Everybody’s talking about screening again, with good reason. Research seems to suggest that screening for breast cancer, using mammography, is not effective (let alone cost-effective)(Miller 2014). Here I present a view on the value of screening; the validity of which I am yet to fully convince myself.
The point of screening is the early detection of disease, or the identification of increased risk of disease, in people without symptoms. It is based on the idea that commencing treatment or care at an earlier stage of disease can be beneficial to an individual’s health or well-being in the long-term, including life-extension. Read that sentence again – it’s important. So, the potential value of screening is commensurable to the incremental value of early treatment or care over and above treatment or care that begins with the onset of symptoms. However, as I suggest below, a screening trial is not the best way to capture this.
The value of treatment for disease is clear. Treatment can directly improve health and well-being, and this is something to which people attach value. The same cannot be said of screening, which in and of itself is not health-improving. I believe that we need to stop valuing screening in terms of its ability to extend life and quality of life. It may serve to give people peace of mind, but this is not something that we routinely consider in the evaluation of screening. The true value of screening lies in the extent to which it provides us with new knowledge about a patient; a screening intervention with better sensitivity and specificity is of greater value. It seems perverse to suppose that an intervention that provides us with information can be ‘ineffective’ in terms of health outcomes, or even harmful. The error is surely in our use of that information.