Synthesis Dr C.Bour, October 20, 2022
1°-We start with an article in Medscape, written by Ryan Syrek,
editorial director of Medscape US, on sexual dysfunction and poor self-image in women treated for breast cancer, often with hormone therapy.
This is an almost taboo subject and is obviously under-addressed. The author's concern is the hype surrounding certain therapies with dubious or non-existent benefits. He also points to overtreatment in women with CCIS (carcinoma in situ) who "are generally uninformed about their diagnosis and make uninformed treatment decisions."
The insufficient information of healthy women (in relation to screening) as well as of affected women (on their therapeutic possibilities), can be once again to be deplored.
But what are the obstacles to informing women properly; laziness? Lack of time? Or is it also a persistent patriarchal consideration that women are insufficiently armed to understand or decide, and that they must be spared any cognitive overload? Is this a caricature? Not at all, the art of manipulating women has even given rise to a real study: https://cancer-rose.fr/en/2020/12/17/manipulation-of-information/
We would also like to add that information should already be focused on the risks of screening in general, and in particular on over-diagnosis, which is largely fuelled by the discovery of many "in situ" carcinomas (see FAQ article), the vast majority of which do not affect women, but which are unfortunately mostly detected by repeated mammograms.
2°-In the BMJ, the authors ask the question about doctors' knowledge of overdiagnosis, which should be a prerequisite for explaining it to patients.... A study is in progress, presented here: https://bmjopen.bmj.com/content/12/10/e054267.info
Piessens V, Heytens S, Van Den Bruel A, et al : "Do doctors and other healthcare professionals know overdiagnosis in screening and how are they dealing with it? A protocol for a mixed methods systematic review" BMJ Open 2022;12:e054267. doi:10.1136/bmjopen-2021-054267
Introduction Overdiagnosis is the diagnosis of a disease that would never have caused any symptom or problem. It is a harmful side effect of screening and may lead to unnecessary treatment, costs and emotional drawbacks. Doctors and other healthcare professionals (HCPs) have the opportunity to mitigate these consequences, not only by informing their patients or the public but also by adjusting screening methods or even by refraining from screening. However, it is unclear to what extent HCPs are fully aware of overdiagnosis and whether it affects their screening decisions. With this systematic review, we aim to synthesise all available research about what HCPs know and think about overdiagnosis, how it affects their position on screening policy and whether they think patients and the public should be informed about it.
Methods and analysis We will systematically search several databases (MEDLINE, Embase, Web of Science, Scopus, CINAHL and PsycArticles) for studies that directly examine HCPs' knowledge and subjective perceptions of overdiagnosis due to health screening, both qualitatively and quantitatively. We will optimise our search by scanning reference and citation lists, contacting experts in the field and hand searching abstracts from the annual conference on 'Preventing Overdiagnosis'.
After selection and quality appraisal, we will analyse qualitative and quantitative findings separately in a segregated design for mixed-method reviews. The data will be examined and presented descriptively. If the retrieved studies allow it, we will review them from a constructivist perspective through a critical interpretive synthesis.
3°-In the Annals of Internal Medicine is presented an initiative that our French National Cancer Institute could learn from. https://www.acpjournals.org/doi/10.7326/M22-1139
For the authors, Aruna Kamineni, V. Paul Doria-Rose, Jessica Chubak, et al, cancer screening should be recommended only when the balance of benefits and risks is favorable. The review presented here evaluates how US cancer screening guidelines report risks.
Objective: To describe current reporting practices and identify opportunities for improvement.
Design: Guideline review.
Setting:United States, study funded by the American Cancer Institute.
Patients: Patients eligible for breast, cervical, colorectal, lung, or prostate cancer screening according to US guidelines.
Results: Harms reporting was inconsistent across organ types and at each step of the cancer screening process. Guidelines did not report all harms for any specific organ type or for any category of harm across organ types. The most complete harms reporting was for prostate cancer screening guidelines and the least complete for colorectal cancer screening guidelines. Conceptualization of harms and use of quantitative evidence also differed by organ type.
The review identified opportunities for improving conceptualization, assessment, and reporting of screening process–related harms in guidelines. Future work should consider nuances associated with each organ-specific process to screen for cancer, including which harms are most salient and where evidence gaps exist, and explicitly explore how to optimally weigh available evidence in determining net screening benefit. Improved harms reporting could aid informed decision making, ultimately improving cancer screening delivery.
4°-Finally, two more publications:
A "letter to the editor" by Rani Marx (Medical Decision MakingVolume 42, Issue 8, November 2022, Pages 1041-1044)and a recent editorial, by Marilyn M. Schapira, Professor of Medicine in Pennsylvania and Katharine A. Rendle, Assistant Professor of Family Medicine and Community Health at the Perelman School of Medicine (Pennsylvania), both advocating for awareness of the need for de-escalation of screening and the need for change for the benefit of women.
In her letter "Overscreening for Women's Cancer: Time for Change," Dr. Marx, an epidemiologist and patient, relates:
"Unnecessary and potentially dangerous cancer screening for women is a burden on health care and likely harms patients." The author decries "abundant testing, despite little evidence of improved population health or reduced mortality..."
Furthermore, she shares her own experience in 2020.
In her commentary "Overscreening for Women's Cancer: Time for Change," Dr. Rani Marx addresses the complex issue of informed, value-based decision-making in women's health. Drawing on her experience in health services research and epidemiology, as well as her own experience as a 'patient', Dr. Marx describes her frustrating attempts over a lifetime of screening to engage clinicians in considering the importance of risk on benefit-risk balance. She exposes the trade-offs involved in making decisions about cancer screening tests.
When asked, Dr. Marx explains, many patients and clinicians accept and recognize the need to de-escalate care when supported by scientific evidence, and to engage in an informed, shared decision-making process.
The editorial by Schapira and Rendle, on the other hand, advocates for the challenge of de-escalation: a multi-level change is needed to improve clinical practice. These improvements should focus on guidelines, efforts to achieve consensus on those guidelines, and shared decision-making processes between a woman and her clinician, leading to individualized screening decisions that reflect the woman's values and preferences.
This is in fact what the citizens' consultation demanded, but the road is long, and shared decision making appears to be a mirage when we see the INCa's television spots encouraging women to undergo screening, or the institute's information documents, which are still insufficiently balanced and scarcely descriptive of the risks of screening.