A perspective from countries using organized screening programs

Applying the Transtheoretical Model to evaluate the effect of a call-recall program in enhancing Pap smear practice: a cluster randomized trial

OBJECTIVE

The objective of this study was to evaluate the effect of a call-recall approach in enhancing Pap smear practice by changes of motivation stage among non-compliant women.

METHODS

A cluster randomized controlled trial with parallel and un-blinded design was conducted between January and November 2010 in 40 public secondary schools in Malaysia among 403 female teachers who never or infrequently attended for a Pap test. A cluster randomization was applied in assigning schools to both groups. An intervention group received an invitation and reminder (call-recall program) for a Pap test (20 schools with 201 participants), while the control group received usual care from the existing cervical screening program (20 schools with 202 participants). Multivariate logistic regression was performed to determine the effect of the intervention program on the action stage (Pap smear uptake) at 24 weeks.

RESULTS

In both groups, pre-contemplation stage was found as the highest proportion of changes in stages. At 24 weeks, an intervention group showed two times more in the action stage than control group (adjusted odds ratio 2.44, 95% CI 1.29-4.62).

CONCLUSION

The positive effect of a call-recall approach in motivating women to change the behavior of screening practice should be appreciated by policy makers and health care providers in developing countries as an intervention to enhance Pap smear uptake.

Communication about colorectal cancer screening in Britain: public preferences for an expert recommendation

BACKGROUND

Informed decision-making approaches to cancer screening emphasise the importance of decisions being determined by individuals' own values and preferences. However, advice from a trusted source may also contribute to autonomous decision-making. This study examined preferences regarding a recommendation from the NHS and information provision in the context of colorectal cancer (CRC) screening.

METHODS

In face-to-face interviews, a population-based sample of adults across Britain (n=1964; age 50-80 years) indicated their preference between: (1) a strong recommendation to participate in CRC screening, (2) a recommendation alongside advice to make an individual decision, and (3) no recommendation but advice to make an individual decision. Other measures included trust in the NHS and preferences for information on benefits and risks.

RESULTS

Most respondents (84%) preferred a recommendation (47% strong recommendation, 37% recommendation plus individual decision-making advice), but the majority also wanted full information on risks (77%) and benefits (78%). Men were more in favour of a recommendation than women (86% vs 81%). Trust in the NHS was high overall, but the minority who expressed low trust were less likely to want a recommendation.

CONCLUSION

Most British adults want full information on risks and benefits of screening but they also want a recommendation from an authoritative source. An 'expert' view may be an important part of autonomous health decision-making.

Trends in Cancer Screening Rates among Korean Men and Women: Results from the Korean National Cancer Screening Survey (KNCSS), 2004-2011

PURPOSE

The Korean National Cancer Screening Survey (KNCSS) is a nationwide survey conducted annually, since 2004. This study was conducted in order to report on trends in rates of cancer screening for five major cancers-stomach, liver, colorectal, breast, and cervix uteri in Korea.

MATERIALS AND METHODS

Data collected by the KNCSS between 2004 and 2011 were used in this study. The eligible study population included cancer-free men who were 40 years old and over, and women who were 30 years old and over. Lifetime screening rate, screening rate with recommendation, and changes in annual rates were calculated.

RESULTS

Both lifetime screening rates and screening rates with recommendation have increased since 2004. On average, screening rates with recommendation have shown an annual increase of 4.2% (95% CI, 3.3 to 5.2%) for stomach cancer, 1.1% (95% CI, -0.5 to 2.7%) for liver cancer, 2.2% (95% CI, 0.8 to 3.6%) for colorectal cancer, 4.0% (95% CI, 3.0 to 4.9%) for breast cancer, and 0.2% (95% CI, -0.9 to 1.3%) for cervical cancer. Increases in rates of cancer screening, with the exception of liver and cervical cancers, were significant, and screening rates for stomach and breast cancer in particular showed a marked increase.

CONCLUSION

Cancer screening rates among Koreans showed a consistent increase from 2004 to 2011 and rates of screening for gastric, breast, and cervical cancer are approaching 70%.

Multilevel factors affecting quality: examples from the cancer care continuum

The complex environmental context must be considered as we move forward to improve cancer care and, ultimately, patient and population outcomes. The cancer care continuum represents several care types, each of which includes multiple technical and communication steps and interfaces among patients, providers, and organizations. We use two case scenarios to 1) illustrate the variability, diversity, and interaction of factors from multiple levels that affect care quality and 2) discuss research implications and provide hypothetical examples of multilevel interventions. Each scenario includes a targeted literature review to illustrate contextual influences upon care and sets the stage for theory-informed interventions. The screening case highlights access issues in older women, and the survivorship case illustrates the multiple transition challenges faced by patients, families, and organizations. Example interventions show the potential gains of implementing intervention strategies that work synergistically at multiple levels. While research examining multilevel intervention is a priority, it presents numerous study design, measurement, and analytic challenges.

A pivotal role for the general practitioner in a mixed mammographic screening model

BACKGROUND

A mixed mammographic screening model presents a country or region with a complex problem. Promoting a significant shift within the target population from opportunistic breast cancer screening to participation in an organised screening programme offers many advantages. The objective was to explore the role of GPs as potential mediators by assessing their specific knowledge, attitudes, and experience on breast cancer and mammographic screening.

METHODS

A detailed questionnaire was mailed in 2007 to 1500 GPs randomly sampled from the GP population in the province of Antwerp, Belgium. Levels of knowledge on epidemiology and screening, opinions and attitudes on systematic mammographic screening, and experience with breast cancer and mammography were evaluated.

RESULTS

We received 317 completed questionnaires, 21.1% of the contacted GPs. General knowledge on basic concepts of mammographic screening was average, while the response to an open question on the differences between screening and opportunistic mammography was very limited. More than half of the participants had a positive or realistic attitude towards many aspects of systematic screening, and had satisfactory experience with breast cancer patients in their daily practice (about 82% saw one to four new cases a year). Many (72%) were favourably disposed towards systematic screening organised by the government.

CONCLUSION

The answers of the GPs suggest a promising potential with regard to the official breast cancer screening programme. Many participants presented qualifications, which could contribute to a change from the mixed model in favour of the official screening system. A number of gaps, however, need to be filled and there is a continuing need to educate physicians on principles and risks and benefits of systematic screening of the target group.

Evaluation of feedback interventions for improving the quality assurance of cancer screening in Japan: study design and report of the baseline survey

OBJECTIVE

The importance of quality assurance in cancer screening has recently gained increasing attention in Japan. To evaluate and improve quality, checklists and process indicators have been developed. To explore effective methods of enhancing quality in cancer screening, we started a randomized control study of the methods of evaluation and feedback for cancer control from 2009 to 2014.

METHODS

We randomly assigned 1270 municipal governments, equivalent to 71% of all Japanese municipal governments that performed screening programs, into three groups. The high-intensity intervention groups (n = 425) were individually evaluated using both checklist performance and process indicator values, while the low-intensity intervention groups (n= 421) were individually evaluated on the basis of only checklist performance. The control group (n = 424) received only a basic report that included the national average of checklist performance scores. We repeated the survey for each municipality's quality assurance activity performance using checklists and process indicators.

RESULTS

In this paper, we report our study design and the result of the baseline survey. The checklist adherence rates were especially low in the checklist elements related to invitation of individuals, detailed monitoring of process indicators such as cancer detection rates according to screening histories and appropriate selection of screening facilities. Screening rate and percentage of examinees who underwent detailed examination tended to be lower for large cities when compared with smaller cities for all cancer sites.

CONCLUSIONS

The performance of the Japanese cancer screening program in 2009 was identified for the first time.

Analysis of ABC (D) stratification for screening patients with gastric cancer

AIM: To evaluate the value of ABC (D) stratification [combination of serum pepsinogen and Helicobacter pylori (H. pylori) antibody] of patients with gastric cancer.

METHODS: Ninety-five consecutive patients with gastric cancer were enrolled into the study. The serum pepsinogen I (PG I)/pepsinogen II (PG II) and H. pylori antibody levels were measured. Patients were classified into five groups of ABC (D) stratification according to their serological status. Endoscopic findings of atrophic gastritis and histological differentiation were also analyzed in relation to the ABC (D) stratification.

RESULTS: The mean patient age was (67.9 ± 8.9) years. Three patients (3.2%) were classified into group A, 7 patients (7.4%) into group A’, 27 patients (28.4%) into group B, 54 patients (56.8%) into group C, and 4 patients (4.2%) into group D, respectively. There were only three cases in group A when the patients taking acid proton pump inhibitors and those who had undergone eradication therapy for H. pylori (group A’) were excluded. These three cases had mucosal atrophy in the grey zone according to the diagnostic manual of ABC (D) stratification. Histologically, the mean age of the patients with well differentiated adenocarcinoma was significantly higher than that of the patients with poorly differentiated adenocarcinoma (P < 0.05). There were no differences in the pattern of atrophy in the endoscopies between the well differentiated and poorly differentiated groups.

CONCLUSION: ABC (D) stratification is a good method for screening patients with gastric cancers. Endoscopy is needed for grey zone cases to check the extent of mucosal atrophy.

Comparison between screen-detected and symptomatic breast cancers according to molecular subtypes

Breast cancer screening programs make it possible to detect early cancer, thus reducing breast cancer mortality. We studied the clinicopathologic characteristics and prognosis of screen-detected invasive breast cancer compared with symptomatic breast cancer. And we compared the result according to molecular subtypes (luminal A, luminal B, Her2, and triple negative), with the goal of identifying the role of screening in each subtypes. From January 2002 to June 2008, 3,141 patients who underwent surgery for the treatment of invasive ductal carcinoma at Samsung Medical Center were included. Among them, 1,025 patients were screen-detected, and 2,116 patients who were screened over 2 years or never were symptomatic. We retrospectively reviewed the clinical and pathologic data. Screen-detected breast cancer was associated with older age, smaller tumor size, more hormone-receptor positive, less lymph node involvement, earlier stage, and reduced mortality compared with symptomatic breast cancer (P < 0.001). According to the molecular subtype, luminal A was most common (63.6%) and showed the most obvious survival benefit in screen-detected tumors in comparison with symptomatic tumors (5-year OS: 99.7 vs. 96.5%, 5-year DFS: 96.4 vs. 90.7%). Screen detection was independently associated with improved overall and disease-free survival outcomes after adjustment for covariates (HR 0.32, P = 0.035; HR 0.58, P = 0.020, respectively) only in the luminal A subtype. Differences in pathological features such as tumor size, nodal status, grade, and age at diagnosis with different molecular subtype distributions may explain the survival advantage of patients with screen-detected breast cancer. Screening programs seem to have a different efficacy depending on the molecular subtype of the breast cancer, especially in the luminal A subtype, for which screen detection acts as an independent prognostic factor itself.

Trends in Cancer Screening Rates among Korean Men and Women: Results from the Korean National Cancer Screening Survey (KNCSS), 2004-2010

Purpose

The Korean National Cancer Screening Survey (KNCSS) is a continuous nationwide survey implemented by the National Cancer Center in Korea since 2004. The purpose of the present study was to report trends in cancer screening rates for the five major cancers (stomach, liver, colorectal, breast, and cervix uteri) in Korean men and women.

Materials and Methods

The study used KNCSS data collected between 2004 and 2010. The survey was conducted on Korean men aged 40-74 years and Korean women aged 30-74 years with no history of cancer diagnosis. The annual percentage change and corresponding 95% confidence intervals were used to examine changes in annual screening rates.

Results

Screening rates with recommendation increased by 4.4% annually for stomach cancer, 1.5% for liver cancer, 2.8% per year for colorectal cancer, 4.5% for breast cancer, and 1.2% for cervix uteri cancer. The increasing trend in cancer screening rates, with the exception of liver cancer, was significant.

Conclusion

Cancer screening rates have increased consistently from 2004 to 2010 among Korean men and women. Stomach and breast cancer screening rates in particular have increased markedly.

Impact of age-specific recommendation changes on organized breast screening programs

BACKGROUND

Recent changes in recommendations for mammography screening for women in their forties could have an impact on organized screening programs, as these require clear definition of target and eligible populations.

CURRENT STATUS

Internationally, a majority of programs target women fifty and over, and so the recent USPSTF age recommendations for screening are quite consistent with this practice. However, there is a good deal of variability in the availability of population-based screening programs to women in their forties should they choose to participate.

FUTURE IMPACT

Several programs are reviewing recommendations regarding the eligibility of women in their forties; as guidelines indicate women in this age group should be eligible for screening, even if not targeted, there is discussion as to whether they should be allowed in programs so that they benefit from the same programmatic quality assurance afforded to the target population of women over 50. Clear communication of the evidentiary basis for the eligibility criteria and target populations is required, so that the public is aware that programs are designed to deliver maximal population impact, while minimizing population risk.

The impact of PSA testing frequency on prostate cancer incidence and treatment in older men

To quantify the downstream impact of PSA testing on cancer characteristics and utilization of cancer therapies among men aged 70 or older, we utilized patients diagnosed with prostate cancer in 2004-2005 in the Surveillance, Epidemiology and End Results (SEER)-Medicare and their Medicare claims before their cancer diagnosis during 2000-2005. Among men in the highest testing group (4-6 PSA tests), 75% were diagnosed with low- or intermediate-risk of disease, but 77% received treatments within 180 days of cancer diagnosis. More than 45% of newly diagnosed patients in 2004-2005 had 4-6 PSA tests before their cancer diagnosis during 2000-2005. Men in the high testing group were 3.57 times more likely to receive cancer treatments (either surgery, radiation or hormonal therapy) when compared with men who had no previous PSA testing during the same time period. Among men aged 75+ diagnosed with low-risk cancer, men in the high testing group were 78% more likely to receive treatment than those who had no previous PSA testing. In conclusion, given the lack of evidence of effective treatment for elderly patients diagnosed with low- and intermediate-risk prostate cancer and our inability to distinguish indolent from aggressive cancer, more frequent PSA testing among elderly population may exacerbate the risk of overdiagnosis and overtreatment.

Organized colorectal cancer screening in integrated health care systems

Colorectal cancer (CRC) is an ideal target for early detection and prevention through screening. Noninvasive screening options are the guaiac fecal occult blood test and the fecal immunochemical test. Organized screening offers the promise of uniformly delivering screening to all members of a population who are eligible and due. Organized screening is defined as an explicit policy with defined age categories, method, and interval for screening in a defined target population with a defined implementation and quality assurance structure, and tracking of cancer in the population. The UK National Health Service; the Ontario, Canada Ministry of Health and Long-Term Care; and the US Veteran's Health Administration have used varied organized approaches to deliver guaiac fecal occult blood test screening to their populations. Kaiser Permanente Northern California began CRC screening in the 1960s, initially using flexible sigmoidoscopy. Implementation of organized fecal immunochemical test outreach was associated with improved Healthcare Effectiveness Data and Information Set CRC screening rates between 2005 and 2010 from 37% to 69% and from 41% to 78% in the commercial and Medicare populations, respectively. Organized fecal immunochemical test screening has been associated with an increase in annually detected CRCs, almost entirely because of increased detection of localized-stage cancers.

Time for a re-evaluation of mammography in the young? Results of an audit of mammography in women younger than 40 in a resource restricted environment

Mammography in younger women is considered to be of limited value. In a resource restricted environment without access to magnetic resonance imaging (MRI) and with a high incidence of breast cancer in the young, mammography remains an important diagnostic tool. Recent technical advances and better regulation of mammography make a reassessment of its value in these conditions necessary. Data of all the mammograms performed at a tertiary hospital and private breast clinic between January 2003 and July 2009 in women less than 40 years of age were collected. Indications were the presence of a mass, follow-up after primary cancer therapy, and screening for patients perceived at high risk due to a family history or the presence of atypical hyperplasia. Data acquired were as follows: Demographics, prior breast surgery, indication for mammography, outcome of mammography, diagnostic procedures, and their results. Of 2,167 mammograms, 393 were performed for a palpable mass, diagnostic mammography. In these, the overall cancer detection rate was 40%. If the mammography was reported as breast imaging reporting and data system (BIRADS(®)) 5 versus BIRADS(®) 3 and 4 versus BIRADS(®) 1 and 2, a final diagnosis of malignancy was established in 96, 48, and 5%, respectively. Of 367 mammograms done for the follow-up after primary treatment of breast cancer, seven cancers were diagnosed for a detection rate of 1.9%. Of 1,312 mammograms performed for screening, the recall rate was 4%; the biopsy rate 2%, and the cancer diagnosis rate 3/1,000 examinations. In contrast to past series, this series has shown that recent advances in mammography have made it a useful tool in the management of breast problems in young women, notably in a resource-restricted environment. Women for screening should be selected carefully.

Trends of mammography use in a national breast cancer screening program, 2004-2008

Purpose

Korea started breast cancer screening as part of the National Cancer Screening Program (NCSP) in 1999. In order to identify under-served groups, we investigated mammography uptake in the National Breast Cancer Screening Program.

Materials and Methods

The study population was participants in the National Breast Cancer Screening Program from 2004 to 2008. We analyzed participation rates by insurance type, age group, and area of residence.

Results

Total participation rates for breast cancer screening increased from 18.2% in 2004 to 35.0% in 2008. The participation rate in the group aged 60 to 69 years showed the greatest increase, 21.3%, among the four age groups. Although the screening rate increased continuously, the participation rate of the Medical Aid Program (MAP) group was low compared to the National Health Insurance (NHI) group. Moreover, the increasing trend of mammography uptake in the MAP group was much lower than that of the NHI group.

Conclusion

The participation rate for breast cancer screening in the NCSP in Korea has increased. However, the participation rate in mammography among MAP recipients is still lower than that of NHI beneficiaries. To increase mammography uptake, it is important to make it available to everyone by ensuring inclusion of all population subgroups.

Prescreening of a high-risk group for gastric cancer by serologically determined Helicobacter pylori infection and atrophic gastritis

BACKGROUND

Though gastric cancer screening by X-ray examination has been confirmed to be effective for reducing gastric cancer mortality, decreases in efficiency have been pointed out. Establishment of an effective screening system, focusing on high-risk status such as Helicobacter pylori infection and atrophic gastritis, is desirable. To date, combined use of serum anti-Helicobacter pylori antibodies and pepsinogen measurement has been assessed prospectively in participants in opportunistic and workplace health check-ups; however, there are no reports of population-based cohort study.

AIMS

To clarify the population-based risk of Helicobacter pylori infection and atrophic gastritis for gastric cancer, a cohort study was conducted in rural towns in Kyoto Prefecture.

METHODS

Subjects were 1,011 males and 1,848 females recruited in a health check-up in 1987. Their serum was examined for anti-Helicobacter pylori antibodies and pepsinogen I and II. Gastric cancer cases were assessed from the cancer registry of those towns.

RESULTS

Up to the end of 1996, 33 males and 28 females developed gastric cancer. A sex- and age-adjusted hazard ratio was calculated by Cox's proportional model. Helicobacter pylori infection increased the risk of gastric cancer even when the subjects had no atrophy (hazard ratio =4.20; 95% confidence interval, 0.96-18.40). The risk increased further when they had both Helicobacter pylori infection and atrophy (hazard ratio =11.23; 95% confidence interval, 2.71-46.51). Subjects with atrophy but negative for anti-Helicobacter pylori antibodies had the highest risk (hazard ratio =14.81; 95% confidence interval, 2.47-88.80).

CONCLUSIONS

A high-risk group for gastric cancer can be selected by serological prescreening.

Surgeon-read screening mammography: an analysis of 11,948 examinations

INTRODUCTION

Mammography was pioneered by surgeons but is now the domain of radiologists. With ever-increasing cost pressures it must be examined whether interpretation of mammography by clinicians and radiation technologists is comparable to that of breast radiologists. We present the largest series of surgeon-read screening mammography to date.

METHODS

All mammography performed between 2003 and 2009 at a comprehensive breast centre was recorded prospectively. First assessment was by a radiation technologist and consensus established after second reading by a breast surgeon, who took responsibility for the reading. Data recorded were: age, hormonal replacement therapy, prior breast surgery, indications for mammography and outcomes. Outcomes were classified based using the Breast Imaging Reporting and Data System (BIRADS). Indeterminate lesions were imaged further or underwent tissue acquisition. All BIRADS 5 lesions underwent tissue acquisition.

RESULTS

Of 11,948 mammograms, 538 were reported as indeterminate/compatible with malignancy; 240 biopsies were performed, and 87 cancers diagnosed. In 40-49-year-old women (4,956 mammograms), the recall rate was 4.2%, the biopsy rate was 1.6%, the malignancy rate of biopsy was 23.7% and the cancer diagnosis rate was 3.6/1,000 examinations; for 50-69-year-old women these figures were 6,546, 4.7, 2.2, 44.1% and 10.0/1,000, respectively, and in women older than 70 years, they were 446, 5.6, 3.4, 33.3% and 11.2/1,000, respectively. Of all cancers, 32.2% were non-invasive; of invasive cancers, 49.1% were 10 mm or less in diameter and 75% were node negative.

CONCLUSIONS

These results are similar to those in high-quality organized screening programs. The role of breast surgeons in mammography interpretation should be expanded.

How to enhance physician and public acceptance and utilisation of colon cancer screening recommendations

Colorectal Cancer (CRC) screening delivery is a multidisciplinary undertaking, aiming at reducing mortality from and incidence of CRC without adversely affecting the health status of participants. The adoption of a public health perspective involves commitment to ensure equity of access and sustainability of the program over time. We reviewed available evidence concerning predictors of CRC screening uptake and the impact of interventions to improve adoption of screening using conceptual frameworks defining the role of determinants of preventive behaviours and the reach and target of interventions. The results of this review indicate that policy measures aimed at supporting screening delivery, as well as organisational changes, influencing the operational features of preventive services, need to be implemented, in order to allow individual's motivation to be eventually realised. To ensure coverage and equity of access and to maximise the impact of the intervention, policies aimed at implementing organised programs should be adopted, ensuring that participation in screening and any follow-up assessment should not be limited by financial barriers. Participants and providers beliefs may determine the response to different screening modalities. To achieve the desired health impact, an active follow-up of people with screening abnormalities should be implemented, supported by the introduction of infrastructural changes and multidisciplinary team work, which can ensure sustainability over time of effective interventions. Continuous monitoring as well as the adoption of plans to evaluate for program effectiveness represent crucial steps in the implementation of a successful program.

Trends in socioeconomic disparities in organized and opportunistic gastric cancer screening in Korea (2005-2009)

BACKGROUND

A growth of consensus and increasing activities related to organized cancer screening programs has occurred in Korea since 1999. It is important to assess disparities in the fight against cancer, and it is crucial to identify particular groups that may be experiencing a high burden of cancer-related illness.

METHODS

Data from 8,160 men and women ages >40 years from the 2005 to 2009 Korean National Cancer Screening Survey were used to analyze the relationship between socioeconomic position and receiving upper gastrointestinal series or upper endoscopy within the past 2 years. We used absolute and relative concentration indexes, that is, summary measures of disparity based on both rate differences and rate ratios.

RESULTS

For organized screening, the education disparity declined, but the income disparity index increased, indicating that participation in organized screening was relatively more concentrated among the lower-income groups. For opportunistic screening, income and education disparities increased due to the widening of socioeconomic differences.

CONCLUSIONS

The results of this study suggested progress toward socioeconomic disparity-related goals in organized screening for gastric cancer. However, the income disparity trends in organized screening may change in a manner similar to those in opportunistic screening in the future because of the much faster rate of organized screening uptake by those higher on the socioeconomic scale.

IMPACT

This study addresses the routine monitoring of coverage of screening among different socioeconomic groups and could be used to inform policies to reduce disparity in coverage.

Social Class Inequalities in the Utilization of Health Care and Preventive Services in Spain, a Country with a National Health System

In Spain, despite the existence of a National Health System (NHS), the utilization of some curative health services is related to social class. This study assesses (1) whether these inequalities are also observed for preventive health services and (2) the role of additional private health insurance for people of advantaged social classes. Using data from the Spanish National Health Survey of 2006, the authors analyze the relationships between social class and use of health services by means of Poisson regression models with robust variance, controlling for self-assessed health. Similar analyses were performed for waiting times for visits to a general practitioner (GP) and specialist. After controlling for self-perceived health, men and women from social classes IV-V had a higher probability of visiting the GP than other social classes, but a lower probability of visiting a specialist or dentist. No large class differences were observed in frequency of hospitalization or emergency services use, or in breast cancer screening or influenza vaccination; cervical cancer screening frequency was lower among women from social classes IV-V. The inequalities in specialist visits, dentist visits, and cervical cancer screening were larger among people with only NHS insurance than those with double health insurance. Social class differences in waiting times were observed for specialist visits, but not for GP visits. Men and women from social classes IV-V had longer waits for a specialist; this was most marked among people with only NHS insurance. Clearly, within the NHS, social class inequalities are still evident for some curative and preventive services. Further research is needed to identify the factors driving these inequalities and to tackle these factors from within the NHS. Priority areas include specialist services, dental care, and cervical cancer screening.

Validation of the pepsinogen test method for gastric cancer screening using a follow-up study

BACKGROUND

Serum pepsinogen (PG) measurement has been used for gastric cancer screening since the 1990s. However, there are no reports comparing the screening validity of the PG test method with that of conventional X-ray examination directly in the same population, using a follow-up study.

METHODS

From April 2000 to March 2001, 12 120 residents of Osaka Prefecture, who underwent opportunistic screening at a medical checkup organization in Osaka city (hereafter, "the organization"), were enrolled. They received both a barium meal examination and PG test simultaneously. All the participants were followed up for a 1-year period after the screening. For the participants advised to undergo endoscopic examination, the results of those who were examined at the organization were tallied. The other participants were checked using the Osaka Cancer Registry (hereafter, "the registry").

RESULTS

Of the 12 120 participants, 493 (4.1%) were positive with the PG method and 728 (6.0%) were positive with the X-ray method. Fifty-four (0.4%) were positive for both methods. Thirteen gastric cancer cases were diagnosed by successive esophagogastroduodenoscopies at the organization. Six additional gastric cancer cases were identified by record linkage with the registry. The sensitivity, specificity, and positive predictive values of the PG method with a PGI cutoff level of <or=30 ng/ml and PGI/PGII ratio of <or=2.0 were 36.8%, 96.0%, and 1.4%, respectively. These values for the direct X-ray examination were 68.4%, 94.1%, and 1.8%, respectively.

CONCLUSION

The PG test method alone with a PGI cutoff level of <or=30 ng/ml and PGI/PGII <or= 2.0 is not appropriate for gastric cancer screening.

Population-based screening for colorectal cancer: Australian research and implementation

Australia is one of the first countries in the world to implement an organized whole-of-population screening program for colorectal cancer (CRC). Australians have made broad contributions to CRC in general ranging from primary prevention through genetics, secondary prevention and treatment, to palliation. This overview focuses on some of the contributions of direct relevance to population-based screening, stretching from technology development to population-based controlled studies and health services research. In terms of simple screening tests in a two-step screening strategy, the evidence is overwhelming that fecal immunochemical tests for hemoglobin (FITs) improve detection and are more acceptable. FIT-based screening is clearly acceptable to Australians and it has been demonstrated that a national organized screening program is feasible. In terms of benefit for Australians, with full roll out and high uptake by the population we could see the number of cases dying from CRC halved by this strategy. To this will be added the extra-screening benefits of improved diagnosis, improved treatment and improved public awareness, all benefits of other screening programs. CRC screening has progressed from a matter of irrelevance and distaste, to commonwealth government policy in the context of an organized program for all Australians.

Overuse of mammography during the first round of an organized breast cancer screening programme

OBJECTIVES

We examined the frequency of mammography screening among women who had had a screening mammogram recently and therefore generally did not need to repeat the examination.

METHODS

A population-based sample of 50- to 69-year-old women were surveyed immediately before and 8 months after they received an invitation to participate in the first round of screening of the newly organized mammography screening programme in Geneva, Switzerland. These women also received a booklet that included the recommendation to have screening mammograms at 2-year intervals.

RESULTS

The baseline survey identified 660 women who had had a mammogram within the previous 12 months. Of these, 23.2% [95% confidence interval (CI), 20.0-26.6] had an opportunistic mammogram and 4.1% (95% CI, 2.7-5.9) had an organized mammogram during follow-up. Women who had had their last mammogram 6-12 months prior to baseline (vs. more recently), intended to have a mammogram within the next 6 months, wished to receive more information on mammography screening, and had a history of surgical breast biopsy were more likely to have an unnecessary screening mammogram (either organized or opportunistic) during follow-up. Compared with women who had an opportunistic mammogram, women who had an organized mammogram were more likely to be of lower socioeconomic status, to have made their own screening decision and to have anticipated the date of their next mammogram by no more than a few months.

CONCLUSIONS

Opportunistic mammography screening in excess of recommendation is common, and persists despite explicit advice about recommended screening frequency.

Guideline implementation for breast healthcare in low- and middle-income countries: early detection resource allocation

A key determinant of breast cancer outcome in any population is the degree to which cancers are detected at early stages of disease. Populations in which cancers are detected at earlier stages have lower breast cancer mortality rates. The Breast Health Global Initiative (BHGI) held its third Global Summit in Budapest, Hungary in October 2007, bringing together internationally recognized experts to address the implementation of breast healthcare guidelines for early detection, diagnosis, and treatment in low- and middle-income countries (LMCs). A multidisciplinary panel of experts specifically addressed the implementation of BHGI guidelines for the early detection of disease as they related to resource allocation for public education and awareness, cancer detection methods, and evaluation goals. Public education and awareness are the key first steps, because early detection programs cannot be successful if the public is unaware of the value of early detection. The effectiveness and efficiency of screening modalities, including screening mammography, clinical breast examination (CBE), and breast self-examination, were reviewed in the context of resource availability and population-based need by the panel. Social and cultural barriers should be considered when early detection programs are being established, and the evaluation of early detection programs should include the use of well developed, methodologically sound process metrics to determine the effectiveness of program implementation. The approach and scope of any screening program will determine the success of any early detection program as measured by cancer stage at diagnosis and will drive the breadth of resource allocation needed for program implementation.

Cancer screenings, diagnostic technology evolution, and cancer control

Screening should allow for the anticipation of cancer diagnosis at an earlier stage, when curative treatment is possible. Screening for cervical, large bowel, and breast cancer were shown to be effective in reducing mortality. The wide acceptance of the screening concept led to the wide diffusion also of screening of uncertain benefit against prostate cancer and skin melanoma. Diagnostic technologies are continuously evolving, and new tests are proposed to improve existing screenings or as screening tests for additional cancer sites (e.g., lung cancer). Cancer screening, however, is a complex and costly intervention that does not result only in benefits but also may cause harm. A major emerging problem of screening is overdiagnosis, or the detection of cases that would have not progressed to the symptomatic phase in the absence of screening. Thus, both experimental and observational evaluation studies are needed to reduce harm caused by screenings and to select effective interventions among many proposed innovations. Finally, the research of markers to assess the aggressive nature of screen-detected lesions is of great importance to improve screenings ' harm/benefit ratio.

Utilization and cost of diagnostic imaging and biopsies following positive screening mammography in the southern breast cancer screening region of the Netherlands, 2000-2005

We prospectively assessed trends in utilization and costs of diagnostic services of screen-positive women in a biennial breast cancer screening program for women aged 50-75 years. All 2,062 women with suspicious findings at screening mammography in the southern region of the Netherlands between 1 January 2000 and 1 July 2005 (158,997 screens) were included. Data were collected on any diagnostic examinations, interventional procedures, and surgical consultations with two-year follow-up. We used national reimbursement rates to estimate imaging costs and percutaneous biopsy costs. Cost prices, charged by hospitals, were used to estimate open surgical biopsy costs and surgical consultation costs. The largest increase in utilization of diagnostic procedures per 100 referrals was observed for axillary ultrasound (from 3.9 in 2000 to 33.5 in 2005) and for stereotactic core biopsy (from 2.1 in 2000 to 26.8 in 2005). Per 100 referrals, the open surgical biopsy rate decreased from 34.7 (2000) to 4.6 (2005) and the number of outpatient surgical consultations fluctuated between 269.8 (2000) and 309.7 (2004). Mean costs for the diagnosis of one cancer were Euro1,501 and ranged from Euro1,223 (2002) to Euro1,647 (2003). Surgical biopsies comprised 54.1% of total diagnostic costs for women screened in 2000, but decreased to 9.9% for women screened in 2005. Imaging costs increased from 23.7 to 43.8%, percutaneous biopsy costs from 9.9 to 27.2%, and consultation costs from 12.3 to 19.1%. We conclude that diagnostic costs per screen-detected cancer remained fairly stable through the years, although huge changes in the use of different diagnostic procedures were observed.

Interval cancers in the beginning years of the breast cancer screening programme in the Belgian province of Limburg

OBJECTIVE

To assess the occurrence of interval breast cancers among those women who attended the mammography screening programme in the Belgian province of Limburg. Interval cancers are tumours that are being diagnosed before the next scheduled screening round and are related to the sensitivity and the screening interval.

METHODS

Biennial screening is provided to all women aged 50-69. The records of the screening programme were linked to those of the cancer registry. The interval cancer rate, expressed as a proportion of the underlying (expected) breast cancer incidence rate was calculated. The observed interval cancer incidence is the number of interval cancers per 10,000 'negative' screening tests.

RESULTS

The interval cancer rate in the first year was 25.37% for all cancers (ductal carcinoma in situ included) and 21.7% when the analysis was restricted to invasive tumours. Proportional incidence of interval cancer in the second year after screening was 12.02% for all cancers.

CONCLUSION

In conclusion, the interval cancer rates in the Belgian province of Limburg were compatible with the European guidelines. However, increasing the recall rate in our programme and systematically reviewing the interval cancers may improve the quality of the programme even further.

Impact of organised programs on colorectal cancer screening

Purpose

Colorectal cancer (CRC) screening has been shown to decrease CRC mortality. Organised mass screening programs are being implemented in France. Its perception in the general population and by general practitioners is not well known.

Methods

Two nationwide observational telephone surveys were conducted in early 2005. First among a representative sample of subjects living in France and aged between 50 and 74 years that covered both geographical departments with and without implemented screening services. Second among General Practionners (Gps). Descriptive and multiple logistic regression was carried out.

Results

Twenty-five percent of the persons(N = 1509) reported having undergone at least one CRC screening, 18% of the 600 interviewed GPs reported recommending a screening test for CRC systematically to their patients aged 50–74 years. The odds ratio (OR) of having undergone a screening test using FOBT was 3.91 (95% CI: 2.49–6.16) for those living in organised departments (referent group living in departments without organised screening), almost twice as high as impact educational level (OR = 2.03; 95% CI: 1.19–3.47).

Conclusion

CRC screening is improved in geographical departments where it is organised by health authorities. In France, an organised screening programs decrease inequalities for CRC screening.

Promoting regular mammography screening I. A systematic assessment of validity in a randomized trial

BACKGROUND

Most health promotion trials in cancer screening offer limited evidence of external validity. We assessed internal and external validity in a nationwide, population-based trial of an intervention to promote regular mammography screening.

METHODS

Beginning in September 2000, study candidates age 52 years and older (n = 23,000) were randomly selected from the National Registry of Women Veterans and sent an eligibility survey. Consistent with intention-to-treat principles for effectiveness trials, we randomly assigned eligible respondents and nonrespondents to one of five groups. We mailed baseline surveys to groups 1-3 followed by intervention materials of varying personalization to groups 1 and 2. We delayed mailing baseline surveys to two additional control groups to coincide with the mailing of postintervention follow-up surveys to groups 1-3 at year 1 (group 4) and year 2 (group 5). Mammography rates were determined from self-report and Veterans Health Administration records. To assess internal validity, we compared groups on participation and factors associated with mammography screening at each stage. To assess external validity, we compared groups 3, 4, and 5 on mammography rates at the most recent follow-up to detect any cueing effects of prior surveys and at the respective baselines to uncover any secular trends. We also compared nonparticipants with participants on factors associated with mammography screening at the trial's end.

RESULTS

We established study eligibility for 21,340 (92.8%) of the study candidates. Groups 1-3 were similar throughout the trial in participation and correlates of mammography screening. No statistically significant survey cueing effects or differences between nonparticipants and participants across groups were observed. Mammography screening rates over the 30 months preceding the respective baselines were lower in group 5 (82.3% by self-report) than in groups 1-4 (85.1%, P = .024, group 5 vs groups 1-4 combined), suggesting a decline over time similar to that reported for US women in general.

CONCLUSION

This systematic assessment provides evidence of the trial's internal and external validity and illustrates an approach to evaluating validity that is readily adaptable to future trials of behavioral interventions.

Awareness of and adherence to cancer screening guidelines among health professionals in Japan

Since 1998 in Japan, guidelines for cancer screening programs have been developed and revised by a research group funded by the Ministry of Health, Labour and Welfare. However, little is known about health professionals' awareness of and adherence to the cancer screening guidelines. Surveys were conducted by mailing questionnaires to two target groups of health professionals: local government officers of municipal cancer screening programs of 3327 municipalities in 47 prefectures (local government officers group; n = 3327) and councilors of an academic society dealing with a mass survey of gastroenterological cancer (expert group; n = 195). The questionnaire contained questions dealing with: (1) awareness of and adherence to the cancer screening guidelines published in 2001, and (2) basic knowledge of and attitude towards cancer screening. We compared the responses of the two groups. The response rate in both groups was approximately 65%. Over 70% of the respondents were aware of the cancer screening guidelines. However, 20% of the local government officers and 35% of the experts thought that non-recommended methods could be used for population-based screening. Fifty-six percent of the local government officers and 76% of the experts responded that there was no problem with using non-recommended methods for opportunistic screening. Almost all health professionals believed that screening was 'almost always a good idea'. Although the two groups' backgrounds differed, both did not sufficiently understand the evidence-based approach for cancer screening. To properly conduct evidence-based cancer screening, it is necessary that health professionals have an appropriate understanding of the guidelines.

Comparison of a community outreach service with opportunity screening for cervical cancer using Pap smears

We sought to compare the take-up of cervical screening with Pap smears in a new outreach and pre-existing hospital-based setting (1) to assess the extent to which the two means of provision would overlap; (2) to establish how the utilization rate is influenced by demographic features and geographical distance from the point of provision; and (3) to access whether an outreach service would lead to increased utilization. We used a pre-test-post-test design and used multiple linear regression to assess the effect an outreach service has on utilization after adjusting for participants age, education and martial status. We found that the outreach service independently provided screening to 89% of eligible women and that coverage was inversely associated with distance from the pre-existing hospital provision. After controlling for age, education and martial status, there was a statistically significant increase (53%; 95% CI: 25, 80%) in utilization. There was little overlap between the outreach and hospital-based cervical screening services so that overall accessibility was enhanced, particularly for the elderly, widowed and less well educated. The outreach service also reduced inequalities due to geography.

Who gets screened, and where: A comparison of organised and opportunistic mammography screening in Geneva, Switzerland

It is unclear whether introducing organised mammography screening programmes in a population where opportunistic screening is prevalent results in the two types of screening mainly competing against each other or attracting different groups of women. To compare women who participate in organised screening and those who prefer opportunistic screening, we conducted a prospective study of 932 women followed for 8 months after an invitation to participate in the first round of an organised screening programme in Geneva, Switzerland. All women were aged 50-69 years and were due for a mammogram according to local guideline. Of the 932 participants, 11.6% had an organised and 39.4% an opportunistic mammogram during follow-up. Women who were in the stage of contemplation, had favourable attitude toward mammography screening, and perceived their risk of breast cancer to be high were more likely to have a mammogram (either organised or opportunistic). Compared to women who had an opportunistic mammogram, women with an organised mammogram were less positive about screening, less likely to be in maintenance at baseline (adjusted odds ratio (OR), 3.0; 95% confidence interval (CI), 1.7-5.5), to have a history of benign breast disease (OR, 2.4; 95% CI, 1.2-5.1) and to perceive their financial situation as comfortable (OR, 1.7; 95% CI, 1.1-2.8). Although screening uptake was low, the programme appeared to attract women in lower socio-economic strata who did not usually undergo mammography screening.

Print information to inform decisions about mammography screening participation in 16 countries with population-based programs

OBJECTIVE

To profile and compare the content and presentation of written communications related to informed decision-making about mammography.

METHODS

Materials from 16 screening programs organized at the national or regional level were analyzed according to five major information domains suggested by the international literature.

RESULTS

A majority of countries provided information on the program (interval, cost and quality). There was considerable variability in comprehensiveness of elements in the domains, e.g., test characteristics (false positive/negative) and pros and cons of screening. The majority noted the likelihood of recall for further tests, few commented on the risks of additional tests or finding unimportant tumors. The audit also found variation in presentation (words and pictures).

CONCLUSIONS

Presentation of comprehensive, but balanced information on screening benefits and risks is complex and daunting. Issues such as framing effects, coupled with debate about screening efficacy are challenging to the design of effective information tools. The objective of increasing screening prevalence at the population level must be balanced with objectively presenting complete and clear information. Additional research is needed on how information (and mode of presentation) impact screening decisions.

PRACTICE IMPLICATIONS

Public health officials need to articulate their objectives and review written communication according to important decision-making domains.

Breast cancer in limited-resource countries: early detection and access to care

Although incidence, mortality, and survival rates vary fourfold in the world's regions, in the world as a whole, the incidence of breast cancer is increasing, and in regions without early detection programs, mortality is also increasing. The growing burden of breast cancer in low-resource countries demands adaptive strategies that can improve on the too common pattern of disease presentation at a stage when prognosis is very poor. In January 2005, the Breast Health Global Initiative (BHGI) held its second summit in Bethesda, MD. The Early Detection and Access to Care Panel reaffirmed the core principle that a requirement at all resource levels is that women should be supported in seeking care and should have access to appropriate, affordable diagnostic tests and treatment. In terms of earlier diagnosis, the panel recommended that breast health awareness should be promoted to all women. Enhancements to basic facilities might include the following, in order of resources: effective training of relevant staff in clinical breast examination (CBE) both for symptomatic and asymptomatic women; opportunistic screening with CBE; demonstration projects or trials of organized screening using CBE or breast self-examination; and finally, feasibility studies of mammographic screening. Ideally, for complete evaluation, such projects require notification of deaths among breast cancer cases and staging of diagnosed tumors.

Screening for Breast Cancer

Strong evidence supports the value of breast cancer screening with mammography, and high-quality mammography screening can be considered a major public health achievement. As noted earlier in the discussion about the evaluation of service screening, the group of women who did not participate in mammographic screening in the decades after screening had been introduced had essentially unchanged or only minor improvements in mortality compared with the pattern before the introduction of screening, despite widespread use of adjuvant chemotherapy or hormonal therapy. Breast cancer should be treated in its preclinical phase if we are to save the lives of women with this disease, and a considerable body of evidence outlines best practices that, with broader adherence, would result in greater breast cancer mortality reductions than have been observed to date.

Clinical Issues in the Management of Early Lung Cancer

Lung cancer is commonly diagnosed after metastatic spread, when therapies are rarely curative, providing an impetus for continued research directed at exploring approaches for cost-effective early lung cancer detection. Recently published pilot studies across three continents support a benefit of spiral computed tomography (CT) in detecting earlier stage non-small cell lung cancer. Improved resolution of early lung cancer is a result of significant changes in CT imaging hardware and software. The status and implications of these developments are reviewed. Many aspects of the management of screening for early lung cancer could be informed by optimizing the downstream clinical management of potential lung cancers identified by CT screening. The first and most critical issue is whether or not this improved detection rate is clearly associated with a reduction in lung cancer-related mortality. However, other related issues such as cost-benefit evaluations are also considered. If smaller, truly localized primary cancer can be routinely detected, then options for less morbid interventions would also be desirable. The rapid improvement in resolution and cost of spiral CT has provided a powerful impetus to reconsider the possibilities for achieving safe, economical, and meaningful early lung cancer detection.

Interventions to improve follow-up of abnormal findings in cancer screening

The potential reduction in morbidity and mortality through cancer screening cannot be realized without receipt of appropriate follow-up care for abnormalities identified via screening. In this paper, the authors critically examine the existing literature on correlates of receipt of appropriate follow-up care for screen-detected abnormalities, as well as the literature on interventions designed to increase rates of receipt of follow-up care. Lessons learned describe what is known and not known about factors that are related to or predict receipt of follow-up care. Similarly, effective interventions to increase follow-up are described and gaps identified. A conceptual model is developed that categorizes the health care system in the United States as comprising four levels: policy, practice, provider, and patient. Some patient-level factors that influence follow-up receipt are identified, but the lack of data severely limit the understanding of provider, practice, and policy-level correlates. The majority of intervention studies to increase follow-up receipt have focused on patient-level factors and have targeted follow-up of abnormal Papanicolaou smears. Insufficient information is available regarding the effectiveness of provider, practice, or policy-level interventions. Standard definitions of what constitutes appropriate follow-up are lacking, which severely limit comparability of findings across studies. The validity of various methods of obtaining outcome data has not been clearly established. More research is needed on interventions targeting provider, system, and policy-level factors, particularly interventions focusing on follow-up of colorectal and breast abnormalities. Standardization of definitions and measures is needed to facilitate comparisons across studies.

The future of research that promotes cancer screening

The authors draw on the lessons highlighted in preceding articles in the current supplement to provide recommendations for cancer screening intervention research and to highlight some of the many questions that will require further investigation.