Evaluation of Cancer Screening

196 Pages·1996·8.327 MB·English

by  Sue Moss (auth.), Jocelyn Chamberlain, Sue Moss (eds.)

Focus on Cancer
Springer
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Jocelyn Chamberlain and Sue Moss (Eds.)
Evaluation of
Cancer Screening
Springer
Jocelyn Chamberlain
Sue Moss
Cancer Screening Evaluation Unit, Section of Epidemiology
Institute of Cancer Research, Block D, Cotswold Road
Sutton, Surrey SM2 SNG, UK
ISBN-13: 978-3-540-19957-1 e-ISBN-13: 978-1-4471-3044-4
DOl: 10.1007/978-1-4471-3044-4
British Library Cataloguing in Publication Data
Evaluation of Cancer Screening. -(Focus on Cancer Series)
I. Chamberlain, Jocelyn II. Moss, Susan III. Series
616·994075
Library of Congress Cataloging-in-Publication Data
Evaluation of Cancer Screening 1 Jocelyn Chamberlain and Sue Moss (eds.)
p. em. --(Focus on cancer)
Includes bibliographical references and index.
1. Cancer--Diagnosis--Evaluation. 2.. Medical screening--Evaluation
I. Chamberlain, Jocelyn, 1932- . IL Moss, Sue, 1952- . III. Series
[DNLM: 1. Neoplasms--prevention & control. 2.. Mass screening.
3. Program Evaluation. QZ 200 E913 19951
RA645.C3E975 1995
362..1" 96994--dc20
DNLMlDLC
for Library of Congress 95-23890
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Contents
Preface. .......................................................................................................... ix
The Editors and the Contributors ............................................................. xi
1. GENERAL PRINCIPLES OF CANCER SCREENING ....................... 1
Introduction .......................................................................................... 1
Consideration of a Potential Screening Test ...................................... 1
Evaluating the Performance of a Test................................................. 3
Evaluating the Effectiveness of Screening .......................................... 5
Mathematical Models of Screening ..................................................... 9
Selection of High-Risk Groups for Screening .................................... 10
Promotion of Early Diagnosis ............................................................. 10
Ethical Issues ......................................................................................... 10
Genetic Issues ....................................................................................... 11
References ............................................................................................. 11
2. SCREENING FOR CANCER OF THE CERVIX ................................ 15
Introduction .......................................................................................... 15
Epidemiology of Cervical Cancer ........................................................ 15
The Natural History of Cervical Cancer ............................................. 16
The "Pap" Test ...................................................................................... 17
Evidence for the Effectiveness of Screening ....................................... 17
The Effectiveness of Screening in the UK ........................................... 20
The Treatment of Screen-Detected Lesions ....................................... 22
Cost-Effectiveness of Cervical Screening ........................................... 23
Frequency of Cervical Screening ......................................................... 23
Quality Control Issues .......................................................................... 24
Sensitivity of Screening ........................................................................ 25
Potential for Automation ..................................................................... 26
Alternative Tests ................................................................................... 26
Screening in Developing Countries .................................................... 26
The Role of HPV in Cervical Cancer ...................................................2 8
References ............................................................................................. 28
3. SCREENING FOR CANCER OF THE BREAST ................................ 33
Epidemiology ........................................................................................ 33
vi Contents
Aetiology ............................................................................................... 34
Treatment, Survival and Prognosis of Breast Cancer. ....................... 35
Predisposing Factors ............................................................................ 36
The Rationale for Screening ................................................................ 37
Screening Tests for Breast Cancer. ...................................................... 37
Effectiveness of Screening in Reducing Mortality ............................ .41
Effectiveness of Screening Younger Women .................................... .43
Effectiveness of Breast Self-Examination .......................................... .45
Disadvantages and Costs of Breast Screening. .................................. .46
Conclusions ........................................................................................... 49
References ............................................................................................ .49
4. SCREENING FOR COLORECTAL CANCER .................................... 55
Introduction .......................................................................................... 55
Time Trends-.......................................................................................... 55
Geographical Variation ........................................................................ 56
Aetiology and Primary Prevention ..................................................... 56
High-Risk Groups for Colorectal Cancer ........................................... 57
Natural History ..................................................................................... 57
Prognosis of Colorectal Carcinomas ................................................... 59
Overall Survival. .................................................................................... 59
The Rationale for Screening ................................................................ 60
Screening Methods ............................................................................... 60
The Acceptability of Screening ............................................................ 65
The Effectiveness ofScreening ............................................................ 66
Disadvantages and Costs ..................................................................... 70
Conclusions ........................................................................................... 71
References ............................................................................................. 72
5. EARLY DETECTION OF MALIGNANT MELANOMA OF
THE SKIN ...................................................................................... 77
Introduction .......................................................................................... 77
Natural History ..................................................................................... 78
The Screening Test for Malignant MeIanoma .................................... 79
Options for Screening .......................................................................... 81
Health Education to Promote Self-Screening .................................... 81
Organised Professional Screening. ...................................................... 87
Other Aspects of Screening. ................................................................. 89
Conclusions ............................ :·. ............................................................. 90
References ............................................................................................. 90
6. SCREENING FOR OVARIAN CANCER ............................................ 95
Introduction .......................................................................................... 95
General Requirements. ......................................................................... 95
Candidate Tests: Evidence from Observational Studies ................... 98
Contents vii
Tumour Markers ........................................................... ;.................... 98
Improving Performance. .................................................................... 102
Intervention Studies ........................................................................... 10 7
Conclusions ................•......................•••.......................•....................... 111
References ........................•.....................•....•....................................... 112
7. SCREENING FOR PROSTATE CANCER ..........................•............. 117
Time Trends and International Differences in Incidence ..•........... 117
Aetiology ............................................................................................. 119
Staging ................................................................................................. 120
Survival ................................................................................................ 121
Natural History ................................................................................... 122
Determinants of Prognosis ................................................................ 123
Screening Tests for Prostate Cancer ................................................. 124
Prevalence of Prostate Cancer at Screening ..................................... 127
Acceptability of Screening ................................................................. 128
The Effect of Screening on Prostate Cancer Mortality .................... 128
The Potential Disadvantages of Screening for Prostate Cancer ..... 129
Conclusions ...................•.•........•.•.....•.•.•.............•.........•...................... 132
References ......................•.••.............•••.•.......................••...................... 132
8. SCREENING FOR CANCERS OF OTHER SITES: LUNG,
STOMACH, ORAL AND NEUROBLASTOMA •..........•........... 137
Introduction ........................................................................................ 13 7
Lung Cancer ........................................................................................ 137
Stomach ............................................................................................... 142
Neuroblastoma ................................................................................... 145
Oral Cancer ......................................................................................... 149
References ........................................................................................... 153
9. PSYCHOLOGICAL ASPECTS OF CANCER SCREENING ............ 159
Introduction ........................................................................................ 159
Research Methodology. ...................................................................... 159
Psychological Effects ofInvitation to Screening .............................. 161
Psychological Effects of a Positive Screening Test .......................... 162
Psychological Effects in Patients with Screen-Detected Cancer ..... 164
Reducing Distress - Improving Attendance .................................... 167
Reduction in the Distress Caused by Recall ..................................... 168
Staff Stress ........................................................................................... 169
Self-Screening ..................................................................................... 170
Selective Screening ............................................................................. 170
Conclusions and Further Research Needs ....................................... 171
References ........................................................................................... 171
viii Contents
10. ECONOMIC ASPECTS OF CANCER SCREENING ....................... 175
Introduction ........................................................................................ 175
The Need for Economic Appraisal .................................................... 176
Methods for Economic Evaluation. ................................................... 176
Economic Appraisal of Cancer Screening Programmes ................. 178
Some Empirical Findings of Economic Evaluations of Cancer
Screening. ........................................•............................................ 183
Conclusions ......................................................................................... 184
References ........................................................................................... 184
Index ........................................................................................................... 187
Preface
In the absence of effective primary prevention of cancer, "secondary
prevention" by means of screening is, on the face of it, an attractive
proposition for many cancer sites. Nevertheless, only for breast and
cervical cancer is the benefit of screening considered sufficiently proven in
many countries for a public-health population-based screening pro
gramme to be implemented.
As with other public-health interventions, there is a particular ethical
responsibility on those providing screening to ensure that the chance of a
person benefiting from it exceeds the chance of his being harmed by it.
Therefore it is necessary to establish by research the extent of benefit, e.g.
the proportion of deaths avoided or life-years gained, and to balance this
against the disadvantages incurred through factors such as false-positive
test results, overdiagnosis of non-progressive disease and opportunity
costs of using public or private resources for this purpose.
The aim of this volume is to provide an up-to-date review of current
evidence on the value of cancer screening. Following an initial chapter
which outlines the general principles of screening and the research meth
odology required, individual chapters describe research-based evidence
on the pros and cons of screening for ten different cancers. For each one,
the size of the problem in terms of incidence and mortality is described
and its aetiology is briefly reviewed, so as to indicate not only the feas
ibility of primary prevention, but also the high-risk groups at which
screening might be targeted. Such evidence as there is on natural history is
described, with an indication of how this could theoretically be altered by
early detection. Estimates of the sensitivity and specificity of potential screen
ing tests are summarised, and the findings of studies aimed at measuring re
ductions in mortality or incidence are reported. Evidence, which is usually
sparse, on the side-effects and costs of screening is also summarised.
The two fmal chapters deal with psychological and economic aspects of
screening, with an emphasis on the difficult methodological problems that
measurement of these aspects entails.
It is hoped that this book will be of value to all health professionals with
an interest in screening and cancer control, but especially to purchasers of
health care, whether in the public or the private sector.
Sutton, 1995 Je
SM
The Editors and the Contributors
Dr Jackie Brown
Institute of Cancer Research, Section of Epidemiology
D Block, Cotswold Road, Sutton, Surrey SM2 5NG
Professor Jocelyn Chamberlain
Institute of Cancer Research, Section of Epidemiology
D Block, Cotswold Road, Sutton, Surrey SM2 5NG
Professor Howard Cuckle
Institute of Epidemiology and Health Services Research
Department of Clinical Medicine, The University of Leeds
34 Hyde Terrace, Leeds LS2 9LN
Dr Ruth Ellman
Institute of Cancer Research, Section of Epidemiology,
D Block, Cotswold Road, Sutton, Surrey SM2 5NG
Dr Jane Melia
Institute of Cancer Research, Section of Epidemiology
D Block, Cotswold Road, Sutton, Surrey SM2 5N.G
Dr Sue Moss
Institute of Cancer Research, Section of Epidemiology
D Block, Cotswold Road, Sutton, Surrey SM2 5NG