Screening and overdiagnosis : public health implications

Overdiagnosis is the diagnosis of an abnormality that bears no substantial health hazard and no benefit for patients to be aware of. Resulting mainly from the use of increasingly sensitive screening and diagnostic tests, as well as broadened definitions of conditions requiring an intervention, overdiagnosis is a growing but still largely misunderstood public health issue. Fear of missing a diagnosis or of litigation, financial incentives or patient's need of reassurance are further causes of overdiagnosis. The main consequence of overdiagnosis is overtreatment. Treating an overdiagnosed condition bears no benefit but can cause harms and generates costs. Overtreatment also diverts health professionals from caring for those most severely ill. Recognition of overdiagnosis due to screening is challenging since it is rarely identifiable at the individual level and difficult to quantify precisely at the population level. Overdiagnosis exists even for screening of proven efficacy and efficiency. Measures to reduce overdiagnosis due to screening include heightened sensitization of health professionals and patients, active surveillance and deferred treatment until early signs of disease progression and prognosis estimation through biomarkers (including molecular) profiling. Targeted screening and balanced information on its risk and benefits would also help limit overdiagnosis. Research is needed to assess the the public health burden and implications of overdiagnosis due to screening activity

Fine forecasts: encouraging the media to include ultraviolet radiation information in summertime weather forecasts

Melanoma and skin cancer are largely attributable to over-exposure to solar ultraviolet radiation (UVR). Reports of UVR levels within media weather forecasts appear to be well received by the public and have good potential to communicate the need for appropriate sun protection to a broad audience. This study describes provision of UVR messages by New Zealand newspapers, radio and TV stations over a 4-year period, and examines the impact of an intervention which aimed to address media concerns about the financial costs of accessing UVR information for broadcast. Newspaper and radio presentation of UVR information increased immediately after these costs were removed; however, among radio stations it dropped in subsequent years. Among those media that were presenting UVR, this information was broadcast throughout the summer period and repeated throughout the day. Furthermore, most reports included concomitant, behavioral sun protection messages. At the final assessment (summer 2001/02), 66% of radio stations, both TV channels and 48% of newspapers reported UVR information in summertime weather reports. Efforts to further increase UVR presentation will need to address media concerns about time constraints on weather forecasts and media perceptions of poor audience demand or understanding of some UVR message

Dense breast on screening mammography: utility and futility of additional ultrasound.

High breast density decreases the sensitivity of mammography. Regardless of masking effect, it is also a stronger predictor for breast cancer than most other risk factors, including family history. Up to 50% of women have dense breast (categories C+D). The relative risk is 2.1 to 2.3 in women with extremely dense breast (category d). There is little consensus on the potential need of additional measures. Breast Ultrasound (US) may be proposed as an adjunctive test, as it is non-invasive and non-irradiating. Since 2012, our program for breast cancer screening propose to realise an additional US to the women with category d breasts. An evaluation of the data of the first year showed that less 50% of the women act upon the recommendation. In spite of the low compliance supplementary cancers were found. Since, no more evaluation was performed. The aim of this study was: To evaluate the effect of the recommendation in term of additional cancer's identification, additional biopsies and additional investigations. To identify the reasons of non compliance

Breast cancer screening programme in Switzerland 2010-2015

This fourth national monitoring report for Swiss Cancer Screening shows the results of organised mammogra-phy screening in Switzerland for the years 2010-2015, subdivided into two triennial periods, 2010-2012 and 2013-2015, respectively. The number of regional programmes increased from 7 in 2010 to 10 in 2015, currently covering the geograph-ical area of 12 cantons. In 2015, 56.5 percent of the 50-69 years old women in Switzerland lived in an area covered by a breast cancer screening programme, nearly a doubling of coverage since 2010. The results in this monitoring report are based on available data from 7 programmes (VD, VS, GE, FR, BEJUNE, SG-GR, TG) in the period 2010-2012 and from 8 programmes (with BE) in the period 2013-2015. The coverage by invitation rate increased from 91% in 2010-2012 to 98% in 2013-2015. Almost 290,000 from the 680,000 eligible women in 2013-2015 attended for screening, resulting in a participation rate of 42.5%. The participa-tion decreased by more than 4% compared to 2010-2012, mainly due to the low participation in the large new programme of Canton of Bern. Similar decreases between the two triennial periods were found in the first round participation (32.9% vs. 38.3%) and in the reattendance of the women who participated in the previous round (81.7% vs. 85.6%). Without Bern, the overall participation rate was stable around 47% and the first round participation around 38-39%. Participation rates are likely slightly underestimated, as some participa-tion records could not be extracted from the new information system MC-SIS. Prevalent screening in 2013-2015 led to a recall rate (73.0 per 1000 women screened) slightly higher than recommended by the European Guidelines but substantially lower than in 2010-2012 (86.9 per 1000). The main consequence of the reduced recall rate is a substantially lower false-positive rate (67 vs. 80 per 1000). There is a concomitant but less pronounced decrease in breast cancer detection (6.1 vs. 6.9 per 1000) given the slightly increased positive predictive value of the screening examination (8.4% vs. 8.0%). Although the classi-fications of tumour characteristics are partly incomplete, most tumour distribution proportions are in accord-ance with the European Guidelines

Detailed site distribution of melanoma and sunlight exposure: aetiological patterns from a Swiss series

Background: The relation between detailed cutaneous distribution of melanoma and indicators of sun exposure patterns has scantily been explored in moderately sun-sensitive populations. Patients and methods: The precise site of 1658 primary malignant melanoma, registered from 1995 to 2002, in Switzerland were retrieved and clinically validated. Relative melanoma density (RMD) was computed by the ratio of observed to expected number of melanoma allowing for body site surface areas, and further adjusted for site-specific melanocyte density. Results: Sites of highest risks were the face, shoulder and upper arm for both sexes, the back for men, and leg for women. Major features of this series were: (i) an unexpectedly high RMD for the face in women (5.6 versus 3.7 in men), (ii) the absence of a male predominance for melanoma on the ears and (iii) for the upper limbs, a steady gradient of increasing melanoma density with increasing proximity to the trunk, regardless of sex. Age and sex patterns of RMD parallelled general indicators of sun exposure and behaviour, except for the hand (RMD = 0.2). Conclusion: RMD increased with (cumulative) site sun exposure, but a few notable exceptions support the impact of intermittent exposure in melanoma ris

Effectiveness of organised versus opportunistic mammography screening

Background: Detailed comparison of effectiveness between organised and opportunistic mammography screening operating in the same country has seldom been carried out. Patients and methods: Prognostic indicators, as defined in the European Guidelines, were used to evaluate screening effectiveness in Switzerland. Matching of screening programmes' records with population-based cancer registries enabled to compare indicators of effectiveness by screening and detection modality (organised versus opportunistic screening, unscreened, interval cancers). Comparisons of prognostic profile were also drawn with two Swiss regions uncovered by service screening of low and high prevalence of opportunistic screening, respectively. Results: Opportunistic and organised screening yielded overall little difference in prognostic profile. Both screening types led to substantial stage shifting. Breast cancer prognostic indicators were systematically more favourable in Swiss regions covered by a programme. In regions without a screening programme, the higher the prevalence of opportunistic screening, the better was the prognostic profile. Conclusions: Organised screening appeared as effective as opportunistic screening. Mammography screening has strongly influenced the stage distribution of breast cancer in Switzerland, and a favourable impact on mortality is anticipated. Extension of organised mammography screening to the whole of Switzerland can be expected to further improve breast cancer prognosis in a cost-effective wa

Association between colorectal cancer testing and insurance type: Evidence from the Swiss Health Interview Survey 2012

Both colonoscopy and fecal occult blood test (FOBT) are commonly used for colorectal cancer (CRC) screening, but colonoscopy costs much more than FOBT. Swiss insurance offers high or low deductibles and choice of basic or private insurance. We hypothesized that high deductibles and basic insurance discourage colonoscopy, but do not change FOBT rates. We determined the proportion of patients tested for CRC in Switzerland (colonoscopy within 10 years, FOBT within 2 years), and determined associations with health insurance type. We extracted data on 50–75-year-olds from the Swiss Health Interview Surveys of 2012 to determine colonoscopy and FOBT testing rates (n = 7335). Multivariate logistic regression models estimated prevalence ratios (PRs) of CRC testing associated with health insurance type (deductible and private insurance), adjusted for socio-demographic factors (age, gender, education, income) and self-rated health. The weighted proportion of individuals tested for CRC within recommended intervals was 39.5%. Testing with colonoscopy was significantly associated with private insurance (PR 1.85, 95% CI: 1.46–2.35) and low deductible (PR 2.00, 95% CI: 1.56–2.57). Testing with FOBT was significantly associated with deductible (PR 1.71, 95%CI:1.09–2.68) but not with private insurance. About 60% of the Swiss population was not current with CRC testing. After adjusting for covariates, private insurance and low deductible was significantly associated with higher prevalence of CRC testing, indicating that waiving the deductible could increase CRC screening uptake and reduce health inequality

Ten-year changes in colorectal cancer screening in Switzerland: The Swiss Health Interview Survey 2007, 2012 and 2017

Recent recommendations for colorectal cancer (CRC) screening suggest fecal occult blood test (FOBT) or colonoscopy. Since 2013, mandatory health insurance in Switzerland reimburse CRC screening. We set out to determine if CRC testing rate and type of CRC screening changed in Switzerland from 2007 to 2017 and between the three main language regions. We extracted data on 50–75-year-olds from the Swiss Health Interview Survey (SHIS) 2007, 2012 and 2017 to determine rates of self-reported testing with FOBT within last 2 years and colonoscopy within last 10 years. We estimated prevalence ratio (PR) in multivariate-adjusted logistic regression models and compared rates in German-, French- and Italian-speaking regions, adjusting for sociodemographic, self-rated health and insurance variables. Overall testing rates (FOBT or colonoscopy) increased in all regions from 2007 to 2017 (German-speaking 33.6% to 48.3%; French-speaking 30.8% to 48.8%; Italian-speaking 37.9% to 46.8%), mainly because of an increase in colonoscopy rate for screening reasons (p < 0.001 in all regions). Rates of FOBT testing fell significantly in the German-speaking region (11.9% to 4.4%, p < 0.001), but not in the Italian- (13.9% to 8.5%, p = 0.052) and French-speaking regions (7.6% to 7.4%, p = 0.138). Overall CRC testing rate rose from 33.2% in 2007 to 48.4% in 2017, mainly because of an increase of colonoscopy rate for screening reasons. Coverage remains below the 65% target of European guidelines. Organized screening programs encouraging FOBT screening could contribute to further increasing the CRC testing rate

Clinical assessment of skin phototypes: watch your words!

Fitzpatrick skin phototype classification is widely used to assess risk factors for skin cancers. This skin type evaluation is easy to use in clinical practice but is not always applied as initially described, nor practiced in a standardised way. This can have implications on the results of relevant dermato-epidemiological studies. To demonstrate, in a large multinational setting, that the phrasing of questions on sun sensitivity can have a strong impact on the perception and reporting of skin phototype, as well as the importance of a standardised procedure for phototype assessment. Using data collected from 48,258 screenees of the Euromelanoma campaign in six European countries from 2009 to 2011, we analysed the impact of change in the question phrasing on phototype classification in each country. Changing the wording of a question to assess the phototype of a person also significantly influenced the classification of phototypes in different countries (p<0.001 for each country). The difference essentially corresponded to a shift towards a less sun-sensitive skin type when a shorter question that did not include skin colour description was used. The only exception was Portugal where phototype was not patient-assessed and classification shifted towards a more sun-sensitive phototype. Results were statistically significant and highly consistent, irrespective of gender. The phrasing of questions on skin type is important and substantially influences reporting. A standardized procedure to classify phototypes should be used in order to obtain comparable data between studies