Marc Gourmelon, MD
Cécile Bour, MD
September 2, 2020
At the beginning of July 2020, a research article detailing how to successfully manipulate women in order to increase their participation in breast cancer screening programs by mammography, was published under the title:
“The Good Outcome of Bad News.
A Field Experiment on Formatting Breast Cancer Screening Invitation Letters” .
This article is published by Italian authors in a journal which defines itself as follows:
“The American Journal of Health Economics (AJHE) provides a forum for the in-depth analysis of health care markets and individual health behaviors. The articles appearing in AJHE are authored by scholars from universities, private research organizations, government, and industry. Subjects of interest include competition among private insurers, hospitals, and physicians; impacts of public insurance programs; pharmaceutical innovation and regulation; medical device supply; the rise of obesity and its consequences; the influence and growth of aging populations; and much more. The journal is published for the American Society of Health Economists (ASHEcon), which is a professional, non-profit organization dedicated to promoting excellence in health economics research in the United States. All ASHEcon members receive the journal as part of membership.”
This article is not a scientific medical analysis about the relevance of screening by mammography for women, but a health economics study, from the point of view of health economics carried out by economists. Screening is an integral part of the "health care market" and women behavior is evaluated, based on the manipulation of the information provided to them.
“We show that giving enhanced loss-framed information about the risks of not having a mammography increases the take-up. This manipulation is most effective among sub-groups with lower baseline take-ups, thereby reducing inequalities in screening.”
OBJECTIVE AND STUDY METHODOLOGY
The goal of this study is to evaluate the impact of the interplay between the "frame” of the invitation letter and the "level" of the information disclosed in it, on the rate of participation in the national breast cancer screening program.
There are four "manipulations" being evaluated, depending on the frame and the level of information. The frame of information refers in this case on how to deliver an information in the form of "gains" from being screened, or rather in the form of a grid of "losses" from not being screened.
The level refers to the quality and completeness of the information.
-The "benefit" of the screening procedure is valued by a high quality information
-The "benefit" of the screening procedure is valued by a basic information
-The emphasis is placed on the "loss" of not being screened by using a high quality of information
-The emphasis is placed on the "loss" of not being screened by using basic information.
“To the best of our knowledge, this is the first experimental study assessing how the interplay between the frame of the invitation letter and the information disclosed in it influences the take-up rates for a national breast cancer screening program” explained the authors.
“Results show that the take-up rate in the group that received the letter combining the loss frame with enhanced information on the negative consequences of not taking the mammography is about 2.5 percentage points higher than in the baseline group.”
According to the authors, “this is a sizeable effect”.
The authors congratulate themselves on these findings showing that that this manipulation “helps to decrease inequalities in screening”, as it allows for a greater manipulative impact for subjects that, according to them, are “with low average education, with no recent screening experience, and for whom the available observable characteristics would lead us to predict a low likelihood of screening in the absence of any manipulation”.
A- THE ETHICAL ISSUE
It seems to us the major one.
First of all, the aim to increase womens participation, at all costs, is clearly stated. Thus, these researchers claim that « the use of letters sent to women at their houses and the invitation for a free and pre-booked mammography increase take-up rates for breast cancer screening »
« In this respect, the present study aims ...at providing insights on how to design effective invitation letters to promote cancer screening activities. »
The intentions are clearly stated. The authors are well aware that providing the most complete information to women incited to be screened, will reduce their participation in screening:
« Previous studies have analyzed the impact of providing a rich amount of detailed medical information concerning the disease (for instance, as in Bourmaud et al. 2016 and Wardle et al. 2016, by including a booklet in the envelope of the invitation letter) on the take-up rate and generally found negative or zero effect ».
They hypothesize that « ...invitation letters containing a loss-framed message (meaning « loss »to the woman or even risk if she declines to participate in screening, editor’s note) with enhanced information about the consequences of not taking part in the program are more effective at increasing take-up rates than letters with a gain-framed content or with a restricted informational content ».
Thus, this is about pure and simple manipulation, perfectly claimed since the term itself is used several times in the text, and the authors justify this manipulation as necessary for « limiting women’s cognitive overload »
We wonder about the authors representation of women.
Cognitive overload is defined as follows: "Cognitive overload corresponds to a mental state in which an individual is engaged in the accomplishment of a task that is extremely demanding for him: he does not have sufficient cognitive resources for the easy implementation of this task. » 
If we understand correctly the authors, women would not have the mental state necessary to understand the comprehensive information on breast cancer screening. Isn't this a sexist and paternalistic attitude?
In any case, this runs contrary to the "shared medical decision" that many medical actors claim.…
B- VALUATION OF THE SCREENING AND NEGATION OF ITS RISKS
Right from the introduction, despite the scientific uncertainty about the interest of screening, which has risen since the 2000s, the doubt about the relevance of breast cancer screening by mammography is swept away.
« Mammography screening programs at population-level are a key component of breast cancer control in many countries. The continuous implementation of these policies over the last decades mirrors the current consensus on the effectiveness of mammography screening. »
The authors are, however, forced to admit that there is « uncertainty about the magnitude of the effects of screening on mortality (see e.g. Welch et al. 2016) and the growing evidence on overdiagnosis » by citing a 2012 study and hurrying to downplay the level of overdiagnosis, which is the major adverse effect.
« However, to the best of our knowledge, the estimated extent of overdiagnosis in Italy is low, as it ranges between 1 and 4.6 percent (see the review by Puliti et al. 2012). These data lead us to consider the phenomenon as negligible for our population of interest ».
The authors deliberately disregard the numerous and more recent studies  which no longer demonstrate effectiveness of screening in reducing mortality in women, in reducing the rate of the most severe cancers, or to alleviating the treatment inflicted to them.
In addition to the lack of benefit, multiple adverse effects of screening, such as false alarms leading to over-medicalization of women and over-diagnosis, currently estimated at between 30% and 50% and indicating that one out of three cancers detected or even one out of two cancers detected is an unnecessary detection, should not be ignored.
In this respect, here is a link to a recent additional study that we already discussed: this research (a review of cross-sectional studies) showed that mammographic screening did not reduce the stage of cancer, nor did it enable cancers to downgrade from the elevated stage to the early stage cancers. The results strongly suggest that it is the adjuvant therapy and not mammographic screening associated with the decrease in specific breast cancer mortality reported since the initiation of these therapies (1990s).
C –CYNISM AND CONFISCATED INFORMATION
Consequently, under no circumstances should women be properly informed or should the risks of participating in the screening be addressed, as the authors have demonstrated. Otherwise, this would decrease the participation in screening, as these Italian authors have well understood, on the basis of a French study.
« Bourmaud et al. (2016) assessed the effect of providing a 12-page information leaflet on the take-up rate for breast cancer screening of a randomly selected sample of French women. They found a significant negative effect on the take-up rate. »
Later in the text, the authors intentionally skip over the details on disclosed information: « our baseline invitation letter contains no information on the consequences of screening ». And they add: « We show that a negatively-framed message, which adds “cheap” information in the form of brief and general statements about the consequences of screening to the original invitation letter, is able to enhance take-ups ».
In their conclusion, the Italian authors reach what seems to us to be the very height of cynicism by stating: « In addition, the effect of our proposed manipulation is stronger for subjects identified by the literature as being at higher risk of non-participation, such as those living farther away from the screening sites, the low educated and those with no recent screening experience. »
As a result, the less educated women are, the more effective it is to hide and manipulate information for them.
THE FRENCH PARALLEL
A– INVOLVEMENT OF MEDICAL DOCTORS
The potential influential role of the medical profession is not forgotten: « endorsement of the screening program by general practitioners on the invitation letter increased the overall take-up rate, while a letter of reminder was especially effective at increasing the take-up rate of subjects residing in socio-economically deprived areas »
The promoters of screening in France are also well aware of this, having included the "screening mammography" item in the performance-based remuneration of general practitioners .
B – THE LACK OF INFORMATION PROVIDED BY OFFICIAL BODIES
The authors of this Italian study state that « the use of letters sent to women at their houses and the invitation for a free and pre-booked mammography increase take-up rates for breast cancer screening »
It should be noted that this is exactly what is being done in France with the organized breast cancer screening program. The citizens' consultation clearly defined the unacceptable gaps in the information provided to women, and in France we are not outdone to regard patients as unworthy to receive quality medical information due to them. In addition, we examined the lack of this information in the material provided by the INCa.
-Denial of the risks of mammography screening for breast cancer.
-Assertion against a large majority of clinical research on the effectiveness of screening.
-The manipulation of the letter of invitation to the screening.
-Sexism and paternalism.
This economic study published in July 2020 by Italian authors, with references to other similar studies, including French ones, leaves us with a deeply bitter taste, on ethics, on the women representation in academic community or on the promotors behavior of breast cancer screening through mammography.
It should be noted that the majority of those involved in screening justify the assumed manipulation of women for the sole purpose of raising their involvement in the public health system, which has not only failed to prove effective but is also harmful to women's health.