions, a similar incidence of mastectomy and of interventions for benign neoplasm, but a lower incidence of unnecessary treatment.

Population‐based study of antenatal detection of congenital heart disease by ultrasound examination

Ultrasound-based screening is widely employed for the detection of congenital malformations in utero including congenital heart disease (CHD), but there is widespread variability in the efficacy of screening programs. We aimed to evaluate current antenatal detection rates of selected congenital heart defects in Victoria. Data were collected from the Victorian Perinatal Data Collection Unit and Birth Defects Registry. There were 631 209 births in Victoria (1993-2002), of which 4897 cases had CHD. Cases included live births, stillbirths and termination of pregnancies because of CHD. We reviewed all cases from 1999 to 2002 with atrioventricular septal defect, simple coarctation of the aorta, double-inlet or -outlet ventricle, hypoplastic left heart syndrome, simple transposition of the great arteries (TGA), tetralogy of Fallot and truncus arteriosus. Outcome measures were antenatal diagnosis, pregnancy outcome and associated malformations. The overall birth prevalence of CHD from 1993 to 2002 in Victoria was 7.8/1000. The antenatal detection rate for the seven selected defects from 1999 to 2002 was 52.8%. All but 4.8% of the cases had an ultrasound examination at > 13 weeks' gestation. Antenatal detection was highest for hypoplastic left heart syndrome (84.6%) and lowest for simple TGA (17.0%). This study shows wide variation in the antenatal detection rate of CHD in Victoria. The low antenatal detection rate of TGA, a defect that should be detected easily, demonstrates suboptimal routine obstetric anomaly scanning.

Outcome-impact of a cervical cancer (CC) screening program (SP) in a developing country

1032 Background: CC is the 2nd cause of cancer death in women in Argentine. Early detection following screening programs has demonstrated to reduce mortality in CC. The evaluation of the efficacy and efficiency of CC SP is associated with the proportion of positive cases in the smears and with the relation between pre-invasive lesion (CIN III) and invasive carcinoma (IC) in the biopsies done in positive cases. In 1997 a population based CC screening program was started in our province. The objective of this trial was to determinate the relationship between CIN III and IC in the program population and compare this results with this proportion in pre-program years an as an indicator of the quality of the program. Methods: We analyzed 2446 cervix biopsies performed in public Hospitals of Tucuman between 1985 and 2004 (archives of biopsies of the Serv. de Patología del Hosp. Centro de Salud Z. Santillán, Regional M. Belascuain and Hospital Angel C. Padilla), Since 1997 biopsies were done in patients within the SP We analyzed the proportions of pre-invasive lesions (CIN III) and invasive lesions in periods of 4 years. Results: The proportion of CIN III by periods of 4 years was: 85–88: 13%, 90–92: 20%; 93–96: 20%; 97–00 32% and 01–04 37%. The proportion of CIN III in pre-screening years was 21% and during the SP: 54%. Conclusion: These results shows an increase of CIN III over IC which could translate into a better survival. The quality control analysis of the public programs must be central in the public health policy. [Table: see text] No significant financial relationships to disclose.

Which tissue should be used to obtain a fetal karyotype after second trimester termination of pregnancy?

TRIMESTER TERMINATION OF PREGNANCY? GARFIELD CLUNIE, STEVEN J. RALSTON, JANET M. COWAN, KAREN KRAJEWSKI, SABRINA D. CRAIGO, Tufts University, OB/GYN, Boston, Massachusetts, Tufts University, Genetics, Boston, Massachusetts OBJECTIVE: The goal of this study was to determine which fetal tissue (cord, placenta, or skin) would most reliably yield a karyotype following second trimester pregnancy termination. STUDY DESIGN: Patients who were referred for pregnancy termination for fetal anomalies or a fetal demise in the second trimester were approached for participation in the study. At the time of their termination, tissue was obtained from the placenta, umbilical cord, and fetal skin. Tissue culture techniques were then used to grow cells from each of these tissues and a karyotypic analysis was performed when possible. A successful culture was defined as one which yielded enough cells for adequate analysis by routine cytogenetic standards. RESULTS: Thirty-five patients were entered over a 12-month period yielding 102 tissue samples; 14 of these patients had demises and 21 had anomalous fetuses. All 3 tissues were obtained in 32 patients; 2 tissues were obtained in the remaining 3 patients. In the 21 cases where there was a living fetus, the placenta, cord, and skin were equally reliable, yielding a result in 95%, 100%, and 100% of cases respectively (P = .4). However, in the subgroup of patients whose diagnosis was fetal demise, placental tissue was the most reliable with a failure rate of 36% (P= .004). In these patients, the incidence of culture failure was 77% for umbilical cord (RR = 2.8, 95% 1.0-8.1, compared to placenta) and 93% for fetal skin (RR= 9.0, 95% CI 1.3-61.9, compared to placenta). Only 3 patients (9%) had failures in all 3 cell lines; all 3 of these patients had fetal demises (P = .09). In the 102 samples, there were 5 cases of karyotypic mosaicism; all 5 were from placental tissue (P = .006). CONCLUSION: For karyotypic analysis after second trimester termination of pregnancy of a living fetus, fetal cord, skin, and placenta are equally reliable sources of fetal cells. In cases of fetal demise, skin and cord become less reliable and placenta tissue should be obtained to determine the karyotype. However, mosaicism occurs more frequently with placental tissue. 131 SECOND TRIMESTER MATERNAL SERUM SCREENING FOR DOWN SYNDROME: AMNIOCENTESIS RATES AND THE NET NUMBER OF AFFECTED PREGNANCIES IDENTIFIED PETER BENN, JAMES EGAN, University of Connecticut, Genetics and Developmental Biology, Farmington, Connecticut, University of Connecticut, Obstetrics and Gynecology, Farmington, Connecticut OBJECTIVE: Traditionally, the efficacy of screening programs has been measured by the sensitivity and false-positive rate and assumes uniform utilization of amniocentesis among all screen-positive women. We evaluated efficacy from the perspective of the actual numbers of amniocenteses performed and Down syndrome (DS) pregnancies prenatally diagnosed. STUDY DESIGN: We reviewed the sensitivity, false-positive rate, amniocenteses performed, and DS pregnancies diagnosed for 99,762 women with singleton pregnancies receiving second trimester screening through our laboratory from 1991 to 2002. Prior to April 1999, screening was based on MS-AFP, hCG, and uE3. Subsequently, inhibin-A was added. The second trimester cut-off was 1:270 and 12.4% of the women screened were aged 35 or more at delivery. RESULTS: Based on 178 DS pregnancies, the screening had a sensitivity of 73.6%. Of the 131 screen-positive women with affected pregnancies, 92 (70.2%) had an amniocentesis resulting in a net detection rate of 51.7%. The screening had a false-positive rate of 6442/99,584 (6.5%) and 3078 (47.8%) of these screenpositive women underwent amniocentesis resulting in a net amniocentesis rate of 3.1% in women with unaffected pregnancies. The rate of amniocentesis was significantly higher in true-positives compared to false-positives (P ! .001). In women with unaffected pregnancies, there was a significant reduction in the rate of amniocenteses between 1991 (70.3%) and 2002 (37.5%) (P ! .001). This trend was not seen for affected pregnancies. The odds of an affected pregnancy, given a positive screening result, were 1:46. The odds of an affected pregnancy when an amniocentesis was performed were 1:32. CONCLUSION: The higher amniocentesis rate in affected compared to unaffected pregnancies is probably attributable to the higher serum screening risks and abnormal ultrasound findings present in many affected pregnancies. The actual number of DS pregnancies prenatally diagnosed and the number of invasive tests performed should be considered when evaluating the various screening protocols available.

Second trimester maternal serum screening for down syndrome: Amniocentesis rates and the net number of affected pregnancies identified

Traditionally, the efficacy of screening programs has been measured by the sensitivity and false-positive rate and assumes uniform utilization of amniocentesis among all screen-positive women. We evaluated efficacy from the perspective of the actual numbers of amniocenteses performed and Down syndrome (DS) pregnancies prenatally diagnosed.

Ovarian cancer in BRCA-positive women: vigilance is mandatory despite screening programs

A young BRCA-1 positive woman turned out to have advanced stage ovarian cancer despite an ensuring check-up 4 months earlier. Much remains unknown regarding the efficacy of screening programs, when applied to individuals predisposed for an inherited malignancy. Therefore, vigilance is mandatory when dealing with women with a positive family history of mammarian and/or ovarian cancer.

Why physicians don't pursue abnormal laboratory tests: An investigation of hypercalcemia and the follow-up of abnormal test results

For unknown reasons, physicians often ignore unsolicited clinical data. This is thought to impair the quality of medical care and the efficacy of screening programs. To investigate this problem the authors followed 156 consecutive hypercalcemic patients for nine to 15 months. Twenty-eight were lost to follow-up, and the hypercalcemia was ignored in 26. Calcium tests were repeated for 102, and hypercalcemia was confirmed in 53. Of these, 39 were and 14 were not further investigated. Analysis by logistic regression revealed a highly significant relationship between the degree of hypercalcemia and the likelihood that calcium testing would be repeated or that abnormal levels would be further investigated. The authors conclude that, contrary to common opinion, when physicians ignore abnormal laboratory values they are making complex clinical judgments based on the degree of abnormality, the likelihood that further investigation will affect therapy, and the cost of the risk associated with further investigation. Evaluation and attempts to modify this behavior should take into account the complexity of these decisions.