Further Iss With Screening

Question 1

LO2: offer critic perspec on screening progs.

Answer 1

iss raised:
-1) alterat of usual dr pt contract: pt us define selves by self present. Screening targs appar healthy. Turns peop into pts. Dr needs ev that screen can alt nat hx of the dis in a sig propor of people screened.
-2) complexity of screen progs: eg cervical screen.
12th most comm CA UK, most comm in under 35’s. Detecs early abn that could lead to CA. Free for women 25-64 every 3-5 yr in england. Over 65 only screen those not screened since 50 or recent abn tests.
Not under 25s as invasive CA v rare but cervix changes comm so lot false pos. Lesions that would cause CA will still be screen detectab, others regress.
Not over 65s if 3 conseq neg res. Nat hx means unlikely.
Speculum and spatula samples. To preservat fluid. Cytology lab grades.
Over 90% res are norm so contin norm screen. Abn= changes id that may req furth investig. Not all abns need immed tx. Abn cells can be destr by laser ablat or cold coag, or cut away using loop diathermy or laser excision.
Cost 175m last yr. 73.5% eligible had screening.
Incorp of HPV testing- HPV vacc intro but new triage role for HPV testing in screening. Triage for low grade abn since 2012, if HPV pos then colposcopy referr.
Debates- is nat hx understood. How many abns would regress spont. Are right wom being screened. Has it reduced mort. Over tx. Psych impact.
-3) evaluating screening progs.
See LO1.
-4) lims of screening:
Cant guarantee protec, risk reduc only. False pos and negs.
Needs for informed choice- not invite all and assume attend desp negs. Can be harmf. Incr emph on prom informed choice about screen.
Eg mammography- incr attention on uncerts and extent of over diag. Rev in 2012 said sig benef and should contin. But for ev life saved, 3 wom treated unecess. Info to allow informed choice req but diffic to comm benef/harm/risks of intervens.
-5) sociological critiques of screening:
See LO4.

Question 2

LO3: egs of screen progs in UK.

Answer 2

-cervical

Breast

Question 3

LO4: expl sociological critiques of health prom and screening.

Answer 3

-victim blaming- can all people take responsib for own health.
Individualising pathology- address underly mater cuses of dis? Screening secondary, why not foc on prim?
(Structural critiques)
- indivs and pops incr surveillance. Prevention part of soc control?
(Surveillance critiques).
- health and illn practices cn be seen as moral- given emanign through partic soc relationships.
(Social constructionist)
- is screen targ more at women?
(Feminist critique)
- eg cervic:
Attendance is not unproblematic- resp to set of normative expecs. Soc prac embedd in moral framew of responsib and oblig. Not attend is deviant.
-is earlier diag and tx a good thing?????

Question 4

LO1: desc diffics of eval effectiven of screen programmes.

Answer 4

• must be based on qual ev. Can be great press to start screen progs eg prostate CA- no robust ev earlier detec improves outcome, and screen could cause harm like unecess tx s/e.
• lead time bias:
  Early diag falsely apps to prolong surv. But only because diag earlier. Just longer while knowing.
  -length time bias:
  Screen better at pick up slow growing unthreaten cases than aggressive fast growing ones as they spont present. So detects cases with good prognosis and poss never would have been problem. Poss false impress of lengthen lives of people who test pos- curing people that didnt need curing.
  -selec bias:
  Healthy volunteer eff in studies of screening. Regul screening likely to do other things to protect from dis. RCT needed.