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What screening aims to achieve and why evidence matters

The examples we have already given show that, before rushing headlong into widespread screening, it is worth pausing a moment to consider the key features of screening programmes and to remind ourselves what they aim to achieve. People being offered screening do not have, or have not noticed, the symptoms or signs of the condition being tested for – they have not sought medical attention for the disorder in question.

The Screening Circus


“Inevitably this whole screening circus is liable to whip up anxiety in vulnerable people without discussing or taking the slightest responsibility for the consequences of any abnormalities found.”

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The purpose of screening individuals or populations is to reduce the risk of death or future ill health from a specific condition by offering a test intended to help identify people who could benefit from treatment. [1, 21] The aim of screening is not simply to diagnose disease earlier – this may not help anyone and it can even do harm.

The basic criteria for assessing the value of screening tests were outlined in a World Health Organization report in 1968. [22] These criteria have been further refined to reflect the way in which healthcare is delivered today. People invited for screening need sufficient, balanced information about the test being offered – including possible harms, consequences, and limitations, as well as potential benefits – so that they can make an informed choice.

Essentially, the key points can be summed up by saying don’t screen unless:

  • The condition being screened for is important in terms of public health – for example, it is serious and/or affects large numbers of people
  • There is a recognizable early stage of the condition
  • There is an effective and acceptable treatment for the condition, so screening is likely to make a difference to its outcome
  • There is a valid and reliable test for the condition that is acceptable to people being offered screening
  • The screening programme is of good quality and cost-effective in the setting in which it is to be offered
  • The information provided to people is unbiased; based on good evidence; and clear about possible harms (eg, overdiagnosis leading to over-treatment) as well as potential benefits
  • The invitation for screening is not coercive – that is, it indicates it is reasonable to decline
  • The chance of physical or psychological harm to those offered screening is likely to be less than the chance of benefit
  • There are adequate facilities for the diagnosis and treatment of abnormalities detected by screening

These criteria reinforce our message at the beginning of this chapter: that any decision to introduce a screening programme should be based on good-quality evidence not only about its effectiveness but also about its potential for doing harm.

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