- Michael Bretthauer, professor and endoscopist12,
- Geir Hoff, professor and head of screening programme234
- 1University of Oslo, Oslo, Norway
- 2Oslo University Hospital, Oslo
- 3Cancer Registry of Norway, Oslo
- 4Department of Research, Telemark Hospital, Skien, Norway
- Correspondence to: M Bretthauer, Institute of Health and Society, Department of Health Management and Health Economy, University of Oslo, 0317 Oslo, Norway
- Accepted 26 March 2012
In recent decades, cancer screening programmes (screening that is publicly organised and includes invitation procedures for eligible people of the average risk population in the screening area) have been established in many countries. While cancer screening in the context of clinical trials is innovative and investigative, cancer screening programmes themselves are largely static and not designed to generate new, evidence based knowledge. However, screening programmes themselves affect health and healthcare, which may in turn substantially affect the effectiveness of the programmes. Many screening programmes today can be regarded as supertankers; once under way, they are difficult to halt or alter in direction or content. In mammography, increasing concern about the benefits and harms of screening programmes has led to the announcement of an independent review of mammography screening in the United Kingdom.1 Here, we outline new approaches that aim to overcome this obstacle, using the principles of comparative effectiveness research.
Screening programmes change medicine
Breast cancer mortality in Norway has declined since the introduction of the Norwegian breast cancer screening programme in the 1990s. According to new evidence, however, most of the observed decline in mortality is not due to the screening itself but is because of the improved patient care that resulted from the introduction of the screening programme (which was accompanied by reorganisation of breast cancer care, improving quality and awareness).2 This surprising finding indicates that screening tests themselves may be of minor importance for the reduced morbidity and mortality achieved by implementing a screening programme.
In the case of the Norwegian breast cancer screening programme, it was possible to tease out the …