PoPulationand Public HealtH etHics

y considerations of the common good. Therefore, if ethical principles are
respected, if the costs to and consequences on the people who receive the
letter of invitation are minimal and, lastly, if it is assumed that the test has
a sensitivity and specificity justifying its use, the ethical soundness of the
program depends only on utilitarian criteria related to the efficiency of the
screening program with respect to the objectives. Regardless of any debate
to determine whether such efficiency considerations relate to ethics or a
cost-benefit analysis, no screening program would be justifiable if it were
inefficient. But, based on the data used in the CesP’s opinion, this is the
source of the letter project’s controversy.
As far as cervical cancer is concerned, the most relevant data have to do
with the relatively low prevalence of the problem. Out of the 280 Quebec
women diagnosed with cervical cancer in 2008, 70 died of cervical cancer.
As it is expected that the personalized invitations will result in a 10 per cent
reduction in the mortality rate of women aged 25 to 64, if this objective were
reached, about seven lives would be saved. If applied across Quebec, 3 additional
cases of cancer and 170 cases of lesions at high risk of progression
to cervical cancer would be detected per year. Statistically, cervical cancer
is far less prevalent than breast cancer, with 1,400 deaths and 6,000 new
cases each year, or colorectal cancer, which is associated with 2,600 deaths
in women. We can agree with the CesP’s opinion about the net impact of the
intervention on women’s health being limited. In addition, considering that
cervical cancer progresses slowly, that this cancer’s five-year survival rate is
74 per cent, that about three-quarters of women already undergo screening
without having to receive a letter, that a significant percentage of the lesions
that are detected resolve naturally (without an intervention) and, lastly, that
current human papillomavirus (recognized as a causative agent of cervical
cancer) vaccinations will reduce the number of cases in coming years, the
expected benefits of a personalized invitation appear relatively limited. Overall,
resource allocation must be taken into consideration. Do financial and
human resource investments (though there is no estimate for the cost of the
program) by the Quebec public health system offer the greatest return when
used for this type of program instead of for other screening programs, especially
when compared to more common and severe cancers? The principle
of proportionality, which calls for a balance between an intervention’s expected
effects and infringements on other ethical principles, appears to be
adhered to only loosely. Such prevention interventions, when multiplied, could
Using personalized letters of invitation to increase participation in cervical cancer screening
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