September 2016
MEMBERS OF THE STEERING COMMITTEE
Steering Committee members of the Citizen and Scientific Consultation on Breast Cancer Screening are the authors of this report.
Chantal CASES
Economist, statistician
Director of Demographic and Social Statistics, INSEE President of the Health Data Institute
Mario DI PALMA
Medical Oncologist
Head of the Ambulatory Department of the Gustave Roussy Institute IGR
Éric DRAHI
General practitioner
Therapeutic Education Trainer
Sylvie FAINZANG
Anthropologist, Inserm research director
Member of Cermes3 (Research Center, medicine, sciences, health, mental health, society, CNRS Inserm EHESS University Paris 5 Descartes)
Paul LANDAIS
Professor of Public Health, Nephrologist
Director of the Laboratory of Biostatistics Depidemiology and Public Health UPRES EA 2415 University Institute of Clinical Research of Montpellier)
Head of the BESPIM department (Biostatistics, Epidemiology, Public Health and Medical Information) of the CHU of Nîmes
Sandrine de MONTGOLFIER
Lecturer in the history of life sciences and bioethics at the University of Paris Est Créteil Val de Marne / ESPE,
Researcher lIRIS Institute for Interdisciplinary Research on Social Issues, EHESS CNRS Inserm Paris 13)
Fred PACCAUD
Professor of Public Health at the Faculty of Medicine of Lausanne
Director of the University Institute of Social and Preventive Medicine of Lausanne
Jean-Philippe RIVIÈRE
General practitioner
Editorial and community manager of the Vidal.fr website
Dominique THOUVENIN
Emeritus Professor of Private Law at the École des hautes études en santé publique EHESP
Co-director of the Research Center "Normes, Sciences et Techniques" (CRNST), Institut des Sciences Juridique et Philosophique de la Sorbonne (UMR 8103)
KEY POINTS
Breast cancer screening is organized at the national level by health authorities. A scientific controversy has arisen because of doubts about the reality and magnitude of the decrease in the risk of death from breast cancer due to screening and the fear that it generates a greater or lesser number of over-diagnoses and over-treatments.
This consultation allowed the Steering Committee, with the support of INCa, to identify and interview citizen, health professionals, experts and to extensively work on this complex issue. The committee was consequently able to confront multiple opinions and reflections, and it relied on INCa's human and bibliographical resources, as well as on knowledge, discussions, personal and group research to observe, analyze, develop and then formulate recommendations and two potential scenarios for the future.
From a scientific point of view, the committee noted that most of the studies used were not French, and therefore obtained under different conditions from those set up in France, which can distort the interpretation that can be made. Moreover, it is not up to the committee to decide whether the benefits of organized screening outweigh the risks. Nevertheless, the committee was able to note the existence of numerous reviews on the subject, in particular numerous randomized or observational studies, as well as meta-analyses and synthesis reports, whose conclusions on the importance of reducing mortality, over-diagnosis and over-treatment diverge greatly. The question is therefore not resolved, in view of the differences observed between the results and the interpretations. These variations and the doubts that accompany them, fuel the controversy on the subject at the French and international levels.
The committee also noted dysfunctions in the current organization of screening and its consequences: unequal access, misunderstanding of the issues, confusion between primary prevention, screening and early diagnosis, lack of information on the risks and uncertainties of screening in the invitation letter sent every two years, absence of general practitioners in the organized screening pathway (they can certainly talk about it with the women who consult them, but only in the context of a consultation for another subject), misleading and outrageous marketing of the Pink October promotional month, partial reimbursement of ultrasounds exams poorly explained to women, doubts about the effectiveness of certain therapeutic strategies etc.
Committee recommendations :
- Taking the controversy into consideration in the information provided to women and in the information as well as the education (initial and continuing) of professionals in this area, to ensure that women concerned by breast cancer screening have access to balanced and complete information, and professionals involved in breast cancer screening receive a training enabling them to acquire the relevant knowledge for accompanying women, offering them adequate aid for making their decision.
- Improving scientific knowledge on breast cancer and conducting an ambitious evaluation of existing and future strategies by :
- Implementation of research projects to study the natural history of breast cancer and its nature, in order to better differentiate the types of cancers and their possible progression;
- Implementation of ambitious information and monitoring systems in order to allow a permanent evaluation of programs.
- Evolution of breast cancer screening program enabling systematically :
- Integration of the general practitioner in the screening process, while also taking into account other health actors such as the midwife and the gynecologist;
- Double reading for all screening mammograms. It is not acceptable that today two screening systems coexist, with different criteria;
- Evaluation of ultrasound practice as a complementary act to mammography;
- Stopping all early screening before the age of 50 for women with no particular risk factor by implementing a delisting of the procedure.
- Integration of breast cancer screening strategies into a more global approach to prevention and screening, by the implementation of a dedicated consultation. This consideration of the person as a whole would allow a more adapted follow-up for each individual. Breast cancer screening, dissociated from other screening and prevention actions, does not really make sense in terms of public health.
- Development of a strategy for breast cancer screening and follow-up that is hierarchically organized according to the level of risk. With the progress of knowledge in the research of markers of evolution, it might be possible to better identify for each woman both the over- and under-risk, which could prevent her from taking part in screening as it currently exists. It will then be necessary to set up a system for identifying risk levels and monitoring according to recommendations validated in reference manuals, with a real evaluation of recommendations implementation and a very strong reactivity for recommended actions according to the advancement of knowledge and the results from evaluations.
In conclusion, the committee considers that the implementation of these recommendations should significantly improve the current situation, which does not meet the requirements of informed decision-making and scientific validity recommended for proposing screening to healthy women.
In addition to these recommendations, the committee proposes two scenarios for making breast cancer screening strategy to evolve and for achieving the same objective: enabling the implementation, in the coming years and with validated technological tools, of a screening strategy adapted to the level of risk. To reach this objective, the committee has made the above recommendations and proposes two ways to achieve this through one or the other of these scenarios :
- Scenario 1: Termination of the organized screening program, the relevance of a mammogram being assessed in the context of an individualized medical relationship.
- Scenario 2: Discontinuation of organized screening as it exists today and implementation of a new organized screening, profoundly modified.
It is not the role of the committee to take a position on the proposed scenarios, but a significant improvement in the program seems essential to it, as a response to the existing controversy, in such a way that confidence in the chosen mechanism could be maintained.
These two scenarios reflect the diversity of opinions of the committee members, who consider as a whole that breast cancer screening should ultimately be part of an integrated and comprehensive public health approach.