This remarkable collection of articles draws to close a generation of research regarding the promotion of cancer screening. Beginning in the mid-1980s with breast cancer screening using mammography, there has been an unprecedented growth in our understanding of how to encourage the use of screening tests, and a transformation in how people conceptualize the issues.1 This supplement highlights the lessons learned from that generation of research and provides the foundation for the next. Looking through this volume offers the rare opportunity to reflect on an entire body of research, representing hundreds of grants and articles published by investigators who worked during what I believe was a golden age for screening.

These last 20 years were a prime time to develop our understanding of screening; we had relatively simple tests for things people could see. Cervical cancer screening had been around since the 1940s and the regular Papanicolaou (Pap) smear was part of the annual examination.2 People could understand breast cancer and knew of it occurring in their friends and family. The work of the 1980s focused on improving follow-up to the familiar Pap smear and promoting mammography. Investigators initially examined how patient characteristics were associated with screening and then considered the characteristics of those physicians who did not appear to be ordering the appropriate tests.3 The belief was if we could just get women to have the right attitude and the physicians to do their job, screening and follow-up would happen.

However, screening promotion became a more complex task as the 1990s evolved. First, it was not so clear that mammography benefited all women.4 There was some backlash with regard to what may have been an overselling of screening.5 It also emerged that mammography was not equally available to all people, and especially not the underinsured.6 The context of screening mattered with regard to whether screening was available and ordered.7 It was not just a question of the right attitude and the right physician; it also became an issue of the right environment.

Additional tests then began to appear such as prostate-specific antigen, sigmoidoscopy, fecal occult blood testing, genetic screens for mutations in specific genes, and tests for the human papillomavirus. Simultaneous with this growth in tests was the growth in “evidence-based” medicine. People began to be more critical concerning the basis for recommending medical interventions such as screening, and pressure grew to go beyond just ordering the test but rather to discuss what was known. Rimer et al.8 describe this growing area of work and clarify the difference between informed decisions and informed consent. There is a future in evaluating how we convey what is known.

Furthermore, as we closed the last millennium, the human genome was being described in detail. The ability to screen for mutations has grown, and this introduces an entirely new set of issues, including the challenge that genes cannot be seen and their implications are not always apparent. Therefore, as we head into the middle of the first decade of the new millennium, it is a more complicated medical world, and screening issues are much bigger than just promotion.

It is the perfect time to take stock of what we have learned, and that is what occurs in this volume. Vernon et al.9 send the message that more attention to methods is needed to move behavioral research forward. Pasick et al.10 point out that the European–American devotion to independent judgments underpins much of our work, but may not apply to many ethnic groups who also live in this world. I am not sure it always applies to European–Americans either, but the lesson is that we need to ask and understand how culture and ethnicity influence screening behavior. Pasick et al.10 also suggest that screening research needs to grow beyond promoting one-organ evaluation. Although that may remain the center of research until colon cancer screening is more common, it cannot be the sole focus when there is so much more to understand. Zapka and Lemon7 propose that one area in which we need to gain more understanding is how the context of screening and health care organization influences the success of the screening process. Glasgow et al.11 take it one step further and suggest that considering the context for an intervention at the point of dissemination is too late, and that providers and people intended to benefit from an intervention should be part of its development. Miles et al.12 argue that organized care does a better job, perhaps because the context can be used and considered as Zapka and Lemon advocate. Nevertheless, the lessons are not just about disseminating efficacious technologies. Meissner et al.13 advocate for being involved in efficacy trials so that the issues are identified early, and by definition this means developing materials and interventions before efficacy is known. It also means understanding the costs and morbidities of tests so that cost-effectiveness considerations can be considered in dissemination efforts. Finally, screening is clearly a process, not a test. Bastani et al.14 help us understand that, once screening is occurring, we must think about the follow-up to screening.

There are lots of lessons to be learned, and there many questions left to ask. The National Cancer Institute, the Centers for Disease Control and Prevention, and the American Cancer Society initiated this work to help us get to the new questions rather than reanswer the old ones. We need an explanation of how interventions work. When are interventions sufficient at the policy and organizational level? When do interventions need to be more complicated and involve multiple levels of care? When can interventions be simplified? What is the minimal set of activities that will achieve the desired result? How do we develop interventions that are viable in clinical practice?

This volume raises those questions, and more. We have more than turned the page on a chapter of screening research; we are closing the book on a generation of work. It is a fascinating read for anyone interested in screening and I for one hope that future researchers take advantage of these lessons learned.


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