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Screening programmes Practice nurse forum 13 th January 2009
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
