VS




 It have to be of a high standard.
 The screening services are checked and monitored by people from outside the programme.
 Everyone who takes part is offered the same services, information and support. Often, large numbers of people are invited to take part in organised screening programmes. The National Screening Unit oversees national organised screening programmes.
 It has important quality advantages over “unorganized” screening: predictable and thorough recruitment, patient recall and follow-up by way of a central registry, ongoing quality assurance, and quality control and evaluation.

( Spontaneous screening )
 It happens when someone asks their doctor or health professional for a check or test, or a check or test is offered by a doctor or health professional.
 It may not be checked or monitored.
 This strategy relies on the patient regularly visiting a family physician. When patients are visiting their doctors for unrelated problems, the doctor applies or refers a patient for a screening test e.g. a blood pressure check for all adults patients coming into the office, regardless of why they are seeing the doctor, or carrying out a
Pap test on a woman who has come in for an ear infection and has not had a Pap test for several years, or referring a woman to have a screening mammogram.
 It does not not include all of the supports and quality assurance features of an organized program, such as reminding patients who have not seen the doctor for a long time to have a screening test because it is overdue.

Opportunistic Screening :
• Reducing the probability of dying from Ca
• Reducing the probability of having an invasive/advanced Ca
• Improving quality of life
Organised Screening :
• Reducing mortality from specific cause
• Reducing incidence of invasive/advanced Ca
• Improving quality of life (minimising adverse effects)
• Equity of access
Coverage of the target population

Opportunistic:
Organised:
Frequently aims at maximum sensitivity: high recall rate
Frequently non validated adjunctive first level tests
II level: decided by single Specialist
Balance between sensitivity and specificity: low recall rate
Only validated tests
II level: frequently decided by multidisciplinary team

• Active call/recall system
• Defined screening protocol (target population, test, interval)
• Protocol for management of positives
• “fail safe system” for diagnostic work-up and treatment
• Quality assurance and monitoring of all phases

Opportunistic:
No or little monitoring:
Only a few process indicators can be obtaines
PPV meaningless in a population with variable prevalence (clinical + screening)
Difficult collecting interval cancers;
Organised:
Monitoring of process indicators,
Linkage of screening data with cancer occurrence

• A large proportion of the target population have no screening at all
• The remaining tend to have too frequent screening
• There is a strong difference in access to screening (e.g by age and education)
• Subjects out of the target population (e.g. too young) are screened

Main steps in implementing a screening programme
1.
Determine whether such a programme is a public health priority.
2.
Determine whether the human and financial resources exist.
3.
Describe the organisation in a adequate protocol.
4.
Conduct a pilot programme to test the protocol.
5.
Design quality assurance and monitoring systems for evaluating the effects, costs and quality indicators.
6.
Solve problems of financing, organisation and evaluation.
7.
Disseminate the programme to the entire target population, when successful.
UICC Evidence-based Cancer Prevention: Strategies for NGOs 2004

An organised screening programmes includes:
• an explicit policy, with specified age categories, method and interval for screening;
• a defined target population;
• a management team responsible for implementation;
• a health care team for decision and care;
• a quality assurance structure;
• a method for identifying cancer occurrence in the target population.
IARC Handbooks of Cancer prevention. International Agency for Research on cancer. World Health
Organisation – Breast cancer screening 2002

• Good management
• Population register
• Call recall system
• Invitation - from centre or from GP, appropriate health education
• Choice of appointment?

• Need to deal with fears/anxieties
• Facilities available for i) diagnostic follow-up ii) prompt reporting iii) treatment
• Fail-safe method to ensure treatment of true positives
• Quality assurance

Adequate resources for starting and continuing the programme
The screening programme must be tailored to the country’s health system. Cancer screening is part of a process, which includes screening, analysis of the results of the screening test, diagnosis and treatment. Close liaison must be maintained between the screening organisation and the curative system, so that people with positive results can be cared for without delay and that the same measures, of the highest possible quality, are used throughout the territory covered by the programme.
 Involvement of a primary care provider or specialised screening facilities.
 The health system must be able to provide timely, accurate responses to the results of the screening tests and a service for potential emotional effects; timely assessment is essential to minimise their anxiety.
 Screening alone does not reduce mortality or morbidity, and there must be access to high-quality assessment and treatment .
 Currently accepted population cancer screening strategies require repeated testing at regular intervals in order to have a substantial effect on mortality rates.
 Population cancer screening should be regarded as a continuous process requiring regular recalls of eligible people.

All staff in a screening programme should:
 hold professional qualifications as required
 undertake specialist training
 participate in continuing medical education and updates
 take part in any recognised external quality assessment schemes
 hold any necessary certificate of competence.

Training of all personnel involved in the programme
Lesions detected at screening are usually different from symptomatic lesions, and the personnel involved in diagnosis require specific training.
Training for communication of benefits and risks, psychological support and the screening process should be provided to all professionals involved.

Invitation system for the target population
If an organised programme does not involve sending invitations, a large proportion of the eligible population may be inadequately covered and the interval between tests for screened subjects may be inadequate.
In addition, people who are not adequately screened tend to belong to lower social classes, resulting in inequalities in access. Active invitation should therefore be introduced to increase coverage, improve cost-effectiveness and reduce inequalities.
A communication strategy should be devised to reach the target population and all the professionals involved in the programme.
Advertising through the mass media could be planned, preferably at regular intervals, to reinforce the message. Newspapers, magazines, television and radio can disseminate information promoting screening.

• Linkage with the registry office for sending invitation letters, reminder letters and result’s letters to the target population
• Electronic diary
• Cancer register
• Specific database for data analysis and evaluation

Evaluation of a screening programme
 to ensure goals are achieved
 to determine whether costs (financial and psychological) are appropriate for benefits obtained.

A screening programme includes many phases, each one submitted to rigorous quality controls:
 Invitation to the target population
 Execution of the test
 Communication of the results
 Invitation for further assessment or technical repetion of the test
 Proposal of a medical or surgical treatment
 Evaluation of the outcomes

Identifying the target population
Invitation (appointments)
Examination
(test, results )
Further assessment
Feedback of the information
Treatment and follow-up

1.
2.
3.
4.
Balance between:
• decentralisation
• N° of screening test per day
(mobile unit, transport facilities)
The screening centre may be in a hospital or clinic, or it may be in a mobile unit.
Caracteristics of the centres:
(cleaning, waiting room, absence of architectural barriers)
Activity hours

Invitation signed by the general practitioner
Prefixed appointment
(modifiable)
Feedback of the information to the GP and to the women
Free test
No medical prescription

 All the screening tests, further assessment and follow-up stages are free
 Quality of the screening programme
 Constant training of the screening operators

Organised screening targets women age 50-69
Mammography
Educational level
50-69 years 35-49
70 and more
Univ. eegree/ higher secondary school
Lower secondary school
79.3
73.6
42.7
37.7
52.8
47.6
Primary school
65.5
31.9
36.1
Total
71.0
39.4
38.2
RR Univ. degree vs primary school
1.21
1.35
1.48
ISTAT 2004-2005

Segnan et al. Tumori 1990. Ronco et al. Europ J Cancer 1997

Interaction of Spontaneous and Organised Screening for Cervical Cancer in
Turin, Italy
Ronco G et al Eur J Cancer, Vol. 33, No. 8, pp. 1262-1267, 1997

US (opportunistic) vs UK (organised) breast
Screening: 10 yrs Detection Rate per 1000
Women, 60-69 yrs of age:
Recalled women
Detected
Cancers
Open Surgical
Biopsy
US (Interval
18 months)
334 - 396
18 - 25
27
UK (Interval
36 months)
133
23
12

coverage recall rate detection rate/1000 p-y
Interval Cancers /1000 p-y
% cancers < 15 mm limphnodes +
Hofvind S, et al J Natl Cancer Inst. 2008 opportunistic
Vermont
81%
9,8%
2,77
1,24
63,6%
26% organised
Norway
83%
2,7%
2,57
0,86
60,8%
29,80% p diff
<0,001
0,12
<0,001
0,46
0,08

Cost effectiveness of breast cancer screening in
Switzerland
Organised screening :
Cost per year of life gained €11,512.
Opportunistic Screening:
Similar effectiveness
Cost per year of life gained €22,671-24,707.
Difference is due to higher frequency of referral for diagnostic work-up.
de Gelder Ret al. Eur J Cancer. 2009

AGE-STANDARDIZED INCIDENCE OF INVASIVE
CERVICAL CANCER AND COVERAGE OF SCREENING,
ENGLAND, 1971–1995
18
16
14
Invasive cervical cancer
12
10
0
National call-recall introduced
Coverage
20
10
0
60
50
40
30
100
90
80
70
Reprinted from Quinn M et al. BMJ 1999;318(7188):904 – 8 with permission from BMJ Publishing group.
YEAR

TIME TRENDS IN AGE-STANDARDIZED (WORLD) INCIDENCE RATES OF
CERVICAL CANCER INCIDENCE IN FOUR NORDIC COUNTRIES
30
20
10
5
1955 1960 1965 1970 1975 1980 1985 1990 1995
YEAR
Denmark Finland Norway Sweden
Parkin DM, et al.
Cancer incidence in five continents, vol. I – VIII. Lyon: IARC CancerBase No. 7; 2005.

Person-years, number of cervical cancers, incidence density and incidence density ratio (IDR) among not invited women and, within invited, among attenders and nonattenders
Crude
Person-years
Cancer cases a
Incidence Age-standardised
(per 10  py) incidence b
IDR c 95% CI
Not invited
1265075 118 9,3 8,5 1,0
Invited
918862 72 7,8 6,9 0,81 0,59-1,09
Invited nonattenders
570186 61 10,7 9,5 1,0
Invited attenders
348676
11 3,2 3,0 0,2 0,13-0,50
ª Cases with morphology specified as nonsquamous or staged as microinvasive excluded.
b Standardised on the world population truncated 24-69 years, per 100 000 py.
c Adjusted for age in 5-year groups by Poisson regression.
Ronco et al. Br. J. Cancer 2005;93:376-8.

Cervical cancers diagnosed among attenders
Person-years
Cancer cases a
Crude
Incidence Age-standardised
(per 10  py) incidence b
After non-normal cytology
30973 7 22,6 23,0
After normal cytology
Independently of time
317702 4 1,3 1,2
Within 3,5 years after last normal cytology
295414 2 0,7 0,4
Over 3,5 years after last normal cytology
22288
2
9,0 11,1
ª Cases with morphology specified as nonsquamous or staged as microinvasive excluded .
b
Standardised on the world population truncated 24-69 years, per 100 000 py.
Ronco et al. Br. J. Cancer 2005.
G. Ronco CPO