Sophie, referent patient,
September 2, 2021
We may be witnessing a shift in certain countries and the World Health Organization's standpoint on breast cancer screening campaigns. The example is given by Ukraine, which opts, with the help of the WHO, for an "early diagnosis" programme for breast cancer control plan rather than classical screening.
This more cost-effective policy is discussed in the following article “Better than screening: with WHO’s help Ukraine chose a cost-efficient policy to prevent breast cancer” https://www.euro.who.int/en/countries/ukraine/news/news/2021/3/better-than-screening-with-whos-help-ukraine-chose-a-cost-efficient-policy-to-prevent-breast-cancer
According to the WHO: « Given the major improvements in breast cancer treatment in the past decades, in cases when breast cancer is diagnosed at early palpable stage, the rates of secure cure are very high.”
Thus, an early and rapid diagnosis procedure for women with symptoms would be preferred rather than a mass screening that would indiscriminately target the entire healthy women population .
According to the WHO, this is an "inspiring story" about searching for the best way of fighting breast cancer. The WHO recognizes the effectiveness of this new approach and suggests taking it as an example as it will save thousands of lives and millions of euros in loans in Ukraine.
The concept of "early diagnosis”
But what does this "early diagnosis", put forward by the WHO, mean?
Early diagnosis is based on the rapid identification of cancer in patients who present symptoms of the disease to offer them a complete and rapid diagnostic follow-up.
In low-resource countries such as Ukraine, the problem is that symptomatic women, who already have a breast cancer symptom and do not seek medical attention early enough, present too late for care.
France was ready to lend Ukraine $24 million to equip it with mammography equipment for a screening program. Still, with WHO support, Ukraine chose a less expensive and more prudent strategy, claiming that the country already had enough mammography equipment to launch an effective early breast cancer diagnosis program.
A detailed explanation of this concept is given in the following document: https://apps.who.int/iris/bitstream/handle/10665/254500/9789241511940-eng.pdf?sequence=1, starting on page 8.
To summarize, the two procedures that are being weighed up here are as follows:
- early diagnosis, only for patients with symptoms
- systematic screening: applied to the entire healthy population
According to the document:
“After consultation with WHO/Europe experts, Ukraine’s authorities became interested in another WHO-recommended cancer prevention strategy – the early diagnosis programme. It is based on the rapid identification of cancer in patients who have symptoms of the disease and rapid full diagnosis follow-up. Given the major improvements in breast cancer treatment in the past decades, in cases when breast cancer is diagnosed at early palpable stage, the rates of secure cure are very high.”
“In comparison to mammography screening programme, centralization of advanced centers providing high-quality early diagnosis of breast cancer is more efficient, economical and sustainable in a setting with limited resources,” said Dr Olga Trusova, a leading Belarusian mammography expert who took part in the BELMED project aimed at implementation of breast cancer screening in Belarus. BELMED was funded by the EU and implemented by WHO/Europe and IARC since 2016.
These quotes are meaningful because they implicitly acknowledge that screening:
1. carries risks that are inflicted on healthy populations,
2. has not been as successful as expected,
3. is very costly compared to the expected population benefits, and
4. once a disease is treated with significant efficacy in symptomatic forms, screening becomes obsolete. This is precisely one of the observations made by P. Autier, professor of epidemiology at IPRI: the ability to reduce breast cancer mortality attributable to treatment makes the ability to screen even more negligible and non-existent, and more women would have to be screened to achieve the number of deaths avoided that would be truly attributable to screening, with all the concomitant over-diagnosis and false alarms.
The more effective the treatments, the less likely screening will be useful.
Screening would be limited to cancers for which it appears to be effective, such as cervical cancer. “Early detection" seems to be a less expensive option with less negative impact for certain cancers, such as breast cancer. Early detection is effective for cancers that can be identified in early stages and cured with immediate treatment; this is true for breast cancer.
The WHO technical consultation on screening
To understand this shift toward a more measured and reasoned approach, we must go back a bit to the time of the WHO's technical consultation on screening for countries in the European region, which was held in Copenhagen in 2019:
The goal of this consultation, namely to limit the harmful effects of screening on the population, inconveniences that are frequently ignored and underestimated by the population, is clearly stated from the start:
“In recent years, countries in the WHO European Region have been introducing new screening programmes for conditions and health checks along the life-course. However, policy-makers, health professionals, and the public are not adequately aware of the potential harms of screening as well as the costs and requirements of implementing an effective screening programme. With this in mind, the WHO Regional Office for Europe held a Technical Consultation inCopenhagen on 26–27 February 2019 aimed at clarifying the harms and benefits of screening in the light of recent scientific evidence and countries’ experience. This Consultation constituted the first step in an initiative by the Regional Office to improve policy decision-making for screening. It was attended by 55 experts from 16 countries, including academics and observers from nongovernmental organizations.”
At the end of 2020, the WHO published the screening guide; concerning breast cancer in particular (page 38), the guide points out the harmful issues of screening (overdiagnosis and false alarms) and emphasizes informed information, an intangible ethical principle, before inciting populations to screening.
In this logic, the WHO titles in March 2021:
“Better than screening: with WHO’s help Ukraine chose a cost-efficient policy to prevent breast cancer.”
Early diagnosis, why not in France?
Often the question is asked: "But what to do instead of the current screening?"
It is now recognized that mass screening causes more harms than benefits, it does not reduce mortality substantially and induces many overdiagnoses with their consequences of over-treatment, and leads to unnecessary illness. Although very much in favour of screening, the Marmot report alleges 3 overdiagnoses for a life lengthened by screening . The Cochrane review mentions 10 overdiagnoses for one life saved .
In France, we have a sufficient number of mammography machines to be able to adopt this policy of early diagnosis, which is more respectful of women, while at the same time providing them with correct and neutral information on breast cancer and the means to fight it, as called for by the public consultation.
But, in practice, this is what we already know! In our country, women are generally vigilant about the health of their breasts; screened or not, women are made aware of breast cancer by the media and the medical profession, and they have the reflex to consult without delay when they perceive abnormal symptoms. Our health care system has vast economic and human resources and does not have the problems of under-resourcing that Ukraine and other European countries have. A symptomatic woman here receives prompt care and has all chances to be correctly treated and followed up.
Early diagnosis instead of costly mass screening procedures: an "inspiring story," says the WHO, an effective tool in the fight against cancer, allowing health resources to be allocated more appropriately.
So, instead of blindly and indiscriminately urging women to undergo routine screening in disregard of balanced information, a screening that is more likely to expose them to an unnecessary disease than to save lives, why don't we make this inspiring story our own?
Is there a necessity for mistrust?
« The early diagnosis approach for breast cancer was recognized as more appropriate for Ukraine than mammography screening. It is less resource-intensive and allows Ukrainian health system to better prepare for future screening measures if needed.”
This line from the first document we mentioned at the start of the post makes us wonder...
We must ensure that the concept of "early diagnosis" is not misused and that it does not serve as a "foot in the door" for pro-heavy imaging and pro-testing lobbies to rush into larger ambitions and to deploy insatiable appetites toward more and more medicine, directed at more and more individuals, many of whom would not have needed it and will not benefit from it.
 As a reminder, a basic notion of knowing the difference between screening mammography and diagnostic mammography:
Screening mammography is the routine mammography that women are asked to have every two years from the age of 50, even in the absence of any symptoms.
Diagnostic mammography is the one that is motivated by the appearance of a sign, a symptom in the breast (swelling, retraction, deformation, etc.). This symptom then requires a mammography exploration to identify and diagnose the problem in the breast.
 Marmot M.G., et al. The benefits and harms of breast cancer screening: an independent review. Br J Cancer. 2013 Jun 11; 108(11): 2205–2240