PREVENTION

NENDYAH ROESTIJAWATI
TYPES OF CLINICAL PREVENTION

Immunization
Screening identification asymptomatic disease or risk
factor
Behavioural counselling (lifestyle change)
Chemoprevention use drugs to prevent disease
LEVELS OF PREVENTION
CRITERIA FOR DECIDING PREVENTIVE CARE

1. The burden of suffering caused by condition 5D +

destitution
2. The effectiveness, safety and cost
3. The performance of screening test
TREATMENT IN PRIMARY PREVENTION

Randomized trials regulated

prevention
Observational study not
regulated prevention,
behavioural counselling
Safety compare the frequency
of adverse effect
Counselling
TREATMENT IN SECONDARY PREVENTION

Generally the same of treatment in curative medicine

Should be efficacious and effective take years
Treatment of early, asymptomatic disease must be
superior to treatment disease
TREATMENT IN TERTIARY PREVENTION

Some drugs are not use only to treat but to prevent

another disease
EVALUATING SCREENING PROGRAM

Prevalence and incidence screens

Biases
PREVALENCE AND INCIDENCE SCREENS

The yield screening decreases as

screening is repeated overtime
First screen prevalence screen
Cases of medical condition will
have present for varying lengths
of time
Second screen incidence screen
Number of cases of disease drops
positive predictive value drop
LEAD TIME BIAS
Period time between the
detection medical condition
by screening and when it
diagnosed
Depends on progression of
disease and how early
screening test can detect
the disease
Lead time short difficult
to demonstrate
effectiveness screening
than treatment
Lead time long effective
LENGTH TIME BIAS

Proportion of slow-growing
lesions diagnosed during
screening is greater than
proportion diagnosed
during usual medical care
It seems that screening
and early treatment are
more effective
COMPLIANCE BIAS

Compliant patients tend to have better prognoses

Not completely clearly, complaint patients are more interested in
their health and are generally healthier than non-compliant
AVOIDING BIAS
Bias Effect
Lead time Appears improve survival time
but actually increase disease
time
Length Outcome appears batter in
time screened group because more
cancer with good prognosis
are detected
Complian Outcome in screen group
ce appears better due to
compliance, not screening
How to avoid
Use mortality rate than
survival rate
Compare outcomes in RCT
with control group and
one offered screening
Compare outcomes in RCT
with control group and
one offered screening
PERFORMANCE OF SCREENING TEST

High sensitivity and specificity

Positive predictive value high positive predictive value
Simplicity and cost
Safety
Acceptable to patients and clinicians
HIGH SENSITIVITY AND SPECIFICITY

Sensitivity does not miss the few case disease

Specificity reduce number people with false positive results
Determined by comparing gold standard test not only
presence of disease, also a period of time for follow up
Gold standard applied only to people with positive screening
results to differentiate between true and false positive results
Period of follow up applied only to people with negative
screening results to differentiate between true and false negative
results important in cancer screening interval cancers
CALCULATING SENSITIVITY

Detection method works well for many screening test

Number of screen-detected cancers
Sensitivity = -----------------------------------------------------------------------------------------
Number of screen-detected cancers plus number of interval cancer

Incidence method
sensitivity = 1 (interval rate in screening group incidence rate in control group)
CONTOH

Screening group = 200

Negative screening test diagnosed cancer = 50
Control group diagnosed cancer = 100
Sensitivity = 200/(200+50) = 0.80 = 80%
Sensitivity = 1 (50/100) = 0.50 = 80%
True sensitivity probably between the estimate of the two
method
LOW POSITIVE PREDICTIVE VALUE

Asymptomatic people have

low prevalence of most
disease positive
predictive value low
Concentrating on people
with higher prevalence for
disease
UNINTENDED CONSEQUENCES OF SCREENING

Risk of false positive result

more test clinicians orders,
greater risk of false positive result
Labelling effects
Risk over diagnosis (pseudo
disease) in cancer screening
extreme length time bias
Incidentalomas : masses or
lesions detected incidentally by
imaging examination
WEIGHING BENEFITS AGAINST HARMS

QALY

Cost effectiveness
analysis
Straightforward
TERIMAKASIH