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Chris Sampson added The solution.tex
over 9 years ago
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\section*{The solution}
It seems to me that the problems set out above can be addressed by making changes to the way we carry out trials of treatments for diseases that have an asymptomatic state. Trials of treatments for such diseases should recruit asymptomatic individuals and subject all participants to a screening programme. Upon detection of disease (with any necessary decision rules and stratifications) individuals can be given the treatment that is being evaluated. Then, at the end of the trial, the cost-effectiveness of the treatment should be reported as a function of disease progression. In some cases disease progression will be categorised --- for example into asymptomatic/symptomatic --- while in others it will be a function of some other indicator, such as tumour size. Using this information it would be simple to elicit the `value' of a screening programme. There will be 3 possible results: i) commencement of treatment is not cost-effective at any stage of disease, in which case screening is not effective; ii) commencing treatment in the asymptomatic stages of disease is no more cost-effective than commencing treatment once symptoms are identified, in which case screening is not effective; or iii) there is a stage of pre-symptomatic disease at which the commencement of treatment provides benefits over and above waiting to start treatment once symptoms develop, in which case screening is effective. It is only in the third scenario that the information provided by screening can be harnessed for health benefit. Using this information it would be possible to implement a screening programme that maximises cost-effectiveness, without carrying out a trial of the `effectiveness' of screening.
No doubt there are problems with this suggested solution. However, the dramatic inconsistency in the findings of screening trials, and the resulting scepticism amongst clinicians and decision makers, suggests that something is wrong with the way we currently think about the value of screening. It's time for a rethink.
