For many years, public information about screening has been aimed at achieving high uptake but concerns are now being raised about this approach. There are several problems that have prompted these concerns. By giving information that emphasizes only the positive aspects of screening the autonomy of individuals is ignored, individuals feel angry when they perceive that they are let down by screening, symptoms may be disregarded because of the belief that screening gives full protection, health service sta carry the blame for problems that are in fact inherent in screening, and sound debate about policy and investment in screening is hampered by misunderstanding about the bene®ts and costs of screening.If we adopt instead an approach that makes explicit the limitations and adverse e ects then a di erent set of problems will be encountered. We risk a reduction in uptake of screening and thus population bene®ts may reduce, those most likely to be deterred from accepting screening may be the most socially disadvantaged, there will be a cost in terms of sta time to explain screening more fully to participants, and cost-e ectiveness could be reduced if uptake falls so low as to make services barely viable.In the UK current General Medical Council (GMC) advice 1 to doctors about informed consent for screening makes it clear that full information should be given. The UK National Screening Committee has also signalled the need for a changed approach to information 2 giving so that individuals are o ered a choice based on appreciation of risks and bene®ts. It will take time for this approach to be fully re¯ected across the full range of UK screening programmes. New national information will be needed to assist sta in giving full information, and some aspects of policy, such as screening coverage targets for Health Authorities and General Practitioners, will need to be altered.There are many questions still to be answered about the kind of information needed to achieve informed participation, and about how it should be framed and communicated. These questions can begin to be addressed when there is clarity at national level about the purpose of information about screening.

People testing negative must stick to infection control recommendations

Objective To determine the frequency of different outcomes in women participating in cervical screening. Design Analysis of screening records from 348 419 women, and modelling of cases of cervical cancer and deaths with and without screening. Setting Cervical screening programme in Bristol. Results For every 10 000 women screened from 1976 to 1996, 1564 had abnormal cytology, 818 were investigated, and 543 had abnormal histology. One hundred and seventy six had persistent abnormality for two years or more. In the absence of screening 80 women would be expected to develop cancer of the cervix by 2011, of whom 25 would die. With screening 10 of these deaths would be avoided. Comparison of cumulative abnormality rates with numbers expected to develop cancer in the absence of screening suggests that at least 80% of high grade dyskaryosis and of high grade dysplasia would not progress to cancer. The lifetime risk of having abnormal cytology detected could be as high as 40% for women born since 1960. Conclusions Screening is labour and resource intensive. It involves treatment for many women not destined to develop invasive cancer. The increased intervention rate for cervical abnormality in England is due to change in practice, not a cohort effect, and is probably the reason for the marked fall in incidence and mortality during the 1990s. For other cancers there is scope for major iatrogenic harm from screening because of invasive tests and treatments.

Should be modelled on successful screening programmes

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You are a family physician seeing a 47-year-old woman and her husband of the same age. They are concerned because a friend recently found out that she had bowel cancer and has urged them both to undergo screening with fecal occult blood tests (FOBTs) because, she says, prevention is much better than the cure she is now undergoing. Both your patients have no family history of bowel cancer and no change in bowel habit. They ask whether you agree that they should be screened.You know that trials of FOBT screening have demonstrated that screening can reduce mortality from colorectal cancer (CRC), but you also recall that FOBTs can have a high false-positive rate that then requires investigation by colonoscopy. You are unsure whether screening these relatively young, asymptomatic people at average risk of bowel cancer is likely to do more good than harm. You decide to check the literature to see if there are any guidelines or recommendations about screening for CRC that might help you.

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