• Open Access

Screening: evidence and practice

By Angela E Raffle and J.A. Muir Gray. Published by Oxford University Press, Oxford, UK, 2007 (Reprinted 2009). ISBN 978-0-19-921449-5; 334 pages

Reviewed by Dr Terri Green

Department of Management, Marketing, and Entrepreneurship, University of Canterbury, Christchurch, New Zealand

This is an unusual book, in that it combines the theoretical aspects of screening with screening practice, drawing on the authors’ extensive experience in screening programs. In fact, half the book (the second half) addresses practice. The first half is the ‘evidence’ part which, in addition to explaining what screening is, includes an interesting history of screening, based mainly on the UK and the US.

The authors stress that their focus is on screening programs, not just screening tests. There is a comprehensive discussion of the benefits and harms of screening, and the text is rich with case studies and ‘stories’ of screening done well, screening done badly, and screening that should not have been undertaken at all.

The book is based on teaching material and is presented in a style to make the topic accessible to a wide audience and with terminology to suit, for example, ‘sieve’ to describe the screening test and ‘sort’ for the follow-on diagnostic investigation. Terms such as false positives and false negatives are explained clearly. There are good screening flow diagrams and an excellent program map diagram, which would work very well in the classroom. Each chapter ends with summary points, study questions and extensive references, which include government reports as well as academic papers. The book would be suitable for public health practitioners and students of public health.

This book needs to be read several times to fully digest not only the main text and case studies, but also the study questions and end of book answers. I tried to read the book assuming I knew nothing about screening and I found some problems with flow. For example, terms like sensitivity and specificity are used before they are defined. Things became clearer on a second reading, and the book was well enough organised and indexed to support looking up and clarifying specific topics.

Following the detailed explanations of some of the diagrams required some concentration. Diagrams used in teaching with a presenter (to point), and with opportunities to use colour don't always work as well in a textbook. A bit more referencing and better placement of diagrams would have helped.

Some material discussed in the last chapter, mainly related to getting evidence into policy, could have been brought forward or at least introduced earlier to support subsequent chapters. It would have been helpful to note early on that some programs, for example breast screening, require tests to be repeated every two or three years, compared to the heel prick test for infants, which is done just once. Programs that involve re-screening are more burdensome for the health system, and require recall systems. Similarly, it would have been worth noting in early chapters that a screening policy (and program) has certain specifications: age group to screen, screening frequency, choice of test etc, and that these have an effect on detection rates, benefits, harms and costs.

There were one or two areas that could have been developed a bit more, again mainly relating to how to get from evidence to policy. Systematic review was mentioned but not explained. QALYs were despatched in one page, with one 1985 reference. Inclusion of the screening criteria developed by the UK National Screening Committee would have been helpful.

Operational aspects of a screening programme are very well covered, including implementation, quality management, ethical issues and dealing with the media. This is mainly based on UK experience, with some reference to other countries including the US. Readers from other countries need to interpret some of the experiences and lessons in light of their own health structures and political environment. This should not be a problem for readers in Australia or New Zealand.

To summarise, this book is an excellent teaching resource for university courses on screening or for screening workshops for policy makers and practitioners. Those involved in screening, or considering involvement, would find it invaluable as a reference text. One would be hard-pressed to find another book that presents the practical and political reality of screening as well as this one does.