Health technology assessment and screening in the Netherlands - Case studies of mammography in breast cancer, PSA screening in prostate cancer, and ultrasound in normal pregnancy

Objective: To review the assessment and implementation of three screening m ethods mammography for breast cancer, screening for prostate cancer, and ro utine use of ultrasound in pregnancy. Methods: To review policy documents and published papers dealing with preve ntion and screening in the Netherlands, focusing on the three screening met hods specified. Results: The results indicate that the Netherlands has an active establishm ent devoted to health technology assessment (HTA). The Netherlands governme nt has also made prevention a high priority in the health services system. Within prevention policy, HTA is given an important place. The general poli cy is that prevention programs should meet high standards of effectiveness and efficiency, as well as ethical, legal, and social acceptability. In add ition, the Netherlands may be unique in the world in having a specific law requiring that proposals for population screening must be carefully assesse d 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 publis hed in this issue (33). In the case of mammography, the assessment was foll owed by a rational implementation of a national screening program for breas t cancer. In the other two cases, however, despite negative conclusions fro m 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 necessar ily 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 wit h opportunistic screening are difficult to imagine.