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3. SCREENING
In its 2003 report, S trategies to Improve and Strengthen Cancer Control Programmes in Europe, the World Health Organisation ( WHO) reaffirms the importance of earlier detection, whether through earlier presentation by individuals (requiring greater awareness of cancer and its signs and symptoms and/or taking more responsibility for personal health) or through organised national screening programmes.
Screening is offered to apparently otherwise healthy people, so that a small number who may develop cancer or who may, unknown to them, already have cancer at a very early stage, can be identified and offered early and effective treatment. An essential part of any cancer control plan is therefore population screening - where there is evidence of benefit and where there is a recognised clinically effective test and treatment.
Current Screening Programmes
The current screening programmes comprise:
- The Scottish Breast Screening Programme ( SBSP) - set up in the late 1980s with the aim of contributing to the reduction in mortality rates from cancer, this programme is subject to rigorous quality assurance and is reviewed regularly to ensure that practice keeps up with emerging evidence. Women aged 50 to 70 are invited to attend for screening every 3 years and women over 70 can request a screening appointment. In light of the evidence that perhaps as many as an additional 275 very early cancers can be detected by taking 2 views at every round of screening, all services in Scotland are planning to introduce this over the next 2 years. Up until now women have had 2 views taken only at the first round of screening with double reporting at every round ( i.e. 2 different radiologists looking at and confirming the results of the screening mammogram). In 2005-06, over 166,000 women were screened and 1,348 cancers were detected.
- Cervical Cancer Screening - women aged 20 to 60 are invited to attend once every 3 years. Statistical evidence indicates that as a direct result of the cervical cancer screening programme as many as 250 cases of cervical cancer are prevented each year in Scotland. Over the last few years the introduction of new technology - liquid based cytology - has seen a significant improvement in the way cervical smears are processed. This, coupled with a new, more effective IT system for calling up women for testing, has resulted in a much faster turnaround time so that women now generally get their results within 14 days of having their smear (previously it may have taken up to 6 weeks to get results back). The cervical screening programme is also subject to rigorous quality control/quality assurance including routine monitoring of attendance. If we are to maintain the excellent progress made in reducing mortality from cervical cancer it is vital that all women attend for their routine smear test and we will therefore be looking at ways to ensure that the importance of screening and awareness of its benefits are better communicated and understood. This will be especially important with the roll out of the HPV vaccination programme. In 2006/07 over 400,000 smears were taken in Scotland and approximately 3.5% showed some degree of pre-cancerous change, thus enabling early and effective intervention.
- Scottish Bowel Cancer Screening Programme ( SBCSP) - this is currently being implemented across Scotland and will be provided by every NHS Board by the end of 2009-10. Men and women aged 50 to 74 will be invited to participate every 2 years by sending a sample to the national screening laboratory for testing (known as the faecal occult blood test ( FOBt)). It is anticipated that when fully implemented the bowel cancer screening programme may save up to an additional 160 lives each year by detecting cancers in the early stages of development or by detecting pre-cancerous polyps which can then be removed. In the latter cases, individuals who need it can then be routinely monitored so that if a cancer does subsequently develop it will be found at its very early stages when much more amenable to successful treatment. The effectiveness of the SBCSP will also be subject to rigorous quality control/quality assurance including monitoring of attendance.
There is evidence that uptake of screening appointments - for breast, cervical and bowel screening where it is currently available - is variable across the country. The uptake of bowel screening between men and women also varies with fewer men than women opting to participate and we need to seek out ways to drive out inequities in uptake.
Research
New screening programmes are introduced only after there has been rigorous assessment via, for example, multi-national clinical trials, to ensure that any programme will be safe and effective. The UK National Screening Committee is the recognised body that advises UK Health Ministers on matters relating to the introduction of new screening programmes and on the evidence for modification and/or enhancement of existing national screening programmes.
Research is underway in a variety of areas and may in time provide evidence to support the National Screening Committee in making recommendations on new opportunities for screening. These include lung cancer, where a call has been made by the UK National Cancer Research Initiative ( NCRI) for a spiral CT screening lung cancer screening proposal in high risk groups. The UK Collaborative Trial of Ovarian Cancer Screening involves some 200,000 women aged 50 to 74 from across the UK, which is assessing the effectiveness of (a) an annual CA 125 blood test and (b) annual trans-vaginal ultrasound. This trial, known as UKCTOCS started in 2000 and results are not expected until approximately 2012.
Cancer Genetics Services
Since the late 1990s, formalised cancer genetics services have been co-ordinated via 4 Regional Genetics Centres supported by a group of cancer genetics associates working in primary care. These services are aimed at supporting people who may be at greater risk of developing breast, ovarian or colorectal cancer because of an inherited genetic pre-disposition. Anyone who is concerned that they may be at increased risk of developing cancer because of their family history can be referred for appropriate risk assessment and advice. All NHS family history clinics work within referral, surveillance and management guidance which was issued in 2001 ( NHSHDL(2001)24) and updated for breast cancer assessment in 2007 ( NHSHDL(2007)8) to take account of the latest evidence.
We are also in an age in which detailed analysis of the cancer cell can influence many aspects of patient care: helping to direct treatment; helping to deliver prognostic advice to patients and identifying those patients requiring the most urgent/immediate treatment. Our aim must be to incorporate genetics tests rapidly into treatment strategies. Action is therefore required to better co-ordinate our approach, improve research and development and ensure that we make best use of our highly trained healthcare professional staff across all aspects of genetics services.
Issues to Consider
- How should we develop our approach to screening in Scotland?
- What more can we do to raise awareness, encourage participation and reduce inequalities in uptake of existing screening programmes?
- What does the research base tell us about how to derive greatest value from future screening programmes in Scotland?
- What more can we do to ensure cancer genetics services are positioned to play their full part as technology develops and knowledge grows of the impact of genetics in prevention, diagnosis and treatment of cancer?
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