Reducing mortality and morbidity through screening

1. Reducing mortality and morbidity through screening Dr Hilary Fielder Director, Screening Services Public Health Wales

2. Screening in Wales • Screening policy advice from UK National Screening Committee to WAG • Operational support and advice from other UK programmes • Most screening programmes have been commissioned centrally by Health Commission Wales.

3. Screening Services Five screening programmes – annual participants Breast Test Wales 100,000 Cervical Screening Wales 240,000 Ante Natal Screening Wales >35,000 Newborn Hearing Screening Wales 33,000 Bowel Screening Wales 440,000

4. Factors Influencing Effectiveness Participation of target population Performance of test Frequency of screening Adequacy of follow-up for those who screen positive Effectiveness of treatment

5. Breast Test Wales • Aim is to reduce mortality from breast cancer through early detection of breast cancer • Invite women 50-70 years – from March 2006 • Self referral over 70 years • Screening interval – 3 years

7. Mammogram with simulated lesion (disc)

8. Same mammogram displayed with lower optical density – disc is harder to seeNote – this can arise if the radiation dose is too low

9. UK 2006/07 Overall SDR

10. Breast Cancer Mortality in Wales Age standardised to the European Standard Population Data from Welsh Cancer Intelligence & Surveillance Unit

11. Newborn Hearing Screening Wales Aim of the programme: To identify babies with significant hearing impairment which is of sufficient severity to cause or potentially cause a disability without the introduction of habilitation in infancy

12. Newborn Hearing Screening Wales Objectives of Programme: • Offered to all babies whose mother resident in Wales • Offered to most babies in first week of life • To identify significant bilateral permanent hearing loss >40dBnHL in better ear • To ensure that adequate services are available up to the age of 2 years

13. Methods of Screening Well babies High risk babies

14. Efficiency of NBHSW • Coverage is over 99% of target population • At present in line with other UK newborn screening programmes have written consent • 100% of those referred from the screening are offered assessment • 90% complete assessment • Above the predicted number from population studies prior to the start of screening are diagnosed with hearing loss (1.3 per 1000 births)

15. Outcomes • Evidence that early fitting of hearing aids improves outcomes for deaf babies. Yasinaga-Itano 2003, Moeller 2000 etc • NBHSW reports on age of diagnosis, hearing aid fitting and other measures of activity. See annual report published on website www.screeningservices.org/nbhsw • Further programme outcome measures being developed – speech and language testing between at 33 mths. • Quality assurance addressed through standards, QA site visits and peer review of assessments.

16. All Screening Programmes Strive to Achieve a Balance! Harm Benefits Types of Benefit Early detection Early treatment Reduced morbidity Reduced mortality Reproductive choice Type of Harm Anxiety (false positive) Condition not detected (false negative) etc.

17. Screening Programme Outcomes Does not have the condition Has the condition SCREEN Negative SCREEN Positive

18. Antenatal Screening: complex screening programme with many interlinking purposes and ethical considerations

19. Established Managed Clinical Network for Antenatal Screening which works with the service and CARIS . ASW published Standards and protocols for its antenatal screening programmes in 2005 (reviewed and soon to be reprinted). Performance Management Framework and information is collected and reported on by ASW bi-annually. Patient Information is provided and published by ASW in Welsh and English and in a number of other languages Antenatal Screening Wales

20. Infectious Disease Antenatal Screening offered for: • Syphilis (Uptake around 96%) • Hep B (Uptake around 97%) • HIV (Uptake around 93%) and Rubella Susceptibility Screening

21. Down’s syndrome screening uptake

22. All women offered: Early pregnancy USS (10-13 weeks) Fetal anomaly USS (18 – 20 weeks) Wales has a structured obstetric reporting module for these scans Ultrasound Screeing

23. ASW standards: Reducing Harm Decrease in the number of amniocentesis without loss of detection Amniocentesis % Abnormality rate Source: Laboratory Genetics Service for Wales

24. Source: Laboratory Genetics Service for Wales

25. ASW standards: Improving detection Maintained number of CVS with increased detection CVS % Abnormality rate Source: Laboratory Genetics Service for Wales

26. Cervical Screening Programme Aims to: reduce incidence of and mortality from cervical cancer by detecting and treating early precancerous changes Invitations 3 yearly 20 – 64 years Liquid based cytology fully implemented 2005

27. Smear taking equipment

28. 100,000 EASR per population for cervical cancer in Wales, 1985-2007 (data source WCISU)

29. Bowel Cancer in Wales 2,200 people diagnosed every year in Wales 1,000 people die of the disease every year in Wales The third most common cancer in Wales

30. Evidence to Support Bowel Screening 1991-1996 Bowel Screening can prevent premature death 2000-2002 Pilots in England and Scotland 2003-2006 Can be delivered in a population based screening programme 2005 National Screening Committee recommendation

31. Bowel Screening Based on Faecal Occult Blood test Colonoscopy or radiological investigations offered if FOBt positive Reduces mortality from bowel cancer by 15%

32. The Screening Centre

34. Other programmes • Diabetic retinopathy • Newborn bloodspot • Abdominal Aortic Aneurysm • Others?

35. Thanks and acknowledgements • WCISU • Screening staff, especially those who helped with the slides!