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A workshop of the Project on Evaluation of Screening Programmes of the International Union against Cancer (UICC) was held in Lyon, France, on November 20-22, 1984. The focus of the workshop was on screening for gynaecological cancer, especially for cancer of the cervix uteri. This report summarizes the presentations, conclusions and recommendations from this workshop.

This is the 5th report of the UICC Project on the Evaluation of Screening for Cancer. Previous reports were based on our evaluation of screening for individual sites or groups of sites. The present report is based on a workshop at which most of the sites were re-evaluated in the light of new information that had become available since we previously considered the sites (4 years for breast cancer to 7 years for cancer of the cervix) together with an evaluation of 4 sites not previously considered (melanoma, neuroblastoma, nasopharyngeal carcinoma and prostate cancer). We elected not to re-evaluate screening for lung, bladder and oral cancer (considered in 1984) and endometrial cancer (considered in 1985) as we were not aware of any new data that would have led us to reconsider our previous conclusion, that screening should not be considered as public health policy for these sites.The present report comprises a summary of the communications presented at the workshop, together with our conclusions on the state of the art of screening for the cancers considered. At the end of the report we summarize some advances in the methodology of the evaluation of screening. A full report on the workshop will be published elsewhere. In drawing our conclusions, we have incorporated the evidence previously available Day et al., 1986;Hakama et al., 1985;Prorok et al., 1984) as well as that presented at the workshop.We emphasize that screening, as considered in our reports, is the detection of unrecognized disease by the application of tests in the general population, or an important subsegment of that population. We have not evaluated medical surveillance or public education campaigns, except to the extent that they have an impact on screening. Our recommendations are, in general, related to the application of screening as public health policy, and the research that we feel should be conducted before such policies on screening are implemented. Further, we are largely concerned with organized programmes of screening, as described in our report on cervical cancer screening (Hakama et al., 1985). Breast cancer screeningRecent results from breast screening trials in Sweden, the UK and Canada were considered. Updated mortality data to December 1989 in the Swedish 2-county (WE) trial show that the relative risk (RR) of dying from breast cancer in the study group allocated to screening has remained around 0.7 since the first publication in 1985. The effects in each 10-year age-group are relatively unchanged, with no reduction in mortality in those aged 4 W 9 on entry. For women aged 50-69 on entry, the reduction in breast cancer mortality is approximately 40%. Death rates due to other causes among women with breast cancer were close in h e 2 study arms.Updated mortality data in the Malmo study show an increasing reduction in breast cancer mortality in the study arm in women aged 55-64 on entry, now approximately 20%. No reduction in breast cancer mortality is seen for women aged 45-54. Poor survival of patients with interval cancers in th...

Summary The 28-item GHQ was used to assess psychiatric morbidity in 302 women attending for routine breast cancer screening, 300 women attending for further investigation of a positive screening result and 150 women referred for investigation of breast symptoms. The GHQ-28 was administered on arrival at the relevant clinic and three months later. Medical records were used to determine the outcome of the clinic attendance. Women were classified into routinely screened women, women with false positive screening results, symptomatic women with a benign diagnosis, newly diagnosed cancer patients and previously treated cancer patients. When tested on arrival at the clinic, 25% of routinely screened, 30% of women with false positive results and 35% of symptomatic women with benign conditions were probable cases of psychiatric morbidity. The only statistically significant difference was between the routinely screened and symptomatic benign groups. Levels of anxiety were significantly higher in those with false positive results and in the symptomatic benign group than in the routinely screened. Three months later the prevalence of probable psychiatric morbidity had fallen to 19% in both the routinely screened and those with false positive results but remained significantly higher in the symptomatic benign group (31%). Probable cases of psychiatric morbidity among newly detected cancer patients rose from 34 to 46% over the 3-month period. Among women who had had breast cancer diagnosed in the past prevalence remained at 21 %. The prevalence of probable psychiatric morbidity in screened women is similar to that in the general population. Among women referred for further investigation because of a false positive screening result prevalence was only slightly increased and there was no evidence of a sustained increase in anxiety. Provided that delays are kept to a minimum and that women are kept informed, a breast cancer screening programme does not increase psychiatric morbidity. Further research is required in cancer patients to determine whether those diagnosed in asymptomatic women have a higher and more sustained degree of psychiatric morbidity than those diagnosed in women who are aware of symptoms.Concern has been expressed that screening for breast cancer may have adverse psychological effects. The invitation for screening may make women more aware of their vulnerability and hence increase anxiety. Recalling women who are found to have an abnormality on screening for further investigation (currently 5-10% of those screened in the UK) may cause distress which is hard to alleviate even when further investigations are negative. Those who are symptom-free on screening but are found to have cancer could find it especially hard to adapt to the diagnosis (Maguire, 1982).The first concern has been partially investigated in Edinburgh (Dean et al., 1986). It was found that women attending for screening had no excess psychiatric morbidity compared to other women in the same age-group, (although little is yet known about morbidi...

SummaryIn the latter part of a large hospital case-control study of the relationship of type of cigarette smoked to risk of various smoking-associated diseases, patients answered questions on the smoking habits of their first spouse and on the extent of passive smoke exposure at home, at work, during travel and during leisure. In an extension of this study an attempt was made to obtain smoking habit data directly from the spouses of all lifelong non-smoking lung cancer cases and of two lifelong non-smoking matched controls for each case. The attempt was made regardless of whether the patients had answered passive smoking questions in hospital or not.Amongst lifelong non-smokers, passive smoking was not associated with any significant increase in risk of lung cancer, chronic bronchitis, ischaemic heart disease or stroke in any analysis.Limitations of past studies on passive smoking are discussed and the need for further research underlined. From all the available evidence, it appears that any effect of passive smoke on risk of any of the major diseases that have been associated with active smoking is at most small, and may not exist at all.

Aims-To determine the harm that ensues from faecal occult blood (FOB) screening for colorectal cancer. Methods-150 251 people were randomly allocated either to receive biennial Haemoccult FOB tests (n =75 253) or not to be contacted (n=74 998). Study group patients returning positive tests were oVered colonic investigation; 1774 underwent complete investigation of the colon. Results-There was no significant diVerence in the stage at presentation of interval versus control group cancers. Survival in the interval cancer group was significantly prolonged compared with the control group. Sensitivity for colonoscopy or flexible sigmoidoscopy and double contrast barium enema (DCBE) was 96.7%. There were no complications of DCBE but seven (0.5%) complications of colonoscopy, of which six required surgical intervention. There were no colonoscopy related deaths. No patients without colorectal cancer died within 30 days of colonic investigation. Five patients died within 30 days of surgery for screen detected colorectal neoplasia and a further two died without having surgery. Six patients died after 30 days but within two years of surgery for screen detected benign adenomas or stage A cancers; in all cases the cause of death was not related to colorectal cancer. Conclusions-There was investigation related morbidity but no mortality and little to support overdiagnosis bias. The group returning falsely negative tests had a better outcome compared with the whole control group. There is a negative side to any screening programme but mortality reduction in this and other trials suggests that a national programme of colorectal cancer screening should be given consideration. (Gut 1999;45:588-592)

The effect on the detection and characteristics of melanoma, resulting from the Cancer Research Campaign's health education programme to promote the early detection of melanoma in the general population, was studied from 1987 to 1989. The seven study areas in England and Scotland yield a target population of 3.6 million. Data were collected from local clinic-based registers, pathology laboratories, and the cancer registries. The average annual incidence rates of melanoma were seven and 12 per 10(5) in males and females, respectively, age-standardized to England and Wales, 1988. These rates are similar to the national figures for Scotland, where there is a national melanoma register, but higher than those reported by the English and Welsh cancer registries. The incidence was significantly higher in females than males (P < 0.001), and increased with age. Fifty-three per cent and 65% of cases in males and females, respectively, were thin (Breslow thickness < or = 1.5 mm), similar to the national figures from Scotland. No significant decrease in the incidence of late-stage tumours was found in either sex as a result of the campaign. Because of difficulties with ascertainment of cases in England, the main evaluation will focus on future trends in mortality rates for melanoma.