To Screen or Not to Screen

Abstract

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

“They Should Be Asking Us”: A Qualitative Decisional Needs Assessment for Women Considering Cervical Cancer Screening

“…Some authors have discussed perceived challenges of autonomous decision-making within the context of a population-based cancer screening program (Elston Lafata et al, 2017; Jepson et al, 2005; Salmi et al, 2016; van Dam, Kuipers, Steyerberg, van Leerdam, & de Beaufort, 2013). In the cervical screening situation, many HCPs were concerned about offering modalities to patients that were considered inferior to the modalities recommended by clinical practice guidelines.…”

“…Findings from this study demonstrated an interesting paradox that HCPs and individuals trusted cancer agencies and networks to know the “best” options for cervical screening for individuals, yet, some respondents also expected system-level institutions to prioritize financial or other system prerogatives above an individual’s wellbeing. As test acceptability is a crucial component of a successful screening program (Dobrow, Hagens, Chafe, Sullivan, & Rabeneck, 2018; Salmi et al, 2016; Wilson & Jungner, 1968), women want confirmation from HCP stakeholders that the options are valid.…”

“…Health care professionals (HCPs) who use these guidelines often feel obligated to promote the recommendations, despite individuals’ preferences for alternative options (Jepson, Hewison, Thompson, & Weller, 2005; Petrova, Dale, & Fulford, 2006; Trevena, 2009). The divide between population and individual perspectives may be augmented for cancer screening programs or policies because of the requirements of a mass screening program (i.e., a defined, long preclinical phase, need for accurate and reliable tests, demonstrable effective early treatment; Salmi, Coureau, Bailhache, & Mathoulin-Pélissier, 2016). Shared decision-making processes can reconcile individual and population perspectives for cancer screening by addressing the individual acceptability of tests in the context of HCP values and evidence-informed recommendations (Grad et al, 2017; Lang et al, 2018).…”

The ethical, social, and cultural dimensions of screening for mental health in children and adolescents of the developing world

“…In line with canonical screening practices [ 35 , 114 , 115 ], most panelists agreed that screening should only be carried out where post-screening follow-up is available. They considered it would be unethical to burden C&A and their families with positive screening results in the absence of access to effective treatment.…”

Development and field testing of a tool to elicit women's preferences among cervical cancer screening modalities

“…Some experts are wary of applying population preferences in individual encounters for cancer screening because extrapolating might be inaccurate or ignore individual's autonomy in decision-making. 10,55,56 Many researchers are currently investigating robust methods to elicit and synthesize preferences for use in population-level recommendations. 14,15,57,58 "Cervical cancer screening-it's your choice" was designed to inform future person-centred cervical cancer screening guidelines and met the quality criteria of an individual-level decision tool.…”