Intended for healthcare professionals

Analysis And Comment Screening and choice

Informed choice for screening: implications for evaluation

BMJ 2006; 332 doi: (Published 11 May 2006) Cite this as: BMJ 2006;332:1148
  1. Les Irwig, professor (,
  2. Kirsten McCaffery, research fellow1,
  3. Glenn Salkeld, associate professor1,
  4. Patrick Bossuyt, professor2
  1. 1 Screening and Test Evaluation Program, School of Public Health, Edward Ford Building, A27, University of Sydney NSW 2006, Australia
  2. 2 Department of Clinical Epidemiology and Biostatistics, University of Amsterdam, Amsterdam, Netherlands
  1. Correspondence to: L Irwig
  • Accepted 11 March 2006

Evaluation of screening should reflect consumer priorities. We need to make more effort to find out what they really are

Most evaluations of screening do not include the full range of benefits and harms.1 2 The United Kingdom and World Health Organization's latest guidelines on screening accentuate the need for more rigorous evidence of effectiveness and greater concern about the adverse effects of subsequent investigation and management.3 4 The UK guidelines now state that the benefit from the screening programme should outweigh the physical and psychological harm caused by the test, diagnostic procedures, and treatment.3 In the updated WHO guidelines for medical screening, Strong et al state that “Identification of either trivial or untreatable conditions can cause anxiety and waste resources with no practical outcome.”4 They also argue that the acceptability of screening is an important issue to consider. We outline three principles concerned with how consumers' views can be ascertained and used to enable value based decisions about screening programmes.

Value all benefits and harms

Evidence from randomised trials that screening reduces mortality is necessary but not sufficient to justify screening. Decisions should be based on an assessment of all the benefits and harms, not only of the screening test but also of follow up tests and treatments. As the UK criteria state, the screening programme must be clinically, socially, and ethically acceptable to the public and the benefits outweigh the harm.3

A holistic approach to evaluation requires studies to identify the benefits and harms perceived by consumers and clinicians. Harms include:

  • Complications of investigation of screen detected abnormalities

  • Unexpected effects, such as increased morbidity and mortality from side effects of screening or subsequent management

  • Overdetection—the identification of disease that would not have presented during the person's lifetime, and

  • Psychosocial effects.

Some harms or downsides may seem trivial, but, …

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