Imperial College London | Global Master of Public Health | Foundations of Public Health Practice | 2.4.

06

SCREENING – AG

APPLYING THE WILSON AND JUNGNER CRITERIA TO PROSTATE CANCER

Criteria Arguments for Arguments against

THE DISEASE
Important public health • “Prostate cancer is (…) the • “In Canada, the five-year
problem
third leading cause of cancer- net survival for prostate
related death among men in cancer is among the
Canada” highest of all cancers at
• “The lifetime risk of Canadian 95%.”
males being diagnosed with • “In Canada approximately
prostate cancer is 14.3%, 75% of prostate cancers
whereas the lifetime risk of are detected in the early
death is 3.6%” stages (stages I and II)”
• “The prevalence of and “Survival for early
undiagnosed prostate cancer stage disease is almost
at autopsy is high and 100% (…)”
increases with age”
• “Survival (…) is much lower
for cancers that present with
distant metastases (stage IV)
at diagnosis (29%).”
• “In Canada approximately
(…)9% of prostate cancers
are late diagnoses (stage
IV).”

Natural history, including • “Prostate cancer usually • “The causes of prostate

development from latent to
declared disease, is develops slowly, and cancer are largely
adequately understood. therefore may remain unknown.”
asymptomatic for many
years.”
• “However, known risk factors
are age, having an affected
father or brother, and (for

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 Imperial College London | Global Master of Public Health | Foundations of Public Health Practice | 2.4.06

reasons not understood)

being of African-Caribbean or
African descent.”

Recognizable latent or early • “(…) may remain • “Many of these symptoms

symptomatic stage.
asymptomatic for many are age-related and are not
years.” due to cancer of the
• “Signs and symptoms of prostate. “
prostate cancer include
frequent urination
(particularly at night), weak or
interrupted urine flow, and
blood in urine or semen.”

THE SCREENING TEST

Suitable test or examination • “Prostate-specific antigen • “(…) PSA does not
available that is safe, valid,
simple, cheap and reliable (PSA) is a biomarker for correctly identify all those
prostate cancer. The test, who do and do not have
which can be done at a prostate cancer.”
doctor’s surgery, is a blood • “No threshold completely
test – it measures the level of excludes prostate cancer.”
PSA in the blood.” • “Lower thresholds
increase the probability of
false-positive results.”
• “The PLCO trial found no
effect of screening on
prostate cancer mortality
or all-cause mortality.”
• “The ERSPC study found
no evidence for a benefit of
screening on all-cause
mortality.”

Test is acceptable to the • “The test, which can be done

population
at a doctor’s surgery, is a
blood test – it measures the
level of PSA in the blood.”

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 Imperial College London | Global Master of Public Health | Foundations of Public Health Practice | 2.4.06

DIAGNOSTIC TEST AND TREATMENT

An agreed policy on whom • “Those with a positive PSA • “This is a more invasive
to treat as patients.
screen will be invited for and painful test with the
biopsy.” potential to do harm.
Harms of prostate biopsy
include haematuria (310
men per 1000), infection (9
men per 1000), hospital
admission (21 men per
1000) and death (2 men
per 1000). “
• “Overdiagnosis occurs
when cancer is detected
correctly but would not
cause symptoms or
death. “
• “The European
Randomised Study of
Screening for Prostate
Cancer (ERSP) estimated
the prevalence of
overdiagnosis ranged from
40% to 56% of men
screened by PSA who
went on the receive a
diagnosis of prostate
cancer.”

An accepted treatment for • “Radical prostatectomy • “Overdiagnosis leads to

patients with recognized
disease. (removal of the prostate), overtreatment.”
radiation therapy and • “Prostatectomy carries a
androgen deprivation therapy number of long-term risks
are the most common including urinary
treatments of prostate incontinence and erectile
cancer.” dysfunction.”

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 Imperial College London | Global Master of Public Health | Foundations of Public Health Practice | 2.4.06

Facilities for diagnosis and

treatment should be
available.
OVERALL SCREENING PROGRAMME
Cost of case-finding • “This is equivalent to • “Screening above the age
(including diagnosis and
approximately $95,000 CAD of 60 was not considered
treatment of patients
diagnosed) should be and is below the $100,000 cost-effective because of
economically balanced in
relation to possible CAD cost effectiveness loss of QALYs due to
expenditure on medical care threshold.” overdiagnosis”
as a whole.
• “Further, the cost data
obtained from the ERSPC
study may not be
generalisable to Canada.”

Case-finding should be a • “A simulation study based on

continuing process and not
ERSPC data found that
a “once and for all” project.
screening between the ages
of 50 and 59 years, with two-
year intervals, had an
incremental cost-
effectiveness ratio of $73,000
US per Quality Adjusted Life
Year (QALY) gained.”

RECOMMENDATION
We recommend not-screening for prostate cancer with the prostate-specific antigen (PSA)
test.
The task force based this recommendation on the overall balance between the possible
benefits and harms of PSA screening:
1. Argument 1
If we have in account that a biopsy has a 48% sensibility, we can say that there isn’t a way to
confirm the diagnostic after the screening test, because the sensibility percentage is too low.
Thus, we can’t engage a screening program with a high possibility of missing diagnoses, giving
people a false negative result, and delaying the treatment. This consequence is particularly
important, regarding the 29% survival rate in individuals in a advanced stage of prostate
cancer.

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2. Argument 2
Prostate cancer is a high prevalence disease which increases with the age. However, prostate
cancer develops slowly, and it can remain asymptomatic for many years. Therefore, many of
the symptoms that appear can be age-related and not a result of prostate cancer.

3. Argument 3
To finish, the ERPSC showed that there is a positive cost-effectiveness in screening males
between the ages of 50 and 59 years old. Consequently, we know that this illness has a higher
prevalence in men over 65 years old and that these parameters are limited and can’t be
generalize.

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