Screening programmes

Practice nurse forum

13th January 2009

• Screening – an overview 12:45 – Helen Knowles

• Cervical screening 13.00– Helen Knowles / Elizabeth Stephens

• Breast screening 13.15– Jane Sarify-Nafis/ Amanda Dixon

• Bowel cancer 14.00– Helen Knowles/ Alison Ball

• Chlamydia 14.10– Cass Golumbina

• Retinal screening 14.20– Helen Knowles

National screening programmes

Antenatal •Downs •Fetal anomaly •Sickle cell and thalassaemia•Communicable disease

HIV Syphilis

Rubella Hep B

Newborn Newborn Hearing

Bloodspot

MCADD CHT CF

Sickle Cell and Thalassaemia PKU

Chlamydia

Cancer Cervical

Breast

Bowel

Vascular Diabetic Retinopathy

Abdominal Aortic Aneurysm

Biological onset of disease

Early diagnosis possible

Usual clinical diagnosis

Recovery/ disability/death

Screening

Longer pre-disease state =

↑ chance of being detected

Detected earlier so less severe disease

Inviting and Informing eligible

population

Screening test

Results and communication about results

Assessment Decision making

A screening programme

Systematic call / recall

Disease

positive

Disease

negative

Test

Positive

True

positive

False

positive

Test negative

False

negative

True

negative

Falsely reassured. No difference to their disease outcome

Further unnecessary

investigations and anxiety

Reassured. But may not lead to

desirable behaviour

May benefit from early detection. But outcome may not change for everybody.

Where’s the harm in screening?

Breast pathology that would become symptomatic

Breast pathology that would remain latent

No breast pathology and not destined to develop symptomatic disease before next routine screen

The test (mammogra

phy)

+ve True positive ‘True positive’ False positive

-ve False negative ‘False negative’ True Negative

L&D

Adden

BHT

Stoke M

Lister

MK

PSU call/recall

GP practices

(58)

PCT

PCT

PCT

Specialist labs

SCG spec

consortium

Child health records

HVs

Lab

Clinical

Lab

Lab

Lab

Lab

Lab

Clinical

Clinical

Clinical

Clinical

Clinical

Clinical Community

Provider

Child health

Records out of area

PSU Out of area

L&D

Adden

BHT

Stoke M

Lister

MK

PSU call/recall

GP practices

(58)

PCT

PCT

Lab

Clinical

Lab

Lab

Lab

Lab

Lab

Clinical

Clinical

Clinical

Clinical

Clinical

Clinical Community

Provider

PSU Out of area

Cervical screening

L&D

Adden

BHT

Stoke M

Lister

MK

GP practices

(58)

PCT

PCT

Specialist lab 1

SCG spec

consortium

Child health records

HVs

Clinical

Clinical

Clinical

Clinical

Clinical

Clinical

Child health

Records out of area

Newborn bloodspot

Specialist lab 2Specialist

lab 3

Screening programmes – key actions

• Develop clarity about service specification and description

• Improved monitoring of performance • Development of programme boards • Development of programme guides/ policies for primary

care: • How the programme works • Flow chart diagrams • Roles and responsibilities within the programme• Local contact information • Failsafe processes• Information material for patients – leaflets, posters etc• Letters etc that are used within the programme

Cervical screening

• Aims to detect abnormalities that could develop into cancer

• National programme 1988; death rate now 50% of what it was then

• Screening programme (changed in 2003)• 25 – 49 year olds 3 yearly screening• 50 -64 year olds 5 yearly screening• Not for under 25s

Under 25 screening

• Incidence of cervical cancer very low in under 25s (less than 40 cases per year)

• Low grade cervical changes relatively common

• Risk of doing more harm than good

Figure 1.1: Numbers of new cases and age specific incidence rates, by sex, cervical cancer, UK 2005

0

100

200

300

4000

-4

5-9

10

-14

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

-84

85

+

Age at diagnosis

Nu

mb

er

of

ca

se

s

0

5

10

15

20

Ra

te p

er

10

0,0

00

po

pu

lati

on

Female cases

Female rates

0

20

40

60

80

100

1200

-4

5-9

10

-14

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

-84

85

+

Age at death

Nu

mb

er

of

de

ath

s

0

2

4

6

8

10

12

14

Ra

te p

er

10

0,0

00

Female deaths

Female rates

Figure 2.1: Number of deaths and age-specific mortality rates, cervical cancer, UK, 2006

Coverage in cervical screening

• BPCT : – 81.2% in 5yrs for 25 -64yr in 07/08– 71.0% in 3.5 yrs in 25-49 in 07/08

• Coverage declining nationally especially in younger age (25 – 34 ) groups

Cervical screening uptake and practice Practice IMD mean

R2 = 0.068

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00

Practice IMD 2007 score mean

Cer

vica

l scr

een

ing

up

take

25-

64

yrs

cove

rag

e (i

n la

st 3

or

5 ye

ars)

Breast screening and IMD score 2007 per practice

R2 = 0.5433

40.0%

45.0%

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00

Practice IMD score

Bre

ast

scr

een

ing

up

tak

e as

% o

f in

vita

tio

ns

Uptake of breast screening per practice Linear (Uptake of breast screening per practice)

TAT - Turnaround time • Target for women to receive results within 14 days of sample from

April 09• LBC introduction to reduce inadequate rate (from 9% to less than

3% and decreasing) • Implications

– Reduce out of programme samples (<25, screening intervals as per programme ie 3 yearly and 5 yearly) – i.e. implement good practice in line with national standards

– Sample to lab time – Lab turnaround time (processing and reading of samples, results

to PSU). Bigger labs- more automation of processing and reading. Regional review of cervical screening lab and call / recall provision

– Planning for PSU to send out all results letters (but those with abnormal results will still need to be contacted by practice)

Inadequate audit

• Local lab providers not yet able to log unique code within IT system to track sample.

• Continue with in-practice codes as now so that each sample can be matched with sample taker

• Working on obtaining practice and PCT level data to be communicated on regular basis.

• Questions

• Discussion