Cancer Screening and Early Detection
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Screening may help detect cancer at an early stage before symptoms develop, or even at a per-cancerous stage, which makes it more likely to be curable. However, in practice screening for certain cancers has proven complex and even counter-intuitive. Also, there is increasing awareness of risks with screening, such as exposure to invasive examinations, and "overdiagnosis" of tumours that may not necessarily have caused a problem within a person's lifetime. For some types of cancer, cervical cancer for example, there is general consensus amongst experts about its value in early detection/prevention and many countries have established national screening programmes. For other types of cancer, the value of screening is more controversial and practice may vary. Also, the optimum age at which to begin screening and the specific tests used can vary and have been refined as further research is undertaken. Screening may be population based ("mass screening") e.g. all women over 40, or it may be targeted at "high risk" groups e.g. people with a known family history or genetic predisposition to cancer.

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Breast Cancer Screening
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Information Patients and the Public (6 links)


Information for Health Professionals / Researchers (6 links)

Latest Research Publications

This list of publications is regularly updated (Source: PubMed).

Etzioni R, Gulati R
Response: Reading between the lines of cancer screening trials: using modeling to understand the evidence.
Med Care. 2013; 51(4):304-6 [PubMed]
In our article about limitations of basing screening policy on screening trials, we offered several examples of ways in which modeling, using data from large screening trials and population trends, provided insights that differed somewhat from those based only on empirical trial results. In this editorial, we take a step back and consider the general question of whether randomized screening trials provide the strongest evidence for clinical guidelines concerning population screening programs. We argue that randomized trials provide a process that is designed to protect against certain biases but that this process does not guarantee that inferences based on empirical results from screening trials will be unbiased. Appropriate quantitative methods are key to obtaining unbiased inferences from screening trials. We highlight several studies in the statistical literature demonstrating that conventional survival analyses of screening trials can be misleading and list a number of key questions concerning screening harms and benefits that cannot be answered without modeling. Although we acknowledge the centrality of screening trials in the policy process, we maintain that modeling constitutes a powerful tool for screening trial interpretation and screening policy development.


Melnikow J, LeFevre M, Wilt TJ, Moyer VA
Counterpoint: Randomized trials provide the strongest evidence for clinical guidelines: The US Preventive Services Task Force and Prostate Cancer Screening.
Med Care. 2013; 51(4):301-3 [PubMed]
BACKGROUND: The US Preventive Services Task Force recommended against prostate-specific antigen (PSA) screening for prostate cancer based primarily on 2 large long-term randomized-controlled trials (RCTs) and a systematic review of harms resulting from screening.
OBJECTIVE: To support use of large, long-term randomized trials as the evidence base for clinical guidelines on screening and to draw attention to limitations of modeling studies used for this purpose.
METHODS: We respond to critiques of use of RCTs as the primary evidence base, considering the results of the Prostate, Lung, Colorectal and Ovarian (PLCO) and European Randomized Study of Screening for Prostate Cancer (ERSPC) trials, documented harms resulting from PSA screening, and methodological concerns with modeling studies.
RESULTS: The PLCO and ERSPC provided 11-13 years of follow-up on over 250,000 subjects. The PLCO, despite limitations, is most representative of US populations, screening and treatment practices, and showed no mortality benefit resulting from annual PSA testing after 13 years of follow-up. The confidence interval was narrow and precluded more than a 13% relative mortality reduction. Competing causes of mortality in older men make it progressively less likely that longer follow-up will demonstrate a large absolute reduction in disease-specific mortality. With continued screening, the increasing prevalence of asymptomatic cancers in older men will increase the rate of overdiagnosis. Potential harms from screening and treatment are significant.
CONCLUSIONS: Projections from models are subject to mistaken assumptions and investigator biases, and should not be accorded the same weight as evidence from RCTs. Current empiric evidence is sufficient to support the US Preventive Services Task Force guideline that clinicians should recommend against PSA screening for prostate cancer.


Smetherman DH
Screening, imaging, and image-guided biopsy techniques for breast cancer.
Surg Clin North Am. 2013; 93(2):309-27 [PubMed]
Mammography remains the primary modality for breast cancer diagnosis. Other imaging studies, most commonly ultrasonography and magnetic resonance imaging, are also used to characterize breast lesions, stage breast cancer, and aid in surgical planning. Although mammography is the only screening examination demonstrated to decrease breast cancer mortality in the general population, other imaging studies have been shown to be beneficial for screening high-risk patients. In the future, new technologies may also improve the sensitivity and specificity of breast cancer screening and detection.


Trombold J, Farmer RW, McCafferty M
The impact of colorectal cancer screening in a veteran hospital population.
Am Surg. 2013; 79(3):296-300 [PubMed]
Colon and rectal cancer is the second most common cause of cancer death in the United States. Screening effectively decreases colorectal cancer mortality. This study aims to evaluate the impact of colorectal cancer screening within a Veterans Affairs Medical Center and treatment outcomes. Institutional Review Board approval was obtained for a retrospective analysis of all colorectal cancer cases that were identified through the Tumor Registry of the Robley Rex VA Medical Center from 2000 to 2009. Data collected included age at diagnosis, race, risk factors, diagnosis by screening versus symptomatic evaluation, screening test, tumor location and stage, operation performed, operative mortality, and survival. A value of P < 0.05 on Fisher's exact, χ(2), analysis of variance, or Cox regression analyses was considered significant. Three hundred fifty-four patients with colorectal cancer (255 colon, 99 rectal) were identified. One hundred twenty-one patients (34%) were diagnosed by screening. In comparison with those diagnosed by symptom evaluation (n = 233), these patients had earlier stage cancers, were more likely to have a curative intent procedure, and had improved 5-year survival rates. Older patients (older than 75 years old) were more likely to present with symptoms. High-risk patients were more likely to have colonoscopic screening than fecal occult blood testing. More blacks had Stage IV disease than nonblacks. Curative intent 30-day operative mortality was 2.1 per cent for colectomy and 0 per cent for rectal resection. Screening for colorectal cancer in the veteran population allows for better survival, detection at an earlier stage, and higher likelihood of resection.


Doubeni CA, Weinmann S, Adams K, et al.
Screening colonoscopy and risk for incident late-stage colorectal cancer diagnosis in average-risk adults: a nested case-control study.
Ann Intern Med. 2013; 158(5 Pt 1):312-20 [PubMed]
BACKGROUND: The effectiveness of screening colonoscopy in average-risk adults is uncertain, particularly for right colon cancer.
OBJECTIVE: To examine the association between screening colonoscopy and risk for incident late-stage colorectal cancer (CRC).
DESIGN: Nested case-control study.
SETTING: Four U.S. health plans.
PATIENTS: 1039 average-risk adults enrolled for at least 5 years in one of the health plans. Case patients were aged 55 to 85 years on their diagnosis date (reference date) of stage IIB or higher (late-stage) CRC during 2006 to 2008. One or 2 control patients were selected for each case patient, matched on birth year, sex, health plan, and prior enrollment duration.
MEASUREMENTS: Receipt of CRC screening 3 months to 10 years before the reference date, ascertained through medical record audits. Case patients and control patients were compared on receipt of screening colonoscopy or sigmoidoscopy by using conditional logistic regression that accounted for health history, socioeconomic status, and other screening exposures.
RESULTS: In analyses restricted to 471 eligible case patients and their 509 matched control patients, 13 case patients (2.8%) and 46 control patients (9.0%) had undergone screening colonoscopy, which corresponded to an adjusted odds ratio (AOR) of 0.29 (95% CI, 0.15 to 0.58) for any late-stage CRC, 0.36 (CI, 0.16 to 0.80) for right colon cancer, and 0.26 (CI, 0.06 to 1.11; P = 0.069) for left colon/rectum cancer. Ninety-two case patients (19.5%) and 173 control patients (34.0%) had screening sigmoidoscopy, corresponding to an AOR of 0.50 (CI, 0.36 to 0.70) overall, 0.79 (CI, 0.51 to 1.23) for right colon late-stage cancer, and 0.26 (CI, 0.14 to 0.48) for left colon cancer.
LIMITATION: The small number of screening colonoscopies affected the precision of the estimates.
CONCLUSION: Screening with colonoscopy in average-risk persons was associated with reduced risk for diagnosis of incident late-stage CRC, including right-sided colon cancer. For sigmoidoscopy, this association was seen for left CRC, but the association for right colon late-stage cancer was not statistically significant.


Green BB, Wang CY, Anderson ML, et al.
An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial.
Ann Intern Med. 2013; 158(5 Pt 1):301-11 [PubMed]
BACKGROUND: Screening decreases colorectal cancer (CRC) incidence and mortality, yet almost half of age-eligible patients are not screened at recommended intervals.
OBJECTIVE: To determine whether interventions using electronic health records (EHRs), automated mailings, and stepped increases in support improve CRC screening adherence over 2 years.
DESIGN: 4-group, parallel-design, randomized, controlled comparative effectiveness trial with concealed allocation and blinded outcome assessments. (ClinicalTrials.gov: NCT00697047)
SETTING: 21 primary care medical centers.
PATIENTS: 4675 adults aged 50 to 73 years not current for CRC screening.
INTERVENTION: Usual care, EHR-linked mailings ("automated"), automated plus telephone assistance ("assisted"), or automated and assisted plus nurse navigation to testing completion or refusal ("navigated"). Interventions were repeated in year 2.
MEASUREMENTS: The proportion of participants current for screening in both years, defined as colonoscopy or sigmoidoscopy (year 1) or fecal occult blood testing (FOBT) in year 1 and FOBT, colonoscopy, or sigmoidoscopy (year 2).
RESULTS: Compared with those in the usual care group, participants in the intervention groups were more likely to be current for CRC screening for both years with significant increases by intensity (usual care, 26.3% [95% CI, 23.4% to 29.2%]; automated, 50.8% [CI, 47.3% to 54.4%]; assisted, 57.5% [CI, 54.5% to 60.6%]; and navigated, 64.7% [CI, 62.5% to 67.0%]; P < 0.001 for all pair-wise comparisons). Increases in screening were primarily due to increased uptake of FOBT being completed in both years (usual care, 3.9% [CI, 2.8% to 5.1%]; automated, 27.5% [CI, 24.9% to 30.0%]; assisted, 30.5% [CI, 27.9% to 33.2%]; and navigated, 35.8% [CI, 33.1% to 38.6%]).
LIMITATION: Participants were required to provide verbal consent and were more likely to be white and to participate in other types of cancer screening, limiting generalizability.
CONCLUSION: Compared with usual care, a centralized, EHR-linked, mailed CRC screening program led to twice as many persons being current for screening over 2 years. Assisted and navigated interventions led to smaller but significant stepped increases compared with the automated intervention only. The rapid growth of EHRs provides opportunities for spreading this model broadly.


Lawrie TA, Medeiros LR, Rosa DD, et al.
Laparoscopy versus laparotomy for FIGO stage I ovarian cancer.
Cochrane Database Syst Rev. 2013; 2:CD005344 [PubMed]
BACKGROUND: This is an updated version of the original review that was first published in the Cochrane Database of Systematic Reviews 2008, Issue 4. Laparoscopy has become an increasingly common approach to surgical staging of apparent early-stage ovarian tumours. This review was undertaken to assess the available evidence on the benefits and risks of laparoscopy compared with laparotomy for the management of International Federation of Gynaecology and Obstetrics (FIGO) stage I ovarian cancer.
OBJECTIVES: To evaluate the benefits and risks of laparoscopy compared with laparotomy for the surgical treatment of FIGO stage I ovarian cancer (stages Ia, Ib and Ic).
SEARCH METHODS: For the original review, we searched the Cochrane Gynaecological Cancer Group Trials (CGCRG) Register, Cochrane Central Register of Controlled Trials (CENTRAL 2007, Issue 2), MEDLINE, EMBASE, LILACS, Biological Abstracts and CancerLit from 1 January 1990 to 30 November 2007. We also handsearched relevant journals, reference lists of identified studies and conference abstracts. For this updated review, we extended the CGCRG Specialised Register, CENTRAL, MEDLINE, EMBASE and LILACS searches to 6 December 2011.
SELECTION CRITERIA: Randomised controlled trials (RCTs), quasi-RCTs and prospective case-control studies comparing laparoscopic staging with open surgery (laparotomy) in women with stage I ovarian cancer according to FIGO.
DATA COLLECTION AND ANALYSIS: There were no studies to include, therefore we tabulated data from non-randomised studies (NRS) for discussion.
MAIN RESULTS: We performed no meta-analyses.
AUTHORS' CONCLUSIONS: This review has found no good-quality evidence to help quantify the risks and benefits of laparoscopy for the management of early-stage ovarian cancer as routine clinical practice.


Haley AC, MacLean M, Bierman J, et al.
Melanoma opportunistic surveillance by physician assistant and medical students: analysis of a novel educational trainer.
J Physician Assist Educ. 2012; 23(4):6-15 [PubMed]
PURPOSE: The objective was to identify first-year physician assistant (PA) students' and third-year medical students' knowledge, attitudes, and behaviors about melanoma and to assess an educational intervention.
METHODS: Thirty first-year PA students and 29 third-year medical students (M3) at Northwestern University completed a questionnaire on participants' views of barriers and facilitators to performing melanoma screening. The students were given a pretest with a melanoma education model trainer to identify suspicious lesions, and following an educational intervention, students were given a posttest model trainer assessment.
RESULTS: Apart from time constraints (87% PA; 79% M3) and comorbidities (53% PA; 57% M3), lack of training was a frequently reported barrier to performing opportunistic surveillance (27% PA; 31% M3). Commonly reported facilitators included identification of patients at high risk for developing melanoma (60% PA; 69% M3) and skin-examination training to recognize melanoma (67% PA; 55% M3). With the melanoma trainer pretest, 35% of PA students and 27% of M3 students identified all of the melanomas (P = .61). Following educational intervention, 67% of PA students and 10% of M3 students identified all of the melanomas (P<.01). PA student identification of melanoma significantly increased from pretest to posttest (P = .035), while M3 decreased, but not appreciably (P = .063).
CONCLUSIONS: Education in melanoma detection may enhance the students' cognitive and technical skills necessary to perform accurate opportunistic surveillance. Although PA and medical students reported the same significant barriers and facilitators to performing skin exams, there was a difference in implementation of skills and in the management decisions.


Tria Tirona M
Breast cancer screening update.
Am Fam Physician. 2013; 87(4):274-8 [PubMed]
Breast cancer is the most common non-skin cancer and the second leading cause of cancer death in North American women. Mammography is the only screening test shown to reduce breast cancer-related mortality. There is general agreement that screening should be offered at least biennially to women 50 to 74 years of age. For women 40 to 49 years of age, the risks and benefits of screening should be discussed, and the decision to perform screening should take into consideration the individual patient risk, values, and comfort level of the patient and physician. Information is lacking about the effectiveness of screening in women 75 years and older. The decision to screen women in this age group should be individualized, keeping the patient's life expectancy, functional status, and goals of care in mind. For women with an estimated lifetime breast cancer risk of more than 20 percent or who have a BRCA mutation, screening should begin at 25 years of age or at the age that is five to 10 years younger than the earliest age that breast cancer was diagnosed in the family. Screening with magnetic resonance imaging may be considered in high-risk women, but its impact on breast cancer mortality is uncertain. Clinical breast examination plus mammography seems to be no more effective than mammography alone at reducing breast cancer mortality. Teaching breast self-examination does not improve mortality and is not recommended; however, women should be aware of any changes in their breasts and report them promptly.


Carney P, O'Neill S, O'Neill C
Determinants of breast cancer screening uptake in women, evidence from the British Household Panel Survey.
Soc Sci Med. 2013; 82:108-14 [PubMed]
Breast cancer screening is an integral part of the cancer control strategies of many developed economies. In Britain individuals screened in a given year are re-called every three years unless results indicate a need for more immediate investigation. This pattern may create a legacy arising from past decisions, a legacy that should be considered when examining current decisions. In this paper we use a balanced panel drawn from the British Household Panel Survey of 1997 women over an 18 year period to examine variations in uptake. A dynamic random effects probit model is used to control for unobserved heterogeneity and the legacy of previous decisions. As might be expected women to whom universal screening is offered are more likely to screen than others. Changes during the study period in the eligible age range saw an increase in uptake among the age group to whom the programme was extended but not among other groups. Past screening behaviour was found to be a significant predictor of current behaviour. Failure to account for past choices may result in model mis-specification and a failure to develop policies aimed at promoting initial engagement that may compromise the screening programme. Income was not found to be a significant determinant of uptake.


Galarowicz B, Jach R, Kidzierska J, et al.
The role of mRNA E6/E7 HPV high oncogenic risk expression in colposcopy of cervical intraepithelial neoplasia (CIN).
Przegl Lek. 2012; 69(9):651-7 [PubMed]
UNLABELLED: The aim of this paper is the evaluation of colposcopy and mRNA E6/E7 HPV detection--as the marker of persistent human papilloma virus (HPV) infection in the triage of abnormal Pap smears and in the assessment of cervical intraepithelial neoplasia progression risk. The clinical material consisted of 85 women, participating the national cervical cancer screening in the period of April 2010, and October 2010, reffered to the Outpatient Clinic of Gynecologic Oncology and Female Genital Tract Neoplasms Prophylaxy of the Jagiellonian University Medical College in Krakow, Poland. All subjects were offered gynecological evaluation, Pap smear, colposcopy, DNA HPV (Hybrid Capture2, Qiagen) and mRNA E6/E7 testing (NulciSens, Biomerieux). In case of positive tests colposcopically directed cervical biopsy with histopathologic evaluation were performed.
RESULTS: The presence of mRNA E6/E7 HPV transcripts correlated with high grade squamous intraepithelial lesions, statistically significantly. There was statistically difference between colposcopic, histologic concordance comparing to mRNA E6/E7 HPV colposcopic histologic concordance (p < 0.001).
CONCLUSIONS: The presence of mRNA E6/E7 HR HPV may be assumed as specific marker of high grade cervical lesions. The combination of mRNA E6/E7 HR HPV ewith colposcopic evaluation increases the colposcopy concordanece with final histologic findings.


Eichenseer PJ, Dhanekula R, Jakate S, et al.
Endoscopic mis-sizing of polyps changes colorectal cancer surveillance recommendations.
Dis Colon Rectum. 2013; 56(3):315-21 [PubMed]
BACKGROUND: Adenomatous polyps greater than 1 cm are defined as advanced adenomas. Inaccurate size estimation can lead to inappropriate surveillance recommendations of colorectal adenomas.
OBJECTIVE: The aim of this study was to determine the impact of endoscopic polyp mis-sizing on colorectal cancer surveillance recommendations.
DESIGN: This is a prospective study.
SETTING: This study was conducted in a gastroenterology practice at a US academic medical center.
PATIENTS: Patients undergoing colorectal cancer screening and surveillance colonoscopies from 2010 to 2011 were included.
MAIN OUTCOME MEASUREMENTS: Endoscopic size estimates of polyps 10 to 25 mm were compared with postfixation histopathologic polyp measurements for 15 different gastroenterologists. Only adenomatous polyps removed in entirety by snare polypectomy were included in the analysis. Size variation was defined as (endoscopic estimate - histopathologic size)/(histopathologic size). Clinical mis-sizing was defined as a size variation of >33%. The mean size variation, the percentage of clinical mis-sizing, and the percentage of inappropriate surveillance recommendation due to size variation >33% were reported per endoscopist.
RESULTS: : Included for analysis were 4990 procedures from 15 gastroenterologists. A total of 230 polyps from 200 patients met inclusion criteria. The average age was 62.6 years (SD 10.1), and 52% were men. The mean size variation between the endoscopic polyp size estimation and the histopathologic polyp was 73.6% (range of mean size variation, 13%-127%). 62.6% (range, 0%-91%) of included polyps had clinical mis-sizing. Of included polypectomies, 35.2% (range, 0%-67%) resulted in an inappropriate surveillance recommendation due to clinical mis-sizing even after considering histology and synchronous polyps.
LIMITATIONS: This was a single-center study.
CONCLUSIONS: There is marked variation in endoscopists' ability to accurately size adenomatous polyps. Some endoscopists rarely mis-size adenomas, and their surveillance recommendations are appropriate in regard to sizing. However, other endoscopists inaccurately size adenomas, and this leads to inappropriate surveillance of colorectal polyps. In this study, approximately 1 of 3 included polypectomies yielded inappropriate surveillance recommendations because of clinical mis-sizing.


Gulati R, Gore JL, Etzioni R
Comparative effectiveness of alternative prostate-specific antigen--based prostate cancer screening strategies: model estimates of potential benefits and harms.
Ann Intern Med. 2013; 158(3):145-53 [PubMed]
BACKGROUND: The U.S. Preventive Services Task Force recently concluded that the harms of existing prostate-specific antigen (PSA) screening strategies outweigh the benefits.
OBJECTIVE: To evaluate comparative effectiveness of alternative PSA screening strategies.
DESIGN: Microsimulation model of prostate cancer incidence and mortality quantifying harms and lives saved for alternative PSA screening strategies.
DATA SOURCES: National and trial data on PSA growth, screening and biopsy patterns, incidence, treatment distributions, treatment efficacy, and mortality.
TARGET POPULATION: A contemporary cohort of U.S. men.
TIME HORIZON: Lifetime.
PERSPECTIVE: Societal.
INTERVENTION: 35 screening strategies that vary by start and stop ages, screening intervals, and thresholds for biopsy referral.
OUTCOME MEASURES: PSA tests, false-positive test results, cancer detected, overdiagnoses, prostate cancer deaths, lives saved, and months of life saved.
RESULTS OF BASE-CASE ANALYSIS: Without screening, the risk for prostate cancer death is 2.86%. A reference strategy that screens men aged 50 to 74 years annually with a PSA threshold for biopsy referral of 4 µg/L reduces the risk for prostate cancer death to 2.15%, with risk for overdiagnosis of 3.3%. A strategy that uses higher PSA thresholds for biopsy referral in older men achieves a similar risk for prostate cancer death (2.23%) but reduces the risk for overdiagnosis to 2.3%. A strategy that screens biennially with longer screening intervals for men with low PSA levels achieves similar risks for prostate cancer death (2.27%) and overdiagnosis (2.4%), but reduces total tests by 59% and false-positive results by 50%.
RESULTS OF SENSITIVITY ANALYSIS: Varying incidence inputs or reducing the survival improvement due to screening did not change conclusions.
LIMITATION: The model is a simplification of the natural history of prostate cancer, and improvement in survival due to screening is uncertain.
CONCLUSION: Compared with standard screening, PSA screening strategies that use higher thresholds for biopsy referral for older men and that screen men with low PSA levels less frequently can reduce harms while preserving lives.
PRIMARY FUNDING SOURCE: National Cancer Institute and Centers for Disease Control and Prevention.


Rychetnik L, Carter SM, Abelson J, et al.
Enhancing citizen engagement in cancer screening through deliberative democracy.
J Natl Cancer Inst. 2013; 105(6):380-6 [PubMed]
Cancer screening is widely practiced and participation is promoted by various social, technical, and commercial drivers, but there are growing concerns about the emerging harms, risks, and costs of cancer screening. Deliberative democracy methods engage citizens in dialogue on substantial and complex problems: especially when evidence and values are important and people need time to understand and consider the relevant issues. Information derived from such deliberations can provide important guidance to cancer screening policies: citizens' values are made explicit, revealing what really matters to people and why. Policy makers can see what informed, rather than uninformed, citizens would decide on the provision of services and information on cancer screening. Caveats can be elicited to guide changes to existing policies and practices. Policies that take account of citizens' opinions through a deliberative democracy process can be considered more legitimate, justifiable, and feasible than those that don't.


Cuzick J, Cadman L, Mesher D, et al.
Comparing the performance of six human papillomavirus tests in a screening population.
Br J Cancer. 2013; 108(4):908-13 [PubMed] Free Access to Full Article
BACKGROUND: Several new assays have been developed for high-risk HPV testing of cervical samples; we compare six HPV tests in a screening population.
METHODS: Residual material from liquid-based PreservCyt samples was assayed. Four tests (Hybrid Capture 2, Cobas, Abbott and Becton-Dickinson (BD)) measured HPV DNA while two used RNA (APTIMA and NorChip).
RESULTS: Positivity rates ranged from 13.4 to 16.3% for the DNA-based tests with a significantly lower positivity rate for the Abbott assay. The Gen-Probe APTIMA assay was positive in 10.3% of women, which was significantly lower than all the DNA tests; the NorChip PreTect HPV-Proofer test was much lower at 5.2%. 40 CIN2+ cases were identified, of which 19 were CIN3+. All CIN3+ cases were HPV positive by all tests except for one, which was negative by the Abbott assay and five which were negative by the NorChip test.
CONCLUSION: All HPV tests except NorChip showed high sensitivity for high-grade lesions positive by cytology, suggesting co-testing is unnecessary when using HPV tests. Positivity rates in cytology-negative specimens were similar for the DNA-based tests, but lower for the APTIMA test suggesting this maintains the high sensitivity of DNA tests, but with better specificity.


de Bekker-Grob EW, Rose JM, Donkers B, et al.
Men's preferences for prostate cancer screening: a discrete choice experiment.
Br J Cancer. 2013; 108(3):533-41 [PubMed] Article available free on PMC after 19/02/2014
BACKGROUND: Screening for prostate cancer (PC) may save lives, but overdiagnosis and overtreatment are serious drawbacks. We aimed to determine men's preferences for PC screening, and to elicit the trade-offs they make.
METHODS: A discrete choice experiment (DCE) was conducted among a population-based random sample of 1000 elderly men (55-75-years-old). Trade-offs were quantified with a panel latent class model between five PC screening aspects: risk reduction of PC-related death, screening interval, risk of unnecessary biopsies, risk of unnecessary treatments, and out-of-pocket costs.
RESULTS: The response rate was 46% (459/1000). Men were willing to trade-off 2.0% (CI: 1.6%-2.4%) or 1.8% (CI: 1.3%-2.3%) risk reduction of PC-related death to decrease their risk of unnecessary treatment or biopsy with 10%, respectively. They were willing to pay €188 per year (CI: €141-€258) to reduce their relative risk of PC-related death with 10%. Preference heterogeneity was substantial, with men with higher educational levels having a lower probability to opt for PC screening than men with lower educational levels.
CONCLUSION: Men were willing to trade-off some risk reduction of PC-related death to be relieved of the burden of biopsies or unnecessary treatments. Increasing knowledge on overdiagnosis and overtreatment, especially for men with lower educational levels, is warranted to prevent unrealistic expectations from PC screening.


Hagemann AR, Wilkinson-Ryan I, Kuroki LM, Squires K
Discussion: 'Comparison of cervical cancer screening strategies,' by Cox et al.
Am J Obstet Gynecol. 2013; 208(3):e1-4 [PubMed]
In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research.


Jain YK, Kokan JS
An interesting case of screen-detected breast cancer encasing a ventriculoperitoneal shunt.
BMJ Case Rep. 2013; 2013 [PubMed]
A 67-year-old woman was diagnosed with a breast cancer via screening encasing the ventriculoperitoneal shunt. Triple assessment including MRI scan of the breast confirmed the presence of a breast mass and the tubing of the ventriculoperitoneal shunt was running directly through the mass. She underwent wide local excision of the breast cancer as well as rerouting of VP shunt as a joint procedure with the neurosurgery team and recovered uneventfully. This is a very rare and an interesting case and required management involving a different specialty.


Hersch J, Jansen J, Barratt A, et al.
Women's views on overdiagnosis in breast cancer screening: a qualitative study.
BMJ. 2013; 346:f158 [PubMed] Article available free on PMC after 19/02/2014
OBJECTIVE: To elicit women's responses to information about the nature and extent of overdiagnosis in mammography screening (detecting disease that would not present clinically during the woman's lifetime) and explore how awareness of overdiagnosis might influence attitudes and intentions about screening.
DESIGN: Qualitative study using focus groups that included a presentation explaining overdiagnosis, incorporating different published estimates of its rate (1-10%, 30%, 50%) and information on the mortality benefit of screening, with guided group discussions
SETTING: Sydney, Australia
PARTICIPANTS: Fifty women aged 40-79 years with no personal history of breast cancer and with varying levels of education and participation in screening.
RESULTS: Prior awareness of breast cancer overdiagnosis was minimal. Women generally reacted with surprise, but most came to understand the issue. Responses to overdiagnosis and the different estimates of its magnitude were diverse. The highest estimate (50%) made some women perceive a need for more careful personal decision making about screening. In contrast, the lower and intermediate estimates (1-10% and 30%) had limited impact on attitudes and intentions, with many women remaining committed to screening. For some women, the information raised concerns, not about whether to screen but whether to treat a screen detected cancer or consider alternative approaches (such as watchful waiting). Information preferences varied: many women considered it important to take overdiagnosis into account and make informed choices about whether to have screening, but many wanted to be encouraged to be screened.
CONCLUSIONS: Women from a range of socioeconomic backgrounds could comprehend the issue of overdiagnosis in mammography screening, and they generally valued information about it. Effects on screening intentions may depend heavily on the rate of overdiagnosis. Overdiagnosis will be new and counterintuitive for many people and may influence screening and treatment decisions in unintended ways, underscoring the need for careful communication.


Ezechi OC, Gab-Okafor CV, Ostergren PO, Odberg Pettersson K
Willingness and acceptability of cervical cancer screening among HIV positive Nigerian women.
BMC Public Health. 2013; 13:46 [PubMed] Article available free on PMC after 19/02/2014
BACKGROUND: The proven benefit of integrating cervical cancer screening programme into HIV care has led to its adoption as a standard of care. However this is not operational in most HIV clinics in Nigeria. Of the various reasons given for non-implementation, none is backed by scientific evidence. This study was conducted to assess the willingness and acceptability of cervical cancer screening among HIV positive Nigerian women.
METHODS: A cross sectional study of HIV positive women attending a large HIV treatment centre in Lagos, Nigeria. Respondents were identified using stratified sampling method. A pretested questionnaire was used to obtain information by trained research assistants. Obtained information were coded and managed using SPSS for windows version 19. Multivariate logistic regression model was used to determine independent predictor for acceptance of cervical cancer screening.
RESULTS: Of the 1517 respondents that returned completed questionnaires, 853 (56.2%) were aware of cervical cancer. Though previous cervical cancer screening was low at 9.4%, 79.8% (1210) accepted to take the test. Cost of the test (35.2%) and religious denial (14.0%) were the most common reasons given for refusal to take the test. After controlling for confounding variables in a multivariate logistic regression model, having a tertiary education (OR = 1.4; 95% CI: 1.03-1.84), no living child (OR: 1.5; 95% CI: 1.1-2.0), recent HIV diagnosis (OR: 1.5; 95% CI: 1.1-2.0) and being aware of cervical cancer (OR: 1.5; 95% CI: 1.2-2.0) retained independent association with acceptance to screen for cervical cancer.
CONCLUSIONS: The study shows that HIV positive women in our environment are willing to screen for cervical cancer and that the integration of reproductive health service into existing HIV programmes will strengthen rather than disrupt the services.


Taghipour S, Banjevic D, Miller AB, et al.
Parameter estimates for invasive breast cancer progression in the Canadian National Breast Screening Study.
Br J Cancer. 2013; 108(3):542-8 [PubMed] Article available free on PMC after 19/02/2014
BACKGROUND: The aim of screening is to detect a cancer in the preclinical state. However, a false-positive or a false-negative test result is a real possibility.
METHODS: We describe invasive breast cancer progression in the Canadian National Breast Screening Study and construct progression models with and without covariates. The effect of risk factors on transition intensities and false-negative probability is investigated. We estimate the transition rates, the sojourn time and sensitivity of diagnostic tests for women aged 40-49 and 50-59.
RESULTS: Although younger women have a slower transition rate from healthy state to preclinical, their screen-detected tumour becomes evident sooner. Women aged 50-59 have a higher mortality rate compared with younger women. The mean sojourn times for women aged 40-49 and 50-59 are 2.5 years (95% CI: 1.7, 3.8) and 3.0 years (95% CI: 2.1, 4.3), respectively. Sensitivity of diagnostic procedures for older women is estimated to be 0.75 (95% CI: 0.55, 0.88), while women aged 40-49 have a lower sensitivity (0.61, 95% CI: 0.42, 0.77). Age is the only factor that affects the false-negative probability. For women aged 40-49, 'age at entry', 'history of breast disease' and 'families with breast cancer' are found to be significant for some of the transition rates. For the age-group 50-59, 'age at entry', 'history of breast disease', 'menstruation length' and 'number of live births' are found to affect the transition rates.
CONCLUSION: Modelling and estimating the parameters of cancer progression are essential steps towards evaluating the effectiveness of screening policies. The parameters include the transition rates, the preclinical sojourn time, the sensitivity, and the effect of different risk factors on cancer progression.


Gonzales KL, Harding AK, Lambert WE, et al.
Perceived experiences of discrimination in health care: a barrier for cancer screening among American Indian women with type 2 diabetes.
Womens Health Issues. 2013; 23(1):e61-7 [PubMed] Article available free on PMC after 01/01/2014
PURPOSE: Breast and cervical cancer-mortality disparities are prominent among American Indian women. These disparities, in part, may result from patients perceived experiences of discrimination in health care. This report evaluates the impact of perceived discrimination on screening for breast and cervical cancer in a sample of 200 American Indian women with type 2 diabetes.
METHODS: Data were collected from patient report and medical records. Prevalence of breast and cervical cancer screening were assessed. Unadjusted and adjusted logistic regression analyses were used to assess associations between perceived discrimination, cancer screening status, and patients' health care-seeking behaviors.
FINDINGS: Substantial proportions of AI women in our sample were behind the recommended schedules of screening for breast and cervical cancer. Adjusted estimates revealed that perceived discrimination was significantly associated with not being current for clinical breast examination and Pap test, and was close to statistical significance with not being current for mammography. The number of suboptimal health care-seeking behaviors increased with higher mean levels of perceived discrimination.
CONCLUSIONS: Among AI women, perceived discrimination in health care may negatively influence use of breast and cancer screening services, and health care-seeking behaviors. More research is needed among AIs to examine features of health care systems related to the phenomenon patients perceived experience of discrimination.


Su SY, Huang JY, Ho CC, Liaw YP
Evidence for cervical cancer mortality with screening program in Taiwan, 1981-2010: age-period-cohort model.
BMC Public Health. 2013; 13:13 [PubMed] Article available free on PMC after 01/01/2014
BACKGROUND: Cervical cancer is the most common cancer experienced by women worldwide; however, screening techniques are very effective for reducing the risk of death. The national cervical cancer screening program was implemented in Taiwan in 1995. The objective of this study was to examine and provide evidence of the cervical cancer mortality trends for the periods before and after the screening program was implemented.
METHODS: Data from 1981 to 2010 of the causes of death registered were obtained from the Department of Health, Taiwan. Age-standardized mortality rates, age-specific rates, and age-period-cohort models that employed the sequential method were used to assess temporal changes that occurred between 1981 and 2010, with 1995 used as the separating year.
RESULTS: The results showed that for both time periods of 1981 to 1995 and 1996 to 2010, age and period had significant effects, whereas the birth cohort effects were insignificant. For patients between 80 and 84 years of age, the mortality rate for 1981 to 1995 and 1996 to 2010 was 48.34 and 68.08. The cervical cancer mortality rate for 1996 to 2010 was 1.0 for patients between 75 and 79 years of age and 1.4 for patients between 80 and 84 years of age compared to that for 1981 to 1995. Regarding the period effect, the mortality trend decreased 2-fold from 1996 to 2010.
CONCLUSIONS: The results of this study indicate a decline in cervical cancer mortality trends after the screening program involving Papanicolaou tests was implemented in 1995. However, the positive effects of the screening program were not observed in elderly women because of treatment delays during the initial implementation of the screening program.


Wang YR, Cangemi JR, Loftus EV, Picco MF
Rate of early/missed colorectal cancers after colonoscopy in older patients with or without inflammatory bowel disease in the United States.
Am J Gastroenterol. 2013; 108(3):444-9 [PubMed]
OBJECTIVES: Patients with inflammatory bowel disease (IBD) have an increased risk for colorectal cancer (CRC). Previous studies on early/missed CRCs after colonoscopy excluded IBD patients. The aim of this study was to compare the rate of early/missed CRCs after colonoscopy among IBD and non-IBD patients, and identify factors associated with early/missed CRCs.
METHODS: All patients in the Surveillance, Epidemiology and End-Results Medicare-linked database who were 67 years or older at colonoscopy during 1998-2005 and those who were subsequently diagnosed with CRC within 36 months were identified. CRCs diagnosed within 6 months of colonoscopy were categorized as detected CRCs; CRCs diagnosed 6-36 months after colonoscopy were categorized as early/missed CRCs. The rate of early/missed CRCs was calculated as number of early/missed CRCs divided by number of detected and early/missed CRCs. The χ(2) test and multivariate logistic regression were used in statistical analysis.
RESULTS: Of 55,008 CRC patients (304 Crohn's disease; 544 ulcerative colitis (UC)), the rate of early/missed CRCs was 5.8% for non-IBD patients, 15.1% for Crohn's, and 15.8% for UC (P<0.001). Compared with older non-IBD patients, early/missed CRCs among older IBD patients were less likely right-sided (both P<0.05). In multivariate logistic regression, the risk of early/missed CRCs was three times as high for IBD patients (Crohn's odds ratio (OR), 3.07; 95% confidence interval (CI) 2.23-4.21; UC OR, 3.05; 95% CI, 2.44-3.81). Sensitivity analyses confirmed the robustness of this finding.
CONCLUSIONS: Older IBD patients had a higher rate of early/missed CRCs after colonoscopy. Our finding supports intensive surveillance colonoscopy for older IBD patients as recommended by guidelines.


Morton RL, Rychetnik L, McCaffery K, et al.
Patients' perspectives of long-term follow-up for localised cutaneous melanoma.
Eur J Surg Oncol. 2013; 39(3):297-303 [PubMed]
BACKGROUND: Little is known about the value of long-term follow-up for localised cutaneous melanoma from the patients' perspective. This study aimed to explore the benefits and potential downsides of follow-up; feelings about changes to frequency of follow-up, and patient-centred recommendations for improving follow-up care.
METHODS: Qualitative analysis of 29 in-depth interviews conducted with Australian patients undergoing long-term follow-up after surgical treatment of stage I/II melanoma.
RESULTS: Patient-perceived benefits of follow-up included reassurance, early detection of new melanomas and non-melanoma skin cancers, education about skin self-examination, the opportunity to ask questions, and reinforcement of 'sunsafe' behaviours. Downsides included anxiety leading up to and during follow-up visits; inconvenience of travel to attend visits; and lost work time. Patients varied in their engagement with skin self-examination, and their views on multiple skin excisions, but highly valued access to specialists for unscheduled visits. Most patients felt their follow-up intervals could be extended to 12 months if recommended by their clinician.
CONCLUSION: The benefits and potential downsides of follow-up should be discussed with patients when deciding on a melanoma follow-up plan to achieve a balance between inducing additional patient anxiety and providing reassurance. Follow-up intervals of 12 months appear to be acceptable to patients.



Cervical cancer screening among women aged 18-30 years - United States, 2000-2010.
MMWR Morb Mortal Wkly Rep. 2013; 61(51-52):1038-42 [PubMed]
Screening women for cervical cancer can save lives. However, among young women, cervical cancer is relatively rare, and too-frequent screening can lead to high costs and adverse events associated with overtreatment. Before 2012, cervical cancer screening guidelines of the American College of Obstetricians and Gynecologists (ACOG), American Cancer Society (ACS), and U.S. Preventive Services Task Force (USPSTF) differed on age to start and how often to get screened for cervical cancer. In 2012, however, all three organizations recommended that 1) screening by Papanicolau (Pap) test should not be used for women aged <21 years, regardless of initiation of sexual activity, and 2) a screening interval of 3 years should be maintained for women aged 21-30 years. ACS and ACOG explicitly recommend against yearly screening. To assess trends in Pap testing before the new guidelines were introduced, CDC analyzed 2000-2010 data from the Behavioral Risk Factor Surveillance System (BRFSS) for women aged 18-30 years. CDC found that, among women aged 18-21 years, the percentage reporting never having been screened increased from 26.3% in 2000 to 47.5% in 2010, and the proportion reporting having had a Pap test in the past 12 months decreased from 65.0% to 41.5%. Among those aged 22-30 years, the proportion reporting having had a Pap test within the preceding 12 months decreased from 78.1% to 67.0%. These findings showed that Pap testing practices for young women have been moving toward the latest guidelines. However, the data also showed a concerning trend: among women aged 22-30 years, who should be screened every 3 years, the proportion who reported never having had a Pap test increased from 6.6% to 9.0%. More effort is needed to promote acceptance of the latest evidence-based recommendations so that all women receive the maximal benefits of cervical cancer screening.


Park ER, Gareen IF, Jain A, et al.
Examining whether lung screening changes risk perceptions: National Lung Screening Trial participants at 1-year follow-up.
Cancer. 2013; 119(7):1306-13 [PubMed] Article available free on PMC after 01/04/2014
BACKGROUND: The National Lung Screening Trial (NLST) research team reported reduced lung cancer mortality among current and former smokers with a minimum 30 pack-year history who were screened with spiral computed tomography scans compared with chest x-rays. The objectives of the current study were to examine, at 1-year follow-up: 1) risk perceptions of lung cancer and smoking-related diseases and behavior change determinants, 2) whether changes in risk perceptions differed by baseline screening result; and 3) whether changes in risk perceptions affected smoking behavior.
METHODS: A 25-item risk perception questionnaire was administered to a subset of participants at 8 American College of Radiology Imaging Network/NLST sites before initial and 1-year follow-up screens. Items assessed risk perceptions of lung cancer and smoking-related diseases, cognitive and emotional determinants of behavior change, and knowledge of smoking risks.
RESULTS: Among 430 NLST participants (mean age, 61.0 years; 55.6% men; 91.9% white), half were current smokers at baseline. Overall, risk perceptions and associated cognitive and emotional determinants of behavior change did not change significantly from prescreen trial enrollment to 1-year follow-up and did not differ significantly by screening test result. Changes in risk perceptions were not associated with changes in smoking status (9.7% of participants quit, and 6.6% relapsed) at 1-year follow-up.
CONCLUSIONS: Lung screening did not change participants' risk perceptions of lung cancer or smoking-related disease. A negative screening test, which was the most common screening result, did not appear to decrease risk perceptions nor provide false reassurance to smokers.


van Dam L, Kuipers EJ, Steyerberg EW, et al.
The price of autonomy: should we offer individuals a choice of colorectal cancer screening strategies?
Lancet Oncol. 2013; 14(1):e38-46 [PubMed]
A difference between colorectal cancer screening and screening for most other types of cancer is that various screening methods are available. A choice between screening methods is common in the USA. Most European programmes currently offer a single screening method, since it is recommended that only screening strategies with sufficient evidence for a reduction in colorectal cancer mortality are introduced. Faecal occult blood testing is widely accepted in Europe, and evidence on the effectiveness of flexible sigmoidoscopy is increasing. The availability of multiple effective screening options warrants deliberation on whether individuals should be given a choice between strategies. In this Personal View, we present arguments in favour and against offering a choice of screening strategies, together with the evidence substantiating these views. We also focus on screening invitees' autonomy, which is a crucial parameter in the debate.


Etzioni R, Gulati R, Cooperberg MR, et al.
Limitations of basing screening policies on screening trials: The US Preventive Services Task Force and Prostate Cancer Screening.
Med Care. 2013; 51(4):295-300 [PubMed] Article available free on PMC after 01/04/2014
BACKGROUND: The US Preventive Services Task Force recently recommended against prostate-specific antigen screening for prostate cancer based primarily on evidence from the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the US Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial.
OBJECTIVE: : To examine limitations of basing screening policy on evidence from screening trials.
METHODS: We reviewed published modeling studies that examined population and trial data. The studies (1) project the roles of screening and changes in primary treatment in the US mortality decline; (2) extrapolate the ERSPC mortality reduction to the long-term US setting; (3) estimate overdiagnosis based on US incidence trends; and (4) quantify the impact of control arm screening on PLCO mortality results.
RESULTS: Screening plausibly explains 45% and changes in primary treatment can explain 33% of the US prostate cancer mortality decline. Extrapolating the ERSPC results to the long-term US setting implies an absolute mortality reduction at least 5 times greater than that observed in the trial. Approximately 28% of screen-detected cases are overdiagnosed in the United States versus 58% of screen-detected cases suggested by the ERSPC results. Control arm screening can explain the null result in the PLCO trial.
CONCLUSIONS: Modeling studies indicate that population trends and trial results extended to the long-term population setting are consistent with greater benefit of prostate-specific antigen screening-and more favorable harm-benefit tradeoffs-than has been suggested by empirical trial evidence.


Han PK, Klabunde CN, Noone AM, et al.
Physicians' beliefs about breast cancer surveillance testing are consistent with test overuse.
Med Care. 2013; 51(4):315-23 [PubMed] Article available free on PMC after 01/04/2014
BACKGROUND: Overuse of surveillance testing for breast cancer survivors is an important problem but its extent and determinants are incompletely understood. The objectives of this study were to determine the extent to which physicians' breast cancer surveillance testing beliefs are consistent with test overuse, and to identify factors associated with these beliefs.
METHODS: During 2009-2010, a cross-sectional survey of US medical oncologists and primary care physicians (PCPs) was carried out. Physicians responded to a clinical vignette ascertaining beliefs about appropriate breast cancer surveillance testing. Multivariable analyses examined the extent to which test beliefs were consistent with overuse and associated with physician and practice characteristics and physician perceptions, attitudes, and practices.
RESULTS: A total of 1098 medical oncologists and 980 PCPs completed the survey (response rate 57.5%). Eighty-four percent of PCPs [95% confidence interval (CI), 81.4%-86.5%] and 72% of oncologists (95% CI, 69.8%-74.7%) reported beliefs consistent with blood test overuse, whereas 50% of PCPs (95% CI, 47.3%-53.8%) and 27% of oncologists (95% CI, 23.9%-29.3%) reported beliefs consistent with imaging test overuse. Among PCPs, factors associated with these beliefs included smaller practice size, lower patient volume, and practice ownership. Among oncologists, factors included older age, international medical graduate status, lower self-efficacy (confidence in knowledge), and greater perceptions of ambiguity (conflicting expert recommendations) regarding survivorship care.
CONCLUSIONS: Beliefs consistent with breast cancer surveillance test overuse are common, greater for PCPs and blood tests than for oncologists and imaging tests, and associated with practice characteristics and perceived self-efficacy and ambiguity about testing. These results suggest modifiable targets for efforts to reduce surveillance test overuse.


This page last updated: 22nd May 2013
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