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Screening Evaluation

Evaluation of screeningScreening tests for the detection of asymptomatic disease are increasingly used in clinical practice and organized screening programs. Our research quantifies the effects of screening for a wide range of diseases. In this way we aim to help individuals, clinicians and policymakers to make informed screening choices.

To screen or not to screen?
Screening of diseases is a popualr concept and many new diagnostic tests are becoming available. Early detection of disease can considerably improve survival or quality of life. But it can also prolong the period during which a person is aware of having a disease.

Moreover, screen results can be false positive or clinically irrelevant, inducing unnecessary diagnostic and treatment interventions. In other words, screening can have a beneficial as well as a harmful impact on health, quality of life, and societal cost. By quantifying these impacts our research section may advise either to introduce screening, or to offer a modified screening program, or to not screen at all.

Some of our recent contributions

  • Cancer screening and age limits - Together with partners in the USA we conducted modeling studies on the benefits of breast cancer and colorectal cancer screening under the age of 50 and over the age of 75. Based on our findings the cancer prevention guidelines in both the Netherlands and the USA were changed. (Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms)
  • Adopting a novel strategy in lung cancer screening - Together with the Department of Pulmonology Erasmus MC and our Belgian colleagues we conduct a randomized controlled trial of lung cancer screening. The trial makes use of a novel nodule management strategy based on volume and volume doubling time to assess potential malignancies found on CT scans. This led to a substantially diminished need for follow-up evaluation, with no significant reduction in the overall sensitivity of CT screening.
  • Cervical cancer screening in the Netherlands- Together with our European partners we have conducted modeling studies on the added value and harmful side effects of replacing cytology by HPV-testing in primary screening. Based on our findings HPV screening has been advised by the Health Council, and implementation research towards HPV screening in the Dutch national programme has been started.
        

Ongoing projects

Monitoring and evaluation of running screening programmes

  • Monitoring and continuous evaluation of effects and costs of the nation-wide breast and cervical cancer screening programme in the Netherlands
    Evaluation is a crucial task within any cancer screening programme. The Dutch breast cancer screening programme was designed on the basis of our analyses and the cervical cancer screening programme was revised substantially in 1996, and Erasmus MC - Department of Public Health has since been given the task to independently monitor the developments within the programme. The monitoring is done on both the short-term basis through process indicators, as well as on long-term basis through monitoring the effectiveness and cost-effectiveness.
  • Cost-effectiveness of breast cancer screening in Norway (and other countries)
    Using modelling, the effects of the breast cancer screening programme in Norway, in terms of breast cancer mortality reduction, life years gained will be predicted. In addition, the costs of overdiagnosis and false positive tests will be predicted and the cost-effectiveness of the programme will be calculated, based on observed screen data from the programme.
  • Monitoring and evaluation of prenatal screening for Down's syndrome and SEO in the Netherlands
    The nationwide monitoring procedure consists of two parts, the evaluation of the offer of information on prenatal screening (part I) and outcome evaluation of the screening programme (part II). We need part I to evaluate if the generally accepted ethical condition of autonomous decision-making on participation (or not) is sufficiently met in a programme of routine by offering prenatal screening and to possibly improve it.
      

Modeling cancer and cancer screening

Cancer Intervention Surveillance Modeling Network (CISNET)

  • Modelling breast cancer incidence and mortality in the USA and the spectrum of disparities Together with partners in the USA we are modeling the breast cancer incidence in the US. Also, separate models for white women, black and hispanic women are constructed to investigate how much of the mortality disparity can be attributed to racial differences in natural history, screening and/or therapy.
  • Modelling effective health policies for colorectal cancer in the USA
    This work is being conducted as part of the of the NCI-sponsored Cancer Intervention and Surveillance Modeling Network (CISNET), which includes collaboration between modellers, statisticians, epidemiologists and clinicians developing computer simulations to evaluate cancer trends and project the impact of future interventions in the USA. Such analyses guide decisions e.g from the USPSTF.
  • Surveillance of lung cancer trends in the US and modelling prevention 
    Together with partners in the USA we are modeling the impact of tobacco control policies and screening on lung cancer mortality in the US.
  • A trial-based MISCAN model for prostate cancer for the USA
    Together with partners in the USA we are modeling the prostate cancer incidence in the US. Also, two large prostate cancer screening trials (ERSPC and PLCO) are modeled to evaluate the effects of screening.
  • Evaluate and compare the effectiveness of screening and intervention
    Programs for Esophageal Adenocarcinoma.
    The goal of is to advance our understanding of esophageal cancer and the impact of cancer control interventions in order to diminish the burden of this disease. We will accomplish this goal through a collaborative and comparative modeling project.


Policy development on emerging technologies in the Netherlands and abroad

  • Erasmus MC in collaboration with the Association of Nation-wide Screening South-western Netherlands and the Comprehensive Cancer Centre Rotterdam performed a colorectal cancer screening trial in The Netherlands comparing screening with repeated fecal occult blood tests. Based on results from this trial the Department of Public Health did a cost-effectiveness analysis to evaluate the best screening strategy for implementation in a nation wide screening program.
  • The DeCoDe (Decrease Colorectal Cancer Death) project focuses on molecular early diagnosis and molecular stratification for personalized therapies in colorectal cancer. In addition, new biomarkers for both laboratory tests and molecular imaging will be identified and added to existing panels of (proprietary) markers. The department of Public Health contributes in this project by evaluating diagnostic efficacy as well as cost effectiveness of the new molecular early diagnosis tests.
  • Surveillance after polypectomy - towards efficient guidelines
    This project aims at proposing more efficient guidelines for surveillance of adenoma patients after polypectomy. For risk stratification, patient characteristics (age and gender) and adenoma characteristics (number, size, location, grade of dysplasia and villousness) will be considered. 
  • Cost-effectiveness of HPV-screening in different European settings: this project aims to determine under which conditions and in which coutnries HPV-screening is to be preferred to primary cytology screening.
  • Cost-effectiveness of self-test in cervical cancer screening: in a situation where the self-test would be sent to non-participators of cervical cancer screening programme, an unknown proportion of the women could decide to wait for the self-test when invited for screening. What would be the impact in terms of benefits and harms of screening?
  • Screening on child abuse at emergency departments, implementation of an optimal protocol
    In collaboration with the department of Pediatrics of the Erasmus MC Sophia Children's Hospital, we implemented a screening protocol and compared it to usual practice through an interrupted time-series design in a multi-center study. The effect on detection rates of child abuse is currently being evaluated.

Randomised Controlled Trials

  • NELSON: Dutch-Belgian randomised controlled lung cancer multi-slice CT screening trial
    Today, only 20% of lung cancers are at a resectable stage (stage I/II). 5-year survival is therefore low (15%). Computed Tomography (CT) screening detects more lung cancers than chest X-ray. It is unknown if this will translate into a lung cancer mortality reduction. The purpose of the NELSON trial is: to establish in a randomised controlled trial if screening for lung cancer by multi-slice low-dose CT in high risk subjects will lead to a 25% decrease in lung cancer mortality, to estimate the impact of lung cancer screening on health related quality of life and smoking cessation, and -to estimate cost-effectiveness and help policy making.
  • ERSPC: European Randomized Study for Screening on Prostate Cancer
    In this trial the effects of screening for prostate cancer are being evaluated. More than 180.000 men are randomized in a screening group and a control group. In the screening group, men between the ages 55-70 are invited every four years for a PSA test. Estimating NNT and HRQol are crucial components.
  • MRI screening high risk women
    Breast cancer screening with additional MRI has been shown to be cost-effective for BRCA1/2 mutation carriers. The higher sensitivity of MRI outweighs the disadvantage of its lower specificity compared to mammography. For the larger group of women with familial risk, but without a mutation, it is not clear whether additional MRI is advantageous and cost-effective.
    In this prospectively randomized trial for women with > 20% life time risk for breast cancer, but no BRCA1/2 mutation, the effectiveness of screening with: yearly mammography and clinical examination (Dutch guidelines) versus yearly MRI and clinical examination and mammography every other year will be evaluated.

Individualized Integrated Prevention

  • Individualized Integrated Prevention; including cardiovascular and cancer screening
    This project investigates the efficiency and effectiveness of a more individualized approach to prevention as well as integration of prevention activities. We will look at cardiovascular screening combined with screening for different types of cancer.
      

Cardiovascular primary and secondary prevention

A dramatic fall has been observed in the cardiovascular mortality in last decades. Netherlands, cardiovascular diseases (CVD) are, beside malignancies, still one of the main causes of death in the Netherlands and impose a high burden on healthcare costs. The current trend in overweight, obesity and diabetes constitutes further cardiovascular threat. Therefore, there is a case for systematic screening for CVD risk, in order to start treatment early. Moreover, as the proportion of CVD events is high among individuals with an intermediate risk, who are not considered eligible for the intensive treatment of risk factors, there is a strong need for improvement of the CVD risk assessment. One suggested approach to improve prediction of the CVD risk is the quantification of coronary artery calcium (CAC) using CT scan. Therefore the overall aim of the proposed study is to investigate whether screening for CVD risk with the traditional risk model for prediction of future CVD events yields significant higher health benefits in comparison to a control group and to assess the added value of CAC.
The proposed study is designed as a three arm RCT with two intervention arms and one control arm. The RCT will be conducted among asymptomatic males and females aged 45-74 years, with an intermediate risk of CVD. The choice for the intermediate risk group is based on the fact that for high-risk and low-risk asymptomatic individuals, additional non-invasive CAC scoring will generally not modify decisions regarding preventive interventions (intensive intervention to reduce risk factors).