Objective information and less acceptance of screening by women

Marc Gourmelon, MD, Cécile Bour, MD

September 8, 2020

A French study in 2016 showed that when women are given slightly more objective information about breast cancer screening by mammography, they are less likely to attend it.

https://www.oncotarget.com/article/7332/text/ : "Decision aid on breast cancer screening reduces attendance rate: results of a large-scale, randomized, controlled study by the DECIDEO group"

Background and methods

This study was conducted in 2016 by Aurélie BOURMAUD who was working at the time for the Cancer Institute of Loire Lucien Neuwirth 1408, Saint Priest en Jarez, France, very invested in screening as shown by her support for the events of October Rose [1].

She is now an Associate Professor in public health and currently works at the clinical epidemiology unit of the Robert Debré Hospital (Paris) and at the University Paris Diderot. Her research themes are prevention, patient education, complex intervention and patient care pathways.

The summary of his study indicates the following:

“The aim of this study was to assess the impact of a decision aid leaflet on the participation of women invited to participate in a national breast cancer screening program. This Randomized, multicentre, controlled trial. »

« 16 000 women were randomized and 15 844 included in the modified intention-to-treat analysis. »

« This large-scale study demonstrates that the decision aid reduced the participation rate. The decision aid activate the decision making process of women toward non-attendance to screening. These results show the importance of promoting informed patient choices, especially when those choices cannot be anticipated. »

In introduction is explained :

« Benefits in terms of mortality reduction are not clearly documented. It has been suggested that prevention campaigns should change from persuasive approaches to approaches based on information and women’s decision empowerment. »

In order to carry out this study, a decision support tool, DECIDEO, was distributed to the participants (Outil DECIDEO, in two languages starting on page 7).

« A decision aid, known as the DECIDEO leaflet, was developed following international guidelines for the ‘provision of information and the construction of decision aid tools ».

The hypothesis of this study was as follows:

« Our hypothesis was that this decision aid would increase informed choice in the intervention group. We estimated the effect of this written decision aid on informed choice, by measuring the participation rate of a population-based breast cancer screening. »

This 2016 study was brought to our attention because it is cited by Italian authors who demonstrated that manipulating the message to women likely to get screened by mammography, increases their participation in screening. We had recently analyzed this study (Italian study analysis).

The Italian study shows that information on the risks of screening reduces women's participation in breast screening, which is a real problem for the Italian authors. They therefore suggest manipulating the information given to women by selectively presenting the negative effects (according to them) of not getting screened.

What are the results of the 2016 study by A.Bourmaud et al.?

"The overall participation rate at 12 months (Table 2) was significantly higher in the control group: 42.13 per cent versus 40.25 per cent in the decision support group (p = 0.02). »

This clearly means that women participating in the decision support group were less likely to be screened than women in the control group.

In other words, when women are given information about screening, they attend less the screening. This finding is critical.

“This study is the first to compare a decision aid to real life: the control group consisted of women aged 50 to 74, receiving the usual information about screening. Our results are however in accordance with previous trials in this field suggesting a decreased attendance as results of the implementation of a decision aid on cancer screening”.

“Our results demonstrate that a decision aid, designed following specific guidelines, sent with a formal invitation to attend breast cancer screening, resulted in a lower attendance rate and a decrease in the delay of attendance for the women who did participate.”

This confirms what the recent Italian study showed: in order to increase participation in breast cancer screening by mammography, the information must be manipulated in the sense of less disclosure of the true risk/benefit balance of screening.

Discussion and analysis

A-Analysis of the tool

According to the authors themselves, the DECIDEO tool has some shortcomings, and not the slightest:

 "Another limitation (of the study, editor's note) is that recent data on over-diagnosis and over-treatment have not been implemented in the decision aid. »

These elements to be informed are however capital among the risks of screening.

The tool's figures (starting on page 8) are not referenced anywhere, and, as stated in the introduction, once again in the authors' own words: "The benefits in terms of mortality reduction are not clearly documented".

However, what women want to know first and foremost when they undergo a medical procedure is whether it can guarantee them less death from the disease and whether the procedure has no major side effects.

Overdiagnosis and overtreatment being the two major adverse effects of screening, there is clearly a form of manipulation by not communicating to women these two fundamental and essential data for their health and well-being.

Furthermore, it is noteworthy that contrary to what is implied by the references cited in the study (reference 26 on IPDAS criteria), this tool distributed to participants in the study does not meet IPDAS criteria in any way.

The IPDAS criteria are very specific items that the tool must meet in order to guarantee quality information[2]

The mention of overdiagnosis and over-reatment is thus an absolute imperative.

In this respect, we were already concerned about the shortcomings in the completeness and quality of the information provided by the National Cancer Institute itself, whose mission it is, however, to do it [3].

B-the ethical problem

In this study, as in the Italian one, the authors have a question that does not miss to surprise:

"the DECIDEO leaflet discouraged older women, as well as those with a low mean household income, from attending the national breast cancer screening program. “

Women with a lower educational level could have had difficulty in understanding the decision aid. Those two phenomena could partly explain the effect of the DECIDEO leaflet on those specific populations, additional studies being needed to confirm this hypothesis.

This hypothesis put forward by the authors, seems to come straight from their lack of knowledge of the social environment of modest women to which, it seems to us, "social class beliefs " are added.

Indeed, there is an aspect that is not at all addressed nor only mentioned by the authors, but that any "field" doctor understands very quickly, provided that he offers an attentive ear to the most socially and economically deprived patients. Low-income women, and even populations with a low socio-economic level in general, do not have such prohibitive problems of understanding that the authors of the DECIDEO group imply that they do, if indeed efforts are made to make medical information available to them.

On the other hand, these populations fear the disease much more than others. In fact, falling ill makes them even poorer and more ostracized; women who have low-paying jobs panic about losing this often thankless job and being deprived of an income that is indispensable to the family. The jobs of these women often require physical commitment (household, home work, labour); they know that they will no longer have the professional skills required of them after certain treatments, and they fear being further discredited as " ill " at the expense of society.  Further studies could demonstrate this, but simply by questioning these economically weak people, the diagnosis appears obvious to explain their lesser compliance with screening recommendations, of all kinds, moreover.

The actual questioning of the need to provide honest information that might decrease participation seems unethical to us, since the obligation to provide fair and complete information is stated in the law [4].

« In this large, randomized, clinical trial we observed that the DECIDEO decision aid resulted in decreased breast cancer screening attendance although it accelerated the decision to attend, for those women who did attend. These results suggest that this leaflet have accomplished its main purpose which was to inform the decision-making process. 

We believe that our results highlight the dilemma between the goals of population health initiatives and individual choices.”

Conclusion

This study went unnoticed.

And for reason, it proves that the more exhaustive the information given to women about breast cancer screening by mammography, the less they participate in the organized screening program set up and promoted by official structures.

And we are surprised that the DECIDEO form, far from meeting the IPDAS standards of exhaustive information on screening, achieves such results in terms of reduction in recourse to screening.

The more women are informed, the less incentive campaigns such as the Pink October campaign can reach them.

Screening uptake does not have strong evidence of an effect on mortality reduction, as stated at the outset in the introduction :

“Benefits in terms of mortality reduction are not clearly documented [10-13]. It has been suggested that prevention campaigns should change from persuasive approaches to approaches based on information and women’s decision empowerment ”

We must therefore stop trying to persuade women at all costs to get screened, stop manipulating the so-called decision-making tools to such an extent; on the contrary, we must inform them so that they can make an informed decision.

This is nothing less than the conclusions of the consultation on screening mammography in 2015 [5].

In the end, one rather amusing thing to note is that even with a biased decision support tool, such as DECIDEO is, women are very difficult to fool and send to a screening test to which, despite the misleading and pink incentives, they do not massively comply…

It therefore seems obvious to us that, as requested by the 2015 citizens' consultation, and in accordance with the ever-increasing scientific evidence on the ineffectiveness of mammography screening, this organized breast cancer screening by mammography need to be stopped in France.

Read also our previous article on the manipulation of women, as a scientific topic.

References

[1]https://www.icloire.fr/wordpress/icln-octobrerose2018/

[2]https://cancer-rose.fr/2020/01/22/faisabilite-dun-outil-daide-a-la-decision-sur-le-depistage-du-cancer-du-sein-a-la-francaise-selon-les-criteres-ipdas/

[3]https://cancer-rose.fr/en/2020/12/31/david-versus-goliath-which-is-better-at-informing-women-cancer-rose-or-national-institute-of-cancer-inca-in-france/

[4] Information is legally required in the french public health code: https://www.legifrance.gouv.fr/affichCode.do?idSectionTA=LEGISCTA000006196409&cidTexte=LEGITEXT000006072665&dateTexte=20180522

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

Cancer Rose est un collectif de professionnels de la santé, rassemblés en association. Cancer Rose fonctionne sans publicité, sans conflit d’intérêt, sans subvention. Merci de soutenir notre action sur HelloAsso.


Cancer Rose is a French non-profit organization of health care professionals. Cancer Rose performs its activity without advertising, conflict of interest, subsidies. Thank you to support our activity on HelloAsso.

Scaling back in health care: more shared decision making and thoughtful consideration of recommendations

Identify recommendations for stopping or reducing unnecessary routine primary care

Summary by Cécile Bour, MD, September 15, 2020

September 14, 2020 "Identifying Recommendations for Stopping or Scaling Back Unnecessary Routine Services in Primary Care".

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2770724

A study by Eve A. Kerr, MD, MPH; Mandi L. Klamerus, MPH; Adam A. Markovitz, BS; et al.

Eve A. Kerr is a Research Professor of Internal Medicine at the University of Michigan School of Medicine. She is an elected member of the American Society of Clinical Investigation and the Association of American Physicians, a Fellow of the American College of Physicians and a member and responsible for measures of Choosing Wisdom International. 

The concept of Less is More[1][2] medicine emerged in North America in 2010. It is an invitation to practice medicine with an awareness of the potential dangers of over-medicalization, challenging the principle that more medicine means better care.

In response, several medical societies around the world have launched campaigns focusing on choice and appropriateness of care (Choosing wisely [3]) and calling for discussion with patients about the usefulness of medical tests, treatments and procedures.

As the rate of discoveries in therapeutics slowed in the late 1980s, the focus shifted from the search for further innovation to a more reasonable application of existing knowledge. Evidence-based medicine (EBM) was born and is the current driving force for achieving a better level of general practice.

What is EBM?

The EBM is based on a tripod:

1) external experience, basically scientific studies

2) Internal experience: what we learn from our professional practice

3) patient preferences and values.

Among these criteria, guidelines, or recommendations, serve as standards to facilitate medical practice.

Guidelines are a kind of... ways developed to help clinicians and patients make better decisions together, in a spirit of sharing perspectives, all in the best interests of the patient. 

But...

The guidelines, as the authors describe, generally act in the cumulative sense of 'more is better'. The solution proposed by the authors is that the guidelines should be reshaped in the sense of de-escalation, in order to achieve 'less is more'.

The problem often pointed out is that the guideline is the result of a more or less valid consensus reached among several experts. Uncertainties about the health processes that are analyzed by the experts are hardly mentioned and often replaced by the opinion of the expert(s). The independence of the experts can also be a subject of discussion...

Recommendations that drive decisions for patients and clinicians may unintentionally discourage real sharing in decision making, and encourage compliance with the guideline, or may result in rejection and less compliance, depending on the patient's values.

Another challenge is the need to re-evaluate the guideline over time as new knowledge about the risk-benefit balance becomes available.

In addition, we are continually witnessing an encouragement to do rather more tests and treatments, an incentive that is societal, administrative and financial at the same time, by remunerating doctors when including patients in screening procedures.

What does Kerr's study say, and what is its purpose?

The conclusion is that a large part of health care involves the agreed and routine use of medical processes as part of the treatment of chronic disease or as part of what is referred to as 'prevention'. It is the latter that interests us.

The authors argue that it is essential to stop these processes and health services when the evidence on their relevance changes, or if the benefits no longer outweigh the risks as is the case with screening. 

 Yet currently most guidelines focus on escalation of care and procedures, and provide few explicit recommendations for reducing or even stopping treatment and screening tests.

The objective of the Choose Wisely group is to develop a systematic, transparent and consistent approach to identifying, specifying and validating recommendations for deintensification in routine adult primary care [4].

A targeted review of existing guidelines and recommendations was conducted to identify and prioritize potential indications of deintensification. 

Validity of these recommendations is examined according to several items: high-quality evidence that deintensification is likely to improve patient outcomes, evidence that intense testing and/or treatment could cause harm in some patients, absence of evidence on the benefit of continued or repeated intense treatment or testing, and evidence that deintensification is consistent with high-quality care.

Finally, in this study, a total of 178 opportunities to deintensify primary care services were identified, 37 of which were validated as high-priority deintensification recommendations. To date, this is the first study to develop a model for identifying, specifying and validating deintensification recommendations that can be implemented and monitored in clinical practice.

Concerning screening, what are these recommendations for deintensification (de-escalation?)

There is no great revolution in this area except that in the additional recommendations given by Choosing Wisely, clinicians are no longer supposed to recommend screening for breast, colorectal, prostate or lung cancer without considering life expectancy (no screening if life expectancy is less than 10 years) and without considering the risks of screening: overdiagnosis and overtreatment.

This is in contrast to the USPSTF and American College of Physicians' guidelines that urge screening with a strong recommendation for women aged 50-74 years, and the American Cancer Society's recommendations for screening as young as 45 years, all of these bodies not considering information on overdiagnosis or overtreatment in the recommended age groups.

For prostate cancer screening, its non-recommendation is recalled by the Choosing Wisely group, which is asking for at least a shared decision aid for men who would like to be screened.

Conclusion

The guidelines for deintensification proposed by Choosing Wisely, although modest on screening, can initiate this necessary change that will enable health care professionals to reverse the trend of 'more care'.

But the evolution towards sharing medical decision making with patients cannot take place, in our opinion, without active assistance through decision support tools, and without the willingness of official health authorities to support practitioners.

Public health education is also needed. Between financial incentives (ROSP: remuneration of doctors on public health objectives in France) to physicians and societal messages to screen more and more (general public TV programs such as "naked stars" [5] and Pink October campaigns in France), there is for the moment only a very timid effort to achieve this informed sharing, too little academic training in this sense (despite local initiatives in medical schools), and certainly too little official and media support to make it clear that it is in the best interests of patients to review our practices towards a deintesification of routine care.

References 

[1] https://www.revmed.ch/RMS/2013/RMS-381/Less-is-more

[2] https://cancer-rose.fr/en/2020/12/15/less-is-more-medicine/

[3] http://www.lessismoremedicine.com/blog/tag/choosing+wisely

[4] https://www.irdes.fr/documentation/syntheses/soins-de-sante-primaires.pdf Primary care includes : - prevention, screening, diagnosis, treatment and follow-up of patients; - dispensing and administration of drugs, medical products and devices, as well as pharmaceutical counselling; - orientation in the health care system and the medico-social sector; - health education.

[5]https://cancer-rose.fr/2020/02/06/ah-mais-quelle-aubaine-ce-cancer/

 

 

 

Cancer Rose est un collectif de professionnels de la santé, rassemblés en association. Cancer Rose fonctionne sans publicité, sans conflit d’intérêt, sans subvention. Merci de soutenir notre action sur HelloAsso.


Cancer Rose is a French non-profit organization of health care professionals. Cancer Rose performs its activity without advertising, conflict of interest, subsidies. Thank you to support our activity on HelloAsso.

Carcinoma in situ, the problem of its overdiagnosis in screening mammography

Cécile Bour, MD

October 21, 2020

What is carcinoma in situ?

Carcinoma in situ (CIS) of the breast is defined by the proliferation of cancer cells within a milk duct without the cells spreading beyond the wall of the duct into the rest of the breast.

It is either strict ductal, developing in the milk excretory duct (ductal carcinoma in situ or DCIS), or in the lobule, the excretory unit around the duct (lobular carcinoma in situ or LCIS).

We have synthesized the main information in a summary for quick reading here: https://cancer-rose.fr/en/2020/11/30/what-is-a-ductal-carcinoma-in-situ-dcis/

In the media library you will also find some examples of images:

A very interesting blog by Donna Pinto is dedicated to DCIS with a lot of very practical and useful information: https://dcis411.com/

Ductal carcinoma in situ (DCIS) was rarely diagnosed before the introduction of breast screening, and now it accounts for 20-25% of all breast cancers, with this increase being directly correlated to over-detection by national routine breast cancer screening programs. 

Yet most DCIS lesions remain indolent. 

The problem

Despite being a pre-invasive or even non-invasive lesion, and although the natural evolution of this intra-ductal process is unknown, DCIS is still considered the early, non-obligatory form of (stage 0) breast cancer. The fear of not being able to distinguish between harmless lesions and potentially invasive forms, leads to over-treatment of this condition in many patients.

Therefore the classical patient management, and also in France, is to treat all DCIS lesions with a treatment that includes either mastectomy or breast conservative surgery supplemented by radiotherapy. 

The Marmot report in the United Kingdom (screening assessment report, 2012), recognized the burden of excessive treatment on women's well-being[1]. 

As a matter of fact, women with DCIS are labeled as "cancer patients", with concomitant anxiety despite the fact that most DCIS lesions are unlikely to ever progress to invasive breast cancer. ... The inflicted treatment (surgery followed or not by  radiotherapy) is therefore excessive for some, and very likely for many women, having a strong negative impact on their quality of life.

This particular form of cancer, that some call "pre-cancer" or " false cancer",  and some even consider as a non-cancer and only as a risk marker for breast cancer, greatly contributes to overdiagnosis, i.e. the discovery of abnormalities that, if they had remained unknown, would never have endangered the woman's life or health.

The problem with DCIS is that it is very easily revealed by mammography because of its association with calcifications, which are easily detected by mammography.

The data

The number of women diagnosed with DCIS in recent decades follows largely the introduction of  breast cancer mass screening, and is growing in parallel with the participation in screening[2] [3] [4] [5] [6].

The European standardised rate (i.e. the age-adjusted rate for the European population) of in situ lesions has quadrupled from 4.90 per 100,000 women in 1989 (representing 4.5% of all registered breast cancer diagnoses) to 20.68 per 100,000 women in 2011 (representing 12.8% of all registered breast cancer diagnoses[7] ). Of all reported in situ breast lesions, 80% are DCIS [8] [9].

Nevertheless, the incidence of breast cancer mortality has not decreased with the detection and treatment of DCIS, indicating that the management of DCIS does not reduce specific mortality from breast cancer.

A review of autopsies in women of all ages revealed a median prevalence (existing cases) of 8.9% (range 0-14.7%).  For women over 40 years of age, this prevalence was 7-39% [10], whereas breast cancer is diagnosed in only 1% of women in the same age group [11]. 

This means that these lesions are present more frequently than they are diagnosed in women in the living population, and that a large number of women carry undetected DCIS that would never become symptomatic, since more of them are found in women who have died from other causes than in the living population at the same time.

Classical lobular carcinoma in situ (LCIS), on the other hand, confers a risk of 1-2% per year of developing into invasive disease[12] [13].

What is also known, is that the stage of carcinoma in situ detected, is not a good and reliable indicator of the risk of progression of this lesion [14] [15].

In addition, patients diagnosed with DCIS have an excellent breast cancer specific survival rate, of approximately 98% after 10 years of follow-up [16] [17] [18] [19] and a normal life expectancy. If low-grade DCIS (considered a low-risk lesion) progresses to invasive breast cancer, it will often be a slow-growing, early-detectable, lower-stage invasive disease with an excellent prognosis.

However, despite this excellent prognosis and normal life expectancy, women diagnosed with DCIS suffer from stress and anxiety [20].  Studies report that most women with DCIS (and early breast cancer) have little knowledge about their condition and have misperceptions about the risk of disease progression, and this misperception is associated with significant psychological distress [21] [22] [23] [24] [25] [26].

In view of all these elements, it is considered that the current management of DCIS involves excessive treatment.

The problem of overtreatment

Currently, a conservative breast treatment for DCIS is frequently recommended. A mastectomy is advised if the DCIS is too large to allow breast conservation. Radiotherapy is often combined, which has been proven effective in reducing the risk of local recurrence.

However, it is also known that treating ductal carcinoma in situ does not reduce breast cancer mortality; also preventing recurrence by radiotherapy or mastectomy has also been shown not to reduce the risk of breast cancer mortality. Treatment would also not extend either breast cancer-specific survival or overall survival [27].

Due to the side effects of hormone therapy and ambiguous clinical trial results, postmenopausal women with DCIS are rarely treated with endocrine therapy in many countries. 

Some leads

Given the disappointing results of DCIS management in terms of reduction of invasive cancers, considering the absence of impact on survival, the implementation of treatments that were ultimately too severe for the results observed, and the major psychological impact, several countries have undertaken clinical trials aimed at testing a simple active surveillance, particularly for low grade CIS, rather than aggressive treatment.

Three clinical trials have randomized patients with low risk DCIS into two groups, one group under active surveillance versus one group receiving standard therapy. 

- COMET(US) [28] [29]
- LORIS(UK) [30]
- LORD(EU) [31]

A research program (PRECISION) has been initiated, encompassing these 3 international trials. https://www.dcisprecision.org/wp-content/uploads/2020/08/DCIS-Nieuwsbrief-Final_140820.pdf

CONCLUSION

There is an uncertainty regarding the manner in which DCIS develops, and there is a lack of global consensus on the best way to manage this lesion in an optimal manner. 

A better understanding of the biology of DCIS and the natural course of the disease is needed to help patients and health care professionals make more informed treatment decisions, to reduce the current over-treatment of DCIS that results in physical and emotional harm to patients and unnecessary costs to society. 

There is even an urgent need to reframe patients' perceptions of risk.

Initiatives and trials will hopefully contribute to better knowledge and informed decision-making between patients and clinicians.

Read also: https://www.nature.com/articles/s41416-019-0478-6

References

[1] Independent UK Panel on Breast Cancer Screening. The benefits and harms of breast cancer screening: an independent review. Lancet 380, P1778–P1786 (2012).

[2] Bleyer, A. & Welch, H. G. Effect of three decades of screening mammography on breast-cancer incidence. N. Engl. J. Med.367, 1998–2005 (2012).

[3] Bluekens, A. M., Holland, R., Karssemeijer, N., Broeders, M. J. & den Heeten, G. J. Comparison of digital screening mammography and screen-film mammography in the early detection of clinically relevant cancers: a multicenter study.Radiology 265, 707–714 (2012).

[4] Ernster, V. L., Ballard-Barbash, R., Barlow, W. E., Zheng, Y., Weaver, D. L., Cutter, G. et al. Detection of ductal carcinoma in situ in women undergoing screening mammography. J. Natl. Cancer Inst. 94, 1546–1554 (2002).

[5] Esserman, L. J., Thompson, I. M. Jr. & Reid, B. Overdiagnosis and overtreatment in cancer: an opportunity for improvement.JAMA 310, 797–798 (2013).

[6] Kuerer, H. M., Albarracin, C. T., Yang, W. T., Cardiff, R. D., Brewster, A. M., Symmans, W. F. et al. Ductal carcinoma in situ: state of the science and roadmap to advance the field. J. Clin. Oncol. 27, 279–288 (2009).

[7] https://www.nature.com/articles/s41416-019-0478-6

[8] Kuerer, H. M., Albarracin, C. T., Yang, W. T., Cardiff, R. D., Brewster, A. M., Symmans, W. F. et al. Ductal carcinoma in situ: state of the science and roadmap to advance the field. J. Clin. Oncol. 27, 279–288 (2009).

[9] Siziopikou, K. P. Ductal carcinoma in situ of the breast: current concepts and future directions. Arch. Pathol. Lab. Med.137, 462–466 (2013).

[10] Welch, H. G. & Black, W. C. Using autopsy series to estimate the disease ‘reservoir’ for ductal carcinoma in situ of the breast: https://www.acpjournals.org/doi/10.7326/0003-4819-127-11-199712010-00014

[11] Siziopikou, K. P. Ductal carcinoma in situ of the breast: current concepts and future directions. Arch. Pathol. Lab. Med. 137, 462–466 (2013).

[12] Lakhani, S. R., Audretsch, W., Cleton-Jensen, A. M., Cutuli, B., Ellis, I., Eusebi, V. et al. The management of lobular carcinoma in situ (LCIS). Is LCIS the same as ductal carcinoma in situ (DCIS)? Eur. J. Cancer 42, 2205–2211 (2006).

[13] Ottesen, G. L., Graversen, H. P., Blichert-Toft, M., Christensen, I. J. & Andersen, J. A. Carcinoma in situ of the female breast. 10 year follow-up results of a prospective nationwide study. Breast Cancer Res. Treat. 62, 197–210 (2000).

[14] Elshof, L. E., Schaapveld, M., Schmidt, M. K., Rutgers, E. J., van Leeuwen, F. E. & Wesseling, J. Subsequent risk of ipsilateral and contralateral invasive breast cancer after treatment for ductal carcinoma in situ: incidence and the effect of radiotherapy in a population-based cohort of 10,090 women.Breast Cancer Res. Treat. 159, 553–563 (2016).

[15] Bijker, N., Peterse, J. L., Duchateau, L., Julien, J. P., Fentiman, I. S., Duval, C. et al. Risk factors for recurrence and metastasis after breast-conserving therapy for ductal carcinoma-in-situ: analysis of European Organization for Research and Treatment of Cancer Trial 10853. J. Clin. Oncol.19, 2263–2271 (2001).

[16] Worni, M., Akushevich, I., Greenup, R., Sarma, D., Ryser, M. D., Myers, E. R. et al. Trends in treatment patterns and outcomes for ductal carcinoma in situ. J. Natl. Cancer Inst.107, djv263 (2015).

[17] Morrow, M. & Katz, S. J. Addressing overtreatment in DCIS: what should physicians do now? J. Natl. Cancer Inst. 107, djv290 (2015).

[18] Fisher, E. R., Dignam, J., Tan-Chiu, E., Costantino, J., Fisher, B., Paik, S. et al. Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) eight-year update of Protocol B-17: intraductal carcinoma. Cancer 86, 429–438 (1999).

[19] Elshof, L. E., Schmidt, M. K., Rutgers, E. J. T., van Leeuwen, F. E., Wesseling, J. & Schaapveld, M. Cause-specific mortality in a population-based cohort of 9799 women treated for ductal carcinoma in situ. Ann. Surg. 267, 952–958 (2017).

[20] Ganz, P. A. Quality-of-life issues in patients with ductal carcinoma in situ. J. Natl. Cancer Inst. Monogr. 2010, 218–222 (2010).[21] Hawley, S. T., Janz, N. K., Griffith, K. A., Jagsi, R., Friese, C. R., Kurian, A. W. et al. Recurrence risk perception and quality of life following treatment of breast cancer. Breast Cancer Res. Treat. 161, 557–565 (2017).

[22] Ruddy, K. J., Meyer, M. E., Giobbie-Hurder, A., Emmons, K. M., Weeks, J. C., Winer, E. P. et al. Long-term risk perceptions of women with ductal carcinoma in situ. Oncologist18, 362–368 (2013).

[23] Liu, Y., Pérez, M., Schootman, M., Aft, R. L., Gillanders, W. E., Ellis, M. J. et al. A longitudinal study of factors associated with perceived risk of recurrence in women with ductal carcinoma in situ and early-stage invasive breast cancer. Breast Cancer Res. Treat. 124, 835–844 (2010).

[24] van Gestel, Y. R. B. M., Voogd, A. C., Vingerhoets, A. J. J. M., Mols, F., Nieuwenhuijzen, G. A. P., van Driel, O. J. R. et al. A comparison of quality of life, disease impact and risk perception in women with invasive breast cancer and ductal carcinoma in situ. Eur. J. Cancer 43, 549–556 (2007).

[25] Partridge, A., Adloff, K., Blood, E., Dees, E. C., Kaelin, C., Golshan, M. et al. Risk perceptions and psychosocial outcomes of women with ductal carcinoma in situ: longitudinal results from a cohort study. J. Natl. Cancer Inst. 100, 243–251 (2008).

[26] Davey, C., White, V., Warne, C., Kitchen, P., Villanueva, E. & Erbas, B. Understanding a ductal carcinoma in situ diagnosis: patient views and surgeon descriptions. Eur. J. Cancer Care 20, 776–784 (2011).

[27] https://jamanetwork.com/journals/jamaoncology/fullarticle/2427491

[28] Comparison of operative versus medical endocrine therapy for low risk DCIS: the COMET Trial. http://www.pcori.org/research-results/2016/comparison-operative-versus-medical-endocrine-therapy-low-risk-dcis-comet.

[29] Hwang, E. S., Hyslop, T., Lynch, T., Frank, E., Pinto, D., Basila, D. et al. The COMET (Comparison of Operative to Monitoring and Endocrine Therapy) Trial: a phase III randomized trial for low-risk ductal carcinoma in situ (DCIS). BMJ Open 9, e026797 (2019).

[30] Francis, A., Thomas, J., Fallowfield, L., Wallis, M., Bartlett, J. M., Brookes, C. et al. Addressing overtreatment of screen detected DCIS; the LORIS trial. Eur. J. Cancer 51, 2296–2303 (2015).

[31] Elshof, L. E., Tryfonidis, K., Slaets, L., van Leeuwen-Stok, A. E., Skinner, V. P., Dif, N. et al. Feasibility of a prospective, randomised, open-label, international multicentre, phase III, non-inferiority trial to assess the safety of active surveillance for low risk ductal carcinoma in situ - The LORD study. Eur. J. Cancer 51, 1497–1510 (2015).

Cancer Rose est un collectif de professionnels de la santé, rassemblés en association. Cancer Rose fonctionne sans publicité, sans conflit d’intérêt, sans subvention. Merci de soutenir notre action sur HelloAsso.


Cancer Rose is a French non-profit organization of health care professionals. Cancer Rose performs its activity without advertising, conflict of interest, subsidies. Thank you to support our activity on HelloAsso.

Covid-19 Pandemic and Cancer management

Gustave-Roussy models the impact of Covid-19 on the management of cancers.

November 11, 2020

Cécile Bour, MD

Patients' concern about possible coronavirus contamination in hospital, especially in oncology, leads them to delay their visits to health centers for treatment.

Researchers from Gustave-Roussy in Villejuif (Val-de-Marne) have carried out a study called "Grouvid", based on a mathematical simulation model to assess the impact of the Covid-19 pandemic on the organization of cancer care. The consequences in terms of prognosis and the possible excess mortality resulting from the delay in the management of patients diagnosed with cancer during the lockdown period are studied and evaluated in the present article.

Grouvid PDF presentation

This work carried out by researchers Aurelie Bardet1,2, Alderic Fraslin1,2, Matthieu Faron2,3, Isabelle Borget1,2, Lucile Ter-Minassian4, Jamila Marghadi5, Anne Aupérin1,2, Stefan Michiels1,2, Fabrice Barlesi6, Julia Bonastre1,2 was presented at the ESMO 2020 virtual congress by Aurélie Bardet (see PDF of the congress).

     • 1 Biostatistics and Epidemiology Department, Gustave Roussy

    • 2. Research team in statistical methodology Oncostat Inserm 1018, Univ. Paris-Saclay, Ligue against cancer

    • 3. Visceral Oncological Surgery Department, Gustave Roussy

    • 4. Department of statistics, Oxford University, Oxford, United-Kingdom

    • 5. Medical Information Service, Gustave Roussy

    • 6. Medical and Clinical Research Department, Gustave Roussy, Paris-Saclay University.

Content of the virtual conference, presentation of the study

This is a microsimulation model to assess the impact of SARS-CoV-2 on cancer prognosis, health care organization and management costs.

A-Objectives

Evaluate the impact of the pandemic on non-covid cancer patients.
The aim is to establish a model based on the current data available from the Gustave Roussy center to model the individual pathways of patients.

The Covid-19 epidemic has led to a decrease in the number of patients managed during lockdown and a limitation of resources dedicated to cancer, with the closure of the marrow transplant unit, reduction of surgical intensive care beds, reduction in the number of operating rooms, reduction of chemotherapy and radiotherapy sessions.

B-Results

1° Modification of patient flow - Treatment delays

  • 13.4% of patients have a delay in treatment of more than 7 days, mainly patients with thyroid and breast cancer.
    Median delay = 55 days, mainly due to patient inherent delay.
  •  5.2% of patients have a treatment delay of more than 2 months

2° Changes in medical care

27% of confined patients see their care modified (mainly in breast cancer and gastrointestinal pathologies).

3° Hospital resources

Two resources are limiting:

- the availability of operating rooms (expected peak activity = mid-June)
- Chemotherapy (expected peak activity = mid-October with creation of waiting lines)

4° Results on cancer prognosis :

  •  2.0% of patients present a major change in their prognosis of disease with
  • 2.25% increase in 5-year cancer deaths, mainly liver, sarcoma and head and neck cancers => 49 additional deaths.

5° Sensitivity analysis of the average time to seek care attributable to patients

This is an estimate of the impact of a staggered and regular (uniform) return of patients (because of this staggering, the median delay in management is estimated at 3.4 months). :

2.4% of patients would present a major change in their prognosis, with a 4.60% increase in deaths at 5 years.

C-Key messages and conclusion

Based on a scenario in the context of the Institut Gustave Roussy :

  • 2% of patients will present a major change in their prognosis
  •  2% additional deaths at 5 years

There is still a great deal of uncertainty about future events and complex behaviours in order to assess the impact of a 2nd wave.

Comments by Cancer Rose

The Grouvid study suggests that delays in patient management, linked to the 1st wave of Covid-19, could be responsible for an excess of cancer mortality of 2 to 5%, 5 years after the start of management. These delays in management are due to 2 factors:

  •  the reluctance of patients to be treated for fear of contamination
  •  and a reduction in hospital care capacity.

In this study, there is no mention of screening, neither for breast cancer screening nor for any other screening.

Contrary to what has been suggested by the ARC Foundation [i] or Professor Kahn, President of the Cancer League [ii] [iii] [iv] [v] [vi] [vii] [viii], the Grouvid study does not provide any information about the potential benefits of reduced participation in screening.

It is already difficult to extrapolate results from a single institution to all France. Extrapolating them to estimate the impact of a decrease in screening is pure fantasy ... or a deliberate lie.

The victims? Women, who, encouraged to frequent medical offices during this period, are thus endangered and exposed by these propagandistic behaviors. 

The media themselves, by lack of discernment and nuance, feed this anxiety-provoking and misleading climate.

On this subject read : https://cancer-rose.fr/en/2020/12/17/manipulation-of-information/

References


[i] https://www.francetvinfo.fr/sante/cancer/covid-19-les-retards-de-depistage-du-cancer-de-sein-vont-entrainer-une-augmentation-de-la-mortalite-entre-1-et-5-dans-les-dix-ans-qui-viennent-selon-la-fondation-arc_4124525.html#xtref=https://mobile.francetvinf


[ii] https://www.sudouest.fr/2020/10/24/cancer-du-sein-axel-kahn-lance-un-cri-d-alarme-pour-inciter-au-depistage-8000781-4696.php


[iii] https://fr.news.yahoo.com/octobre-rose-axel-kahn-implore-085353145.html


[iv] https://www.europe1.fr/societe/debut-doctobre-rose-axel-kahn-alerte-sur-les-retards-de-diagnostic-des-cancers-du-sein-3995432


[v] https://www.topsante.com/medecine/cancers/cancer/covid-19-depistage-cancer-639344


[vi] https://www.la-croix.com/Sciences-et-ethique/Deprogrammation-doperations-Linquietude-immense-malades-cancer-2020-10-27-1201121508


[vii] http://www.francesoir.fr/opinions-tribunes/chronique-covid-ndeg34-le-geneticien-axel-kahn-president-de-la-ligue-contre-le

[viii] https://www.lemonde.fr/planete/article/2020/10/26/cancers-infarctus-avc-ces-pathologies-victimes-indirectes-du-covid-19_6057437_3244.html

Cancer Rose est un collectif de professionnels de la santé, rassemblés en association. Cancer Rose fonctionne sans publicité, sans conflit d’intérêt, sans subvention. Merci de soutenir notre action sur HelloAsso.


Cancer Rose is a French non-profit organization of health care professionals. Cancer Rose performs its activity without advertising, conflict of interest, subsidies. Thank you to support our activity on HelloAsso.

EDUCATIONAL ACTIONS OF CANCER ROSE IN 2020

To access our actions in previous years: https://cancer-rose.fr/en/2021/01/17/educational-actions-of-cancer-rose-2017-2019-2/

International days on the partnership of care with the patient, Côte d'Azur University, France

L’attribut alt de cette image est vide, son nom de fichier est Nice.jpg.

Videoconference Monday, September 28 and Tuesday, September 29, 2020

The complete list of the presentations that took place during the International Days of the Patient and Public Partnership Innovation Centre, here :

https://ci3p.univ-cotedazur.fr/2020/06/06/journee-internationales-2020/

Participation of C.Bour MD as Jury Member for medical thesis

Defended on November 13, 2020, Faculty of Medicine, University of Rennes

Title : Perception by French general medicine interns of a video presenting the relevance of organized breast cancer screening.

Can this video open discussion and enable shared decision making between future GPs and their patients about screening mammography?

The video in question is Cancer Rose's " Screening Mammo, yes or no? "intended for the public and professionals. Click on "parameters" (bottom right of the video) to access to the subtitles of several languages.

Cancer Rose est un collectif de professionnels de la santé, rassemblés en association. Cancer Rose fonctionne sans publicité, sans conflit d’intérêt, sans subvention. Merci de soutenir notre action sur HelloAsso.


Cancer Rose is a French non-profit organization of health care professionals. Cancer Rose performs its activity without advertising, conflict of interest, subsidies. Thank you to support our activity on HelloAsso.

EDUCATIONAL ACTIONS OF CANCER ROSE (2017-2019)

To interested people, health professionals, organizations, students, doctors, non-medical professionals :

Do not hesitate to contact us on the contact page if you wish an intervention of our collective for evenings-debates, documentaries, training meetings ...

We answer all the mails.

Presentations in English on Slideshare :

Conference Preventing Overdiagnosis, Sydney, December 5-7, 2019

Conference "Preventing overdiagnosis" Sydney December 2019, intervention Dr. J. Doubovetkky Saturday, December 7, in the afternoon.

Presentation Cancer Rose in BMJ Evidence Based Medicine, December 2019 issue, vol.4, supplement 2, page A43, abstract 76.

Dr. J. Doubovetzky with Prof. Alexandra Barratt, organizer of the 2019 session of the Preventing Overdiagnosis congress; Sydney

Click on picture

L’attribut alt de cette image est vide, son nom de fichier est ABJV.jpg.

Conference "Preventing Overdiagnosis" Copenhague August, 20, 2018

Click on picture

L’attribut alt de cette image est vide, son nom de fichier est Cop-1024x507.jpg.

Conference  15th International Meeting of Psychiatry, Psychoanalysis and Clinical Psychology, Budapest, May, 2018

Click on picture

L’attribut alt de cette image est vide, son nom de fichier est Bud.jpg.

Conference Women and Health, Bruxelles , November, 2019

Click on picture

L’attribut alt de cette image est vide, son nom de fichier est Femmes-santé.jpg.

Colloquium - over-medicalization, organized by Princeps group, November 29-30, 2019

Program: https://surmedicalisation.fr/?page_id=5649

Presentation and discussion with sound files

POSTER 4 BOBIGNY

Conference-Debate, Nancy, April 23, 2019

Dr. Annette Lexa led a conference-debate at the University of Permanent Culture in Lorraine, in the form of a powerpoint presentation followed by a question-and-answer session from the floor.

http://www.ucp-nancy.org/conferences/

Category: Nancy-Nature, Life and Health

"Systematic breast cancer screening: what benefits for what risks?"

Evening debate at the Case de Santé Toulouse

On December 18, 2018, evening debate at the Case de Santé de Toulouse animated by Dr Jean Doubovetzky, "Understanding and explaining to women the controversy on breast cancer screening".

With presentation of our new information posters for doctors' waiting rooms.

https://www.facebook.com/LaCaseDeSante/

CINE-CONFERENCE-DEBATE - NICE

On October 27, 2018 at the Maison de la Culture et Médecine, with the participation of Dr. Jean Doubovetzsky who presented a ludic presentation.... After the projection of Agnès Varda's film, "Cléo from 5 to 7".

An evening debate in Lunéville

invitation from Dr Bour Cécile

September 21, 2018

With the midwife who initiated this evening, Mrs. Amélie Henneguelle-Bataglia, once again our warm thanks to her!

L’attribut alt de cette image est vide, son nom de fichier est Lunév.jpg.

Autonomous Grouping of Young General Practitioners and Replacements

Workshop: "Breast cancer screening, explaining the controversy".
Animated by Dr Jean Doubovetzky, in Paris on March 17, 2018, as part of the Conferences of the National Union of Young General Practitioners.

The union RéAGIR (Regroupement Autonome des Généralists Jeunes Installés et Remplaçants (ReAGJIR)) is an inter-union federating 15 regional member structures. It represents replacements in general medicine, young GPs who have been in practice for less than 5 years (regardless of how they practice in primary care) and heads of general medicine clinics.

Conference-debate in Sélestat, November 26, 2017. Dr. C.Bour

"Cancers and screenings" https://fr2.slideshare.net/CancerRose1/cancer-and-screening-a-presentation-by-cancer-rose-241499601

Dr Bour Cécile

Cancer Rose was invited to a conference-debate in Selestat by the cultural organization "les Alevis de Sélestat". About sixty participants listened to my presentation in the company of Bilgür, who was translating simultaneously.

It was an excellent moment of sharing, of questions and answers, but also of cordiality and extreme human warmth.

L’attribut alt de cette image est vide, son nom de fichier est Desktop80-1024x430.jpg.

Conference of the French Society of Mammary Senology and Pathology (French Society of Mammary Senology and Pathology)

November 8 to 10, 2017

Cancer Rose participated in the conference of the French Society of Mammary Senology and Pathology November 2017, Lille. Our présentation, click here:

L’attribut alt de cette image est vide, son nom de fichier est Lille.jpg.

Dr Vincent Robert presented the poster, and Dr Bour Cécile presented the 10 minutes oral communication. We proposed an abstract, to be found here

abstract CR

We should mention the very remarkable presentation of Professor Philippe Autier, epidemiologist at the IRPI (International Prevention Research Institute), Dardilly, to be found here: presentation P.Autier

slideshow of our intervention : diaporama de notre intervention

Poster

An interactive and humorous presentation in Lyon

Dr. Jean Doubovetzky has been invited to participate in a conference-debate on the theme "Understanding the controversy on breast cancer screening", jointly organized on October 31, 2017 by the Lyon pharmacy students' association (AAEPL) and the Lyon East Carabinieri Association (ACLE), in an amphitheater of the University of Lyon I.

The aim of the conference was to give both pros and cons opinions on the subject in order to clearly define the scientific controversy, to be interactive, with numerous interventions from the audience, both to answer questions asked during the slide show or to ask or even give an opinion.
Approximately 35 students, mostly future pharmacists, attended the presentation, which was supported by a slide show and left plenty of room for questions from the presenter, students, and discussion. The discussion continued well after the scheduled time, a sign of the students' interest and commitment.
The conference lasted about 2h30.

L’attribut alt de cette image est vide, son nom de fichier est shadok.png.

(Shadok motto: "By trying hard, you will succeed. So: the more it fails, the more likely it is to work. »)

"Prescrire" meetings Toulouse June 2017 "Medication in society, everybody's business";

L’attribut alt de cette image est vide, son nom de fichier est Jean.jpg.

presentation of a poster, by Dr. J. Doubovetzky

Cancer Rose est un collectif de professionnels de la santé, rassemblés en association. Cancer Rose fonctionne sans publicité, sans conflit d’intérêt, sans subvention. Merci de soutenir notre action sur HelloAsso.


Cancer Rose is a French non-profit organization of health care professionals. Cancer Rose performs its activity without advertising, conflict of interest, subsidies. Thank you to support our activity on HelloAsso.

Hormone Replacement Therapy (HRT) and Breast Cancer

Synthesis by Cécile Bour, MD, 

December 29, 2020

The debate on the question of the link between HRT and breast cancer is long-standing, dating back to 2002 when an American study suggested an over-risk of cancer in patients on HRT. This first study resulted in great controversy. This WHI (Women Health Initiative) trial is a large randomized American study whose objective is to evaluate the risks and benefits of different dietary and medical strategies that can reduce the incidence of cardiovascular disease, breast cancer, colorectal cancer and fractures in postmenopausal women.

Planned to last more than 8 years, the trial was prematurely stopped in the first half of 2002 after a little more than 5 years, as the risks were deemed to outweigh the benefits, in particular due to the appearance of unfavorable and unexpected cardiovascular effects of HRT.

Indeed, the study confirmed a vertebral and femoral anti-fracture effect, a beneficial effect on the decrease of colon cancer rate, but found an increase in cerebrovascular accidents, myocardial infarction, phlebitis and pulmonary embolism, and breast cancer.

The results were contested in France on the basis that the products used in the study were orally administered and normodosed equine estrogens (whereas in France were used transdermally or orally estradiol), and medroxyprogesterone acetate which was not used in France. Great relief therefore when JAMA[1], in 2017, came back on these first rather frightening results and contested this excess mortality in the WHI study, the French gynecologists then considering HRT globally as a "good thing if the treatment is not standardized but personalized"[2].

However, in medicine, nothing is ever set in stone, and in 2003, another study, an English one[3] conducted from 1996 to 2001 including more than a million menopausal women between 50 and 64 years old, showed an over-risk of breast cancer under HRT, even with treatments commonly used in Europe. The result of the study was that the risk of developing breast cancer as well as the risk of cancer-related death was greater in treated women than in untreated women, and greater in women treated with combined estrogen-progestin therapy than in women receiving estrogen therapy alone. This English study examined many of the treatments used in Europe, both for the types of estrogen-progestin and for their means and routes of administration.

The controversy was such that the systematic prescription of HRT was drastically slowed down in 2004. And it is true that a decrease in the incidence of this cancer was observed around 2004, when HRT was stopped being prescribed on a large scale and for long periods of time. [4]

A 2019 study – an over-risk of cancer confirmed under HRT treatment

This is a review of 58 epidemiological studies on the subject of the association between HRT and breast cancer, mostly observational, involving more than 100,000 women in total. Published in 2019 in The Lancet [5], this review demonstrates an increased risk of breast cancer in women undergoing hormonal treatment for the effects of menopause. While this excess risk decreases well after stopping treatment, it persists for at least ten years.

The study is innovative in that it quantifies the risk for each type of treatment.

For example, a fifty-year-old woman who has been on HRT combining estrogen and progesterone continuously for 5 years has a risk of developing breast cancer within 20 years of starting treatment of 8.3%. The risk would be only 6.3% for women of the same age who have had no treatment.

The risk of developing breast cancer after 20 years would be 7.7% for women who have been treated with estrogen and progesterone but intermittently, and 6.8% for those treated with estrogen alone, according to the researchers.

What should be learned essentially from the study?

  • All hormonal treatments for menopause are associated with increased risk, with the exception of estrogen gels for local application.
  • The risk would also increase with the duration of treatment, the use of HRT for 10 years would result in an excess risk of breast cancer about twice as high as the risk of a 5-year treatment alone.
  • Conversely, using HRT for less than a year would result in a low risk.

Adapt according to the need

Currently the practice aims to individualize prescriptions, carefully considering the risks and benefits of treatment for each woman and taking into account whether or not to use HRT, depending on the woman's climacteric disorders (Climacteric refers to the years of hormonal change experienced by the woman before and after menopause).

The recommendation of the High Authority of Health (HAS-France)

In 2004 the French High Authority for Health (HAS) issued a recommendation[6] that is still in force: HRT should be prescribed for a short period of time. The HAS specifies that there is no need to prescribe additional or specific radiological examinations for women treated with HRT, but the HAS does request that all women treated be systematically included in the screening program. The following is recommended  [7]:

  •  In case of hormone replacement therapy or menopause hormone treatment in progress :

In case of prescription before the age of 50 and in the absence of sufficient data to determine the benefit-risk balance of mammography, no specific radiological monitoring is recommended.
In case of prescription after the age of 50, no specific radiological monitoring is recommended. The woman should be encouraged to participate in the national organized screening program.

Therefore, in the case of prescribing HRT, the prescribing physician cannot, at the risk of legal action, manage the treatment without recommending the systematic screening of his patient for breast cancer[8].

References

[1] https://jamanetwork.com/journals/jama/article-abstract/2653735

[2] https://www.lequotidiendumedecin.fr/actus-medicales/recherche-science/thm-letude-whi-montre-finalement-une-absence-de-surmortalite

[3] https://www.ansm.sante.fr/S-informer/Communiques-Communiques-Points-presse/Traitement-hormonal-substitutif-et-risque-de-cancer-du-sein

[4] Page 6 of the document: " STATUS AND KNOWLEDGE REPORT / GUIDELINE FILES".

FEBRUARY 2015

HORMONE TREATMENTS/MENOPAUSE AND RISKS OF CANCERS

Document written and coordinated by the Prevention Department, Public Health and Care Unit (PSPS)-INCa. "Although this hypothesis needs to be further explored, the decrease in breast cancer incidence has also been described in other countries where the drop in the prescription of THMs (hormonal treatment for menopause) has been spectacular, such as in Canada, Germany, the United States, Belgium and Australia".

[5] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31709-X/fulltext

[6] https://www.has-sante.fr/jcms/c_1754596/fr/traitements-hormonaux-de-la-menopause

[7] https://www.has-sante.fr/jcms/c_1741170/fr/depistage-du-cancer-du-sein-en-france-identification-des-femmes-a-haut-risque-et-modalites-de-depistage#toc_1_2

[8] https://cancer-rose.fr/2020/03/02/depistage-et-paradoxe-lors-de-lusage-de-certains-medicaments/

Cancer Rose est un collectif de professionnels de la santé, rassemblés en association. Cancer Rose fonctionne sans publicité, sans conflit d’intérêt, sans subvention. Merci de soutenir notre action sur HelloAsso.


Cancer Rose is a French non-profit organization of health care professionals. Cancer Rose performs its activity without advertising, conflict of interest, subsidies. Thank you to support our activity on HelloAsso.

DIABETES AND CANCER

By Dr. C. Bour, January 5, 2021

The link between diabetes and cancer in general and diabetes and breast cancer in particular is well known, as shown in a 2012 meta-analysis [1].

This meta-analysis revealed a significant increase in the risk of breast cancer in women with diabetes compared to non-diabetic women. However, the association between diabetes and breast cancer risk appeared to be limited to postmenopausal women. Type 1 diabetes and diabetes in premenopausal women were not associated with a significant increase in breast cancer risk.

People with type 2 diabetes have a higher risk of developing cancers of the breast, pancreas, liver, kidney, endometrium and colon. 
While patients with type 1 diabetes are more likely to develop cervical and stomach cancers.

Several studies have also shown that patients with diabetes and cancer have a poorer prognosis than those without diabetes. Diabetes and hyperglycemia are associated with higher infection rates, shorter remission periods and shorter median survival times, as well as higher mortality rates[2].

Several mechanisms might explain why type 2 diabetes could increase the risk of cancer are being implicated: hyperinsulinemia, hyperglycemia and inflammation. The increase in blood glucose levels is believed to have carcinogenic effects by causing DNA damage.

Particular case of breast cancer

The meta-analysis discussed at the beginning of this article was conducted using a random effects model to study the association between diabetes and breast cancer risk [3].

The risk of breast cancer in women with type 2 diabetes is increased by 27%, a figure that decreases to 16% after adjusting for BMI. Obesity is an aggravating factor as shown in other studies.  

No increase in risk has been observed in women in pre-menopausal age or with type 1 diabetes.

In addition to the over-risk of cancer in the diabetic patient, what about the management of the patient with both diabetes AND cancer? [4] [5]

The management of the diabetic patient requires treatment not only by hygienic and dietetic measures but also by a finely tuned medication protocol that may include insulin and one or more oral agents.

Chemotherapy and analgesics can affect glucose homeostasis[6] and insulin sensitivity; drug interactions can interfere with the patient's tolerance to diabetes drugs; decreased appetite, nausea, vomiting and weight loss resulting from both disease and cancer treatment can cause imbalances in blood glucose levels.

Chemotherapeutic agents

Several chemotherapies are known to cause or exacerbate these adverse conditions. For example, cisplatin is known to cause kidney failure, and anthracyclines can cause cardiotoxicity. Cisplatin, paclitaxel and vincristine may be neurotoxic. Unfortunately, many of these side effects may remain permanent.

For cancer treatment to be effective, at least 85% of the chemotherapy dose must usually be administered. Patients with diabetes should be carefully monitored before the start and during chemotherapy. Treatment decisions should be based on the patient's clinical picture, but always be aware that any change in dose, or alteration in the timing of administration, or substitution of another chemotherapeutic agent may compromise results by reducing the response rate to treatment.

Corticosteroids

They represent an important part of treatment in cancer pathologies and are widely used to improve nausea and vomiting associated with chemotherapy, as well as to suppress neurological symptoms when the cancer has metastasized to the spine or brain. And they cause significant hyperglycemia within hours after administration. 

The treatment of hyperglycemia resulting from glucocorticoids then depends on the type of diabetes, the severity of the hyperglycemia levels, the dose and the duration of therapy. Administering steroids in multiple doses throughout the day instead of a single bolus dose, or administering the entire daily dose of steroids intravenously over 24 hours, can help control hyperglycemia.

Patients with pre-existing diabetes can be maintained on oral hypoglycemic agents and closely monitored. However, these medications are generally unsuitable for managing hyperglycemia in this setting and insulin is used.

Patients using insulin prior to glucocorticoid therapy will typically require both basal and preprandial insulin. These patients may require two to three times their usual insulin dose. Insulin is the preferred drug for the management of steroid-induced or steroid-exacerbated hyperglycemia in patients with known diabetes.

Patients with type 1 diabetes will need to adjust their dose. Type 2 patients who are already taking oral agents at baseline will add insulin, but only during this period when their blood glucose levels are high.

Several studies of cancers as disparate as small cell lung cancer and breast cancer have found an association between poorly controlled hyperglycemia and poor outcomes in these patients with both diabetes and cancer. Hyperglycemia also increases the risk of infection.

In patients with active cancer, the management of hyperglycemia focuses on the prevention of long-term complications to avoid acute and sub-acute outcomes, such as dehydration due to polyuria, infection, catabolic weight loss, hyperosmolar non-ketotic states and diabetic ketoacidosis [7].

Analgesics

Analgesics can cause constipation that affects patients in two ways. It can make them want to not eat, but also, by slowing down intestinal motility, narcotics may delay the absorption of nutrients. This can lead to a mismatch between the administration of insulin and the absorption of glucose. The patient faces the risk of hypoglycemia.

Statins and chemotherapy [8]

Statins and chemotherapeutic agents are metabolized by the same enzymes in the liver. 

If the liver enzymes are all captured by statin therapy, this may result in less elimination of chemotherapy. Some research suggests that it also works the other way around. If you give a statin to a patient on chemo and then stop the statin, he or she will eliminate the chemotherapy drug much more quickly. 

In general, therefore, there is a reluctance to start statin therapy in someone just starting chemotherapy because of possible hepatotoxicity," says Lavis [9] . If patients are already on statins, it is important to be aware of their effects and monitor them carefully. 

It is appropriate to target therapeutic interventions according to the patient's prognosis. If the prognosis is poor, we should be less demanding about the goals and not overburden the patient's treatment based on excessive expectations.

Prognosis and comfort

Prognosis, longevity and quality of life are important considerations in setting blood glucose targets. A pragmatic approach to the management of hyperglycemia in these patients is necessary.

The interest of a very strict glycemic control is to try to prevent complications in 10, 15, 20 years. 

But in a person with a poor prognosis or a life expectancy of only a few years, one must be more concerned about comfort and quality of life in the remaining years.

The goal would then be to avoid the effects of acute hyperglycemia, such as dehydration and ketoacidosis.

Conclusion

There is strong epidemiological evidence that diabetic diseases are associated with an accumulated risk of several cancers. There is also growing evidence that the degree of hyperglycemia and the treatment modalities for hyperglycemia influence cancer risk. 

The risk of breast cancer in women with type 2 diabetes is increased and obesity is an aggravating factor. On the other hand, there is no over-risk observed in women in pre-menopausal age or with type 1 diabetes.

The management of blood glucose levels in patients with diabetes and cancer can pose a significant clinical challenge. As there is no clear evidence that tight glucose control improves cancer outcomes, hyperglycemia must be managed pragmatically to ensure that the patient remains asymptomatic and at low risk of acute decompensation. 

Proactive management of glucocorticoid-induced hyperglycemia can help reduce large fluctuations in glucose levels. 

Read also :

https://www.healthline.com/diabetesmine/living-with-cancer-and-diabetes#1

References

[1] Diabetes and breast cancer risk: a meta-analysis  British Journal of Cancer (2012) 107, 1608–1617 https://pubmed.ncbi.nlm.nih.gov/22996614/

P Boyle M Boniol A Koechlin .....and P Autier1/Prevention Research Institute, 95 cours Lafayette, 69006 Lyon, France

[2] Clinical Challenges in Caring for Patients With Diabetes and Cancer
Helen M. Psarakis, RN, APRN-Diabetes Spectrum Volume 19, Number 3, 2006

https://spectrum.diabetesjournals.org/content/19/3/157

[3] https://pubmed.ncbi.nlm.nih.gov/22996614/

[4] https://endocrinenews.endocrine.org/july-2014-double-jeopardy/

[5] Clinical Challenges in Caring for Patients With Diabetes and Cancer-Helen M. Psarakis, RN, APRN-Diabetes Spectrum Volume 19, Number 3, 2006

https://spectrum.diabetesjournals.org/content/19/3/157

[6]  Phenomenon by which a key factor is regulated to persist around a beneficial value for the body.

[7] https://www.cancernetwork.com/view/diabetes-management-cancer-patients

[8] https://endocrinenews.endocrine.org/july-2014-double-jeopardy/

[9] Victor Lavis, MD, professeur au Département de néoplasie endocrinienne et des troubles hormonaux à l'Université du Texas MD Anderson Cancer Center à Houston.( https://endocrinenews.endocrine.org/july-2014-double-jeopardy/)

 

Cancer Rose est un collectif de professionnels de la santé, rassemblés en association. Cancer Rose fonctionne sans publicité, sans conflit d’intérêt, sans subvention. Merci de soutenir notre action sur HelloAsso.


Cancer Rose is a French non-profit organization of health care professionals. Cancer Rose performs its activity without advertising, conflict of interest, subsidies. Thank you to support our activity on HelloAsso.

Study of three pairs of countries compared

October 27, 2017

Breast cancer mortality in neighbouring European countries, with different levels of screening but similar access to treatment: trend analysis of WHO mortality database

Pr. Philippe Autier research director (International Prevention Research Institute), Mathieu Boniol senior statistician
(Northern Ireland Cancer Registry, Belfast, Northern Ireland, UK; Department of Public Health, Norwegian University of Science and Technology, Trondheim, Norway)
BMJ 2011;343:d4411 doi: 10.1136/bmj.d4411

https://www.bmj.com/content/343/bmj.d4411

Setting

Breast cancer mortality is compared (non-randomized comparative study) by matching countries in pairs, with the second country having introduced screening ten years later.

Northern Ireland (United Kingdom) 1990 / Republic of Ireland 2000
Sweden 1986 / Norway 1996
The Netherlands 1989 / Belgium and Flanders (Belgian region south of the Netherlands) 2001

The study concludes that breast cancer mortality declines similarly despite a significant difference in the year of introduction and participation in screening. Therefore, there is no link between screening activity and decreased mortality. Metastatic invasive cancer remains at the same rates. One of the best proofs that this screening is not effective.

Between 1989 and 2006, deaths from breast cancer decreased by 29% in Northern Ireland and by 26% in the Republic of Ireland; by 25% in the Netherlands and by 20% in Belgium and by 25% in Flanders; by 16% in Sweden and by 24% in Norway. The time trend and year of the downward inflexion was similar between Northern Ireland and the Republic of Ireland and between the Netherlands and Flanders. In Sweden, mortality rates have decreased steadily since 1972, with no downward inflexion until 2006. Countries of each pair had similar health care services and prevalence of risk factors for breast cancer mortality, but different implementation of mammography screening, with a gap of about 10-15 years.

Conclusion of the authors

The contrast between the time differences in implementation of mammography screening and the similarity in reductions in mortality between the country pairs suggest that screening did not play a direct part in the reductions in breast cancer mortality.

Cancer Rose est un collectif de professionnels de la santé, rassemblés en association. Cancer Rose fonctionne sans publicité, sans conflit d’intérêt, sans subvention. Merci de soutenir notre action sur HelloAsso.


Cancer Rose is a French non-profit organization of health care professionals. Cancer Rose performs its activity without advertising, conflict of interest, subsidies. Thank you to support our activity on HelloAsso.

PRESS RELEASE, English version of Cancer Rose web site.

2021, January 7

After several months of dedicated work, time and energy, we are pleased to announce the launch of English version of Cancer Rose web site.

Cancer Rose is a Non-Profit Organization under French law made up of independent Medical Doctors, a Doctor in Toxicology and a patient representative, with the goal of providing fair, transparent and objective information for French women on mass screening for breast cancer, based on scientific evidence.

We participated in the French Citizen and Scientific Consultation on Breast Cancer Screening organized by French Minister of Health in 2015, following the controversy on this topic in France.

We founded Cancer Rose organization and created the website in 2016.

At the international level, we exchange and share information on medical issues including over-diagnosis and the resulting over-treatment, with members of different organizations such as HealthWatch Charity in the UK,  the Institute of Scientific Freedom in Denmark, Choosing Wisely health organization in Canada, Wiser Healthcare Group of collaborating researchers in Australia, as well as American patient advocate Donna Pinto, member of the Steering Committee of the International “Precision” Project.

Our aim with this English version is to inform international visitors about our activities, to create connections and share our views on mass breast cancer screening controversy with women and professionals around the world.

We will update our content with new information, posts, announcements, events.

We hope you can find this website useful and easy to navigate.

Please follow us on Twitter and Facebook for news.

If you have any questions, suggestions, feedback or comments, please contact us.

Members of Cancer Rose have no sponsorships, honoraria, monetary support or conflict of interest from any commercial sources. They dedicate their time to this activity on a voluntary basis. The funds necessary for the functioning of this website and production of information materials (educational films, brochures, posters) are generated by individual donations and members contributions.

Cancer Rose est un collectif de professionnels de la santé, rassemblés en association. Cancer Rose fonctionne sans publicité, sans conflit d’intérêt, sans subvention. Merci de soutenir notre action sur HelloAsso.


Cancer Rose is a French non-profit organization of health care professionals. Cancer Rose performs its activity without advertising, conflict of interest, subsidies. Thank you to support our activity on HelloAsso.