Response to ‘Why case finding is bad science’

McCartney et al.¹ make a strong argument against the implementation of (any) population screening programmes without endorsement from the National Screening Committee. Their advocacy on this is welcomed; however, there is a simultaneous and pragmatic requirement on the public health community to ensure that we evaluate these programmes to assess their true value.

Taking the Lung Health Checks Programme ² as an example, this is a four-stage process: letters to ‘ever smokers’ via Primary Care; self-selection and presentation for a ‘lung health check’; escalation to screening; and then further escalation to diagnostic tests.

The argument against lung screening rests on the number needed to screen to prevent lung cancer deaths and harm caused by false-positive results.

What if we expand our consideration of outcomes to include those who attended the health check who were not referred for screening?

Targeting resulted in a median deprivation rank of participants in the lowest decile for England. This contrasts with other screening programmes that assess risk on age and gender and where there are inequalities relating to deprivation. ³

All attendees were offered smoking cessation support. Uptake was not reported but is an important outcome. Participants were also screened for respiratory disease such as chronic obstructive pulmonary disease. A further study ⁴ found that one-third had high QRISK scores but were not prescribed primary prevention according to guidelines.

Current scrutiny is focused on the screening ‘test’ and does not account for the health improvement activity in which it is embedded or the impact on the inequalities gradient. There are opportunities for local health systems to improve the ‘science’.

A strength of the Lung Health Check programme is successful targeting of our most deprived communities, disproportionately affected by lung cancer and associated respiratory diseases. This outcome is not accounted for in best practice screening programme criteria – do we therefore need to amend the criteria? There is an argument here for further public health advocacy.