Objective: To review the assessment of screening in the United Kingdom, focusing on three methods: mammography for breast cancer, screening for prostate cancer, and routine use of ultrasound in pregnancy.

Method: To review policy documents and published papers dealing with prevention and screening in the United Kingdom.

Results: Indicate that the United Kingdom has an active policy concerning the assessment of screening methods. Generally speaking, this assessment policy is part of the national program for health technology assessment (HTA). The government has given HTA an important place within health care in the United Kingdom, and prevention and screening is no exception to this general rule. The assessment of screening is now implemented through the National Screening Committee, established in 1997. The three issues reviewed in this paper have all been assessed within the context of the Department of Health. In the case of mammography, the assessment was done more than 10 years ago and was followed by a rational implementation of a national screening program for breast cancer. In the case of prostate cancer screening, two systematic reviews have concluded that screening should not be carried out. In general, this recommendation has been accepted in the United Kingdom. Use of ultrasound in pregnancy has been assessed by the National Screening Committee. This complex technology is difficult to assess, and the screening procedure is deeply embedded in clinical practice in the United Kingdom, so assessment has not had much impact on the frequency of screening.

Conclusion: HTA and the assessment of screening are well established in the United Kingdom. Policy is generally based on the assessments done, and practice generally follows the results of assessment. Assessment of screening is expected to become increasingly important in the United Kingdom during the next years.

Objective: To present a summary of the papers in this volume, illustrating the links between health technology assessment (HTA), health policies and specifically policies toward prevention and screening, and implementation of screening tests in the case of three screening methods: mammography screening for breast cancer, screening for prostate cancer, and routine use of ultrasound in pregnancy.

Method: To commission papers from eight European countries based on a set of questions to be answered, as well as a paper synthesizing the scientific literature on the three screening procedures.

Results: Indicate that few of the countries examined have developed effective links between HTA, health policy, and implementation related to screening procedures. Only Sweden and the Netherlands appear to have developed such links. In the other countries, HTA has a limited role in determining health policy. It also seems to be uncommon for countries to have a specific prevention strategy.

Conclusion: The major conclusion is that countries of Europe need to develop HTA as part of prevention policies.

Objective: To review the assessment and implementation of three screening methods: mammography for breast cancer, screening for prostate cancer, and routine use of ultrasound in pregnancy.

Methods: To review policy documents and published papers dealing with prevention and screening in the Netherlands, focusing on the three screening methods specified.

Results: The results indicate that the Netherlands has an active establishment devoted to health technology assessment (HTA). The Netherlands government has also made prevention a high priority in the health services system. Within prevention policy, HTA is given an important place. The general policy is that prevention programs should meet high standards of effectiveness and efficiency, as well as ethical, legal, and social acceptability. In addition, the Netherlands may be unique in the world in having a specific law requiring that proposals for population screening must be carefully assessed before they are implemented.

Conclusions: The three cases examined in this paper have all been assessed, and the conclusions are similar to those presented in the synthesis published in this issue (33). In the case of mammography, the assessment was followed by a rational implementation of a national screening program for breast cancer. In the other two cases, however, despite negative conclusions from assessment, the tests are frequently carried out, especially in what has been termed opportunistic screening. Prostate cancer screening seems to be spreading rapidly. Use of ultrasound in pregnancy is frequent, not necessarily for medical reasons but because parents wish to have a picture of their fetus. The conclusion is that HTA is well established in the Netherlands, as illustrated in these three cases, and policy is based on the assessments done. However, practice is not in accord with the assessment in the cases of prostate cancer and routine ultrasound. Policies to deal effectively with opportunistic screening are difficult to imagine.

Objective: To describe how scientific evidence has influenced healthcare policy making in Belgium in the field of sickness prevention for mammography, PSA testing in prostate cancer screening, and use of ultrasound in pregnancy.

Methods: Review of published and gray literature and interviews with stakeholders and experts.

Results: At the end of 1999, a systematic national/regional screening program had not yet been implemented for any of the three screening strategies. A systematic breast cancer screening program is being prepared for implementation only in Flanders. This limited impact can be attributed to the fragmentation in healthcare policy, the different options among the different regions, fragmentation in healthcare practice, the strong impact of healthcare stakeholders (provider groups and sickness funds) on decision making, and limited attention to scientific evidence in health policy and technology assessment.

Conclusions: Health technology assessment has had very little impact on policy and practice in use of mammography, PSA testing, and ultrasound in pregnancy in Belgium.