Foreword: Promoting cancer screening

Abstract

T his remarkable collection of articles draws to close a generation of research regarding the promotion of cancer screening. Beginning in the mid-1980s with breast cancer screening using mammography, there has been an unprecedented growth in our understanding of how to encourage the use of screening tests, and a transformation in how people conceptualize the issues. 1 This supplement highlights the lessons learned from that generation of research and provides the foundation for the next. Looking through this volume offers the rare opportunity to reflect on an entire body of research, representing hundreds of grants and articles published by investigators who worked during what I believe was a golden age for screening.These last 20 years were a prime time to develop our understanding of screening; we had relatively simple tests for things people could see. Cervical cancer screening had been around since the 1940s and the regular Papanicolaou (Pap) smear was part of the annual examination. 2 People could understand breast cancer and knew of it occurring in their friends and family. The work of the 1980s focused on improving followup to the familiar Pap smear and promoting mammography. Investigators initially examined how patient characteristics were associated with screening and then considered the characteristics of those physicians who did not appear to be ordering the appropriate tests. 3 The belief was if we could just get women to have the right attitude and the physicians to do their job, screening and follow-up would happen.However, screening promotion became a more complex task as the 1990s evolved. First, it was not so clear that mammography benefited all women. 4 There was some backlash with regard to what may have been an overselling of screening. 5 It also emerged that mammography was not equally available to all people, and especially not the underinsured. 6 The context of screening mattered with regard to whether screening was available and ordered. 7 It was not just a question of the right attitude and the right physician; it also became an issue of the right environment.Additional tests then began to appear such as prostate-specific antigen, sigmoidoscopy, fecal occult blood testing, genetic screens for mutations in specific genes, and tests for the human papillomavirus. Simultaneous with this growth in tests was the growth in "evidencebased" medicine. People began to be more critical concerning the basis for recommending medical interventions such as screening, and pressure grew to go beyond just ordering the test but rather to discuss what was known. Rimer et al. 8 describe this growing area of work and 1105