The promise that regular screening would allow women to anticipate breast cancer before it occurred has reinforced the myth that healthy women require a scheduled test, breast cancer screening, to save their lives.
However, counter-intuitively, breast cancer screening can result in iatrogeny (medically induced illness), unnecessary diagnoses, and fears of a disease that will not necessarily occur, even if not screened, a route some women choose.
What about "doing nothing?"
Screening should remain a personal choice
This article does not concern women with genetic or familial risk because they often have a personalized and specialized follow-up. These are specific cases [1].
Women aged 50 to 74, in good health and with no personal history, invited for screening every two years, need to know that the invitation is optional and not urgent. Women can take the time to think about it and, most importantly, to obtain information.
If you are in this situation, you can make your personal choice, which may be based on knowledge and information you already have about breast cancer screening.
If this is not the case, and you have legitimate concerns about the benefits of participating in this screening, you can make your decision with the help of a "decision-aid tool" that presents you with the benefit/risk balance of screening, as examples can be found on the Cancer Rose homepage.
This decision varies from one woman to another, depending on their values and preferences, personal experiences, beliefs, and, most importantly, the value each woman places on the benefits and risks that a neutral and objective decision-aid exposes to her.
During the consultation, the health care professional should assist you in using and understanding the decision-aid and explain the items that appear on it without influencing you.
The terms 'mortality'[2], 'overdiagnosis'[3], and the consequences of 'overtreatment' should be explained to you, as should the term '5-year survival'[4].
Again, shared decision-making is influenced by the relative importance you place on the potential benefits and harms of screening. This is the tool's goal that will be available to help with shared decision-making.
If you choose not to be screened, it is essential to remain vigilant (this is true for all women, regardless of age) about any symptoms that may occur in the breast and which should, of course, lead you to seek medical attention.
All women must understand that screening is not the same as prevention.
In general, physical activity, avoiding excessive alcohol consumption, and not smoking are reasonable recommendations for better health and lowering cancer risk.
This is a very personal decision
To participate or not to participate? First and foremost, this decision is not final; you can change your mind.
Some women adopt a "do nothing" attitude, which is not as extreme as it appears, given that most breast cancers respond well to treatment, even when they have progressed through the organ sufficiently to manifest as a symptom.
Lung cancer and cardiovascular disease kill more women each year than breast cancer. Still, no public awareness campaign encourages women to get regular check-ups to detect these diseases early.
Given the uncertainties surrounding the efficacy of breast cancer screening, independent scientists and researchers recommend that women pay attention to and be watchful of this easily accessible organ, the breast, and encourage them to consult when they notice something is wrong, without becoming so compulsive as to seek out things that do not exist.
Decision aids, which are illustrated representations of numerical results for better understanding and memorization, should be used during a medical consultation to allow the woman to make an autonomous and personal decision.
There is no "correct" answer to the question "should I get screened ?" No one knows better than the woman herself, assuming she is well informed. The health care provider's opinion has no place in this decision.
What is at stake?
Not taking part in organized screening does not imply that you are careless, irresponsible, or unwilling to take charge of your health or that you do not care about your health at all.
This simply means choosing a different approach to care based on vigilance and quick response in the event of symptoms. There may be a slight (but not significant) loss of earlier diagnosis with this alternative strategy, but this is offset (primarily) by a substantial reduction in unnecessary treatments and their side effects.
This approach is known as "early clinical diagnosis," It is described in detail in an article [5]. Whether or not they have been screened, all women should be aware of changes in their breasts and consult a doctor if they notice any changes or the appearance of a symptom.
What we know:
- There is significant uncertainty about the benefit of screening in reducing breast cancer mortality. [6]
- The value of screening is further questioned because current breast cancer therapies are effective: whether detected by screening or not, breast cancer has a high chance of being cured.
- Screening causes anxiety (false alarms) [7].
- Screening does not prevent breast cancer from occurring after a mammogram (interval cancer), resulting in false reassurance [8].
- There is a significant proportion of overdiagnosis [9], a well-known and recognized harm of screening.
- Cancer survival [10] is the same in screened and unscreened women.
- Contrary to what they are made to believe, for screened women, interventions (surgery, radiotherapy, chemotherapy) do not decrease [11]
- The biology of cancer itself, the presence of aggressive biological characteristics inherent in cancer, not what a woman does or does not do to find it, will determine whether cancer will kill its host. An advanced tumor is not the "fault" of a woman who did not get screened but rather of the nature of cancer itself. [12]
So, what should women do in the meantime?
According to Pr. M.Baum, professor emeritus of surgery and professor, some recommendations can be given to women as stated in his book "The History and Mystery of breast cancer".
-The risk of breast cancer can be reduced by keeping the weight down, taking exercises, eating lots of fruits and vegetables, and keeping alcohol intake down to no more than 7 units a week ...
-M.Baum recommend not to ritualize Breast Self-Examination, but to be aware of changes in the breasts such as the chance appearance of a dimple in the breast, distortion of the nipple or feel a lump. In this case, says the author, an appointment with your doctor has to be made. M.Baum : "don’t look upon it as an emergency but for peace of mind don’t postpone the visit for too long".
-It is important to remember that there is more to life and death than breast cancer. The author asserts that breast cancer no longer ranks in the top 5 causes of deaths for women. Women should consider the totality of their health and how to avert a premature death from more common conditions (like heart diseases, editor's note).
-Furthermore, as M.Baum says, we could aim identifying a subgroup of women with a high risk of breast cancer; so we could offer them treatment that avoid the toxicity of radiotherapy (eg TARGIT/IORT).
Health Policy
Health Policy Policymakers implementing national cancer control plans must be aware of serious gaps in data that are frequently presented to them as unquestionable.
It is complicated to provide women and society with consensus-based information about the harms and benefits of breast cancer screening in the context of ongoing incentives to women each October and a scarcity of adequate information available.
The alternative is to educate the public about the differences that exist and, in any case, to allow women to make their own decisions.
If policymakers want to respect the principles of nonmaleficence and medical ethics [13] [14], they must consider that it is not screening participation rates that must be improved, but rather individual informed consent, which requires not only complete information on the problem but also the format in which this information is presented, without overemphasizing the benefits of breast cancer screening.
Références
[1] https://cancer-rose.fr/en/2017/11/20/what-is-high-risk/
[2] https://cancer-rose.fr/en/2021/03/29/what-is-an-effective-screening/
[3] https://cancer-rose.fr/en/2021/03/27/what-is-overdiagnosis/
[4] https://cancer-rose.fr/en/2021/03/28/what-is-survival/
[5] https://mypebs-en-question.fr/actus/duggan_lancet_en.php
[6] https://cancer-rose.fr/en/2021/03/29/what-is-an-effective-screening/
[7] https://cancer-rose.fr/en/2021/03/30/what-is-a-screening-mammogram/
[8] https://cancer-rose.fr/en/2021/03/29/what-is-an-effective-screening/
[9] https://cancer-rose.fr/en/2021/03/27/what-is-overdiagnosis/
[10] https://cancer-rose.fr/en/2021/03/28/what-is-survival/
[12] https://www.youtube.com/watch?v=pbGZdyUCITc
[14] https://cancer-rose.fr/en/2021/09/04/screening-campaigns-a-move-toward-greater-caution/