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Cholesterol screening - or snails and problem evangelists

The main terminal at Dulles International in Washington DC is a remarkable building with a roof that is curved like the wing of a soaring gull. High in this magnificent building is a very large sign exhorting American males to attend for prostate cancer screening. Are the Americans right or is UK policy correct? In the case of prostate cancer screening Bandolier firmly believes that the Americans are wrong and that there is no evidence to justify prostatic cancer screening. However, it is wise to pause and think a moment about right and wrong when interpreting evidence, and recent articles on cholesterol screening in the United States clearly demonstrate how attitudes influence the interpretation of the same body of evidence.

ACP Guidelines

The American College of Physicians has come out with a new set of guidelines [1], and although these are complex and not as clear as they could be, they do not recommend whole population screening for primary prevention. The guidelines, which are based on good quality research which clearly emphasises the lack of evidence about screening for primary prevention, led to a fascinating Editorial by the former Editor of Annals, Frank Davidoff [2].

This Editorial reminds us of one of the central articles on screening, that by Sackett and Holland, which emphasises the need to think of people who discussed screening as either snails or evangelists, with the snails interpreting the evidence to indicate no progress and the evangelists preaching progress on the same evidence [3].

An article in the same edition of Annals gives the evangelical author the opportunity to disagree completely with the American College of Physicians' policy; the author argues that cholesterol lowering agents are under-used in the US, whereas most people in this country would be of the opinion that they were over-used.

Snails & evangelists

Differences of opinion within America are similar to the differences of opinion between the United States and the UK. In general we are snails and they are evangelists.

America is the "can-do" society where disease is to be tackled, fought and overcome and where the mere existence of technology is often sufficient justification for its use. It is easy to equate this approach with commercialism but there is a strong idealistic streak that drives the pioneering spirit that still exists in America.

Bandolier still believes firmly that there is no place for whole population screening for cholesterol and none of its Editors know their cholesterol levels. We are snails and proud of it. We also believe that we are right to keep total population cholesterol screening and screening for prostate cancer on our screening blacklist.


  1. American College of Physicians. Guidelines for using serum cholesterol, high-density lipoprotein cholesterol, and triglyceride levels as screening tests for preventing coronary heart disease in adults. Annals of Internal Medicine 1996 124: 515-7.
  2. F Davidoff. Evangelists and snails redux: the case of cholesterol screening. Annals of Internal Medicine 1996 124: 513-4.
  3. DS Sackett, WW Holland.Controversy in the detection of disease. Lancet 1975 2: 357.

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