Screening PHIL THIRKELL. What is screening? A process of identifying apparently healthy people who...
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![Page 1: Screening PHIL THIRKELL. What is screening? A process of identifying apparently healthy people who may be at risk of a disease or condition Identify.](https://reader036.fdocuments.in/reader036/viewer/2022062421/56649da65503460f94a91add/html5/thumbnails/1.jpg)
ScreeningPHIL THIRKELL
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What is screening?
A process of identifying apparently healthy people who may be at risk of a disease or condition
Identify
Apparently healthy
Increased risk of a disease/condition
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Give 4 screening programmes undertaken in the UK.
Antenatal screening
Postnatal screening – hearing, heel prick, neuroblastoma
Cervical smear
Mammography
Chlamydia screening
Bowel Cancer – FOBT
Prostate cancer
Abdominal Aortic Aneurysm
Depression – PHQ-9 questionnaire
etc.
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Criteria for a Screening Programme Wilson + Jungner criteria
1. Important health problem
2. Treatment available
3. Facilities available for diagnosis and treatment
4. Latent stage of the condition
5. Test available to detect the condition
6. Test is acceptable to the population
7. Natural history of the disease is known
8. Policy of who gets treatment has been made
9. Financially viable
10. Case-finding is a continual process, not just a one off
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Neonatal screening
Which conditions are screened for with blood spot testing?
Phenylketonuria
Sickle cell disease
Cystic fibrosis
Congenital hypothyroidism
Medium-chain acyl-CoA dehydrogenase deficiency
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Antenatal Screening
What is a pregnant woman screened for?
Pre-eclampsia
Rhesus antigen status / blood group
Anaemia
Diabetes
Syphilis
Hepatitis B/C
HIV
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Anomaly Scan – USS between 18-21 weeks
What is an anomaly scan used for? Spina bifida
Down’s syndrome
Hydrocephalus
Cleft lip/palate
Date the pregnancy
Sex of the baby
Multiple pregnancy
Organ development
Abdominal wall
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Test Outcomes
Diseased Non-Diseased
Test positive True Positive False Positive
Test negative False Negative True Negative
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Sensitivity
The number of people who have the disease who get a positive test result
True positive / (True positive + False Negative)
e.g. 50 people with known Rheumatoid Arthritis. RhF blood test is positive in 42 of the patients.
Sensitivity is 84%
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Specificity
The number of people who don’t have a disease who are correctly told they don’t have it
True negatives / (True negatives + False positives)
E.g. 30 patients with no evidence of rheumatoid arthritis have a blood test for RhF. 2 patients have a positive result.
Specificity = 93%
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Positive Predictive Value
The number of people who have a positive test result who actually do have the disease
True positives / (True positives/False positives)
e.g. 2500 PSA blood tests performed on men >65yr. 800 are raised above normal levels. Biopsy reveals that 95 of these have prostate cancer.
PPV = 95/(95+800) = 11%
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Negative Predictive Value
The number of people who have a negative test result who definitely don’t have the disease
True negatives / (true negatives + false negatives)
e.g. 2500 PSA blood tests on men >65yrs. 1700 have normal PSA results. 20 of these turn out to currently have prostate cancer despite a normal PSA.
1680/ (20 + 1680) = 98.8%
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Diseased Non-Diseased
Test positive True Positive False Positive
Positive Predictive Value
TP / (TP + FP)
Test negative False Negative True Negative
Negative Predictive Value
TN / (TN + FN)
Sensitivity
TP / (TP + FN)
Specificity
TN / (TN + FP)
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Screening Bias
Healthy screenee
Length time
Lead time
Overdiagosis
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Healthy screenee
Proactive patients who turn up to screening opportunities take better care of themselves are less likely to have a positive result
Less likely to smoke, drink too much, have low income
More likely to exercise, eat healthily, attend healthcare at other times
Internal locus of control
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Length time
Screening appears to improve prognosis because slow-forming conditions are detected and treated earlier than they would compared to waiting for symptoms to start
e.g. 500 slow forming and 500 fast forming cancers happen each year
Slow forming – no symptoms and better prognosis
Fast forming – obvious symptoms and poor prognosis
Screening can detect lots of slow forming, but not many fast cancers
Because slow has better prognosis, it appears that screening helps outcome, but actually just selects a high proportion of slow cancers
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Lead time
A screening test diagnoses something earlier but has no impact on outcome
Appears to increase survival time, but doesn’t
Screening detects a disease
Symptoms start
Death
Screened patients
Non-screened patients
Lead time
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Overdiagnosis
Patients are diagnosed with a condition which isn’t going to affect their life expectance
e.g. prostate cancer diagnosis in old men
Get a PSA blood test done, high result but managing with symptoms ok
Now told they have cancer – anxiety, health insurance etc.
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A new blood test is developed for rheumatoid arthritis. What is the sensitivity, specificity, PPV and NPV?
Diseased Non-Diseased
New test positive 250 26
New test negative 3 150
Sensitivity = 250 / (250+3) = 98.8 %
Specificity = 150 / (150+26) = 85.2 %
PPV = 250 / (250+26) = 90.5 %
NPV =150 / (150 + 3) = 98 %