Screening for coeliac disease: what evidence is required before population programmes could be considered?

I n the traditional doctor-patient consultation, the patient initiates a visit and the physician’s imperative is to respond to the best of his or her ability. However, in a screening programme, the initiation comes from health professionals, and many commentators have argued that this poses different ethical challenges. In particular it is argued that the level of evidence concerning the balance of overall benefit and harm from the screening programme must be much greater than that for a traditional therapeutic intervention. Although screening may intuitively be logical for a particular condition which is prevalent and detectable in the preclinical stage, intuition is not an appropriate basis for commencing a screening programme. A number of criteria have been described that allow the evidence for screening programmes to be more formally evaluated. Calls are regularly made for the introduction of population screening programmes, such as that for coeliac disease (CD) in the paper by Alberto et al in this issue. These screening criteria form the basis for evaluating the strength of the evidence supporting that call. They also highlight key uncertainties, which could be the subject of future research. This process has been undertaken for screening for type 2 diabetes in adults, and the history of the debate on this topic may shed some light on how to reach a more speedy decision for CD.