In a bid to streamline and coordinate health screening programmes nationally, Sweden’s health authorities have begun to assess and recommend which tests regional authorities may implement to identify people who may be ill but do not yet have symptoms.
For instance, Sweden’s National Board of Health and Welfare has recommended national screening programmes for cervical cancer, colorectal cancer, breast cancer and 25 congenital diseases for newborn children – but it is up to each health-care region to decide whether to implement the programme.
“We decide on the recommendation but implementing the screening programme is up to the health-care regions,” says Lina Keller, Programme Officer, National Board of Health and Welfare.
Before making their recommendation, the National Board of Health and Welfare might initiate an investigation about a screening programme by reviewing the recommendations of international organizations, such as WHO, and the activity of other national health boards to determine which diseases are being screened for. These investigations might also be initiated by the government or by other stakeholders, such as professional or patient groups.
Recommendations
Then the National Screening Council meets to broadly assess the proposed programmes. The Council includes politicians from Sweden’s six health-care regions, the Public Health Agency of Sweden, the Dental and Pharmaceutical Benefits Agency and licensed clinical experts.
“The idea is that screening programmes should only be started if their effectiveness has been demonstrated, and when resources – personnel and equipment – are sufficient to cover nearly all the target group and also when facilities exist for confirming diagnoses and for treating those with abnormal results. Finally, the prevalence of the disease must also be high enough to justify the effort and costs of screening,” explains Lina Keller.
The requirements for an effective screening programme include the following:
- The screening programme should reduce death or illness associated with the condition.
- The target population must understand and accept the actions to be taken after diagnosis, including treatment.
- The overall health benefits of screening should outweigh the harm.
When the health-care region decides to go forward with screening, then members of the target population group receive a written invitation to take the test. To increase participation, the regions might also begin a health literacy campaign on social media or by using posters and fliers sent to people’s homes. Authorities also make individual telephone calls in their effort to increase participation.
Screening programmes worldwide
In recent years, countries in the WHO European Region have been introducing new screening programmes for conditions and health checks along the life-course. However, policy-makers, health professionals and the public are not always aware of the potential harm of screening and of the costs and requirements of implementing effective screening programmes.
The popularity of screening and health checks had grown across the Region, not all evidence informed, and countries varied considerably in their approaches to screening. The quality of screening varied, so that the benefits were not fully realized, according to WHO.
Even when implemented properly, screening programmes can be associated with undesirable effects:
- false-positive screening tests that result in additional testing, invasive diagnostic procedures and patient anxiety;
- false-negative screening tests that provide false reassurance and result in delayed diagnosis; and
- overdiagnosis, which might lead to treating people for benign conditions found in screening and that physicians and/or the person do not want to leave untreated, such as a benign breast lump.
The National Board of Health and Welfare is learning the lessons and is eager to avoid misdiagnosis and false positives.
“These kinds of undesirable effects can worry people. For example, the National Board of Health and Welfare does not recommend screening for prostate cancer for men older than 50 years because of the risk that screening would cause patients additional pain, tests and treatment and leave men with important sequelae,” says Lina Keller. “The overall health benefits of screening did not outweigh the harm, which ultimately meant that the screening programme was not ethically acceptable.”