SCREENING TEST

Learning objectives
Student to be able:
 describe the concept of screening
 describe the similarity and differences between
screening and diagnostic test
 briefly explain sensitivity and specificity, false positive
and false negative
 briefly explain positive and negative predictive values
 outline criteria of a good screening test
 outline criteria of a good screening program
SCREENING
Concept
 Screening people for disease is an aim of secondary
prevention; screening for risk factor is primary
prevention.

 The use of test to detect the presence of a disease at an

earlier time than it would be detected through
routine diagnostic method.

 Process of identifying individuals who are at sufficiently

high risk of a specific disorder to warrant further
investigation and treatment at an early stage when it
is treatable.
SCREENING
Definitions
 The detection of disease
 in asymptomatic apparently healthy individual
 asymptomatic subject who already had the
pathological disease
 risk factor in a subject without pathological disease
 by application of test which can be applied
rapidly to sort out apparently well person who
probably have a disease from those who do not.
The Screening Process
Natural History of Disease
DPCP

Lead time

Preclinical Clinical
phase phase

Biologic onset Symptoms Diagnosis Therapy Outcome

of disease
Screening

Disease is detectable
by screening Lead time = the amount of
time by which the diagnosis
has been advanced by
DPCP = detectable pre-clinical phase screening
Screening method
 History taking
 Asking the subject on smoking status

 Physical examination
 Blood pressure measurement for hypertension

 Laboratory test
 Random blood sugar to detect diabetes

 Invasive / special procedure

 Exercise stress test for CAD
Screening in Public Health
 A widespread use of a simple test for disease in an
apparently asymptomatic population which separate
people who are more likely to have the disease from
those who are less likely to have it.

 The improved public health outcomes are reduced

morbidity, mortality and/or disability.
List of important
screening test 1 (Example)
Cancerous Non-cancerous Infectious disease

Cervical Ca Diabetes TB
(Pap smear) (RBS) (Mantoux test)
Breast Ca Hypertension HIV
(Mammogram) (BP) (Rapid test)
Colorectal Ca Diabetic retinopathy
(Fecal Occult Blood Test) (Fundoscopy)

Prostate Ca Glaucoma
(Prostate Specific Antigen: (Vision test)
Ca 125, Ca 19-9)
List of important
screening test (example)
UK screening programme
 Cervical cancer

 Diabetic retinopathy

 Breast cancer

 Antenatal

 Neonatal hearing

Currently under evaluation

 Ovarian cancer

 Lung cancer

 Colorectal cancer

 Prostate cancer
Type of screening strategy
 Mass screening
 Screen the whole or subgroup of population/community

i.e regardless the probability of getting the condition

 eg. Vision screening in school children

 Selective or targeted screening

 Screening of selectively high risk group for a particular
problem
 e.g. HIV screening for IVDU
Type of screening strategy
 Opportunistic screening
 Seen by health professionals for reasons other than
the disorder related to the screening (eg. CVD
screening)

 Mix/Multiple/Multiphasic
 Uses several screening tests at the same time for a
group of people.
 First, screening of suspected diseases followed by
other tests.
 e.g. Health questionnaire, clinical, blood investigation
The Screening Process
SCREENING vs DIAGNOSTIC TEST
Practical
Feature Screening Diagnostic test
Approach Public health Clinicians

Aim Detect risk factor Confirm disease

Subject Asymptomatic Symptomatic

person patient
Intervention Preventive Curative

Procedure Rapidly conducted Maybe extensive

SCREENING vs DIAGNOSTIC TEST
Practical
Feature Screening Diagnostic test
Measurement Se, Sp, PPV, NPV Se, Sp, PPV, NPV
Prevalence, Accuracy Prevalence, Accuracy

Gold standard Yes and additional follow Yes

up for negative test

Special biases in Length Time bias -

evaluation Lead time bias
 Lead time bias - the systematic error of
apparent increased survival from detecting
disease in an early stage
 The earlier we diagnose a disease, the longer
patients will appear to survive, when in fact we just
started counting earlier.

 Length time bias - the systematic error from

detecting disease with a long latency or pre-
clinical period
 Patients with slowly progressing diseases are more
likely to be detected through screening
MEASUREMENT
General 1
Note: DISEASE
Dichotomous test with
(Gold standard)
dichotomous gold standard
2x2 table Present Absent

Positive True positive False positive

Screening (TP) a b (FP)
TEST c d
Negative (FN) (TN)
False negative True negative
Test performance / validity
 Sensitivity
 The probability of a positive test in people with the disease

 Specificity
 The probability of a negative test in people without the disease

 Positive Predictive Value

 The probability of the people having the disease when test is
positive

 Negative Predictive Value

 The probability of the people not having the disease when test is
negative

 Accuracy
 The ability to differentiate people with and without the disease
correctly
 MEASUREMENT
General 3
 Se @ True Positive Rate = (TP / all disease) x 100%
 Sp @ True Negative Rate = (TN / all no disease) x 100%
 PPV = (TP/ all positive test) x 100%
 NPV = (TN / all negative test) x 100%
 Accuracy = (TP + TN / Total) x 100%
 Prevalence = (All disease / Total) x 100%
 MEASUREMENT
General 2
DISEASE
Present Absent
Screening Positive a b
PPV = a/(a+b)
TEST
Negative c d
NPV = d/(c+d)

Se = a/(a+c) Sp = d/(b+d)

Accuracy = a+d / (a+b+c+d) Prevalence = a+c / (a+b+c+d)

MEASUREMENT
Example 1: Calculation
DISEASE
Present Absent
TEST Positive 34 168 +PV = 34 / 202 = 16.8%
Negative 1 282 -PV = 282 / 283 = 99.6%

Se = 34 / 35 = 97.1%
Sp = 282 / 450 = 62.9%

Prevalence = 35 / 485 = 7.2%

Accuracy = 316 / 485 = 65.1%
 Sensitivity Vs Specificity
Sensivity Specificity
The proportion of people who test The proportion of people who test
positive out of all those having the negative out of all those not having the
disease. disease.
Q: How likely the test is positive, if Q: How likely the test is negative, if
patient does have the disease? patient does have the disease?
The test’s ability to obtain positive The test’s ability to obtain negative
results when the disease really results when the disease really absent
present @correctly identify those who @correctly identify those who do not
have the disease have the disease

A highly sensitive test rarely misses A highly specific test rarely misses to
people with the disease. exclude people without the disease.

Important consideration : Important consideration :

Not to miss a dangerous but treatable When the costs, risks, or the
disease (examples; TB, syphilis, subsequences of further testing are
Hogdkin’s disease) significant.
FACTORS INFLUENCE Se Sp
 Spectrum of disease
 A disease range of clinical severity
 Example: Mammography has greater sensitivity when
it is applied to patients with advanced breast cancer

 Patient characteristics
 Example: Mammography is better able to detect
lesions in fatty breast of old women

Note: Se & Sp is not affected by prevalence

Predictive value
 Clinician is more concern with predictive value (PV)
than sensitivity or specificity.

 PV determine whether the patient has/ do not has the

disease given the results of a test.
Predictive Value
 Factors affect PV:

 Prevalence
 Higher prevalence, increase PPV

 Screening in high risk group is more effective

Predictive value
Positive Predictive Value (PPV)
 Probability of disease in a patient with a positive
(abnormal) test result.

 Q: How likely patient does have the disease if the test is

positive?
Negative Predictive Value (NPV)
 Probability of not having a disease in a patient with a
negative (normal) test result.

 Q: How likely patient does not have the disease if the

test is negative?
Accuracy
 Proportion of all test results (both negative & positive)
that are correct.

 Probability of correct test results.

 Has limitation because it is influenced by prevalence.

CRITERIA FOR SCREENING
A Good Screening Test
1. Accurate
 Sensitive: does not miss cases, sensitive at early disease
especially in serious disease with effective intervention
 Specific: to reduce false positive especially if false positive
brings serious consequences
 High PPV: detect those who have the disease, high disease
prevalence in the population tested
2. Reliable: consistent
3. Simple: require minimal time and preparation
4. Economical: inexpensive for a large scale
5. Safe: free or minimal risk, no complication
6. Acceptable: emotional, social & cultural to patients & clinicians
7. Labelling effect: no or positive psychological effect
CRITERIA FOR
A GOOD SCREENING PROGRAMME
 The condition is an important public health problem
 Natural history is well understood
 Detectable early stage (long lead time)
 Suitable test to detect early stage is available
 Treatment at early stage is of more benefit than at late
stage
 Benefit outweigh risk (physical and psychological)
 Interval for repeating the test have been determined
 Accessible with adequate health service provision
 Acceptable to the target population
 Cost effective
Wilson Jungner, 1968
Quiz 1
DISEASE
Present Absent
TEST Positive 15 13 +PV =
Negative 1 5 -PV =

Se =
Sp =

Prevalence =
Accuracy =
Quiz 1 (answer)
DISEASE
Present Absent
TEST Positive 15 13 +PV = 15/28 = 53.6%
Negative 1 5 -PV = 5/6 = 83.3%

Se = 15/16 = 93.8%
Sp = 5/18 = 27.8%

Prevalence = 16/34 = 47.1%

Accuracy = 20/34 = 58.8%
Quiz 2
Disease

Mammography Cancer No cancer Total

Positive 132 985 1,117

Negative 47 62,295 63,342

Total 179 63,280 63,459

Se = PPV = Prevalence =
Sp = NPV =
Quiz 2 (Answer)
Disease

Mammography Cancer No cancer Total

Positive 132 985 1,117

Negative 47 62,295 62,342

Total 179 63,280 63,459

Se = 73.7% PPV = 11.8% Prevalence = 0.3%

Sp = 98.4% NPV = 99.9%
Quiz 3
SCREENING vs DIAGNOSTIC TEST

Feature Answer
Aim Confirm disease
Aim Detect risk factor
Subject Symptomatic patient
Intervention Preventive
Procedure Extensive
Method Gold standard comparison
Quiz 3 (Answer)
SCREENING vs DIAGNOSTIC TEST

Feature Answer
Aim Confirm disease Diagnostic
Aim Detect risk factor Screening
Subject Symptomatic patient Diagnostic
Intervention Preventive Screening
Procedure Extensive Diagnostic
Method Gold standard comparison Diagnostic &
Screening