[MUSIC] In this talk, we will address the question, should we implement a screening program? If yes, what test, what frequency, to what eligible population should we offer these programs? Although is it needed to have a pilot phase or not? And if the answer is no, we do not need this screening program. Should screening not be recommended, or should the screening even be stopped from starting? There are essentially four main pillars about decision making for screening. The first is evidence, the scientific evidence. Is this screening worthwhile, is it proven to be efficient? The second is about the resource, can we afford it? Do we have not only the financial resource, but the human resources, staff able to perform these screening programs? And the third and fourth pillars are to do with our societal values and beliefs, to think something which is good for the population. Should we offer screenings, rather than an intervention for these given the amount of money for healthcare? So let's start with the first pillar, the assessment of evidence. There has been, about half a century ago, already developed by the World Health Organization some guiding principle on what are the conditioning criteria to offer health screening? And if we assume these criteria are satisfied, we need to evaluate the burden of the disease. To look at what are are the screening tests, which are available. What are the characteristic and their preferments, and also, look at in other countries, in the literature, What is available in terms of evidence-based result of efficacy, the effectiveness, and the cost effectiveness of screening. But for your local context, looking what has happened elsewhere in the world is not enough. You also need to look locally, or nationally, depending if your programs is planned to be local or national programs. What are your current screening practices? Is there already some screening going on or not? What tests or screenings are being done? For instance, if you're intending to plan a colorectal cancer screening program, with rectal sigmoidoscopic tests but your medical practitioners are mostly conducting a fecal occur blood test or A colonoscopy, it will not match what is currently in practice. You also need to have an idea of what's the frequency of the tests, being performed at a time and to understand, what are the factors that can affect the screening and the screening uptake. We'll give you an example shortly. In terms of resources available, this goes far beyond the resources just needed to run a program. You need to think, do we have the trained workforce capable of delivering During the screening programs? For instance, I was referring to colorectal cancer. Do we have enough gastroenterologists to perform colonoscopy for people who have been screened positive? Do we have the finance to achieve high quality-assured screening programs? There are cost to have a high quality equipment, to maintain it, to plan about evaluation, then the quality in there. That's all different aspect that needs to be taken into account, and intending to write a cheap program is the best recipe for failure. So this point have to be taken on board. And ought to be aware if any other health improvement services will may compete with the resources that your healthcare system has to put into the screening programs. Generally, the full cost of providing screening programs tend to be underestimating at the planning stage. Often, as aspect such as the necessity to have the coordination, the management, a center, is sometimes not taken into account. Or the necessity to have a performing computing software, to record all data is not often included. And it is also a good idea to assess different screening scenario of less or more intensity, to see the impact it has on the cost. Knowing that a screening abides to the law of the diminishing returns. That is because effective cost ratio tends to decrease with increasing frequency of the tests. The extra gain you get from screening more intensively is not compensating for the extra cost and the extra harms which are involved. As an example of assessment of the evidence and the resources available, let's take cervical cancer screening in Russia as an example. In Russia, cervical cancer is a high burden. It is the second cause of cancer related deaths. The mortality trends are very unfavorable, one of the highest rate in Europe, and trends are very different for the country where mortality rates tend to decrease from cervical cancer, which is not the case in Russia. And also, about seven out of ten cervical cancer being diagnosed are in advanced, incurable stage. But there are a lot which could be improved with screening. We know that pap smear screening is being efficient. So when you look at other resources available in Russia about screening, It has been estimated that about 80% of the medical equipment, and gynecological consultations was depreciating, that some of the medical equipment in hospitals have been exploited for about 15 to 20 years. And that requirements of hospital and clinics in getting new equipment were satisfied to both 30 to 40% only so there was a lot in infrastructure to be provided or to offer such screenings. And when you look from a corporation's perspective, the screening uptake of cervical cancer was only about 30%, which is very low compared to other European countries. That woman had no knowledge about the pap smear screening, about 40%, which is again low, compared to the other countries. And that the general practitioners were often not recommended to the patient screenings, or encourage them to get screened. Though you could see all the limitations and the hurdles which need to be tackled in order to offer an organized cancer screening program in the context of Russia and cervical cancer. Okay, let's move to the third and fourth pillars, which are the values and the beliefs about screening. So social values varies across countries and societies. And we can consider, more or less, individualistic versus collectivist ethos are the two main approaches. The individualistic approach that, there is a potential to improve someone else’s health, regardless of the cost or harm that can be made to other people in screening, this potential should be realized. This is for instance, the value conveyed by the commercial industries, where the commercial interest in screening are being adopted as often as possible. The collectivist approach is to acknowledge the right to benefit from an intervention. But this right has to be balanced against the other needs of the population. Beliefs about screening are strong, the intuitive reasoning is that any screening must be good. At least we're doing something for the population. The belief in screening, that are widespread, is that it can not fail to be beneficial. The value of a new test being developed being available, then the clinical application also must be good since these tests has been made available. So there is a strong belief in society and accepting evidence that screening can sometimes cause harm, or cannot be efficient. It's hard when it is so contrary to our belief. There is also pressure, pressure from the politics to do something for the populations. You can hear men saying, well, women have access to mammary screening, there is no prostate cancer screening. They don't care the government doesn't care about us. So with all these aspects, these demands from the population put pressure on the politics. And overall, if we come back to These four pillars, the irrationality which is conveyed by the values and the beliefs can in many instances overrule the more rational and scientific evidence about the benefits and harms of screening decisions to implement a screening program. What about stopping screening? One thing is sure, it is much more difficult to stop screening than to start it, is that to stop screening from starting. How could our values and beliefs, which were right yesterday, can be wrong today? It is a challenging issue to justify why screening should be stopped. Maybe a lot of commercial worker put pressure to keep going on screening. A lot of financial interests involved which a politician would take an unpopular decision to stop providing screening to its population. Generally, it has more to do with changing in the screening strategy. It could be a new test be made available to improve the quality of screening. Such fecal occult test replacing the guaiac test for colorectal cancer screening. Digital mammography, which has replaced imagery mammography, or test like ultrasound for very dense breasts to improve the quality of mammography for the specific population of female. So it's mostly to improve the quality, maximizing the benefits and minimizing the harm rather than stopping screening which is common. But probably the main rationality to stop screening will come from a lack of financial resources. Finally, do we need a pilot phase? Well, a pilot phase for screening is to validate or demonstrate the feasibility, not about the usefulness of screening. So when you're planning a pilot phase means you've already decided you want to move on then to go to screening programs. So it's more about to assess where they've got the medical context and quality to do so. Do you want to test the front invitation strategy, do you want to be sure about how much harm can lead from screening. It’s all these aspects which is to be assessed locally or nationally about decisions to start or not with a pilot phase of a screening program. [MUSIC]
