Is screening for anal cancer warranted in homosexual men?

Some investigators have proposed screening homosexual men for anal cancer and its probable precursor, high grade anal intraepithelial neoplasia (AIN). Using widely accepted criteria for the introduction of screening programmes, this paper reviews the current evidence for screening for this condition in this high risk population and highlights areas where additional research is required. While it is accepted that the incidence of anal cancer is at least 20 times higher in homosexual men than the general population, the natural history of anal cancer and its precise relationship with AIN is not clearly understood. Anal intraepithelial neoplasia is a very highly prevalent disease among homosexual men, but little is known about what predicts progression to invasive disease. The screening tests, exfoliate cytology and high resolution anoscopy, have a sensitivity of between 45 and 70%. Treatment options for AIN are limited by morbidity and high recurrence rates and there are no randomised controlled trials studying the efficacy of therapeutic agents or surgery for high grade AIN, although immunotherapies show very early promise. Theoretically, early detection may lead to better treatment outcomes. Studies of the potential negative consequences of screening programmes on the homosexual population are needed. The currently available data does not support the implementation of a screening programme for AIN and anal cancer in homosexual men in Australia.     

Fruits and vegetables, 5+ a day: are we getting the message across?

Fruit and vegetables have important health promoting properties. The 5+ a day programme aims to promote awareness of the need to eat more of these foods. This paper presents and discusses the results of two surveys designed to determine the success of the 5+ a day programme across New Zealand. Household surveys were carried out by a marketing research company in 1999 and 2000. The 1999 questionnaire focused on awareness and understanding of the 5+ a day campaign. The 2000 questionnaire focused on attitudes to health and on intakes of fruits and vegetables. Data were collected from households nationwide (1999 survey N = 200, 2000 survey N = 520). Spontaneous consumer awareness of messages promoting the need to eat more fruit and vegetables was high. Seventy-one percent of all respondents identified the 5 servings a day message from the 5+ a day logo regardless of whether they had seen it before. The meaning of the hand in the logo was less clear with only 2.5% identifying the 'serving size' element of the logo. Fruit and vegetable intakes of respondents were influenced by demographic factors: gender, ethnicity, education and occupation (all P < or = 0.05). Positive attitude towards the relationship between fruit, vegetables and health was influenced by similar factors and in turn affected fruit and vegetable intakes. The 5+ a day message is well recognised and understood. Portion size is less well understood. The 5+ a day message promotes positive attitudes towards healthy eating which are associated with healthier eating habits, but some groups within society may need further attention.     

Why do men refuse or attend population-based screening for prostate cancer?

BACKGROUND: The aims of this study were to investigate the motives for refusing or attending population-based screening for prostate cancer, in relation to various background characteristics. METHODS: The present study is part of the European Randomized Study of Screening for Prostate Cancer (ERSPC), and took place in 1995-1996. Men aged 55-75 years were invited using the Rotterdam population registry (100 per cent coverage), of whom 42 per cent gave written informed consent. These men were randomized to receive either determination of prostate specific antigen (PSA), digital rectal examination (DRE), transrectal ultrasound (TRUS) and biopsy on indication (screening group), or no screening (control group). To 626 consecutive men of the screening group a questionnaire was sent before the screening. To 500 randomly selected refusers (no written informed consent) a similar questionnaire was sent, followed by two reminders. In both refusers and attenders we addressed motives, knowledge of prostate cancer, attitudes towards screening, background characteristics and urological complaints (American Urological Association symptom index, AUA7). RESULTS: Response rates for questionnaires were 48 per cent in refusers and 99 per cent in attenders. Main reported motives for refusing were absence of urological complaints (57 per cent) and anticipated pain or discomfort (18 per cent). Main reported motives for attending were personal benefit (82 per cent), contribution to science (49 per cent) and presence of urological complaints (25 per cent). Compared with attenders, refusers were slightly and significantly older, less often married and had a lower level of education; they had less knowledge about prostate cancer and a less positive attitude towards screening; they had worse general health but fewer urological complaints (AUA7 median 2 versus 4, p < 0.001). CONCLUSION: In refusing or attending population-based prostate cancer screening, urological complaints but also knowledge, attitudes and sociodemographic factors seem to play a role. Therefore, the approach of the general population should be carefully considered.     

Is the mass screening for prostate cancer justifiable?

In Hungary, prostate cancer is a major public health problem, therefore screening should be considered to reduce the number of deaths. Screening tests are available, i.e. prostate-specific antigen (PSA) and digital-rectal examination, nevertheless their sensitivity, specificity and positive predictive value are far from being perfect. Evidences from non-randomized screening trials suggest possible benefit but randomized controlled trials are still needed for conclusive evidence. The screening might cause more harm than good due to overdiagnosis and overtreatment as a result of limited specificity of the test. According to authors' point of view, opportunistic screening as part of diagnostics of patients having symptoms indicative of prostatic disorder is fully justified but mass screening of population of average risk should not be introduced until supportive evidence is available from the ongoing randomized-controlled screening trials.     

Breast cancer screening: Should it be introduced and how?

Summary This brief discussion of the papers by Gästrin and Paccaud is looking at differences in the results of different study types. Introducing screening means changing unsystematic to systematic screening: only the latter has been shown to be effective. The comparison between randomized trials, and follow-up of acceptors only, suggests that the non-acceptors have much higher risks. Programmes should therefore concentrate on trying to reach non-acceptors. The combination of mammographic screening and self-examination in a randomized trial could add to the existing evidence.

---

Zusammenfassung Die Diskussion der beiden Arbeiten von Gästrin und Paccaud befasst sich mit den Unterschieden zwischen systematischem und unsystematischem screening: Nur ersteres hat in der Vergangenheit Effekte gezeigt. Nachuntersuchungen von Frauen, welche Screening akzeptiert haben, zeigen bessere Resultate als die randomisierten Studien; dies weist darauf hin, dass Frauen, welche in unsystematischem Screening nicht erfasst werden, ein höheres Risiko haben. Neue Programme sollten deswegen unbedingt darauf achten, auch diejenigen Frauen für Screening zu gewinnen, welche sonst nicht kommen. Die Kombination der zwei Ansätze: Mammographie Screening und Selbstuntersuchung der Brust in einer randomisierten Untersuchung könnte wichtige Hinweise zur Ergänzung der bestehenden Evidenz geben.

---

Résumé La brève discussion des articles de Gästrin et Paccaud porte sur la diversité des résultats obtenus lors d'études de types différents. En introduisant le dépistage, le dépistage non-systématique fait place à un dépistage systématisé, qui s'est révélé être efficace. La comparaison entre des essais randomisés et des études de suivi chez des femmes acceptant le dépistage suggère que les femmes nonsoumises au dépistage ont un risque plus élevé. Les nouveaux programmes devraient porter leur attention sur la motivation de ces femmes à haut risque. La combinaison du dépistage par mammographie et de la palpation du sein par la femme elle-même pourrait, dans le cadre d'un essai clinique randomisé, apporter des éléments complémentaires renforçant l'evidence déjà existante.

---

---

Paper presented at a symposium on The Public Health Perspective of Social and Preventive Medicine, in celebration of the 20th anniversary of the Department of Social and Preventive Medicine, University of Berne, 25 June 1992 in Berne.     

Prostate-specific antigen for prostate cancer screening. Do physician characteristics affect its use?

PURPOSE: Screening for prostate cancer with the prostate-specific antigen (PSA) test remains controversial. This controversy is reflected in a lack of consensus in the medical literature and among professional and policy organizations regarding routine screening by PSA. It is not known how physicians respond when recommendations from experts are inconsistent. METHODS: A questionnaire was mailed to 1369 primary care physicians in active practice in Washington State in 1994. Response rate to the survey was 63%. Chi-square tests and multivariate logistic regression analysis were used to examine the effects of physician characteristics on physicians' self report of use of the PSA test for screening asymptomatic male patients, aged 50 to 80, for prostate cancer. RESULTS: Of the 714 physicians included in the analysis, 68% reported routine use of PSA. Use of PSA varied among physicians on the basis of practice setting, years since medical school graduation, and whether compensation was fee-for-service or salaried. Male physicians trained before 1974 and physicians receiving fee-for-service were significantly more likely than other physicians to recommend screening by PSA. CONCLUSIONS: Results suggest that physicians' personal characteristics such as year of medical school graduation, gender, and mode of reimbursement are related to self-reported PSA use.     

Widening the cervical cancer screening net in a South African township: who are the underserved?

Cervical cancer screening services in South Africa have failed to reach the majority of the population and to significantly reduce mortality. A household survey in a predominantly Black African population living in a low-income township on the outskirts of Cape Town was undertaken to ascertain the characteristics of women reporting never having been screened. In our group of 664 representatively sampled women. 45% of women reported having had a cervical screening test. However, in what at first glance appears to be a fairly homogeneous population, there were significant differences in the types of women who access and who do not access cervical smear services. The underserved tend to be the older, poorer, less educated, and unemployed (or working in the informal sector) women. They tend to live in nonpermanent dwellings without a partner, they do not know anyone else who has had a cervical smear, and they have not recently sought care for other ailments, or used contraception. Cervical cancer is a slow-to-develop, eminently preventable disease, and yet opportunistic screening through antenatal and family planning services has failed to reach the women most at risk. Efforts in the future must include targeting older women in health centres where they present for other curative services (diabetes, hypertension). Most importantly, areas of the community with the greatest concentration of marginalized women need to be targeted through peer education and other innovative programs. As the underserved tend to be the poorer and less educated women in the community, we must ensure that messages are culturally relevant and appropriate and have a holistic focus on women's physical, mental, and emotional health.     

Clinical inquiries. Does anal cancer screening reduce morbidity and mortality in men who have sex with men?

It's unclear whether anal cancer screening benefits men who have sex with men because high-quality studies on this subject are lacking. In the absence of high-quality data, anal pap smears aren't recommended for routine screening of men who have sex with men (strength of recommendation: C, expert opinion).