October 30, 2017
Less Is More
Reform of the National Screening Mammography Program in France
Alexandra Barratt, MBBS, MPH, PhD Sydney School of Public Health, University of Sydney and Wiser Healthcare, Sydney Australia.
Karsten Juhl Jørgensen, MD
The Nordic Cochrane Centre, Rigshospitalet Department 7811, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
Philippe Autier, MD, International Prevention Research Institute, Lyon, France.
(Mr. Pr. P.Autier entrusted us with the French translation of the article reporting on the French citizen consultation.)
The authors summarize the conduct of the citizen inquiry
In October 2016 the French Minister of Health released the report of the independent consultation into mammography screening.
The report presented two options: ending the national breast cancer screening program, or ending the current program and implementing a radically reformed program. (1)
In 2004, after years of ad hoc screening, a national mammography screening program was introduced.
Every two years, women aged 50-74 receive invitations by mail for mammography screening, covered by health insurance. Over time, however, doubts have emerged about the program's reach, accessibility, effectiveness and potential adverse effects of overdiagnosis and overtreatment.
Why and how the French inquiry took place?
In September 2015, the Minister of Health announced what the French know as a "citizen and scientific inquiry," and appointed an independent steering committee to oversee it.
This committee brings together leading health professionals, (in oncology, general medicine, epidemiology, public health) and social science professionals (in anthropology, law, economics, history of science, and bioethics), all without financial or academic links to breast cancer screening.
In addition to reviewing evidence reviews on specific issues (provided by a technical committee of the French National Cancer Institute (Inca)), the committee also oversees a "civil dialogue," a concept inherited from the French Revolution of 1789.
A website provides information about the consultation and invites the public to submit their opinions. Two pillar consultations were set up: a citizen consultation of a group of 27 women from different regions of France and different socio-economic groups, and a parallel consultation of a group of 19 health professionals with relevant professional experience but no connection to breast cancer screening. Each of these consultations took place over 5 days of information, presentations, expert interviews, questions and discussions. Each focus group addressed four questions and developed a collective response to each. A final public meeting was held to present the recommendations and answer questions.
The steering committee considered the scientific controversy over mammography screening to be particularly intense, focusing on the uncertainty of its benefit and concerned with the issues of overdiagnosis and overtreatment. The national screening program had never been controversial, despite extensive discussion in the scientific literature.
The committee found that the evidence on breast cancer screening outcomes was limited, coming from old trials and studies, none of which had been conducted in France.
The committee members pointed out that knowledge of the natural history of breast cancer was incomplete, and that breast cancer screening therefore infringed a fundamental principle of screening (2), namely that the natural history of the disease from latent to declared disease should be adequately understood. In addition, the committee was critical of the information promoted during Pink October, or breast cancer awareness month, which the committee felt overstated the benefit of screening. The citizens concluded that they did not want to keep the breast cancer screening program as currently defined and implemented. They spoke of the difficulty of making recommendations without regular evaluation of the program, and the importance of measuring the impact of the program on quality of life (not just mortality). They noted the need for economic responsibility when a program is publicly funded. The health professionals consulted recommended continuing the program, but with major reforms including improvements in the quality of information, accessibility, and evaluation of the program.
The steering committee recommended that the program be discontinued, or that radical reforms be made.
If the program were to be continued, their key recommendations included:
- - Providing neutral, comprehensive information for women, the public and physicians.
- - Acknowledgement of scientific controversy in information for women and physicians.
- - Training for doctors to better assist women in making an informed decision about breast cancer screening.
- - A research program into the natural history of breast cancer(s) and the effectiveness of new treatment approaches.
- -An improved program evaluation to monitor the impact of screening on quality of life, mortality, and cost impact.
- - An end to screening of women age 50 years or younger who are ar average risk
- - Consideration of screening based on risk level, so that low-risk women could be screened less frequently or not at all, while higher-risk women could be followed more intensively.
The Minister of Health asked the French National Cancer Institute to develop a plan for reform.
April 2017 the Minister of Health published a plan composed of broad reforms intended to be implemented over several years (3).
The first immediate steps are focused on information for women so that they can make their own decisions with the help of their physician: a new medical consultation for every woman at age 50 to discuss cancer screening and prevention options (including primary prevention through lifestyle changes to reduce the risk of cancer); provision of comprehensive information in the form of a booklet accompanying screening invitations and also via an online decision aid; and additional tools and training to help physicians communicate about the benefit/risk balance and limitations of screening.
Other measures include improving access to the program, providing more support to women during the screening process, improving the technical quality of the program, and establishing a research program alongside the screening.
But the authors of the point of view in the JAMA underline that the plan does not detail how these measures will be evaluated.
What is the specificity of the French consultation?
The authors recall that this French consultation is the third independent evaluation of breast cancer screening in Europe, following those of Switzerland and the United Kingdom (4,5). All emphasized the need for comprehensive and balanced information, and all recognized overdiagnosis as a serious harm; two (the Swiss and French evaluations) made a recommendation to stop screening as currently proposed.
These results differ greatly from the recommendations of other panels, such as the US Task Force, the American Cancer Society, and the International Agency for Research on Cancer, which recently concluded that the benefits outweigh the harms of breast cancer screening and continue to recommend it. (6)
Where might these differences between different program reviews and recommendations come from?
The authors give several explanations :
1- Avoiding conflicts of interests
One explanation is that some panels may be compromised by conflicts of interest (7), something carefully avoided in the three European surveys.
2- A broader range of represented disciplines
It is also important that views from a broader range of disciplines be represented, so that panel members with expertise in the humanities and social sciences will be more likely to raise social, legal, and ethical considerations for discussion regarding population screening.
Juries making recommendations for medical treatment do not necessarily look for the values and preferences of citizens in making their recommendations. But screening programs do impact the lives of asymptomatic citizens, and so their choices are important in decision-making.
3- Inclusion of a citizen perspective
That the French consultation included a citizen perspective in its investigation and recommendation process is another possible explanation.
One approach to mammographic screening is to ask individuals to make their own informed decision to participate, with assistance in the form of shared decision making.
This approach, although often advocated (8), is challenging to obtain and sustain.(9)
Seeking the views of informed citizens and their preferences through a collective approach is an alternative that provides a sharp contrast to shared decision-making with one patient at a time.
The authors share the view that community discussions, such as in the French inquiry, allow for the sharing of meaningful information and the exchange of opinions among citizens from diverse backgrounds. This kind of deliberative process offers advantages for developing actions with implications for other countries, well beyond breast cancer screening.(9,10)
1. Comité d’orientation de la concertation citoyenne et scientifique sur le dépistage du cancer du sein. Rapport du Comité d’Orientation. Boulogne-Billancourt, France: Institut National du Cancer; 2016. http://www.concertation-depistage .fr/. Accessed September 14, 2017.
2. WilsonJMG,JungnerG.PrinciplesandPracticeof Screening for Disease. Geneva, Switzerland: World Health Organization; 1968.
3. Plan d’action pour la rénovation du dépistage organisé du cancer du sein: Ministère des Affaires Sociales et de la Santé; 2017.
4. MarmotMG,AltmanDG,CameronDA,Dewar JA, Thompson SG, Wilcox M. The benefits and harms of breast cancer screening: an independent review. Br J Cancer. 2013;108(11):2205-2240. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3693450/
5. Chiolero A, Rodondi N. Lessons from the Swiss Medical Board recommendation against mammography screening programs. JAMA Intern Med. 2014;174(10):1541-1542.
6. Jørgensen KJ, Kalager M, Barratt A, et al. Overview of guidelines on breast screening: Why recommendations differ and what to do about it. Breast. 2017;31:261-269.
7. NorrisSL,BurdaBU,HolmerHK,etal.Author's specialty ans conflicts of interest contribute to conflicting guidelines for screening mammography. J Clin Epidemiol. 2012;65(7):725-733.
8. ElmoreJG,KramerBS.Breastcancerscreening: towardinformeddecisions.JAMA.2014;311(13): 1298-1299.
9. IrwigL,GlasziouP.Informedconsentfor screening by community sampling. Eff Clin Pract. 2000;3(1):47-50.
10. RychetnikL,CarterSM,AbelsonJ,etal. Enhancing citizen engagement in cancer screening through deliberative democracy. J Natl Cancer Inst. 2013;105(6):380-386.