New French cancer plan 2021-2030, a “Soviet” plan

February 7, 2021
Cécile Bour MD

Emmanuel Macron has just launched on Thursday 4 February a decennial national strategy (for 2021-2030)  in fight against cancer, with a funding of €1.74 billion over 5 years, i.e. 20% more than for the three previous cancer plans. The aim is to reduce the number of so-called "avoidable " new cancers by 60,000 cases per year from now to 2040.
Several media are talking about it, but we rely on the rather exhaustive report made by the newspaper Le Monde [1] on February 4, 2021 and on the 6th report to the president elaborated by the INCa[2].

We are going to review the "plans" from their origin until today, and we will see the evolutions through ages, from great demagogic objectives of past times to ...great demagogic objectives of nowadays, complemented by the intrusion of drug manufacturers. Already in 2013, Roche laboratory was not far away from breast cancer screening and watchful when analyzing "women's compliance" with screening through the EDIFICE[3] study. And when a pharmaceutical company takes such a close interest in a controversial measure, it is often to find out how to protect its interests...

The more patients there are, the more pharmacopoeia is sold.

Focus on screening

Main axes of this new cancer plan are deployed in the article published in Le Monde newspaper and we will focus on screening, our core target, which the president promises to strengthen in the first axis called "prevention". 

  • "Every year in France," the article says, "9 million people participate in one of the three organized screening programs (breast, colorectal and cervical cancers). The goal is to increase this number to 14 million in 2025". "Every year, more than 157,000 people die of cancer in France. In total, 3.8 million people live with the disease. Four out of ten new cancers would be avoidable. That represents 153,000 new cancers per year that would be prevented if the population adhered to organized screening programs, had a balanced diet and regular physical activity".
  • The "urban legend" of "preventive" screening, so precious to the INCa correspondents, comes up against the very definition of prevention, which is to ensure that the disease does not occur. Yet screening aims to detect, to track down a disease, which is already there. Screening procedures, whether for colorectal, breast or prostate cancer, do not anticipate the disease but detect a lesion that is already present in the body.

This misleading confusion between "prevention" and "screening" is found in the "improving prevention" axis[4] of citizen consultation that the INCa (National Cancer Institute) proposed at the end of last year[5] [6].
However, French women citizens, during the 2016 citizen and scientific consultation on breast cancer screening, pointed out this dishonest confusion between the two terms.[7]

       Page 5 : The committee also noted dysfunctions, abnormalities in the current organization of screening and consequences it generates: inequalities of access, lack of understanding of stakes, confusion between primary prevention, screening and early diagnosis, lack of information on risks and uncertainties of screening in invitation letter sent every 2 years,

      Page 125 " Moreover, information provided about organized screening maintains confusion between prevention and early diagnosis. "

Difficult to admit a simple awkwardness this time, on the contrary, this amalgam of terms is maintained deliberately, serving to falsely attribute to screening a preventive power that it obviously does not have.

Review of previous cancer plans

We review what has been previously designed in different successive cancer plans, while following evolution of lung and breast cancer.[8]

1° Plan 2003-2007[9]

Heading

"The Plan allows to reduce tobacco consumption through a comprehensive tobacco control strategy combining price increases, a ban on sales to minors under 16 years old, information campaigns and actions targeted at youth and women, and the development of aids to help people stop smoking"."The organized breast cancer screening program was generalized in 2004, while the organized colorectal cancer screening program was the subject of an experimentation from 2002 to 2007 in 23 pilot departments".

Epidemiological results of the 2000s

Lung (Remontet Report 2013 page 79)[10]

"The incidence of lung cancer has been steadily increasing over the past two decades. This trend is more pronounced in women, although both incidence and mortality remain much higher in men. ... At the same time, mortality follows a similar trend.... The number of deaths has increased from 15,473 to 22,649 in men and from 1,997 to 4,515 in women".

Page 84 tables 5 and 6

Breast (Page 99 of the report)


"The incidence of breast cancer has increased dramatically over the past two decades. Between 1978 and 2000, the average annual rate of change in incidence was +2.42%. The number of new cases has almost doubled in 20 years, from 21,211 cases in 1980 to 41,845 cases in 2000. 
At the same time, mortality has remained stable (slight annual increase of 0.42%). The number of deaths rose from 8,629 in 1980 to 11,637 in 2000".

Table 5 page 104

All in total : What should be concluded from a review of these data? Duperray notes[11]: "For breast and prostate cancer, there is a stable mortality and an incidence that escalates as the screening intensifies, whereas for lung cancer which is not routinely screened, the number of deaths is proportional to the number of diagnoses.  Incidence of lung cancer increases in parallel with the real cause of the disease, tobacco consumption.

Table page 155

"Indeed, for cancers that are screened, such as breast and prostate cancer, the overdiagnosis generated by screening is expanding, resulting in a sharp increase in the incidence of cancer in 2005, with no impact on mortality, which remains comparable to previous years without screening. In comparison, lung cancer, which does not benefit from any screening, shows a comparable rate of death and diagnosis.

In this graph, we see that the rate of serious cancer remains unchanged, whereas it was expected to decrease with the introduction of screening.(Figure 9 in the book, page 121 [11] ).

Unbridled and ideological enthusiasm for screening, despite the warnings made by whistleblowers as early as 2000, makes this fact inaudible and encourages the continuation of programs, especially given the disappointing participation of women.

2° Plan 2009-2013 [12] [13]

Heading

P.56: "The actions taken have not led to increased participation in organized screening programs for breast and colorectal cancer. The "Pink October" and "Blue March" information and mobilization campaigns have been renewed annually by adaptation of messages... Participation in organized screening programs is not progressing for breast cancer (national participation rate of 52.7% in 2012 for a target of 65% set by the Plan) as well as for colorectal cancer (31.7% in 2012 for a target of 60%)".

In the face with this observation, it would seem important for health technicians to intensify participation, as we can read in the following pages; therefore, recommendations of the High Authority for Health (HAS) are aimed at maintaining the objective of organized screening while at the same time strengthening the conditions that allow women who are not at high risk of developing breast cancer to limit individual screening practices (page 81 of the report).

On the tobacco smoking aspect, the report states on page 47 :

Thus, while 76% of people surveyed consider the risks associated with tobacco smoking to be "certain", the prevalence of smoking is still 32% among 15-85 year olds. Sixty-five per cent of respondents also continue to believe that "breathing city air is as bad for your health as smoking cigarettes".

Results of epidemiological data

Lung[14]

We can read in the Remontet report on solid tumor incidence and mortality, page 176  "Lung cancer incidence and mortality are still twice as high in men as in women in 2018".

The report states:

"The evolution of mortality from lung cancer mortality is closely linked to the evolution of incidence in both sexes and for all ages...Mortality is still increasing in women for all ages and more significantly for those in the 50-60 age group..."

Breast

Remontet Report Page 204 tables 4 and 5

In relation to incidence, a slight inflexion of the specific mortality from breast cancer can be noted, but this, as we can see below, takes place as early as the 90s, well before the generalization of screening, and cannot be attributed to it.

The report states (page 207): "The introduction of organized screening is generally accompanied by a temporary increase in incidence and to some extent by overdiagnosis (cancer that would not have developed before the patient's death and which is more likely to be in situ cancer not included in this study)".

Regarding mortality, the report states:

"A decrease in the mortality rate has been observed since the mid-1990s, linked to major therapeutic advances (hormone therapy, taxanes, targeted treatments adapted to the molecular profile of the tumor) and an increase in the proportion of cancers diagnosed at an early stage, notably through screening. "

But this last point is strongly contested by several international researchers who object that overdiagnosis is increasing with more and more screening in an almost proportional way.[15]

Others suggest that screening may be providing unaccounted for excess mortality due to the effects of overtreatment. [16]
Disturbingly, there is no difference between screened and unscreened groups of women. [17]
And in any case, mortality from all causes is not reduced.

All in total :
When looking at and comparing all the data on lung cancer and breast cancer, we can see that tobacco consumption, the leading cause of cancer-related death in France, has not decreased and it contributes to inequalities, by progressing among women and unemployed. It is clear that measures banning the sale of cigarettes to minors under 18 years of age and graphic warnings on packages are largely insufficient.

Meanwhile, despite the observation of a marked increase in the incidence of breast cancer, still without a massive impact on the reduction in mortality expected from successful screening*, the Pink October campaigns for awareness and promotion of breast cancer screening, are going well and without saving resources  (city lighting, races organized by municipalities, placarding of slogans), without any questioning or reflection on the overtreatment generated in population.

*PS: (When there is such a marked discrepancy between increasing incidence (number of new cases) and non-proportionally declining mortality), this case inflation is due to one thing: unbridled screening activity).Once again, we can see that despite overabundance of resources for the Pink October campaign, breast cancer mortality, particularly in women, is only on the increase. And smoking alone kills more than breast and prostate cancer combined![18]

The fight against tobacco smoking is clearly not meeting its stated intentions, probably because tobacco generates a lot of revenue in the form of taxes[19]. It is clear that  emphasis on intensifying screening makes us forget that the fight against smoking and alcoholism is not up to what would be possible if politicians, instead of sparing lobbies, really intended to reduce cancers.

3° 2014-2019 Plan[20] [21]

This plan focused on facilitating access to breast cancer screening for women who are farthest away and by any means possible. 

As the women who were easily accessible seemed to be recalcitrant to this screening, the authorities decided that it was necessary to stimulate participation of women who were usually little solicited or geographically inaccessible.

And there is no shortage of ideas:

-To set up regional training courses for women to relay awareness of cancer screening (organized breast cancer screening) targeting women in precarious situations (partnership with IREPS2 ) (Picardie). 

-Favor access to screening for women furthest away from screening sites by organizing the payment of transportation costs for a mammogram in Cayenne (French Guiana) and fight against inequalities in access and recourse (Martinique). »

-Carry out an inventory of access to organized breast cancer screening for disabled people in social and medico-social establishments (Franche-Comté). 


-Facilitate access to screening for detainees by raising awareness among the teams of the Consultation and Ambulatory Care Units (Indian Ocean)

Pages 72 and 74:

"the objective of achieving 75% coverage of organized or spontaneous breast cancer screening for women aged 50-74 by 31/12/2018" "to increase the effectiveness of organized breast cancer screening programs".

There is a need to increase women's participation, again and again; this 2014-2019 cancer plan only addresses the technocratic side of the system and anticipates in its terms what the high authorities want to promote, in defiance of the information to which the female population is entitled and which it has demanded in the meantime during the citizen and scientific consultation on breast cancer screening and its harms[22]. The aim is to keep this screening program on the tracks set in 2013, directed towards intangible five-year objectives.

Epidemiological results

In 2017 (see on the official website of the INVS), in France, among the causes of cancer deaths in women, breast cancer, responsible for 11,883 deaths, comes first, followed by lung cancer (10,176 deaths) then colorectal cancer (8,390 deaths).

 All in total

Observation is still indisputable: In France, the decline in specific mortality (from breast cancer) is not significant, despite the fact that breast cancer has been made a public health priority and that more resources have been devoted to it than to other pathologies.

Mortality from lung cancer, on the other hand, remains a major concern, especially among young people, which the current plan aims to address once again .

One plan followed another, and none of the problems have been solved: smoking continues to take its toll, and cases of breast cancer have risen alarmingly to 54,000/year with an overdiagnosis acknowledged by the authorities, but largely minimized and appearing to these authorities, in no way to question our medical practices, while we still record, despite organized screening, between 11,000 and 12,000 deaths/year, a figure that has been stable since 1996.[23]

Additional remarks before concluding

1°The illustrative image in the article from Le Monde published online, is a skin cancer screening case.

We relay here an interesting podcast[24] in English, on the overdiagnosis of melanoma, a cancerous skin tumor.

Dr. Adewole Adamson's observation is alarming: no reduction in mortality and massive overdiagnosis due to a lowering of the tolerance thresholds used by dermatologists and anatomo-pathologists regarding skin lesions.

Dermatologists request increasingly and more quickly the use of biopsies, while anatomical pathologists prefer to upgrade their diagnosis of lesions examined under the microscope (i.e. to classify as malignant lesions that are simply dubious and that could only be monitored), giving rise to an apparent melanoma epidemic with even more artificial "survivors".

The vicious circle is endless, prompting patients and doctors to do more and more routine skin examinations.

2° specifically on breast cancer

We read in the 6th report to the President of the Republic published in March 2020 by INCa, page 7, prelude to the 2021/2025 cancer plan presented on February 4, 2021 [25]:

A strengthening of the quality of organized breast cancer screening.

"In terms of organization, according to a decree published on February 22, 2019, only digital mammography facilities are now authorized in the program. The decree confirms that the radiologist, as the first reader, must analyze the images on an interpretation console. »

Looking back at the changes imposed to radiologists throughout the history of screening, it is interesting to note that decision-makers have always opted to improve the form, but never to question, the very substance of this system. 
In the course of my career as a radiologist, and since the 1990s, I have witnessed the transition from two to three breast images per breast, to compensate for the problem of interval cancers, which occur between two mammograms and escape screening.

Then we had to complete this "mammotest" with the addition of ultrasound and clinical examination. We therefore went from a "test" to an individual examination in the face of the method's failure!

Then we witnessed the advent of digital mammography, a technology that at first coexisted with analog mammography depending on the radiology office, and now imposed on everyone.

There is no doubt that we will soon see the arrival of tomosynthesis[26] [27],, which is highly radiant and often performed in addition to mammography without the patient's knowledge in some practices, with the prospect of a surge in false alarms and overdiagnosis.

Support for a study experimenting with personalized breast cancer screening.

"An international experiment in targeted breast cancer screening has been initiated. Supported by the French National Cancer Institute, the ARC Foundation for Cancer Research and the Ligue contre le cancer, and funded by the European Union, the MyPeBS (My Personal Breast Screening) study intends to evaluate whether personalized breast cancer screening could be a better screening option for women aged 40 to 70. »

The best proof of the failure of the current screening system is that we are now trying an "individualized" screening, a real trap for women, especially in the younger age groups, since, if deemed at risk, they will have mammograms that can be annual and from the age of 40....

What better way, by means of a study of an arrangement that is as hermetic as it is pernicious[28], to extend screening to age groups that have not been concerned until now because of a benefit-risk balance that has proved harmful for these young women.

These are the continuous "improvements" made to breast cancer screening, a veritable absurd race instead of an in-depth questioning on: rethinking the fundamental relevance of screening.[29]

3°For prostate cancer,[30]

we had already mentioned the problem of overdiagnosis, and had also talked about the problem of thyroid cancer[31], the latter with a predominant impact on women's lives.

Surprising to read in the article from Le Monde "Another challenge: to intensify research to find new screening tests, particularly for lung and prostate cancer. »

A new prostate screening? It's precisely because the old one wasn't very brilliant in terms of efficiency....

And since critical questions are not asked in any media, medical information can shamelessly continue through the show "Stars in the Nude" on French Television, where stars strip to "raise awareness" about screening and for the "good cause", without any respect for scientific data. The presenter, Mrs. Sublet, states in an interview in a feigned modesty that her show is "of public utility"[32].

Last year, in the week following this TV show, our radiology consultations were literally assailed by young men finding "balls" in their purses (absolutely true), and young women in tears who also found various swellings in their chests.No diagnosis was made, all of them were fortunately healthy. All this useless excitement mobilized the already scarce doctor's time, to the detriment of a patient in real need of care.

Conclusion :

A "Soviet" planning that makes a mockery of scientific data

There is no question of providing better information to women or of reducing the number of screenings, we still find objectives set in advance, pre-decided, and built up in minds of technocrats centered on an inventory of figures to be reached.

We see the unfortunate results of the failure of real prevention campaigns (tobacco, alcohol, obesity), with lung cancer inexorably on the rise and deaths in parallel.
     

Why not give priority to health education with real large-scale campaigns instead of a waste of resources to promote screening, most of which, it must be admitted, has no perceptible impact on overall mortality, and on the contrary leads to overdiagnosis in healthy populations, plunging them into pointless situations of ill people?

Why? In a opinion column Annette Lexa, toxicologist, gives some clues[33]:

-"Destructive behaviors have been valued for a long time; hygiene and prevention are supposed not to be hedonistic;

-Curative sector is economically more interesting;

-Occupational cancers continue to be neglected and minimized by the health funds themselves (CPAM, MSA), forcing long, improbable and costly procedures;

-Society, which is so promptly in controlling its citizens when the political and economic system is in danger, pretends to fear that this is an attempt to reduce individual "freedoms" (freedom to smoke, to drink, etc.);

-Tobacco, alcohol, industrial food marketed by advertising bring in a lot of VAT;

-Contraceptive pill, a symbol of female emancipation, yet cancerogenic and endocrine disruptive as proven by the IARC (http://www.cancer-environnement.fr/479-Classification-par-localisations-cancereuses.ce.aspx#Seins), is still and always presented as the most popular means of contraception while skillfully minimizing undesirable effects, so great is the collective stake in sexuality.

-How many young women buy "organic" cosmetics guaranteed free of bisphenol A and parabens presumed to be carcinogenic while taking the pill and smoking?

-Our modern societies have not been able to reinvent the ritual of passage to adulthood, trapping adolescents in risky behaviors (addiction to tobacco, alcohol, drugs, trivialization and precocity of risky sexual practices ...).

-Finally, opportunistic marketing aimed at developing a connivance with women (cosmetics, mutual insurance companies, e-health professionals, "sports" events) symbolizes the power of manipulation and misinformation as well as the cynicism of an entire society busy developing business by giving itself a virtuous endorsement and sometimes even sincerely thinking of clumsily repairing the damage it has itself created, while it should put all its energy (albeit less profitable) into cancer prevention and provide everyone, from a very young age, with the keys to optimal life and health. "

Finally, this new cancer plan was developed under the supervision of the pharmaceutical industry.

And here is our colleague Dr. Gourmelon who explains:

"What is immediately striking in the two press releases, in addition to the means implemented, is the place that the cancer "lobbies" have taken in the prospective group that drew up the 220 proposals with Pr IFRAH. (See Annex 3 of the 29-page press kit).  In this small group of 24 people, we find the representative of the drug companies Mr Eric Baseilhac. He is the director of economic affairs".

Full article available here: https://cancer-rose.fr/2020/12/15/inca-une-consultation-citoyenne-pourquoi/

Broadly speaking, the objectives vary little, and neither do the epidemiological data, demonstrating the inanity of these large plans, which are invariable from one five-year plan to the next, from one president to the next.

In the end, only the easy and demagogic causes remain, giving the illusion of "doing", of grasping the problems, to the great delight of the firms and their "innovations".

Read here: https://ec.europa.eu/commission/presscorner/detail/en/ip_21_342
"Early detection of cancer by improving access, quality and diagnostics and support Member States ensuring that 90% of the EU population who qualify for breast, cervical and colorectal cancer screenings are offered screening by 2025. To support achieving this, a new EU-supported Cancer Screening Scheme will be put forward.
......In addition, to support new technologies, research and innovation, a new Knowledge Centre on Cancer will be launched to help coordinate scientific and technical cancer-related initiatives at EU level. A European Cancer Imaging Initiative will be set up to support the development of new computer-aided tools to improve personalised medicine and innovative solutions."

Références


[1] https://www.lemonde.fr/planete/article/2021/02/04/une-nouvelle-strategie-nationale-pour-faire-reculer-le-cancer_6068728_3244.html

[2] https://www.e-cancer.fr/Presse/Dossiers-et-communiques-de-presse/L-Institut-national-du-cancer-publie-le-dernier-rapport-annuel-au-president-de-la-Republique-du-Plan-cancer-3-et-precise-les-echeances-de-la-strategie-decennale-de-lutte-contre-le-cancer

[3] https://www.roche.fr/fr/pharma/cancer/depistage-cancers-france.html

[4] https://consultation-cancer.fr/project/axe-1-ameliorer-la-prevention/consultation/consultation

[5] https://cancer-rose.fr/2020/12/15/inca-une-consultation-citoyenne-pourquoi/

[6] https://cancer-rose.fr/2020/12/17/la-concertation-citoyenne-de-linca-sur-le-futur-plan-cancer-une-mascarade/

[7] https://cancer-rose.fr/en/2020/12/14/final-report-of-the-citizen-consultation-report-of-the-steering-committee/

[8] https://www.e-cancer.fr/Plan-cancer/Les-Plans-cancer-de-2003-a-2013

[9] https://cancer-rose.fr/wp-content/uploads/2021/02/Plan_cancer_2003-2007_MILC.pdf

[10] https://www.santepubliquefrance.fr/maladies-et-traumatismes/cancers/cancer-du-colon-rectum/documents/rapport-synthese/evolution-de-l-incidence-et-de-la-mortalite-par-cancer-en-france-de-1978-a-2000

[11] B.Duperray "le dépistage du cancer du sein, la grande illusion" Ed Thierry Souccar, page 155

[12] https://www.e-cancer.fr/Plan-cancer/Les-Plans-cancer-de-2003-a-2013/Le-Plan-cancer-2009-2013

[13] https://cancer-rose.fr/wp-content/uploads/2021/02/2009-2013.pdf

[14] https://www.santepubliquefrance.fr/maladies-et-traumatismes/cancers/cancer-du-sein/documents/rapport-synthese/estimations-nationales-de-l-incidence-et-de-la-mortalite-par-cancer-en-france-metropolitaine-entre-1990-et-2018-volume-1-tumeurs-solides-etud

[15] https://cancer-rose.fr/en/2020/12/29/analysis-of-harding-american-study-2015/

[16] https://cancer-rose.fr/en/2020/12/29/excess-mortality-due-to-treatment-outweighs-the-benefit-of-breast-cancer-screening-synthesis-of-several-studies/

[17] https://cancer-rose.fr/en/2021/01/06/miller-study/

[18] http://www.unicancer.fr/le-groupe-unicancer/les-chiffres-cles/les-chiffres-du-cancer-en-france#:~:text=Cancer%20colorectal%20%3A%209%20294%20d%C3%A9c%C3%A8s,la%20prostate%20%3A%208%20207%20d%C3%A9c%C3%A8s

[19] https://www.who.int/tobacco/economics/taxation/fr/

[20] https://cancer-rose.fr/2016/10/10/a-propos-du-plan-cancer-2014-2019/

[21] https://www.e-cancer.fr/Expertises-et-publications/Catalogue-des-publications/Plan-Cancer-2014-2019

[22] https://cancer-rose.fr/2016/12/15/nouvelles-du-front-premiere-manche/

[23] https://cancer-rose.fr/2016/07/30/mortalite-donnees-de-la-base-cepidc-de-1996-a-2012/

[24] Podcast dermato https://www.youtube.com/watch?v=068KMIe-gys&feature=emb_logo

[25] https://www.e-cancer.fr/Expertises-et-publications/Catalogue-des-publications/Sixieme-rapport-au-president-de-la-Republique-Mars-2020

[26] https://cancer-rose.fr/2019/11/28/avis-de-la-haute-autorite-de-sante-sur-la-performance-de-la-mammographie-par-tomosynthese-dans-le-depistage-organise/

[27] https://cancer-rose.fr/2019/03/09/association-de-la-tomosynthese-versus-mammographie-numerique-dans-la-detection-des-cancers/

[28] https://cancer-rose.fr/my-pebs/2019/06/13/argument-english/

[29] l'étude dont on rêvait : https://cancer-rose.fr/my-pebs/2019/03/09/letude-dont-on-re%cc%82vait/

[30] https://cancer-rose.fr/en/2021/02/11/parallel-to-breast-screening-prostate-screening-overdiagnosis-as-well/

[31] https://cancer-rose.fr/en/2021/02/01/overdiagnosis-of-thyroid-cancer-another-womans-concern/

[32] https://m.youtube.com/watch?v=7NQOTNDeM1c

[33] https://cancer-rose.fr/2016/11/05/la-vraie-prevention-parent-pauvre-du-plan-de-lutte-contre-le-cancer-du-sein/