Quality assurance in screening strategies

The pre-requisites for successful screening programmes include understanding and acceptance of the necessity for tests with achieved high coverage of those at risk for the disease, provision of screening tests, provision of facilities for treatment of abnormalities, and acceptance by women of the necessity for further investigation of abnormalities, all requiring attention to quality assurance. Screening programmes for cancer of the cervix have been very effective in many developed countries but in very few developing countries. In general, the failures in developing countries can be directly related to failure to achieve adequate quality in one or other component of a programme. Some of these failures occur at the level of the laboratory, but in several Latin American countries, there are superb laboratories, but overall the programme has failed to achieve the expected impact. In some countries this has led to alternatives to the cytology smear being evaluated, without recognition that it is not the test that has failed, but another essential component of an effective programme. The solution is attention to management and organisation at all levels, with quality assurance at each. This is required at the level of: definition of the target population, identification of the individual women in the target population, recruitment of the at risk woman to screening, administration of the screening test, laboratory examination of the test, communication of results from the laboratory to the woman and her physician, ensuring the woman attends for investigation and management of abnormal screening tests, ensuring adequate therapy of lesions identified by the diagnostic process, ensuring adequate follow-up of treated women, ensuring women with negative screening tests return for re-screening at the appropriate intervals, and monitoring and evaluation of the programme.