18.6 Screening

Last updated: August 2016 

Suggested citation: Greenhalgh, EM, & Scollo, MM 18.6 Screening. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from: http://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/18-6-screening

Screening is used to promote the early detection of cancer. Australia currently has three national cancer screening programs: BreastScreen, which recruits and scans women aged 50–74 for early signs of breast cancer; the National Bowel Cancer Screening Program, which offers people over the age of 50 a free screening test that tests for blood in the bowel movement and can be undertaken in their own home; and The National Cervical Screening Program, which recommends regular pap tests for women aged between 18 and 70.1

There is considerable interest, both in Australia and internationally, in the potential for population based screening using low-dose CT scans to detect nodules that might be lung cancer early, when it is still treatable. Research has suggested that annual spiral CT screening can detect lung cancer that is curable.2 The largest study performed to date, the US National Lung Cancer Screening Trial (NLST), showed a 20% reduction in lung cancer mortality after screening high risk individuals (heavy smokers) using low dose computed tomography,3 leading to recommendations that support screening in the US.4

A number of expert reviews have concluded that while annual screening of individuals at a substantially elevated risk of lung cancer may be a promising way forward, there is still too much uncertainty for large-scale population-based implementation. They have suggested that further investigation is needed in the areas of: over-diagnosis and false positives; weighing up the potential benefits versus harm; at risk population to screen; frequency and duration of screening; the most appropriate diagnostic work-up of screen detected abnormalities; and implications for public policy.5,6

A similar conclusion has been reached in Australia, where decisions regarding screening programs are guided by criteria set out in the Population Based Screening Framework.7 Due to screening having the potential to cause both harms and benefits, high-level evidence is required prior to the establishment of a screening program. Potential harms include the financial costs of the program and personal costs to the person such as anxiety, discomfort, adverse effects, follow-up investigations, over-diagnosis and possible treatment (which can carry its own risks).7 Among high-risk Australians, research has shown that there is high willingness for lung cancer screening and surgical treatment.8 However, Australian researchers have argued that national lung screening is likely to strain health care expenditure, and that the cost of systematic screening may be equivalent to the annual expenditure on all lung cancer care. They suggest that a more cost- and outcome-effective method of reducing mortality is smoking cessation programs.9 The Standing Committee on Screening concluded that further evidence is needed before a national lung cancer screening program might be considered for implementation in Australia.10

Relevant news and research

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1. Department of Health, Cancer screening. Australian Government; 2015. Available from: http://www.cancerscreening.gov.au/ .

2. Henschke CI, Yankelevitz DF, Libby DM, Pasmantier MW, Smith JP, et al. Survival of patients with stage I lung cancer detected on CT screening. New England Journal of Medicine, 2006; 355(17):1763–71. Available from: http://europepmc.org/abstract/med/17065637

3. The National Lung Cancer Screening Trial Research team. Reduced lung-cancer mortality with low-dose computed tomographic screening. New England Journal of Medicine, 2011; 365(5):395–409. Available from: http://europepmc.org/abstract/med/21714641

4. Wender R, Fontham ET, Barrera E, Colditz GA, Church TR, et al. American Cancer Society lung cancer screening guidelines. CA: A Cancer Journal for Clinicians, 2013; 63(2):106–17. Available from: http://onlinelibrary.wiley.com/doi/10.3322/caac.21172/full

5. Canadian Partnership Against Cancer and Lung Screening Expert Panel, Lung cancer screening expert panel: summary of existing and new evidence. Toronto: Canadian Partnership Against Cancer; 2011. Available from: http://www.lungcancercanada.ca/resources/site1/general/PDF/CPAC_Lung_Cancer_Screening_FINAL.pdf .

6. Bach PB, Mirkin JN, Oliver TK, Azzoli CG, Berry DA, et al. Benefits and harms of CT screening for lung cancer: a systematic review. Journal of the American Medical Association, 2012; 307(22):2418–29. Available from: http://dx.doi.org/10.1001/jama.2012.5521

7. Australian Population Health Development Principal Committee – Screening Subcommittee. Population based screening framework. 2008. Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/16AE0B0524753EE9CA257CEE0000B5D7/$File/Population-based-screening-framework.PDF

8. Flynn AE, Peters MJ, and Morgan LC. Attitudes towards lung cancer screening in an Australian high-risk population. Lung Cancer International, 2013; 2013:7. Available from: http://dx.doi.org/10.1155/2013/789057

9. Hew M, Stirling RG, and Abramson MJ. Should we screen for lung cancer in Australia? The Medical Journal of Australia, 2013; 199(2):82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23879486

10. Department of Health – Standing Committee on Screening, Lung cancer screening: overview of the evidence and issues. Australian Government; 2013. Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/lung-cancer-screening.