The epidemiologic approach to evaluating screening program

Dr. Rizwan Asst. Professor, department of Epidemiology

Introduction Primary prevention: Prevention of Occurrence of disease Secondary prevention: Early detection of disease

Early detection
The term early detection of disease means detecting a disease in earlier stage that would usually occur in standard clinical practice. This denotes detecting disease at a presymptomatic stage, at which point the patient has no clinical complaint and , therefore, no reason to seek medical care for the condition.

Benefit from early detection depends on following components

Can the disease be detected early? What are the sensitivity and specificity of the test? What is the predictive value of the test? How serious is the problem of false positive test results? What is the cost of early detection in terms of funds resources and emotional impact?

Benefit from early detection depends on following components

Are the subjects harmed by the screening test Do the individuals in whom disease is detected early benefit from the early detection, and is there an overall benefit to those who are screened?

Assessing the effectiveness of screening programs

Operational measures 1. Number of people screened 2. Proportion of target populations screened and number of times screened 3. Detected prevalence of preclinical disease 4. Total costs of the program 5. Costs per case found 6. Costs per previously unknown case found

Assessing the effectiveness of screening programs

7. Proportion of positive screenees brought to final diagnosis and treatment. 8. Predictive value of a positive test in population screened.

Assessing the effectiveness of screening programs

Outcome measures 1. Reduction of mortality in the population screened 2. Reduction of case-fatality in screened individuals 3. Increase in percent of cases detected at earlier stages 4. Reduction in complications 5. Prevention of or reduction in recurrences or metastases 6. Improvement of quality of life in screened individuals

BEFORE DISEASE STARTS

DISEASE PRESENT

Clinical Outcome No Disease Biologic Onset of Disease Symptoms First Appear Disease Diagnosed

Therapy Given

BEFORE DISEASE STARTS

DISEASE PRESENT

Normal

Preclinical Phase

Clinical Phase Clinical Outcome

No Disease Biologic Onset of Disease Symptoms First Appear Disease Diagnosed

Therapy Given

Primary prevention

Secondary Prevention

Tertiary Prevention

Normal

Preclinical Phase

Clinical Phase Clinical Outcome

No Disease Biologic Onset of Disease Symptoms First Appear Disease Diagnosed

Therapy Given

Remove Causes Of Disease or Immunize

Screen for Detect and Treat Disease Early

Treat Clinical Disease to Prevent Death or Complications

Normal

Preclinical Phase

Clinical Phase Clinical Outcome

No Disease Biologic Onset of Disease Symptoms First Appear Disease Diagnosed

Therapy Given

Important assumptions
Preclinical phase Detectable preclinical phase Lead time Critical point All or most clinical cases of a disease first go through a detectable preclinical phase. In the absence of intervention, all or most cases in a preclinical phase progress to clinical phase

BEFORE DISEASE STARTS

DISEASE PRESENT

Normal

Preclinical Phase

Clinical Phase Clinical Outcome

No Disease Biologic Onset of Disease Symptoms First Appear Disease Diagnosed

Therapy Given

Disease Detectable by Screening

BEFORE DISEASE STARTS

DISEASE PRESENT

Detectable Preclinical Phase

Clinical Phase Clinical Outcome

No Disease Biologic Onset of Disease Symptoms First Appear Disease Diagnosed

Therapy Given

Disease Detectable by Screening

Lead Time
Clinical Outcome No Disease Biologic Onset of Disease

Symptoms

Usual Time of Diagnosis

Therapy Given

Disease Detectable by Screening

Critical Point

Biologic Onset

Positive Pathologic Detection Changes Test Possible

Usual Time of Diagnosis

Final Outcome

Positive Detection Test Possible

Usual Time of Diagnosis

NORMAL CERVIX

CARCINOMA IN SITU

INVASIVE CERVICAL CANCER

NORMAL CERVIX

CARCINOMA IN SITU

INVASIVE CERVICAL CANCER