Chapter 8 Screening

Screening
• The early detection of

– disease
– susceptibility to disease
in individuals who do not show any signs and symptoms of
disease (in apparently healthy individuals).
The presumptive identification of unrecognized disease by

application of rapid tests or examinations..’
‘The examination of asymptomatic people in order to classify

them as likely or unlikely to have the disease of interest.’
Purpose of Screening
• Aims to reduce morbidity and mortality from disease among

persons being screened
• to prevent or delay occurrence of disease or improve its prognosis

to prevent transmission of disease
• To determine the frequency or natural history of health related

condition
• Is the application of a relatively simple, inexpensive test,

examinations or other
Diagnosis = Screening
• Screening is generally in done among individuals who are
not suspected of having disease
• Diagnosis involves confirmation of presence or absence of

disease in someone suspected of or at risk for disease
• Screening tests can also often be used as diagnostic tests

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Types of screening
There are different types of screening, each with specific aims
a) Targeted screening of groups with specific exposures – is
often used in environmental and occupational health
b) Mass screening – involves screening of a whole population
c) Case-finding or opportunistic screening – is restricted to

patients who consult a health practitioner for some other
purpose.
d)Multiple or multiphasic screening –
involves a variety of
screening tests on the same occasion.
Screening Tests
• For a screening to be successful a suitable screening test must be

available.
• A screening test should ideally be inexpensive, easy to

administer, and impose minimal discomfort on the patients.
• results of the screening test must be valid and reliable.
• A test is reliable if it provides consistent results
• A test is valid if it correctly categorizes people into groups with

and without disease.
Validity of Screening Tests
• The ability of screening test to differentiate accurately
those who have the condition from those who don’t have
• Key measures
• Sensitivity
• Specificity
• Validity assumes that there is a gold standard to which a

test can be compared
Golden standard test
Disease
Present Absent
a b a+b
Screening
Positive
Test
Negative c d c+d
a+c b+d N
Sensitivity
• Proportion of individuals who have the
disease who test positive (true positive rate)
• tells us how well a “+” test picks up disease
Disease
yes no
a
Screening
+ a b a+b Sensitivity =
Test
- c d c+d a+c
a+c b+d N
Specificity
• Proportion of individuals who don’t have the
disease who test negative (a.k.a. true
negative rate)
• tell us how well a “-” test detects no disease
Disease
yes no
d
Screening
+ a b a+b Specificity =
Test
- c d c+d b+d
a+c b+d N
Screening Principles
• Sensitivity
– the ability of a test to correctly identify those who
have a disease
• a test with high sensitivity will have few false
negatives
• Specificity
– the ability of a test to correctly identify those who do
not have the disease
• a test that has high specificity will have few false
positives
A test is used in 50 people with disease and
50 people without. These are the results.
Disease
Present Absent
48 3 51
Screening
Positive
Test
Negative 2 47 49
50 50 100
Disease
Present Absent
48 3 51
Screening
Test Positive
Negative 2 47 49
50 50 100
Sensitivity = 48/50
Specificity = 47/50
Positive Predictive Value = 48/51
Negative Predictive Value = 47/49
Example
• Total of 64,810 women screening examinations (consisting of
a combination of mammography and physical examination)
were performed. During the first 5 years of observation, 132
breast cancers were diagnosed among 1,115 screened women's
that were recommended for biopsies or aspirations.
• 45 cases of breast cancer were detected among women who
screened negative but were diagnosed with the disease during
biopsies examination .
Validity cont…
Table : Sensitivity and specificity of breast cancer screening examination
golden standard (biopsy or aspiration)

Cancer cancer not
Total
Confirmed confirmed
Screening test (Physical

Examination & mammography)
Positive 132 983 1115
Negative 45 63,650
63,695
Total 177 64,633
64,810
Validity cont…
• Sensitivity =132/177 = 74.6%
• 74.6% means that of those diagnosed with
breast cancer during the study period,
approximately 75 % tested positive on the
screening procedure
• Specificity = 63,650/64,633 =98.5 %
indicates that virtually all women who did not
have the disease tested negative
Predictive Value
• Measures whether or not an individual actually has the
disease, given the results of a screening test
• The ability of the test results to predict the presence or
absence of disease
• Affected by
– Sensitivity
– specificity
– prevalence of preclinical disease
• Prevalence = a+c
a+b+c+d
Disease
Present Absent
a b a+b
Screening
Positive
Test
Negative c d c+d
a+c b+d N
Positive Predictive Value
• Proportion of individuals who test

positive who actually have the disease
Disease
yes no
a
Screening
+ a b a+b P.P.V. =
Test
- c d c+d a+b
a+c b+d N
Negative Predictive Value
• Proportion of individuals who test

negative who don’t have the disease
Disease
yes no
d
Screening
+ a b a+b N.P.V. =
Test
- c d c+d c+d
a+c b+d N
Example:
• PVPT = 11.8 % means the probability that a woman who

tested positive on the screen actually had breast cancer is
11.8%.
• PVNT = 99.9% means the probability that a woman who
tested negative truly did not have breast cancer is 99.9%.
• The ability to predict the presence or absence of diseases

from test results is dependent on the prevalence of the
preclinical disease in the population tested, as well as on the
sensitivity and specificity of the test.
Predictive Value cont…
• The higher the prevalence, the more likely it is that a
positive test is predictive of the diseases i.e PVPT will be
high.
• The more sensitive a test, the less false negative (likely it
is that an individual with a negative test will have the
disease) and thus the greater negative predictive value
(NPV).
• The more specific the test, the less false positive (likely
an individual with a positive test will be free from the
disease)and the greater positive predictive value (PPV).
Example: 2
• Suppose a new test named “Test X" is

developed for screening of cervical cancer.
This new test was applied on 500 known early
cases of cervical cancer and 550 women with
out cervical cancer. The test was positive for
450 women with cervical cancer and 30
women with out cervical cancer.
Show the results by 2X2 table
How do you determine the validity of Test X?

Calculate and interpret the measures of validity.
How do you determine the predictive value of

Test X? Calculate and interpret the predictive
value of Test X.
Criteria for screening
Table 1: Criteria for instituting a screening programme
Disease -Serious
-High prevalence of preclinical stage
-Natural history understood
-Long period between first signs and overt disease
Diagnostic test -sensitive and specific
-Simple and cheap
-safe and acceptable
-Reliable
Diagnostic and -Facilities are adequate
treatment -Effective, acceptable, and safe treatment
available
Criteria for …..
• Disease
– present in population screened
– high morbidity or mortality; must be an
important public health problem
– early detection and intervention must
improve outcome
– The natural history of the disease should
be understood, such that the detectable
sub-clinical disease stage is known and
identifiable
Criteria for ……
• Screening Test
– should be relatively sensitive and
specific
– should be simple and inexpensive
– should be very safe
– must be acceptable to subjects and
providers
Criteria for …
– Facilities for diagnosis and appropriate

treatments should be available for
individuals who screen positive
– It is unethical to offer screening when
no services are available for subsequent
treatment
Risks of Screening
• False Positives
– anxiety
– fear of future tests
– monetary expense
• False Negatives
– delayed intervention
– disregard of early signs or symptoms
which may lead to delayed diagnosis
Thank you

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Screening

• The early detection of

The presumptive identification of unrecognized disease by

‘The examination of asymptomatic people in order to classify

• Aims to reduce morbidity and mortality from disease among

• to prevent or delay occurrence of disease or improve its prognosis

• To determine the frequency or natural history of health related

• Is the application of a relatively simple, inexpensive test,

• Diagnosis involves confirmation of presence or absence of

• Screening tests can also often be used as diagnostic tests

b) Mass screening – involves screening of a whole population

c) Case-finding or opportunistic screening – is restricted to

• For a screening to be successful a suitable screening test must be

• A screening test should ideally be inexpensive, easy to

• results of the screening test must be valid and reliable.

• A test is reliable if it provides consistent results

• A test is valid if it correctly categorizes people into groups with

• Validity assumes that there is a gold standard to which a

golden standard (biopsy or aspiration)

Screening test (Physical

• Proportion of individuals who test

• Proportion of individuals who test

• PVPT = 11.8 % means the probability that a woman who

• The ability to predict the presence or absence of diseases

• Suppose a new test named “Test X" is

How do you determine the validity of Test X?

How do you determine the predictive value of

– Facilities for diagnosis and appropriate

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