Intended for healthcare professionals


Health screening needs independent regular re-evaluation

BMJ 2021; 374 doi: (Published 27 September 2021) Cite this as: BMJ 2021;374:n2049
  1. Fabienne G Ropers, consultant1,
  2. Alexandra Barratt, professor2,
  3. Timothy J Wilt, professor3,
  4. Stuart G Nicholls, researcher4,
  5. Sian Taylor-Phillips, professor5,
  6. Barnett S Kramer, consultant6,
  7. Laura J Esserman, professor7,
  8. Susan L Norris, doctor8,
  9. Lorna M Gibson, consultant9,
  10. Russell P Harris, emeritus professor10,
  11. Stacy M Carter, director11,
  12. Gemma Jacklyn, consultant2,
  13. Karsten Juhl Jørgensen, chief physician12
  1. 1Department of General Paediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Center, Leiden, Netherlands
  2. 2Sydney School of Public Health, University of Sydney, Sydney, New South Wales,
  3. Australia
  4. 3Minneapolis VA Center for Care Delivery and Outcomes Research and the University of Minnesota, Minneapolis, MN, USA
  5. 4Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
  6. 5Warwick Medical School, Coventry, UK
  7. 6Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
  8. 7Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
  9. 8Oregon Health and Science University, Portland, OR, USA
  10. 9Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
  11. 10School of Medicine, University of North Carolina at Chapel Hill, NC, USA
  12. 11Australian Centre for Health Engagement, Evidence and Values, University of Wollongong, Wollongong, NSW, Australia
  13. 12 Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark 
  1. Correspondence to: F G Ropers f.g.ropers{at}

Changing circumstances may alter the benefit and risk profile of screening programmes. Fabienne G Ropers and colleagues propose a framework for re-evaluation to ensure continued public benefit

From tentative beginnings over 70 years ago,1 screening to detect disease or risk factors before symptoms appear has become a familiar feature of modern healthcare. Screening delivers a mix of health benefits, harms, and costs.23 Importantly, these outcomes are not constants: they change with new evidence, vary between contexts, and over time.

Screening practices (whether organised as programmes or not) tend to be slow to react to these changes; alterations are often resisted and controversial.45 The reasons include financial interests, attention to sunk costs, lack of high certainty evidence or proper evaluation of existing evidence, a problematic belief that earlier detection is always better, or simple inertia or preference for the status quo.67

Screening programmes are often financed within finite collective healthcare budgets. They target asymptomatic people, most of whom are not those who need healthcare most. Continuing screening in the face of changing circumstances therefore deserves careful consideration, as it potentially leads to harm to healthy citizens and waste of scarce resources.

While there are well established principles for starting screening,1 none exist for stopping it.8 As experts who have worked on screening over many years, we see an urgent need for clear, agreed methods for actively re-evaluating existing practices that address inherent biases towards maintaining the status quo.

Why screening practices need re-evaluation

The value of screening may be changed by several factors, including changes in disease incidence, advances in diagnosis and treatment, evidence from ongoing programmes, and preventive possibilities.

Change in incidence

Primary prevention may decrease disease incidence and thus the absolute benefit from screening. For instance, the incidence of abdominal aortic aneurysm fell by 70% in the UK …

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