Scuola H di YGIENE COURSE Medicina - Benvenuto · 2020. 1. 10. · DPCM 29 novembre 2001. S L OF E...

HYGIENE COURSE

Scuoladi

Medicina

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URSEScreeningtest

• Systematic exam,conducted withclinical,instrumental tecnique orlaboratory testdesigned todetect cases ofdisease inpre-clinical stageinapopulation

• Secondary prevention• Means:early detection• Goal:reducing mortality byreducingincurable forms

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E

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URSETwobytwotable

D+ D-

Positive

Negative

80 40

20 60

TP + FN FP + TN

TP + FP

FN + TN

N

Disease

Screeningtestresults

SCHOOLOFMED

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E

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URSETwobytwotable

D+ D-

Positive

Negative

80 40

20 60

TP + FN100

FP + TN100

TP + FP120

FN + TN80

N = 200

Disease


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E

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IENECO

URSETwobytwotable

D+ D-

Positive

Negative

80 40

20 60

TP + FN100

FP + TN100

TP + FP120

FN + TN80

N = 200

Disease


P P

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E

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URSETwobytwotable

D+ D-

Positive

Negative

80 40

20 60

TP + FN100

FP + TN100

TP + FP120

FN + TN80

N = 200

Disease


P P

N N

SCHOOLOFMED

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E

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URSETwobytwotable

D+ D-

Positive

Negative

80 40

20 60

TP + FN100

FP + TN100

TP + FP120

FN + TN80

N = 200

Disease


TP P

N N

SCHOOLOFMED

ICIN

E

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URSETwobytwotable

D+ D-

Positive

Negative

80 40

20 60

TP + FN100

FP + TN100

TP + FP120

FN + TN80

N = 200

Disease


TP FP

FN TN

SCHOOLOFMED

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E

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URSE

Screeningtestformularule

“Trues”ontopanddividebyeverything

• Sensitivity,Specificity,Positivepredictivevalue,Negativepredictivevalueandaccuracy

SCHOOLOFMED

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E

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URSE

Sensitivity

D+ D-

Positive

Negative

80 40

20 60

TP + FN100

FP + TN100

TP + FP120

FN + TN80

N = 200

Disease


TP FP

FN TN

SCHOOLOFMED

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E

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URSE

Sensitivity

Negative Positive

Healthy people

Disease

SCHOOLOFMED

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E

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IENECO

URSE

Screeningtest:reality

Negative Positive

Healthy people

Disease

SCHOOLOFMED

ICIN

E

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IENECO

URSE

Sensitivity

D+ D-

Positive

Negative

80 40

20 60

TP + FN100

FP + TN100

TP + FP120

FN + TN80

N = 200

Disease


TP FP

FN TN

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Screeningtestparameters

• Sensitivity:identifyingcasesofdiseaseFormula=TP/(TP+FN)Sens:80/(80+20)=80%

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Specificity

D+ D-

Positive

Negative

80 40

20 60

TP + FN100

FP + TN100

TP + FP120

FN + TN80

N = 200

Disease


TP FP

FN TN

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• Sensitivity:identifyingcasesofdiseaseFormula=TP/(TP+FN)Sens:80/(80+20)=80%

• Specificity:identifyingdisease–freepeople,healthypeople

Formula=TN/(TN+FP)Spec:60/(60+40)=60%

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URSE

Theideal test

healthy

diseased

cut-off

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URSEThereal test...

cut-off

TP

TN

FPFN

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URSE

PositivePredictiveValue

D+ D-

Positive

Negative

80 40

20 60

TP + FN100

FP + TN100

TP + FP120

FN + TN80

N = 200

Disease


TP FP

FN TN

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URSE


• Positivepredictivevalue:likelihoodthatapositivetestresultindicatesrealdisease

Formula=TP/(TP+FP)PPV:80/(80+40)=66.7%

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URSE

NegativePredictiveValue

D+ D-

Positive

Negative

80 40

20 60

TP + FN100

FP + TN100

TP + FP120

FN + TN80

N = 200

Disease


TP FP

FN TN

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URSE


• Positivepredictivevalue:likelihoodthatapositivetestresultindicatesrealdisease

Formula=TP/(TP+FP)PPV:80/(80+40)=66.7%

• Negativepredictivevalue:likelihoodthatanegativetestresultindicatesnorealdisease

Formula=TN/(TN+FN)NPV:60/(60+20)=75%

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• Twosetsofscreeningtestvalues1) Sensitivityandspecificity2) PPVandNPV

• Sensitivityandspecificity:pre-testprobabilities

• PPVandNPV:post-testprobabilities

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Understandingscreeningtests

Sens=80% Spec=60%

PPV:66.7% NPV:75%

Agoodtest?

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URSE

Understandingscreeningtests

Sens=80% Spec=60%

PPV:66.7% NPV:75%

Agoodtest?Onlyso-so

SCHOOLOFMED

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E

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URSE

Accuracyorefficiencyofthetest

D+ D-

Positive

Negative

80 40

20 60

TP + FN100

FP + TN100

TP + FP120

FN + TN80

N = 200

Disease


TP FP

FN TN

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E

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URSE

Accuracyorefficiencyofthetest

• PercentagecorrectOVERALL• Formula:TP+TN/(TP+TN+FP+FN)

TP+TN/N,samplesize• Acc:80+60/200=70%

SCHOOLOFMED

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E

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IENECO

URSEIncreasing specificity

cut-off

VP

VN

FPFN

SCHOOLOFMED

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E

HYG

IENECO

URSEIncreasing sensitivity

valore di cut-off

VP

VN

FPFN

SCHOOLOFMED

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URSENecessary conditions

forthefeasibility ofscreeningprograms

1. Disease toscreenis animportant publichealthissue

2. Epidemiologyandnatural history should bewell known

3. Exists anindicatorofthedisease inpre-symptomaticphase

4. History ofthedisease canbemodifiedwithearly detection

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Necessary conditionsforthefeasibility ofscreening

5. Effective screeningtest:§ simple,harmless,reliable,validated§ reproducible andaccurate§ consensus onthedefinition ofpositivetest§ agreement onthediagnostic study protocol andtheoptions available forthepositivetestsubjects'

6. Effective treatmentforthescreeneddisease

SCHOOLOFMED

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URSE


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Leadtime=interval oftimebetween themomentinwhich thediagnosis is performed forthescreeningeffect andthetimewhen thediagnosis would have been madefortheappearance ofclinical signs ofdisease

SCHOOLOFMED

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URSE

Goalofancancer screeningprogramme

• Reducemortality fromcancer byreducing theincidence ofincurableforms

• It’s secondary prevention (keep it inmind always !!!)

GrazziniG.,etal.MinisterodellaSalute.Roma,2006.

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URSE

Organized screeningprograms vs.spontaneous screening

• Freeandactiveoffer(personalinvitation)tothepopulationat-risk

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URSE

Organized cancer screeningprograms

• Publichealth interventions includedintheLEA

• Possibility toanticipateacancer diagnosisshouldbeuniversally guaranteed

DPCM29novembre2001

SCHOOLOFMED

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E

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URSE

Recall tonextscreeninground

Invitation to2°level=

Diagnostic level

Invitation fromthescreeningcentre

1° level test=ScreeningTest

3° levele =terapeuticIntervention (surgery and/or

chemiotherapy)

+

Pathway

+

SCHOOLOFMED

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E

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URSE

Screeningtestis NOTdiagnostic

Testdiscreening

NEGATIVO

Nessunaltroesame

Verinegativi Falsinegativi

NONNEGATIVO

Esamediapprofondimento

Veripositivi Falsipositivi

• Breast Cancer• Cervical Cancer• Colorectal (Colon)Cancer

Cancer screening

www.ccm-network.itwww.epicentro.iss.it

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URSENecessary conditions

forthefeasibility ofscreeningprograms

SCHOOLOFMED

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E

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IENECO

URSE

Incidence andMortality worldwide:women

Ferlayetal,GLOBOCAN2008:CancerIncidenceandMortalityWorldwide,IARC2010

SCHOOLOFMED

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E

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IENECO

URSE

Incidence andMortality worldwide:men

Ferlayetal,GLOBOCAN2008:CancerIncidenceandMortalityWorldwide,IARC2010

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E

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IENECO

URSE

Breast Cancer Screening• Womenaged 50– 69years• Screeningtest:Mammography (bilateral inadoubleprojection)

• Every 2years

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URSE

IIlevel

� Clinical breast exam,mammography� Fineneedle aspiration� Corebiopsy

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E

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URSE

IIIlevel

� Surgical treatment:§ Quadrantectomy

§ Mastectomy

� and/orchemioteraphy

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URSE

Benefits

Mortality reduction:38%

Womennotincluded

inascreeningprogram

Screenedwomen

Euroscreen working group.Lancet2013

vs

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Benefits

SCHOOLOFMED

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E

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URSE

Risks

• Overdiagnosis• Psycological harm(anxietyinadvanceofthetest,distressifabnormalitiesaredetected)

SCHOOLOFMED

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E

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URSE

Breast cancer incidenceItaly,2006- 2009

AIRTUM – AIOM. I numeri del cancro 2013.

SCHOOLOFMED

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Cervical cancer screening

�Women25– 64years� Screening(Ilevel):Pap smear

� Every 3years� BethesdaClassification,2001

SCHOOLOFMED

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E

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URSE

BethesdaClassification 2001

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IIlevel

Different according toPap smear results:

� HPVtest(all positivetests)� Repeat Pap smear (ASC– US,LSIL,inadeguati)� Colposcopywithorwothout endometrial biopsy(HSIL,ASC– H,AGC,Cr)

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URSE

IIIlevel

• TreatmentforCIN2andCIN3:– laservaporization– cryotherapy– radicaldiathermy– conization– ….

• 6months follow upforCIN1

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URSENewguidelines

• Pap testevery 3years:women 24to30years

• HPVtestevery 5years:Women>30years

Ronco G.etal.,TheLancet,February2014

SCHOOLOFMED

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Colorectal cancer screening

SCHOOLOFMED

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E

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URSE


� Menandwomen between 50and70years

� Screeningtest(LevelI):Fecal OccultBloodTest

� Every 2years

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• SomeItalian programs (Piedmont andVeneto)usethesigmoidoscopy as ascreeningtest(level I)

SCHOOLOFMED

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E

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URSE

IIlevel

• Colonoscopy• Biopsy• If colonoscopy is not executable orisrejected:Rx colonwithdoublecontrast orTACcolonography

SCHOOLOFMED

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E

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URSE

IIIlevel

• Surgery

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Familiarity forbowel cancer

• managementis not thesame inItaly• Each program implements differentprotocols

• InPuglia:– First-degree relatives ofpatientswithcancer:colonoscopy

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Monitoring ofscreeningprograms

• It’s necessary totrack every action:fromtheidentification ofthetargetpopulationtothepossible treatment

• Dataallow us tocomparetheperformanceoftheprogram withindicators contained intheguidelines

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Performanceindicators

• Thesame forall ofItalian screeningprograms

• Published annually onthewebsitewww.osservatorionazionalescreening.it

• Foreach screeningprogram andeachscreeningis needed tofill outapre-formedsheet:– GISMAform– GISCIform– GISCORform

SCHOOLOFMED

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URSEInformativeflow

Responsabiledelprogrammadi

screeningterritorialecompilaeinviala

SCHEDARaccoltadelle schede

edelaborazioneGruppoItaliano

Screening(Gisci,Gisma,Giscor) Pubblicazionesulsitoe

presentazioneinoccasionedel

congressoannualeEntroil30settembredell’anno

successivoaquelloinesame

MinisterodellaSaluteTraGennaioe

Febbraiodell’annosuccessivoallaraccoltadeidati

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Toimprove you knowledge…

• http://www.cdc.gov/cancer/dcpc/prevention/screening.htm

• http://www.cancer.org/healthy/findcancerearly/cancerscreeningguidelines/

Scuola H di YGIENE COURSE Medicina - Benvenuto · 2020. 1. 10. · DPCM 29 novembre 2001. S L OF E...

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Transcript of Scuola H di YGIENE COURSE Medicina - Benvenuto · 2020. 1. 10. · DPCM 29 novembre 2001. S L OF E...