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Health Screening - StatPearls - NCBI Bookshelf

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Health Screening
Donald N. Givler; Amy Givler.

Author Information and Affiliations

Last Update: February 19, 2023.

Continuing Education Activity

A health screening test is a medical test or procedure performed on members of an asymptomatic
population or population subgroup to assess their likelihood of having a particular disease.
Health professionals often think of screening for early diagnosis of cancer (such as Pap smears
for cervical cancer or colonoscopy for colon cancer), but there are many other screening tests
commonly used, for example, thyroid-stimulating hormone (TSH) for congenital hypothyroidism
in newborns, cholesterol level for heart disease, urine drug screen for illicit drug use, or blood
pressure for hypertension. Some screening tests are applied to a large segment of the population
(for instance, all adults older than age 50), while others target a smaller subset of the population
(pregnant women). Many screening tests are widely used in the United States. This activity
provides guidelines on the current screening tests and the role of the interprofessional team in
patient education on the benefits of screening.

Objectives:

Identify the function of screening tests.

Describe the issues of concern with screening test.

Explain the benefits of screening tests.

Outline interprofessional team strategies for improving care coordination and

communication to advance approved screening tests and improve outcomes.

Access free multiple choice questions on this topic.

Introduction
A health screening test is a medical test or procedure performed on members of an asymptomatic
population or population subgroup to assess their likelihood of having a particular disease. We
often think of screening for early diagnosis of cancer (such as Pap smears for cervical cancer or
colonoscopy for colon cancer), but there are many other screening tests commonly used, for
example, thyroid-stimulating hormone (TSH) for congenital hypothyroidism in newborns,
cholesterol level for heart disease, urine drug screen for illicit drug use, or blood pressure for
hypertension. Some screening tests are applied to a large segment of the population (for instance,
all adults older than age 50), while others target a smaller subset of the population (pregnant
women). Many screening tests are widely used in the United States. Healthcare providers can
agree that early diagnosis of a life-threatening disease, for which there is an effective treatment,
is a positive action.

Unfortunately, health screening is complicated. Many articles about screening present a

bewildering array of medical economics and biostatistics to make their points and a multitude of
credible organizations have offered their own (often differing) screening recommendations. The
economic implications of screening are real. Even a single screening test, applied to a large
number (millions) of people, can result in billions of dollars of health care expenditure annually.
There are legitimate debates about sensitivity and specificity, disease prevalence, predictive
values, lead-time bias, screening intervals, and appropriate cutoffs for positive or negative
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results. Recently, "shared decision making" has been suggested as an option when there is
uncertainty about the advisability of a particular screening test (such as the prostate-specific
antigen, or PSA, for the early diagnosis of prostate cancer). That may be possible if your patient
is an educated professional. However, asking a patient without medical training to understand
issues that challenge the intellect and judgment of most trained clinicians does not seem realistic.
That the issue even arises highlights the urgent need for better screening tests.[1][2][3][4][5][6]

Function
The function of health screening is to assess the likelihood that an asymptomatic individual has a
particular disease, with the goal of preventing illness or death from that disease. There are
several characteristics of a good screening test.

1. Diseases that are good candidates for screening are those that are prevalent in the
population and cause significant morbidity and mortality. In the United States, heart
disease and lung cancer are good examples. In contrast, trypanosomiasis might be a good
target for screening in Tanzania, but not in the United States.

2. The disease must have an asymptomatic period during which treatment will reduce
morbidity and mortality significantly more than waiting until symptoms develop.
Congenital hypothyroidism and cervical cancer are good examples. In contrast, chest x-
rays as a screening test for lung cancer were discontinued because of failure to
demonstrate the value of early diagnosis.

3. The screening test should have the highest possible sensitivity (few false-negative results)
and specificity (few false-positive results). The ideal screening test will be 100% sensitive
and 100% specific, identifying all patients with the disease and falsely diagnosing none.
Unfortunately, no ideal test exists. For example, PSA screening for prostate cancer has a
very high false-positive rate, as well as the very real possibility of diagnosing an indolent
disease that may never cause symptoms.

4. The screening test should also be inexpensive, readily available, safe, and easy. Many
current screening tests are less than ideal. Ask anyone who has had a colonoscopy for
colon cancer screening or a low-dose helical CT scan for lung cancer screening. These
tests are expensive, inconvenient, and not universally available.

5. Effective treatment for the disease in question should be available at a reasonable cost.
Why screen for a disease for which there is no real treatment?

Issues of Concern
There is no perfect screening test, but looking at a questionable screening test and a reasonable
screening test is helpful for understanding the issues.

First, consider a questionable (bad) screening test. Many patients get an annual (or periodic)
complete blood count (CBC) and comprehensive metabolic panel (CMP). Doctors do this to
identify some asymptomatic disease (screening for anemia or hypokalemia). Is there any
scientific support for this? No. There is none. It is a shot in the dark. The patient in question is a
healthy asymptomatic adult, not a hypertensive patient in whom we are following serum
chemistry or a patient with menorrhagia in whom we are following a CBC. There's no evidence
that a routine CBC or CMP in a healthy, asymptomatic adult is useful, reasonable, or cost-
effective. However, doctors order these tests. The reason (not without some basis in reality) that
they are more likely to be criticized (or sued) for doing too little rather than too much, so they err
on the side of doing too much. Moreover, they may rationalize that at least they are not ordering
a total body CT scan for screening. Multiply one CBC or CMP by thousands or millions of
patients per year. By eliminating these unnecessary tests, we can pay for thousands or millions of
rational screening tests per year.
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Then, consider a reasonable ("good") screening test. Checking a blood type on a woman early in
her pregnancy has become standard of care in the US since the 1970s. It is done as a screening
test primarily to identify women with Rh-negative blood type. Why? Because if Rh
incompatibility is present, antenatal and postnatal RhoGAM given to the mother dramatically
reduces the incidence of the problems that can result. (The problems occur when a woman is
Rh-negative, and her baby is Rh-positive, and they mainly affect the baby. If untreated, the
problems get worse with subsequent pregnancies.) Because checking the mother's blood type in
pregnancy is now almost universal, and most Rh-negative women receive RhoGAM, most
younger US physicians have never seen a case of severe hemolytic disease of the fetus or
newborn. A simple, inexpensive, and readily available screening blood test, with appropriate
follow-up treatment when indicated, has virtually eliminated what used to be a common and
potentially fatal consequence of Rh incompatibility.[7][8][9]

Clinical Significance
A good screening test should target diseases that are prevalent in the population and cause
significant morbidity and mortality. The leading cause of death in the United States is heart
disease. The second leading cause of death is cancer, with lung cancer and colorectal cancer
accounting for the highest number of cancer deaths. The following are the screening tests
available for these three diseases.

Heart Disease (ischemic heart disease or coronary artery disease, rather than valvular heart
disease, hypertrophic cardiomyopathy). The following can be done to diagnose heart disease
while it is asymptomatic.

First, doctors can identify risk factors to determine patients at increased risk for heart disease, for
example, they can routinely inquire about smoking and family history of heart disease.

They can check blood pressure and lipids (total cholesterol, LDL, and HDL), and blood sugar (to
detect diabetes) periodically. Exactly when to start checking blood pressure and lipid profiles and
fasting blood sugar, and how often to check them, is less clear.

There are a variety of heart disease risk-assessment tools, none of which are superior to the
others. Then screening tools become more controversial among healthcare professionals. For
example, the value of high-sensitivity C-reactive protein (hs-CRP), resting EKG, exercise stress
testing (with or without nuclear imaging), coronary artery calcium (CAC) score determined by
electron beam or multidetector-row computed tomography (EBCT or MBCT), and CT
angiography have yet to be determined. They are not recommended in an asymptomatic low or
average-risk individual. Their place in screening an asymptomatic high-risk individual is less
clear, but there is no consistent recommendation for their use. Doctors should get a complete
history, a blood pressure reading, a lipid profile, and a fasting blood sugar as screening tests, not
for heart disease itself but to determine the risk factors for heart disease.[10][11]

Lung Cancer

As we noted above, previous recommendations for screening chest x-rays for the early diagnosis
of lung cancer were stopped. While lung cancer could be diagnosed earlier by a screening chest
x-ray in an asymptomatic individual, it became clear that early diagnosis did not change the
course of the disease. This is an example of lead-time bias. Patients may seem to live longer, but
only because the cancer is diagnosed earlier. Other tests, such as sputum cytology, have not been
shown to be beneficial. The most promising test currently being studied is low-dose helical CT
scanning (LDCT) performed with maximum inspiratory breath-hold, in 25 seconds or less, with
high-resolution reconstruction. There is evidence of a mortality benefit from LDCT, but more
studies are needed. Candidates for annual screening are patients aged 55 to 74 (some recommend
up to age 80) years, a history of smoking at least 30 pack-years, and, if a former smoker had quit
within the previous 15 years. For former smokers, annual screening should continue until 15

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