A letter from Ameli (French Health Insurance)

27 October 2022, by Cancer Rose
Updated December 2022

Dear Sir or Madam,

Your attending physician plays a central role in prevention actions. Depending on your situation, he can inform you and answer your questions about organized screening for breast, cervical and colorectal cancer, which can save lives. The earlier these cancers are detected, the better the prognosis.
To help your doctor in his mission of providing health advice to his patients, the Health Insurance will provide him with the list of his patients concerned by these screenings and who have not completed them (1).
Under the provisions relating to personal data protection, you have until December 1, inclusive, to oppose this transmission via the following link: https://www.demarches-simplifiees.fr/commencer/declarer-mon-opposition.
If you make your objection after December 1st, your request will not be considered for the first available list but will be considered for future lists.
Your situation could mean that some of these organized screenings do not apply to you; in this case, please disregard this message.

Please be assured of our attention and availability,
Your Health Insurance Correspondent

This is the letter that everyone has received from their Health Insurance.

Remember that during the citizens' consultation, the Health Insurance Institution's simplistic communication was criticized; read pages 95 and 96 of the citizen consultation on breast cancer screening report.
It cannot be stated that communication is more advanced in 2022, leaving any opportunity for reflection or doubt.

In this email, it is claimed that these screenings save lives. However, there is no scientific evidence, no study given, no justification, and no single reference. The message notifies you that your attending physician will be informed of the screenings you have not yet completed...
Ideally, one would hope that this approach would encourage discussion with the family physician about the relevance of screening, leading to a consultation that would result in a shared decision and information that would allow an informed choice. But what about in real life? One of our readers correctly asks if this will not instead allow putting a little more pressure on patients to participate in screenings that are losing momentum rather than an informed decision consultation if the health insurance institution itself starts with the presumption that screenings save lives, which is far from reality. There is little communication about the scientific challenges still rising regarding the true relevance of screening and its harms. [1] [2] [3] [4] [5].

The user who receives this email must activate the rejection; hence, if he does not click on the link allowing him to oppose, his acceptance is activated by default.

This initiative appears to be a part of the larger European plan to increase European population participation in various screenings, despite many scientists' requests for better information on the benefit-risk balance of these health programmes.
The target is for 90% of EU citizens to participate in colorectal, breast, prostate, and cervical cancer screenings by 2025.

The new French 10-year plan states (https://www.e-cancer.fr/Institut-national-du-cancer/Strategie-de-lutte-contre-les-cancers-en-France/La-strategie-decennale-de-lutte-contre-les-cancers-2021-2030):

“Improving access to screening will be strengthened.”

"It will be a matter of better understanding the determinants of reluctance to screening and simplifying access to screening (direct order, diversified health professionals, mobile teams in particular). Approaches will be developed that offer screening after a preventive intervention or unscheduled care.

For example, partnerships with food aid organizations will be considered to carry out awareness-raising efforts, particularly among the most disadvantaged. First, contact information tools for health, medical, and social workers will be provided, and mobile applications with information and reminders will be developed. To encourage people to participate in screening, material incentives will be tested. Finally, screening age limits will be reconsidered. "

The financial incentives specified in the text allow for the recruitment of the most economically disadvantaged people, again disregarding any medical knowledge, as was denounced in an article in the BMJ, whose one of its authors is a French citizen[6]. For these more vulnerable persons, the consequences of abusive screening can be dramatic, resulting in impoverishment, loss of income, and difficulty getting jobs.
The problem of these underprivileged people is much more the access to care than finding unnecessary cancers that would never have harmed them. It is also a problem of good medical information and fight against risk factors to which they are more exposed.

But sometimes, too much is the enemy of the good. With the other screenings of the European plan that are going to be added with new invitations, reminder letters, mobile applications, and increased medical consultations, the effect obtained could be the opposite: a weariness of the population, already more and more distrustful of medical injunctions, and who will turn away, as it is already the case, from traditional medicine that is more and more coercive and harassing.

Enough is enough.

Update December 2022

https://www.ameli.fr/medecin/actualites/depistages-organises-des-cancers-envoi-aux-medecins-traitants-de-listes-de-patients-eligibles

The summum is reached in a communication dated November 23, 2022, in which doctors are explicitly asked to incite their patients to undergo screening.

In addition to the ROSP system (remuneration based on public health objectives, which is already highly questionable and contested), the Assurance Maladie (French National Insurance) wishes to strengthen the role of primary care physicians in inciting screening by using lists of patients who are eligible but have not participated in screening.

"The effectiveness of these screenings has been demonstrated because the earlier cancers are detected, the better the prognosis: they save lives," they write in their letter.

This is inaccurate, incomplete, and unethical in its deliberate silencing of the harms and risks of screenings, for which the citizen consultation requested clear information for women. The EU Council has recently reaffirmed and reiterated this demand for transparent information.

The Health Insurance views the doctor as a simple inciting player for patients who are listed and are not compliant with the screening; the comprehensible information requested by the citizens, which is the primary responsibility of the attending physician, is thus buried, and informed consent is a utopia....

Communication text :

Organized cancer screenings: lists of eligible patients sent to attending physicians

November 23, 2022

At the beginning of December, the Assurance Maladie (French National Health Insurance) will mail to attending physicians a list of their patients who have not had cancer screening (cervical cancer, breast cancer, and colorectal cancer) within the recommended intervals.

Based on the double observation that France lags behind its European neighbors in terms of participation rates in organized screenings and that these have stagnated since 2018, Assurance Maladie wishes to strengthen the role of attending physicians in inciting screenings by providing them with a list of their eligible patients.

These screenings have demonstrated effectiveness because the earlier cancers are detected, the better the prognosis: they save lives.

The crucial role of general practitioners in screening participation has been demonstrated both in France and abroad. Because of their privileged relationship with their patients, doctors can incite them to undergo these screenings and answer their questions during a consultation.

To facilitate the execution of this public health mission, the list made available to attending physicians includes their patients who have not participated in the screenings for which they are eligible, according to the recommended intervals, whether within the framework of organized screenings or an individual approach.

These are:

- women aged 25 to 65 for organized cervical cancer screening ;
- women aged 50 to 74 for organized breast cancer screening;
- women and men aged 50 to 74 for organized colorectal cancer screening.

Please note: despite all the attention paid by Assurance Maladie to the targeting of the insured persons on this list, it is possible that some of them are not concerned (specific follow-up, recent screening, etc.). Some patients may have expressed opposition to being included on these lists.

References

[1] https://cancer-rose.fr/en/2022/09/13/the-risks-of-screening-an-elephant-in-the-room/

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

[3] https://www.nejm.org/doi/full/10.1056/NEJMoa2208375

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

[5] https://cancer-rose.fr/en/2021/02/24/being-a-woman-and-smoking-x-rays-in-perspective/

[6] https://www.bmj.com/content/376/bmj-2021-065726

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.

Screening: it is urgent to improve the information for women

DECEMBER 14, 2022, BY CANCER ROSE

Recently, we relayed the EU Council's new screening guidelines, which we found to be rather prudent and thoughtful.
The text of the EU Council can be found here.

In broad terms, the Council emphasizes the need for additional information on the effectiveness, cost-effectiveness, and feasibility of certain screening strategies in the real life, especially for new screenings such as prostate, lung, and stomach cancer.
Member States are invited to evaluate the introduction of cancer screenings based on conclusive scientific evidence, taking into account the balance between the benefits and risks of the screenings, about which the public should be informed.

Publication in the Official Journal

The text has been published in the Official Journal. The following paragraphs seem to be of capital importance because they reflect the 2016 French citizens' consultation demands.

(8) “Screening is the process of testing for diseases in people in whom no symptoms have been detected. In addition to its beneficial effect on disease-specific mortality and on incidence of invasive cancers, the screening process also has inherent limitations, which can have negative effects for the screened population. These include false positive results, which can cause anxiety and may require additional testing that may pose potential risks, false negative results, which provide false reassurance leading to delays in diagnosis, overdiagnosis (i.e. detection of cancer not expected to cause symptoms during the patient’s lifetime) and subsequent overtreatment. Healthcare providers should be aware of all the potential benefits and risks of screening for a given type of cancer before embarking on new organised cancer screening programmes. Furthermore, these benefits and risks need to be presented in an understandable way that allows individual citizens to give informed consent to participate in the screening programmes.”

(24) It is an ethical, legal and social prerequisite that cancer screening should only be offered to fully informed people with no symptoms, if the benefits and risks of participating in the screening programme are well-known and the benefits outweigh the risks, and if the cost-effectiveness of the screening is acceptable. This assessment should be an inherent part of the implementation at national level.

The Council also recommends, in the same text, that Member States :

(4) “ensure that benefits and risks, including potential overdiagnosis and overtreatment, are presented to the people participating in the screening in an understandable way, potentially including on a health professional-to-participant basis, allowing individuals to express informed consent when deciding to participate in the screening programmes, and that the principles of health literacy and informed decision-making to increase participation and equity are taken into account;.”

Improving women's access to information: an absolute necessity


We emphasized the insufficient information in the INCa booklet sent to women, which, although some changes over the previous one, still lacks a visual pictogram allowing a simple understanding of the benefit/risk balance and does not mention screening risks but instead uses the term "limits" along with explanations to minimize them.

Download / Télécharger


This publication is not in accordance with EU Council recommendations.
It is sent to the woman only once when she reaches the age of 50, after which she will only receive a leaflet at each subsequent screening, that fails to mention any of the risks of screening and refers to a website that is similarly susceptible to criticism. Over the course of a woman's lifetime, it is evident that the message that will remain in her memory will be the "embellished" leaflet, that omits the risks completely.

Leaflet - Breast Cancer Screening. Practical guide

This leaflet, whose content is largely based on that of the booklet, will be sent to women aged 50 and over when they renew their invitation to participate in the DOCS. It can also be distributed at information meetings.

In the EU Council's document, the different risks of screening, such as false alarms and overdiagnosis, are well defined (in part 8). In contrast, in the INCa leaflet, the definitions of these concepts are sometimes imprecise, often minimized, the definition of overdiagnosis is incomplete, and overtreatment is not explained (see our analysis).
In the booklet, there is no mention at all of overdiagnosis.
It is therefore urgent, based on the EU requirement regarding the presentation of screening risks to targeted populations, to improve the information provided to women invited to screening beyond the age of 50, from the age of 52 onwards, while also respecting the requirements for good literacy and without obscuring the concepts of false alarm and overdiagnosis, the two major risks of breast cancer screening.
In addition, 5-year survival is highlighted as a "benefit" in both the booklet and the leaflet, despite the fact that it is not a measure of screening effectiveness.
In the recommendation of the Council, it is stated:
(6) The main indicator of the effectiveness of screening is a reduction in disease-specific mortality or in incidence of invasive cancers.

In addition, the presentation of benefits and risks does not conform to EU Council recommendations for comprehension. The reduction in breast cancer mortality is given as a relative percentage reduction (15-21%), whereas the percentage of overdiagnosis is described as an absolute percentage (10-20%), making comparison impossible. This flaw already exists in the 2017 publication.
A 20% reduction in cancer mortality does not correspond to 20 fewer cancer deaths per 100 women screened.

This is an indication a relative risk only. 20% fewer deaths does not imply that 20 fewer women out of 100 will die of breast cancer if screened. The 20% reduction in mortality is simply a relative risk reduction between the two groups of women being studied.
In fact, according to a projection produced by the Cochrane Collective based on numerous studies, out of 2,000 women screened over a 10-year period, four die of breast cancer, whereas out of the same number of women who were not screened, five die of breast cancer. The shift from five to four represents a 20% reduction in mortality, but in absolute terms, just one woman's death will be prevented (absolute risk of 0.1% or 0.05%).
The range of 10-20% provided for the rate of overdiagnosis represents the lowest estimate. Other research indicate substantially higher overdiagnosis rates. Overdiagnosis is largely overlooked in the leaflet, and there is a striking omission of risk information that is easily understood.

Read more:

What could be improved?

It is time for the health authorities to finally respond rigorously to the Council's recommendations published in the Official Journal and to respect the French population by complying with these recommendations.
These recommendations state that "the benefits and risks must be presented in an understandable way to allow citizens to give their informed consent to participate in screening programs."

To do this, a modern and validated strategy employs decision support tools, such as the one developed by the Harding Center for Literacy, which describes how harms might be presented visually.
https://www.hardingcenter.de/en/transfer-and-impact/fact-boxes/early-detection-of-cancer/early-detection-of-breast-cancer-by-mammography-screening

The methodology is perfectly described here:
https://www.hardingcenter.de/de/transfer-und-nutzen/faktenboxen,
with the reference: https://www.hardingcenter.de/sites/default/files/2021-06/Methods_paper_Harding_Center_EN_20210616_final.pdf
8) Page 13, “Handling numbers and presentation of risks. The benefits and harms of medical intervention are balanced in fact boxes. By specifying the references and using the past tense, it is clear that these are study results, and thus no individual prediction is possible. The reference in numbers is always the same for the intervention and control groups. The event frequencies are communicated in absolute numbers. Relative risks are not reported. Which reference value is chosen (100, 1,000, or even 10,000) depends on the study data. It has to be ensured that the indication of integers is possible and that existing statistically significant differences become clear. The absolute change in risk is shown in the short summary of the fact box and the accompanying text. Mismatched framing (the presentation of advantages and disadvantages in different formats) is not used. ”

Another illustration is available in the WHO guide, on pages 37/38
https://apps.who.int/iris/handle/10665/330829
“Both laypeople and clinicians tend to overestimate the benefits of screening and underestimate the harm of screening (36). Training personnel on communicating risk and tools such as infographics, videos and decision aids can be used to facilitate understanding and promote informed consent and evidence-informed practice (Fig. 15).”
See the infographic on page 38
We propose on our side a short illustrated tool, "Cancer Rose", based on French data, which you can consult here: https://cancer-rose.fr/en/breast-cancer-decision-aid/

To conclude

The Council of the EU has issued recommendations, particularly on public information and the presentation of information that meets citizens' demands.

- The WHO calls for the respect of the Wilson and Junger principles (read here, middle of the article);

- the French citizen and scientific consultation asks for an improvement of the information with an honest and neutral presentation of the data,

- the EU Council strongly recommends an understandable presentation of the risks of screening, so what is the additional step that our French health authorities need to take in order to honestly and sincerely explain the benefits and risks to women allowing them to make a real informed choice?

We must stop hiding the risks of screening, to which women are shamefully subjected. Instead, we should inform them that screening might expose them to inconveniences and risks, including overdiagnosis, which can unnecessarily lead to a disease they would never have known without it.

Yes, it's really time....

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.

Booklet WHO

Download/Télécharger

WHO Screening programmes: a short guide. Increase effectiveness, maximize benefits and minimize harm. Copenhagen: WHO Regional Office for Europe; 2020.
https://apps.who.int/iris/handle/10665/330829

« Screening programmes should provide unbiased and easy-to-understand informa­tion so that people can make an informed decision on whether to participate in screening.
Both laypeople and clinicians tend to overestimate the benefits of screening and underestimate the harm of screening. Training personnel on communicating risk and tools such as infographics, videos and decision aids can be used to facilitate understanding and promote informed consent and evidence-informed practice (Fig. 15, p38). »
« Fig. 15. Use of infographic to illustrate overdiagnosis in breast cancer screening, »

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.

Caution of the Council of European Union regarding screenings extension

By Cancer Rose, December 11, 2022

In September 2022, the European Commission issued recommendations for a new approach to screening.
We wrote about it here: https://cancer-rose.fr/en/2022/09/24/a-new-eu-approach-to-cancer-screening/

The European Commission proposed an extension and/or a reintroduction of some screenings and an implementation of new ones, some of which do not exist ( gastric cancer screening)...
The objective is that by 2025, 90% of the EU population should be screened for breast, prostate, cervical and colorectal cancer.
Lung and gastric cancer screenings would be added, although no conclusive study exists for the latter.
We are relieved that the Council of the European Union has not followed these recommendations and has been cautious. In this month of December is published the adopted text which we will analyze.

Comparison of press releases
Comparison of the recommendations between the initial proposal and the adoption of the final recommendations by the member states
Summary of breast cancer screening recommendations
Recap of the lung cancer screening controversy
Reminder of the prostate cancer screening controversy
Conclusion
Reactions
Reaction of WONCA

Comparison of press releases

Below is a comparison between the original draft from September 2022 and the one issued in December 2022, which presents the adopted final recommendations.

Download/Télécharger

Differences between the proposal and the adopted text are highlighted :

- For cervical and colorectal cancer, more moderate terms are used on the use of tests, described as a "preferred" tool for cervical cancer screening or as a "preferred screening" regarding immunochemical tests for colorectal cancer screening.

- For the three new screening tests (lung, gastric, prostate cancers), the Council invites to carry out research beforehand to study the feasibility and effectiveness of these tests and therefore refrains from introducing them as initially recommended.

- For breast cancer, the recommendation remains between 50 and 69, and screening is only suggested between 45-74 (not "recommended" as initially intended by the EC).
It should be noted that screening at 45-50 years was already initially only "suggested."

Comparison of the recommendations between the initial proposal and the adoption of the final recommendations by the member states

Caution: link modification for the new proposal for a Council Recommendation (CR) on Strengthening prevention through early detection: A new approach on cancer screening replacing CR 2003/878/EC https://health.ec.europa.eu/publications/proposal-council-recommendation-cr-strengthening-prevention-through-early-detection-new-approach_en

Download/Télécharger

Here are the main improvements in the final text and the precautions retained by the decision-makers:

  • The Junger and Wilson* principles are recalled, which should be applied as well as other criteria set out by the WHO to assess the feasibility of screening before its implementation
  • The risks of overdiagnosis (with a clear definition) and overtreatment were added, as well as the need for information.
  • Technical support for informed decision-making is mentioned
  • The notion of "screening effectiveness" is finally defined by mentioning that the decrease in specific mortality and the decrease in the incidence of invasive cancers defines it.
  • It is recalled that for lung and prostate screening, the evidence is limited
  • It is emphasized that aspects of the health system's capacity to support screening and the resources required must be considered.
  • "Screening should be offered when there is evidence that screening improves specific mortality" is replaced by "screening should be offered when the benefits and risks are well known, and benefits outweigh the risks."
  • Regarding cost-effectiveness, this should be considered at the national level
  • It is recalled that screening tests (for the 3 current screenings (cervical, colo-rectal and breast cancers) and for 3 new screenings (lung, gastric and prostate cancers) to be studied) should be offered only if it is proven that the Junger and Wilson criteria outlined by the WHO are met and that information on benefits and risks is reliable.
  • Emphasis is placed on considering national capacities and priorities when implementing new screening programs.
  • The objective of 90% of the European population to be offered all 3 screenings (breast, colorectal, and cervical) by 2025 is removed from the text (probably unrealistic).
  • In informing the population, the benefits and risks, including overdiagnosis and overtreatment, must be presented, potentially through an exchange between the patient and the health professional, for an informed decision made by the patient.
  • For new screening tests, the implementation should be considered only after randomized trials with scientific evidence of effectiveness.
  • It is also necessary to work and cooperate on predictive tests and algorithms to reduce overdiagnosis and overtreatment.
  • The need to have scientific evidence (evidence-based) is recalled, and the term "risks" is added next to "benefits" in the evaluation of screening programs,
  • Technical support with information activities, where relevant, for the general public and stakeholders about the benefits and the risks of participation in the screening programmes, taking into account the principles of health literacy and informed decision-making, could be provided.

*Junger and Wilson's principles for implementing screening:

What are the criteria used by the WHO to determine the appropriateness of screening?

The 10 criteria used by the WHO are:

- The disease studied must present a major public health problem
- The natural history of the disease must be known
- A diagnostic technique must be able to visualize the early stage of the disease
- The results of the treatment at an early stage of the disease must be superior to those obtained at an advanced stage
- Sensitivity and specificity of the screening test should be optimal
- The screening test must be acceptable to the population
- The means for diagnosis and treatment of abnormalities found in screening must be acceptable.
- The screening test should be repeatable at regular intervals if necessary
- The physical and psychological harm caused by screening should be lower than the expected benefit
- The economic cost of a screening program should be outweighed by the expected benefits

Summary of breast cancer screening recommendations

- 1) Current European guidelines for 45-50 and 70-74-year-olds

The current guidelines, published on the European website, do not recommend screening for women aged 45-50 and 70-74 but only "suggest" it.

https://healthcare-quality.jrc.ec.europa.eu/european-breast-cancer-guidelines/screening-ages-and-frequencies/women-45-49

https://healthcare-quality.jrc.ec.europa.eu/ecibc/european-breast-cancer-guidelines/screening-ages-and-frequencies#recs-group-70-74

These guidelines, which date from 2019, are published in the journal :https://www.acpjournals.org/doi/10.7326/m19-2125

The supplement provides the table with the current recommendations that "suggest" but do not recommend screening between the ages of 45-50 and 70-74.

https://www.acpjournals.org/doi/suppl/10.7326/M19-2125/suppl_file/M19-2125_Supplement.pdf

- 2) European Commission proposal to extend screening to the age range 50-69 to 45-74

In September 2022, the European Commission attempted an extension of the cut-off points with a proposal to change the guidelines

PROPOSAL:

Text, page 1: https://health.ec.europa.eu/publications/proposal-council-recommendation-cr-strengthening-prevention-through-early-detection-new-approach_en

“Extending breast cancer screening from women aged 50 to 69 to include women between 45 and 74 years of age and to consider specific diagnostic measures for women with particularly dense breasts;"

Annex page 1

https://health.ec.europa.eu/publications/annex-proposal-council-recommendation-cr-strengthening-prevention-through-early-detection-new_en

« Breast cancer: 
Breast cancer: Breast cancer screening for women starting aged 45 to 74 with digital mammography or digital breast tomosynthesis 1 , and for women with particularly dense breasts consider magnetic resonance imaging (MRI), where medically appropriate."

- 3) EU Council counter-proposal: no change to current guidelines, no extension to include 45-74 year olds, screening not recommended but only suggested for ages 45-50 and 70-74

In response to this proposal, the Council of the European Union, in the text published on 9 December 2022, did not adopt this extension.
The guidelines for the 45-50 and 70-74 age groups have remained the same (identical to the current guidelines)

Annex, page 21

https://data.consilium.europa.eu/doc/document/ST-14770-2022-INIT/en/pdf

“Breast cancer:
Considering the evidence presented in the European guidelines 9, breast cancer screening for women aged 50 to 69 with mammography is recommended. A lower age limit of 45 years and an upper age limit of 74 years is suggested. The use of either digital breast tomosynthesis or digital mammography is suggested. The use of magnetic resonance imaging (MRI) should be considered when medically appropriate."

Recap of the lung cancer screening controversy

We have reported on the lung cancer screening controversy and subsequent reactions and publications here, updated to March 2022: https://cancer-rose.fr/en/2021/02/24/being-a-woman-and-smoking-x-rays-in-perspective/

Reminder of the prostate cancer screening controversy

Here's a reminder about prostate cancer screening and why the French National Authority for Health does not recommend it:
https://cancer-rose.fr/en/2021/02/11/parallel-to-breast-screening-prostate-screening-overdiagnosis-as-well/

https://www.has-sante.fr/jcms/c_1238318/fr/cancer-de-la-prostate-identification-des-facteurs-de-risque-et-pertinence-d-un-depistage-par-dosage-de-l-antigene-specifique-de-la-prostate-psa-de-populations-d-hommes-a-haut-risque

"To date, there is no robust demonstration of the benefit of prostate cancer screening by prostate-specific antigen (PSA) testing in the general population, either in terms of reduced mortality or improved quality of life. Thus, no prostate cancer screening program is recommended in the general population, in France, in the United States, New Zealand, or the United Kingdom."

Conclusion

The Council stresses the need for further evidence on the effectiveness, cost-effectiveness, and feasibility of specific screening strategies in real-life settings.
Member States are invited to consider the implementation of the mentioned cancer screenings based on conclusive scientific evidence while evaluating and deciding at the national or regional level based on the burden of disease and available healthcare resources, the balance of benefits and harms, and the cost-effectiveness of cancer screening, as well as the experience from scientific trials and pilot projects

For breast cancer: a low limit of 45 years and a high limit of 74 years are suggested (not recommended as in the original proposal).(The inclusion of MRI for women with dense breasts is highly debated; see https://cancer-rose.fr/2022/04/26/grosse-deconvenue-pour-lirm-mammaire/)

The Council adopts a moderate position for the new screenings (prostate, lung, gastric cancers), inviting further research to assess the feasibility and including the notion of effectiveness.
For lung cancer, the program should also include primary (tobacco control) and secondary prevention strategies.
For gastric cancer, the proposal for immediate implementation is deleted, and feasibility tests are requested.

Reactions

The reaction of the European Commissioner who initiated the project of new recommendations:

Today’s adoption by the Council of new EU recommendations for cancer screening is a milestone for cancer care both at national and European level. 20 years have passed since the current recommendations were adopted and medicine has made incredible advances. It is high time that new, up-to-date, screening recommendations are rolled out across the EU and that the unacceptable disparities in access are addressed. Whilst I would have liked to see an even more ambitious approach, today represents a watershed moment for citizens in the EU and a key achievement for Europe’s Beating Cancer Plan.
Stella Kyriakides, Commissioners for Health and Food Safety - 09/12/2022

The protest letter of the European Cancer Organisation (gathering urologists, radiologists, gastro, oncologists, ...) 

https://www.europeancancer.org/screening

" Late interventions to insert excessive caution and reduced ambition

...However, following a closed meeting of Member State representatives on Monday 24 October we understand that significant rewriting of the Commission’s proposal has taken place to:

  • Undermine and contradict advice provided by the EU’s Group of Chief Scientific Advisors, particularly with regards to the addition of new cancer screening programmes and areas for update in respect to tumour types presently covered in the 2003 EU Council Recommendations;
  • Delete from the text the Beating Cancer Plan targets on screening uptake;
  • Insert whole new sections stating every potential and historic cited risk of cancer screening;
  • Impose specific criteria each EU member state should use in making decisions on cancer screening,
  • Insert exaggerated emphasis on national prerogatives for countries to exempt themselves of the recommendations;
  • Dilution of advice on meeting the psychological needs of those diagnosed with cancer as a result of screening; and,
  • Weakening of sections relating to the need for fit for purpose systems for recording and publishing information on screening performance. "

Members - European Cancer Organisation

Reaction of WONCA

EUROPREV Statement about European Commission announcement of a new EU approach on cancer detection

https://europrev.eu/2022/11/27/statement-about-a-new-eu-approach-on-cancer-detection/

November, 27, 2022

EUROPREV – the European Network for Prevention and Health Promotion in Family Medicine and General Practice

EUROPREV is one of the five network of WONCA Europe

WONCA Europe
The European Regional Branch, WONCA Europe, is the academic and scientific society for general practice/family medicine in Europe, that  represents 47 member organisations and more than 90,000 family doctors in Europe. 

WONCA World 
WONCA is an acronym comprising the first five initials of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians. The short name is the World Organization of Family Doctors. WONCA was established by 18 members in 1972. It currently consists of 122 member organisations in 102 countries, with a total of 500,000 family doctors. WONCA represents and acts as an advocate for its constituent members at an international level, where it interacts with world bodies such as the World Health Organization. It is comprised of seven regions: Africa, North America, Asia Pacific, Europe, South Asia, Iberoamericana-CIMF and WONCA East Mediterranean Region.

PDF version

In cancer screening, often less is MORE 

To the European Commission – Health and Food Safety
To Directorate-General Health & Food Safety
To European Union Health Authorities
To European Family Medicine and Public Health professionals

 Last September 20th, the European Commission announced: “A new EU approach on cancer detection – screening more and screening better”.(1)
Among others, the new recommendations include: 
– The extension of the target group for breast cancer screening to include women between 45 and 74 years of age (as compared to the current age bracket of 50 to 69);
– Lung cancer testing for current heavy and ex-smokers aged 50-75.
– Prostate cancer testing in men up to 70 on the basis of prostate specific antigen testing, and magnetic resonance imaging (MRI) scanning as follow-up.

Considering the best available scientific evidence, we call your attention to the following facts:

Breast cancer screening

– For every 2000 women screened with annual mammography for ten years, one death of breast cancer will be prevented. But, at the same time, 200 women will suffer the long-lasting consequences of having a false positive result, and ten women will be overdiagnosed and overtreated including all the harms from being labelled as a cancer patient to side-effects and late effects of cancer treatment. Therefore, the balance between benefits and harms is unclear, and every woman should be given this information.(2)

– The extension of the target group will relatively increase the harm and diminish the benefits associated with this screening. Increased harm: younger women have denser breast tissue, and this increases the rate of false positives and elderly women have a higher competing risk of dying from other reasons than breast cancer and thereby the risk of overdiagnosis will increase. Diminished benefits: the incidence of breast cancer is much lower among women aged 45-49 and thereby the reduction in mortality is in absolute numbers much smaller and in elderly women the expected benefit from a mortality reduction is much less likely due to their shorter expected lifespan.

Prostate cancer screening

– If best available evidence is used from two independent institutes: the Cochrane Collaboration and the USPSTF, then there is robust evidence of no mortality reduction from PSA screening. If cherry picking the evidence, than in best case scenario is has been shown that for every 1000 men screened with PSA, two avoid death from prostate cancer. But, at the same time, 155 men will experience a false alarm. Usually, this is associated with unnecessary tissue removal. And 51 men will be overdiagnosed and unnecessarily treated, with significant deterioration of the quality of life (urinary incontinence, erectile dysfunction).(3)

– The potential harm associated with this screen is of great concern, and this is why, until now, no population-based prostate cancer screening programs have been implemented in Europe.  

Lung, gastric and other cancer screenings

– The available evidence about the benefits and harms of this screening is still scarce. There are also concerns about false positives and overdiagnosis with these screening programs. No population-based cancer screening program should be implemented without adequately designed randomized controlled trials in European populations assessing the balance of benefits and harms related to each screening.(4)

The myth of early diagnosis

According to the European Commission, these new recommendations aim “to increase the number of screenings, covering more target groups and more cancers“. 

Although well intended, this will, in practice, translate into more healthy people unnecessarily transformed into patients – overdiagnosis. 

In addition, and again although well intended, this will, in practice, translate into more suffering, cancer, and costs to health systems that are already overloaded and with scarce resources.

Finally, and again, although well intended, in a perspective of the climate crisis, carbon emissions of such low-value care interventions, as the suggested screening programs, are not sustainable. Moreover, these programs will increase social inequity in health and promote the inverse care law.

The EU Commission’s proposal is based on a medical myth. According to the EU Commission statement, “The sooner cancer is detected, it can make a real difference by increasing treatment options and saving lives”. In screening, this is a myth. We now have data from population-based screening programs showing that the critical factor in reducing mortality of cancer is not related to early diagnosis but to good access to healthcare and new cancer treatments.(5–7)

In cancer, very often, early diagnosis means only more burden of disease, with more suffering. 

OUR RECOMMENDATION 

The current EU Commission proposal needs to be revised.

If we really want to improve the way cancer is handled in Europe, then the focus should be:

– Primary prevention: on a population level improve diet, increase physical activity, diminish smoking and lower the consumption of alcohol. Structural societal interventions has with robust evidence of high quality been shown to be effective, while primary preventive intervention on an individual level has been shown to have no – or only short-term effect.

– Good access to Primary Healthcare Care. Every European citizen should have the right to have their Family Doctor, and this means having the right to be cared for by doctors with a specialty in Family Medicine in a trustful relationship with continuity and where the general practitioner is trained in evidence-based medicine. 

– Tertiary prevention: when diagnosed with cancer, good and quick access to specialized oncological centres (or other relevant specialists) is key to improving the outcome. This also includes good access to novel evidence-based cancer therapies.

-Quaternary prevention: new screening programs should only be implemented when the benefits outweigh the harms.

References

1. European Health Union: cancer screening [Internet]. European Commission - European Commission. [cited 2022 Nov 8]. Available from: https://ec.europa.eu/commission/presscorner/detail/en/ip_22_5562
2. Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database Syst Rev. 2013 Jun 4;(6):CD001877.
3. Harding Center for Risk Literacy. Early detection of prostate cancer with PSA testing [Internet]. Available from: https://www.hardingcenter.de/en/transfer-and-impact/fact-boxes/early-detection-of- cancer/early-detection-of-prostate-cancer-with-psa-testing
4. Heleno B, Thomsen MF, Rodrigues DS, Jorgensen KJ, Brodersen J. Quantification of harms in cancer screening trials: literature review. BMJ. 2013 Sep 16;347(sep16 1):f5334–f5334.
5. Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ. 2014 Feb 11;348:g366.
6. Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med. 2012 Nov 22;367(21):1998–2005.
7. Autier P, Boniol M, Gavin A, Vatten LJ. Breast cancer mortality in neighbouring European countries with different levels of screening but similar access to treatment: trend analysis of WHO mortality database. BMJ. 2011 Jul 28;343:d4411.

 

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.

Increase of cancers, an epidemic?

Dr. C.Bour, October 27, 2022

Marie Négré Desurmont is a journalist and lecturer who studied anthropology at École des Hautes Études in Paris in Social Sciences. She is a science journalist who has studied specifically on the subject of breast cancer after being affected herself and being struck, as Maëlle Sigonneau was, by the injunctions towards patients conveyed by language and that they have to face in their daily lives.

In a dedicated piece titled "Pink October or the Non-politics of the Breast," the author denounces what she calls the pink month's neutralization of social, environmental, and political issues. She advocates for a broader vision beyond the simple Pink October campaign to ensure a healthy future for the following generations.
"Let us have the courage to look beyond Pink October and require that we bring into the world little girls who won't have to waste so much energy trying to survive, cared for by the same world that made them sick," she writes.

She denounces:
"...rather than politicizing this serious disease, we prefer to repeat that it is best-treated cancer. We focus on individual behaviors by valuing the survivors who have learned so much from this difficult experience.."
The emphasis is placed, with a colorful and smiling veneer, on appearance and well-being "because," the author writes, quoting Audre Lordre (Cancer Journal*), "it is easier to demand that people be happy than to clean up the environment. Let's look for joy, shouldn't we, instead for healthy food, clean air, and a less crazy future on livable earth ."

*Audre Lorde, Journal du Cancer, translated from the American by Frédérique Pressman, Éd. Mamamélis, Geneva, 1998.

Cancer Politicization

In her book "Impatiente," Malle Sigonneau already called for a fight that must go beyond focusing exclusively on the particular behaviors of "survivors."
For her, it would be necessary to boycott Pink October, replacing pink messages with large posters on endocrine disruptors; we could imagine a month, she wrote, where we would 'sensitize' (to use an overused and meaningless word) on the carcinogenic effects of the environment, for example, pesticides...

Mrs. Desurmont sums up our society's attitude very well: "Our society has so much faith in its technological capabilities that it is more concerned with fixing the damage of growth than with creating another form of production and exchange, less mortifying."

Behavioral and environmental factors are responsible for almost half of all cancers. The author correctly points out that risk factors include not only tobacco, alcohol, or obesity but also endocrine disruptors, ionizing radiation (including mammography! ), air pollution, new chemicals (pesticides), exhaust fumes, occupational exposures, and general population exposure to chemical substances.

The pink campaigns and health authorities' messaging speak little about it. "By trying to make us believe that we are masters of our health, impenetrable to the surrounding conditions, and independent of our societal structures, we patients begin to anxiously seek the origin of our illness, psychologizing this sickness at any costs."

We talk about the injustice of a disease that hits women in their absolute femininity, but according to Desurmont, " What is unfair is what we have done to the world, not cancer that just can take advantage of the red carpet we roll out for it to thrive."
The reality is that by talking about injustice and little individual battles, we convince ourselves that cancer is anecdotal, that it's "poor luck," and that all it takes to beat it is a strong spirit. However, it is not a rosy epidemic and worsens as the environment deteriorates. Ladies, adopt a healthy lifestyle, but remember that while you jog, you breathe contaminated air."

Marie Négré Desurmont, like Malle Sigonneau, rightly condemns the guilt and responsibility put on cancer patients.

But what about the "epidemic"?

An epidemic?

What if the "epidemic" also came from medicine?

In his book "Dépistage du cancer du sein, la grande illusion" (ed.Souccar), Bernard Duperray explains:
"From the 1980s to the 2000s, the number of mammograms performed exploded. At the same time, the number of senographs, the devices used to perform mammograms, increased considerably: from 308 senographs in 1980 with 350,000 mammograms in 1982 to 2,511 senographs with 3 million mammograms in 2000. What was the result of this spectacular increase in mammography activity? 21,387 breast cancers were diagnosed in 1980, 42,696 in 2000, and 49,087 in 2005. An epidemic of breast cancer? Is epidemic independent of human activity or the result of uncontrolled human activity?
EPIDEMIC OR OVERDIAGNOSIS LINKED TO SCREENING ACTIVITY?
Two hypotheses can be considered to explain this surge of cancers:

-either it is a simple coincidence between the introduction of screening and the onset of a breast cancer epidemic

- or it is a plethora of breast cancer diagnoses linked to screening.

Let's look at the first hypothesis. If the continuous increase in new diagnoses each year corresponds to an epidemic of progressive cancers, the reduction in mortality due to screening would have to be considerable. There would be 1 cured cancer for every 1 death in 1980 and 3 cured cancers for every 1 death in 2000.
Neither the most optimistic results of randomized trials regarding mortality reduction, nor the therapeutic advances during this period, can support this hypothesis.

Let's look at the second scenario, in which screening is the cause of the increase in the number of new cases of cancer diagnosed each year.
Between 1980 and 2000, the incidence rate increased by an average of 2.7% per year. The increase affected all age groups but was most pronounced among women aged 50 to 75. This is the age group for which systematic mammography screening is performed (in the ten pilot departments). ......

The current epidemic of breast cancer is only apparent. Why apparent? Without screening, many of the cancers diagnosed today would not have occurred. With the overdiagnosis generated by screening, we are thus creating an only visible epidemic. When we admit to overdiagnosis, an increase in incidence does not imply an epidemic.
There is no concrete counterargument to the concept of increased overdiagnosis associated with screening. "Demonstrating its reality is based on indisputable epidemiological data and reliable facts."

I give a detailed explanation in my book "mammo ou pas mammo" (ed.Souccar), which I share with you here:
"A study has been conducted in France to allow this analysis of the situation: it is a survey conducted in 2011 by international epidemiologists, including a Frenchman, Bernard Junod, a prominent epidemiologist from the École des Hautes études en santé Publique de Rennes (EHESP) (Junod B, et al. S. An investigation of the apparent breast cancer epidemic in France: screening and incidence trends in birth cohorts. BMC Cancer. 2011;11(1):1-8. ).

Their observations are as follows:

- ✹ The number of mammography machines in operation in France increased steadily over 20 years, from 308 in 1980 to 499 in 1984, 1351 in 1990, 2282 in 1994, and 2511 in 2000. The number of devices has thus increased eightfold between 1980 and 2000. As a result, screening has intensified.
- ✹ When the incidence of breast cancer at different times in women of the same age group is compared, it increases over time. It is significantly higher when women are intensively screened. The most significant increase, 112%, occurred in 2005 for the 60-64 age group.
Thus, this increase in breast cancer incidence has occurred in parallel with the rise in screening intensity, as illustrated in Figure 1.

As screening increases, so does incidence. This increasing incidence rate as soon as the systematic screening is introduced is striking. It has been observed in all countries where screening has been introduced. "

The denunciation of the failure to consider environmental factors is entirely justified and relevant. Still, the role of medicine must be included and denounced in the same way.
We must ask ourselves the right questions in the face of an increase in new cases of cancer. The simultaneous absence of a reduction in serious cancers, the consequent lack of a reduction in these cancers that kill, that screening does not detect because they cannot be anticipated and evolve with a growth rate that makes them serious cancers. Incidence is increasing. Mortality is not falling in parallel with the intensity of screening.

At the same time, massive and systematic screening finds a plethora of tumors that would never have killed if undetected, a phenomenon known as overdiagnosis. Carcinomas in situ are a substantial source of overdiagnosed cancers and, according to some scientists, are wrongly labeled as cancers.

Why is overdiagnosis a real danger?

It excessively increases the incidence (the rate of new cancer cases) of breast cancer; as these are cancers that would never have been harmed, survival rates are artificially improved, leading to the reassuring slogan: "breast cancer is very well treated and often cured." Of course, it is cured all the better because we over-treat lesions that should never have been detected and would never have killed anyway. The medical profession cannot refrain from telling patients that they have been "saved," whereas screening may have harmed them.

Above all, overdiagnosis leads to overtreatment, which includes radiation therapy. Radiotherapy treatments, like breast surgery (partial and total mastectomies), which is not "lightened," contrary to what health authorities state, are only rising, contributing to what our two authors decry, namely exposure to ionizing radiation.
It is likely that the issue here is not so much the direct exposure during mammography (except for young, non-menopausal women under 50 years old who have an increased risk of radiation-induced cancer) as the treatment that a woman receives.
Speaking of "light" treatment, as the health authorities do, appears cynical because the issue is not one of the lightening therapies but of ensuring that women are not overdiagnosed and do not receive abusive therapy that they should not have had.

Radiation toxicity, downplayed in breast cancer screening, is a reality; radiation-induced cancer should not be ignored.
Radiation-induced heart disease is the biggest killer in survivors of treated cancer.
Hematological cancers can occur after radiation and chemotherapy.

Experiencing this is not harmless; sharing it abusively because a woman has not been alerted to the risk of overdiagnosis inherent in screening is ethically unacceptable.

Conclusion

So yes, let's return to Ms. Desurmont's conclusion: "Let's have the courage to look beyond Pink October and demand that we be able to bring into the world little girls who won't have to waste so much energy trying to survive, cared for by the same world that made them sick."

But this courage must include questioning medicine and how it makes healthy people sick by making them go through tests, they don't need.

This is what the public, the sick and the healthy, and especially the politicians need to be "made aware of." And this is done by telling women the truth about the risks and benefits of screening, not by using pink propaganda that wrongly makes women heroes when some of them should never have known they had this disease and others have this disease in its most serious form, which makes them invisible, impoverishes them, and isolates them from society.

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.

The short news of October 2022

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.

Conclusion:
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.

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.

The new INCa 2022 booklet on breast cancer screening

October the 20th

In 2017, we conducted a critical review of the French National Cancer Institute (INCa) information booklet for women on breast cancer screening, being sent with their first invitation.

At the time, the score for the quality of the information was not outstanding. A new 2022 edition for women is now accessible online. We will examine and compare the changes made between the two editions.

Sophie, our patient referent, compared the two booklets to assess how the INCa's communication was progressing. Below is a summary of the analysis she conducted.

The negative points 

1) This booklet is only sent once, at the age of 50, for the first screening, and then at each of the subsequent screenings, a different document (a short leaflet) is provided: the leaflet does not mention any of the harms of screening. Instead, it indicates a link to a website for more information. It is obvious that, over time, the message that will remain in the minds of women will be the one in the leaflet, with none of the harms presented, which will be completely forgotten.

2) Among the benefits, a special emphasis is placed on 5-year survival, which is not an indicator for screening effectiveness.

3) The mortality reduction is presented as a relative percentage reduction (15-21%), meanwhile the overdiagnosis is presented as an absolute percentage (10-20%), which are not comparable. This flaw exists in the 2017 booklet as well.

ATTENTION: A 20% decrease in cancer mortality does not mean that 20 fewer women screened out of 100 will die of cancer. This is just an indication of relative risk. The authors disregard the request of women citizens to no longer be misled by numbers that do not mean what they appear to suggest. The 20% fewer deaths does not mean that 20 fewer women out of 100 will die of breast cancer if they are screened. The 20% reduction in deaths is only a relative risk reduction between two compared groups of women.

In fact, according to a projection made by the Cochrane Collaboration based on several studies, for every 2,000 women screened over a period of 10 years, 4 will die of breast cancer; for a group of women not screened over the same period of time, 5 will die of breast cancer; the reduction from 5 to 4 mathematically represents a 20% reduction in mortality, but in absolute terms, only one woman's death will be prevented.

Actually, this corresponds to an absolute risk reduction of 0.05% (1 woman in 2000) to 0.1% (1 woman in 1000) at the end of 10 to 25 years of screening, depending on the estimates used (American, US TaskForce, Prescrire journal). (5)

Concerning the rate of overdiagnosis, the 10 to 20% indicated corresponds to the lowest evaluation, other studies suggest much higher rates of overdiagnosis.

4) The NIH (National Cancer Institute) website is cited in the booklet's references to support the survival statistics put forward in the booklet. But it omits the page of the same institute that indicates that survival is not a good indicator of the effectiveness of screening, and it also omits the page where the rate of overdiagnosis is given as 20 to 50%. Indicating a rate at its low range is an option in a document, but the high range must also be honestly given.

What does the NIH say specifically regarding these two parameters ?

On overdiagnosis rates https://www.cancer.gov/types/breast/hp/breast-screening-pdq#_13_toc
Magnitude of Effect: Between 20% and 50% of screen-detected cancers represent overdiagnosis based on patient age, life expectancy, and tumor type (ductal carcinoma in situ and/or invasive).[11,12] These estimates are based on two imperfect analytic methods:[11,13]
Long-term follow-up of RCTs of screening.
The calculation of excess incidence in large screening programs.[11,12]
Study Design: RCTs, descriptive, population-based comparisons, autopsy series, and series of mammary reduction specimens.

On survival and screening effectiveness https://www.cancer.gov/about-cancer/screening/research/what-screening-statistics-mean

Much of the confusion surrounding the benefits of screening comes from interpreting the statistics that are often used to describe the results of screening studies. An improvement in survival—how long a person lives after a cancer diagnosis—among people who have undergone a cancer screening test is often taken to imply that the test saves lives.

But survival cannot be used accurately for this purpose because of several sources of bias.

5) The “choice of screening” is no longer mentioned in the booklet title, and the last chapter on screening options (to accept or do not accept) has been removed and replaced with testimonials on the benefits (a reassuring example of a screening that "saved" a woman's life, another of a woman who, not having been screened, might have received a more aggressive treatment)

This option of choice was included at the end of the 2017 booklet:

6) There is still no visual pictogram (as requested by women citizens), that illustrates in absolute numbers the benefits and the harms, to have a global vision and to allow the women to make their choice.

7) The harms of screening continue to be named "limitations" (page 13 of the booklet), whereas the term in English is "harms".

"Limitations" rather implies the inability to detect correctly.

8) Messages from personalities (president of INCa), authorities (recommendation in Europe), appeals to fear (if you don't get screened...), are used as influence techniques.

The positive points.

1) A specific page that groups screening harms (also present in 2017, but not grouped together and without a clear title for each harm).

2) Better organization of information on prevention (risk and protective factors, table on cancer statistics related to each risk factor, page 9)

3) Easier to read, a more visual document

4) The addition of the midwife (alternative to the general practitioner or gynecologist) in the follow-up clinical examinations and to answer questions on screening.

Comparison of the texts of the two booklets in the table

Download / Télécharger

In conclusion

This booklet, ideally corrected to address the persistent deficiencies that Sophie identified for us, may be sent with each screening invitation, not just at age 50.

In the leaflet for successive screenings (beyond the age of 50), the harms of screening and recommendations on prevention have been omitted, resulting in abbreviated and insufficient information.

Women must now be completely and appropriately informed, as requested during the citizen consultation, and that for the rest of their lives of “screened women”.

Those women who had their initial screening before 2022 will never receive this information.

This can be implemented without too much difficulty by simply replacing the leaflet planned for the next invitations by this booklet, duly completed and corrected for its weaknesses.

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.

The irreversibility of screening

Dr. C.Bour, September 26, 2022

A short history

Whether useful or not, introducing screening into the population is irreversible. This is demonstrated by history.

1° Prostate cancer screening

The American doctor who developed the test in 1970, Richard Albin, was himself alarmed by the "public health disaster" caused by his discovery. In an op-ed published in the New York Times in 2010, he wrote: "I could never have imagined, four decades earlier, that my discovery would cause such a public health disaster, driven by the pursuit of profit. The improper use of this dosage must be stopped. It would save billions of dollars and millions of men from unnecessary and mutilating treatments."

PSA testing has been controversial since 1989 in France. A "consensus conference" was organized by three urologists, Professors François Richard, Guy Vallancien, Yves Lanson, and the economist Laurent Alexandre. This expert consultation already concluded that "the organization of mass screening for prostate cancer is not recommended.”
A new consensus conference was held in 1998. The same year a clinical practice recommendation was issued that ruled even more clearly: "Since screening for prostate cancer (whether mass screening, directed at the entire population concerned or opportunistic screening, on a case-by-case approach) is not recommended in the current state of knowledge, so there is no indication for proposing a PSA test in this context.

But things are not that simple. The majority of learned societies and professional groups around the world are against screening. Still, three American associations (American Cancer Society, American Urological Society, and American College of Radiology) do not agree. Gradually, the French Association of Urology (AFU) (specialists in the male reproductive system) is gradually drifting away from this position, and a campaign is being launched to promote PSA testing.

The problem with this screening lies in the fact that there is no established effect on mortality, but that, on the other hand, it detects a large number of very slowly progressing cancers that would never have been manifested (overdiagnosis), but which, once detected, will be treated, with disastrous effects in terms of impotence and incontinence.
Another problem is that radiotherapy treatments can lead to the development of secondary cancers.

In 2011, the US Preventive Service Task Force (USPSTF) recommended that PSA screening for prostate cancer be discontinued, emphasizing its side effects. For every 1000 people treated, there are 5 premature deaths one month after surgery. Between 10 and 70 patients have serious complications but survive. Radiation therapy and surgery have long-term effects, and 200 to 300 patients will become impotent and/or incontinent.

And the French High Authority for Health (HAS) concluded, "No new scientific evidence is likely to justify re-evaluating the appropriateness of implementing a systematic screening program for prostate cancer by PSA testing." Opinion renewed in 2016: 2016 HAS opinion
"The French National Authority for Health thus recalls that current knowledge does not allow for the recommendation of systematic screening for prostate cancer by PSA testing in the general population or in populations of men considered to be at higher risk."
The National Cancer Institute's conclusion is along the same lines.

Unfortunately, the recommendations and day-to-day practice are making a big gap, and biopsies, as denounced in 2013, are increasing.

Prescription habits have a hard time, but credit insurers also impose this test in the "formalities" requested to take out a loan, exposing people to seriously harmful effects on their health.

2° breast cancer screening

From 1970 to 1980, in various countries (Norway, Denmark, Canada, New York, Sweden), women were included in experimental studies, called trials, which simply compared the outcome for screened women with unscreened women. At the time, this was possible because the women had never x-ray taken on their breasts. These studies showed a supposedly tremendous reduction in mortality due to screening, up to 30% less risk of dying of breast cancer.

However, as we now know, these first experiments were subject to numerous biases in the method, the distribution of women between the two groups, and the statistical analyses. The methodology did not meet the current qualification criteria. The best results were obtained with the worst mammograms.

From 1992 to 2000, the number of victorious and enthusiastic publications multiplied with a colossal media echo.

Finally, from 2000 to 2001, voices were raised to warn about the irregularities of the first trials and to raise the alarm about the risks of this screening.

Peter Gøtzsche and Ole Olsen, two independent Nordic researchers, performed a meta-analysis according to the methodology of the Cochrane collaboration to which they belong. And there is a shock because even by combining the best trials, there appears to be no statistically significant difference in mortality between screened and unscreened women: "there is no reliable evidence that screening decreases breast cancer mortality," concludes the study [1].
This conclusion was later confirmed by the independent journal Prescrire in 2006 [2].

Unfortunately, these researchers were not allowed to publish their results in the Cochrane reviews, except on the condition that they would include even the most biased trials to improve the results.

Lengthy negotiations followed, and in 2009, researchers Peter Gøtzsche and Margrethe Nielsen estimated that if all the trials, including the worst ones, were included in the meta-analysis, then screening could reduce breast cancer mortality by 15%, which is still a minimal and supposed benefit [3].
Above all, a surprise “guest” emerges, and that is overdiagnosis, i.e., the detection of indolent lesions, unnecessary to detect, which would never have had an impact on the life or health of the woman, but which will all be treated like any other cancer, with surgery, radiotherapy, or even chemotherapy, leading to deleterious overtreatment for the person. These over-treatments have physical, psychological, economic (loss of job), trans-generational (descendants labeled as 'at risk'), etc., consequences.

In 2005, Norwegian statistician Per-Henrik Zahl, a member of the Cochrane Collaboration, raised the problem of discrepancies between studies showing a decrease in mortality and data from the official Swedish cancer registry. There would be more reported deaths in the unscreened group and missing deaths in the screened group. The researcher proposed an article on these discrepancies to the medical journal The Lancet, which was rejected.

One year later, Per-Henrik Zahl managed to have it published online in the European Journal of Cancer [4]. This article was censored and was finally published in a Danish journal shortly afterward [5].

In The Lancet, Peter Gøtzsche, co-founder of the Cochrane Collaboration, denounced the unacceptable pressure he had been subjected to [6].

But the machine had been launched, and European countries had started campaigns with much media coverage, with slogans, celebrity endorsements, and popular events colored in pink. And the press, as well as the learned societies, the women largely influenced by the media, the doctors, the health authorities, preferred to stick to the enchanting story of a screening that saves...

In 2004, under the presidency of Jacques Chirac, breast cancer screening was generalized in France.

In 2015/2016, under the aegis of Health Minister Mrs. Marisol Touraine, a citizen and scientific consultation on breast cancer screening was organized. The steering committee proposed two scenarios in the final report, both calling for the cessation of breast cancer screening in its current form because of a very uncertain balance of benefits and risks, with a non-significant reduction in mortality and, in parallel important adverse effects, such as irradiation, false alarms (see video at the bottom of this link) leading to stressful complementary examinations, and overdiagnosis of course. The citizens request better information.

Nowadays, screening is still conducted in its usual form, and women receive information on the benefit-risk balance that is still unclear and obviously unbalanced[7][8].

The scientific controversy about this screening is qualified as fake news by the National Cancer Institute[9].

3-Bronchopulmonary cancer screening.

Two trials essentially (there were several studies) were supposed to provide evidence of a significant reduction in specific mortality from bronchopulmonary cancer due to low-dose radiation thoracic scanner (LDRT) screening. These were the US National Lung Screening Trial (NLST) and the NELSON trial conducted in Belgium and the Netherlands.

Already in 2014, in a scoping note, the HAS noted, ".... it is likely that the low specificity of low-dose CT screening will remain a major obstacle to the implementation of screening in clinical practice and a screening program."
"Disadvantages and risks associated with FD CT (low-dose CT) screening include radiation exposure ranging from 0.61 to 1.5 mSv, some degree of overdiagnosis that varies among studies, and a high rate of false-positive exams, usually explored with more imaging."

When we look at the study published in the NEJM on the NELSON trial, the last line of table n°4 reads: "All-cause mortality - deaths per 1000 person-yr 13.93 (screening group) 13.76 (control group) RR 1.01 (0.92-1.11)". Clearly, there is no impact on all-cause mortality by this scan screening. (Remember that the "overall mortality" figure includes everything, cancer, its treatment, and its non-treatment, and is, therefore, a better reflection of "real life" data)

But the Academy of Medicine has retained this criterion and expresses its concerns in a published report here and there. It notes several problems for not generalizing this screening:

  • The two major lung cancer screening trials with low-dose CT scans greatly underestimated the potential harms (false positives, overdiagnosis, false negatives, radiation, and overtreatment). The magnitude of the benefit and the magnitude of the risks are unknown, and even if the 25% cure rate is achieved among the subjects included in the study, the majority of patients will die early from other smoking-related diseases (other cancers, heart disease, emphysema, etc.) without increasing their life expectancy.
  • For screening to be effective, it is necessary to have cancers with a sufficiently long latency to "catch up" during a screening (thus the least possible number of interval cancers); however, the proportion of long latency cancers in the lung is low.
  • These cancers are mostly due to active smoking and, marginally, to passive smoking: more than 85% of cases can be attributed to smoking. The progressive decrease of smoking among men (60% of smokers in the 60s to 33% today) is reflected in the reduction of incidence and mortality due to these cancers", which is equivalent to saying that this cancer is simply accessible to good primary prevention campaigns, and to incentives to stop the main risk factor, tobacco.
    "The natural and progressive history of the disease must be known and the various forms defined." Between the ages of 50 and 74, lung cancers are mainly composed of adenocarcinomas, which seem to be the most easily detectable. For example, in the European NELSON trial, 61% of PBCs in the screened group were adenocarcinomas compared to 44% in the control group, which could explain a better effect of screening in women", explains the Academy.
  • Unknowns: on the target population, the desirable participation rate, the frequency of scans, the therapeutic indications for cancers discovered during the scan, the acceptability by patients, the motivation and the respect of smoking cessation, etc...
  • The people who participate in the trials are not representative of the entire population eligible for screening at a later date, which may lead to an overestimation of the effectiveness in the Nelson study.
  • An economic evaluation is also needed, as the Academy rightly points out that primary prevention is certainly more effective and less costly.

To rebound on the arguments of the Academy of Medicine, one must keep in mind the economic stakes of this screening, not only of the initial examination but also of the importance of the expenses caused by the iterative examinations in case of intermediate nodules (which must be followed during the years to control their evolution). Screening for bronchial cancer by CT would be 4 times more expensive than screening for breast cancer and 10 times more costly than screening for colorectal cancer.

For academics, what is essential is the fight against the main risk factor: smoking, the acceptance of its reduction is the very condition for the candidates selected for a possible regular screening.

The reactions were not long in coming. An APM news release of February 24, 2021, tells us three learned societies have taken a position.
"The three learned societies are the Francophone Intergroup of Thoracic Oncology, the Society of Pneumology in the French Language, and the Society of Thoracic Imaging. In this text, which updates previous recommendations, the learned societies reaffirm their position in favor of individual screening, by low-dose thoracic CT scan without injection of contrast medium, for which they specify the modalities." ......
"Contrary to the French Academy of Medicine, which proposes a low-dose CT scan once during a smoker's health check-up, the learned societies envisage a recurrent examination. They believe 2 CT scans should be performed one year apart and then one every 2 years, except for risk factors or previous examinations with an intermediate result, which should continue every year. And this screening should be continued "for a minimum period of at least 5.5 to 10 years."

Three radiologists contest the opinion of the Academy of Medicine, which persists and signs: https://lequotidiendumedecin.fr/specialites/cancerologie/controverse-sur-le-depistage-du-cancer-du-poumon-lacademie-de-medecine-repond-aux-prs-revel-lederlin... with an argument that should prevail in any screening: namely that of the GLOBAL mortality.
"The authors mention that PBC (bronchopulmonary cancer) mortality is reduced in the Nelson and NLST trials, but without taking into account the general mortality of the smoking population, the only important parameter to consider organized screening and which does not change in the various trials."
This parameter, let's remember, includes PBC mortality but also mortality due to treatments and mortality due to other causes, smokers being exposed to other pathologies (emphysema, other cancers, cardiovascular diseases).
The Academy still says it does not want to return to the "irradiation controversy" the authors write: "... our report is factual on this point, and we encourage you to reread this paragraph. However, it is regrettable that in none of the trials was precise dosimetry performed."

The High Authority of Health, initially reluctant in 2016, completely changed its attitude and gave in 2022 its green light to an experiment on lung cancer screening, despite the ineffectiveness of this scannographic screening to reduce all-cause mortality.

"The HAS considers that the state of knowledge is still incomplete and insufficiently robust for implementing a systematic and organized screening of PBC (bronchopulmonary cancer) in France. However, the data shows a decrease in specific mortality and authorize the initiation of a pilot program to document: the modalities of screening, the performance/efficacy and efficiency, the organizational constraints, and the ethical and social dimensions by testing several possible scenarios and on several screening ranks.

Thus, the HAS recommends that experimentation be carried out in real life concerning the French healthcare system to answer the outstanding questions."

In its report on page 70, the HAS considers that "The meta-analyses do not show a significant reduction in all-cause mortality, whatever the procedures compared: this criterion of judgment is not very relevant because of the interference of age and chronic smoking on mortality, and the need for very long-term follow-up on a large cohort.

This means that the HAS does not recognize overall mortality as the primary efficacy criterion, puts specific lung cancer mortality ahead, ignoring other causes of smoking-related mortality and morbidity, and considers randomized studies with 10-year follow-up insufficient. This means that any unproven screening can be defended and maintained, as is the case with breast cancer screening, which is currently unable to prove its effectiveness.

A new study is published in 2022. This population-based ecological cohort study found that low-dose CT screening of low-risk, mostly nonsmoking Asian women was associated with significant overdiagnosis of lung cancer. Five-year survival is biased by the increased detection of indolent, early-stage lung cancers that would never have killed.
She concluded that unless randomized trials can show some value for low-risk groups, low-dose CT screening should remain targeted only at heavy smokers.

A HAS opinion on the relevance of screening

Dr. Catherine Rumeau-Pichon, Assistant to the Director of Medical, Economic and Public Health Evaluation, HAS, explained in this video from 5 years ago, that screening must meet the following six criteria:

1- A disease that can be detected early before the onset of symptoms

2- A reliable test

3- Effective treatments against the disease must exist

4- People at risk must be identifiable

5- Screening must be known to decrease cancer mortality.

6- The benefit/risk balance must favor a preponderant benefit over the risks.

Let's examine screening (breast, prostate) in the light of these criteria

1- Early detection of disease before symptoms.

For breast and prostate, not always...

Cancers with a long residence time in the breast, therefore not very progressive, are easily detected by screening before their symptoms because they are slowly progressive. They contribute to the overdiagnosis of many cancers.

On the other hand, cancers with a poor prognosis, with a high potential for progression and rapid growth, are 'missed' by screening because they are too fast to be 'caught' (these are the false negatives).

Their natural history is, therefore, not linear and predictable and is still not known at present. For prostate cancer, aggressive cancers often release their metastases from the start.

2- Reliability of the test

No

Mammography is a poor screening tool; it has good sensitivity for atypical lesions and in situ cancers, the least aggressive ones; it has poor sensitivity for high-stage cancers, triple negatives, and infiltrating forms.

The PSA level may be high in cases of simple benign prostate hypertrophy. A high level is not specific to cancer.

3-Effective treatments

Yes

For breast cancer, the effectiveness of treatments has improved significantly since the 1990s, and it is said that 9 out of 10 cancers are cured, even for those not detected.
For this reason, moreover, the usefulness of screening is diminishing.

Whether treated or not, prostate cancer rarely metastasizes (about 1 in 10 cases). When it does metastasize 90% of the time, it results in bone metastases.
While bone metastases usually have a poor prognosis for other cancers, this is not necessarily the case for prostate cancer. Whether it has metastasized or not, prostate cancer is often a slow-moving disease.
For this cancer, patient survival is improving year after year thanks to the appearance of new treatments and therapeutic combinations.

4-Identifiable persons at risk.

No

For breast cancer, risk factors predisposing to cancer can be identified, such as exposure to toxic substances, night work, and family history...
But not all women who smoke or work at night will automatically develop breast cancer, and there is no reliable link between a specific risk factor and breast cancer, not as clear-cut as smoking and developing bronchopulmonary cancer (and yet, here again, systematic screening of smokers is not recommended).

Only 5% of cancers are hereditary. This is too rare a phenomenon to impose screening on an entire healthy population with no family risk.

Women without risk, neither exposure nor intrinsic, can develop breast cancer without apparent 'reason.'

For prostate cancer, too, no risk factor has been identified and linked to this cancer.

5-Decrease in mortality

No

Impact studies have shown that mortality decline for several solid cancers has been effective since the 1990s and was not attributable to screening. This pattern of decline was also found for cancers not included in screening programs.

Breast: Norway study; impact study
Prostate: Ref: http://onlinelibrary.wiley.com/doi/10.1002/pros.20017/abstract; Labrie, Quebec, 2004

6-The benefit/risk balance in favor of the benefit

No

For the breast, this is no longer the case. Even in the most favorable hypotheses, such as the Marmot report, there is still more overdiagnosis than "lives saved."
M.G. Marmot, D. Altman, D. Cameron, J. Dewar, S. Thompson, M. WilcoxThe benefits and harms of breast cancer screening: an independent review Lancet, 380 (2012),. Marmot
Other independent reviews are even more severe; see our summary here: https://cancer-rose.fr/en/2020/12/15/the-over-diagnosis-in-a-graph-and-a-table/

When the three main disadvantages of systematic breast cancer screening are added: overdiagnosis, false alarms, radiation-induced cancers, and deaths attributable to overtreatment, the benefit/risk balance is always unfavorable.

For prostate cancer, really aggressive cancers release their metastases at the beginning of the disease. In this case, treatment will not protect against death. The treatments for this cancer have adverse effects that can be important (urinary incontinence, impotence). The patient's life will be altered more than "saved."
The elderly patient is more likely to die before from something other than his cancer.
Between 50 and 75, there is no proof that screening for this cancer would save people (HAS). The WHO does not recommend this screening either.

In the Canadian study, there is more mortality in the screened group because the risks of screening and the collateral effects of biopsies and treatments in screened men outweigh the benefit, which is minimal.

Overall all-cause mortality was almost the same in men who had surgery as in men who did not have surgery.

==> in total:

Of 6 requirements, breast and prostate cancer screening fail to meet 5 of them.

And nevertheless...

...the European Commission proposes at the end of 2022 an extension and/or a resumption of certain screenings and the implementation of new ones.
The objective is that by 2025, 90% of the EU population will be screened for breast, prostate, cervical, and colorectal cancer.
In addition, lung and stomach cancer screening will be included, although no conclusive studies exist for the latter.

Many media have copiously relayed this information without any further critical analysis...

The European commissioner Mrs. Stella Kyriakides issued in September the following speech
"Today, we know that it is estimated that one in two EU citizens will develop cancer during their lifetime."

However, the European Commissioner fails to mention that life expectancy in Europe continues to increase.
This is pure fear-mongering, creating a feeling of urgency, threatening the population, and must be addressed with great diligence.
This is a well-known technique to push for a change to be immediate and experienced as necessary, as is advocated in the business world.

John P. Kotter, Professor at Harvard Business School, outlines the elements for management of change:
"To succeed in a project or a change, it is important to demonstrate the need for it. The most effective way is to trigger a need that your project will meet by creating a sense of emergency among all your employees. Expose the risks the company is taking by not changing the way it operates."

Conclusion

Cancer takes a particular place, unlike other pathologies, even the most serious or deadly. It has replaced the scourges of the Middle Ages, tuberculosis, and syphilis of our elders. It symbolizes insidious evil and is always associated with the silent killer.

Despite all the knowledge accumulated over the last decades on the flaws and failures of screening, the fear of cancer is so deeply rooted in us, perpetually conveyed by societal, medical, and media messages, that any call for caution about the myth of saving early detection is vain.

Advances have been made, thanks to the failure of screening, our knowledge has progressed on the mechanics of cancer evolution, and we have learned about the complexity of the natural history of the disease.

But often, during the media communication of the pink October campaigns, it is enough for one or several "cancer-survivor" stars, television hosts, or politicians to claim to have survived thanks to a "saving" screening, feeling missioned to carry his experience as exemplary and emblematic, presumptuously setting himself up as a spearhead of a "noble cause," for everything to be reconsidered.
Or a blind decision by the European Commission...

There is nothing more powerful than the infusion of terror to suppress all reasoned, prudent, and scientific argumentation and to sweep away all efforts of neutral and objective information of the population.

We have not learned from past medical errors, the history outlined at the beginning of this article shows to what extent decisions taken too hastily and prematurely in the implementation of screenings lead to health disasters, carefully concealed from the public to whom only "benefits" are dangled.
These disasters and endangerment of people continue, and the media only communicate very sparingly on this subject.
Many screenings, especially for breast cancer, should never have been done and have resulted in resounding fiascos (like thyroid, neuroblastoma in children, and melanoma).
The European Commission even plans to implement a stomach cancer screening for which there is NO scientific evaluation...

The future seems quite dark because, at this frantic pace of repeated screenings, the only healthy individuals will be the ones who escape these macabre rituals, renewed during their life like a morbid litany, and which will propel healthy people into diseases they should never have known.

Read also the last post of Luc Perino-(in French)

References


[1] Olsen, O., & Gøtzsche, P. C. Screening for breast cancer with mammography. The Cochrane Database of Systematic Reviews. 2001; (4): CD001877.

[2] Mammographies et dépistage des cancers du sein : Pour un choix éclairé des femmes désirant participer au dépistage. In : Prescrire. [En ligne : https://www.prescrire.org/aLaUne/ dossierKcSeinDepSyn.php]. Consulté le 12 mai 2021.

[3] Gøtzsche P. C., Nielsen M. Screening for breast cancer with mammography. The Cochrane Database of Systematic Reviews. 2009 Oct 7; (4): CD001877.

[4] Zahl PH., et al. WITHDRAWN: Results of the Two-County trial of mammography screening are not compatible with contemporaneous o icial Swedish breast cancer statistics. European Journal of Cancer. 2006 Mar 9.

[5] Zahl PH, et al. Results of the Two-County trial of mammography screening are not compatible with contemporaneous o icial Swedish breast cancer statistics. Danish Medical Bulletin. 2006 Nov; 53(4): 438-40.

[6] Gøtzsche P. C. What is publication? The Lancet. Nov 2006; 368(9550): 1854-56

[7] https://cancer-rose.fr/en/2021/01/01/critical-analysis-of-the-new-inca-information-booklet/

[8] https://cancer-rose.fr/2018/02/11/10552/

[9] https://cancer-rose.fr/en/2021/06/24/press-release-cancer-rose/

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.

A new EU approach to cancer screening

September 22, 2022 - Abstract Dr. C.Bour

https://ec.europa.eu/commission/presscorner/detail/fr/QANDA_22_5584

Within the framework of the European program of the fight against cancer and cancer screening, which will be included in a large European plan, the European Commission proposes an extension and/or a restart of certain screenings and an implementation of new ones.
The objective is that by 2025, 90% of the EU population will be screened for breast, prostate, cervical and colorectal cancer. Lung and stomach cancer screenings are also included, although no conclusive studies exist for the latter.

Regarding funding: “Europe's Beating Cancer Plan is supported using the whole range of Commission funding instruments, with a total of €4 billion being earmarked for actions addressing cancer. This includes around € 38.5 million committed from the EU4Health programme for screening-related projects and € 60 million under the Horizon Europe. The Commission will propose additional funding for cancer screening under the 2023 EU4Health programme.”

A blatant disregard for acquired knowledge and established recommendations

1° breast cancer

The Commission wishes to extend breast cancer screening to younger women, including women starting at 45 years of age.

However, a British trial, the UK Age Trial, delivered its results in 2021. After 23 years, the results of the UK Age Trial no longer showed a significant decrease in the number of deaths from breast cancer in women screened between the ages of 40 and 49. The authors of the trial concluded: "Overall, there was no significant reduction in breast cancer mortality in the intervention group compared with the control group.”
The results also showed no reduction in total mortality (or all-cause mortality).
The justification for this extending screening to a younger age is as brief as it is unscientific:
https://healthcare-quality.jrc.ec.europa.eu/european-breast-cancer-guidelines/screening-ages-and-frequencies/women-45-49#rec-question

“The GDG (development group of these guidelines)  agreed this recommendation by consensus with no need for voting.”
“The decision on this recommendation takes into account the balance between desirable and undesirable effects that probably favours organised mammography screening for women aged 45 to 49 in the context of moderate certainty of the evidence.”

Yet the downloadable 2016 PDF detailed the doubts that exist for this screening: "Mammography, compared with no screening, did not significantly reduce the risk of breast cancer mortality..... in women invited to screening during 16.4 years of follow-up."...
"Mammography, compared with no screening, reduced the risk of stage IIA or higher breast cancer (46 fewer cases of breast cancer per 100,000 women ...but did not reduce the risk of all-cause mortality."
(Recall that overall mortality includes all elements of healthcare, so also the effects of treatment, overdiagnosis, and overtreatment. This figure is more meaningful because any cancer detected will be treated; the treatments themselves sometimes cause deaths, which will be included and encompassed in the 'all-cause mortality,' thus better reflecting the reality of screening).

"Adverse events:
Women aged 40-74 randomized to 'invitation to screening' were more likely to undergo mastectomy....
Overdiagnosis is estimated to be 12.4% (moderate quality evidence) from a population perspective and 22.7% from the perspective of a woman invited to screening (moderate quality evidence).
The number of false positives will depend on age at the first screening. Estimated cumulative risk of false-positive screening: The rate of women aged 50 to 69 years who underwent 10 biennial screenings was 19.7%. However, higher false-positive rates were observed among women younger than 50 years than among women aged 50 to 69 years.
In addition, 2.2% of women had a needle biopsy after the initial screening mammogram.
False-positive mammograms are also associated with greater anxiety and distress about breast cancer as well as negative psychological consequences that can last up to three years (low quality evidence). ..."

2.Prostate cancer

The Commission proposes introducing a prostate-specific antigen (PSA) test - similar to a blood test - in men up to age 70, combined with additional magnetic resonance imaging (MRI) as a follow-up test.

Yet, prostate cancer screening has been long debated and is not longer recommended by the HAS since 2013- https://www.has-sante.fr/jcms/c_1623737/fr/detection-precoce-du-cancer-de-la-prostate
"the HAS recalls that the implementation of a screening program for prostate cancer using total serum PSA measurement is not recommended, either in the general population or in men at high risk."

The lack of benefit in mortality reduction and significant overdiagnosis motivated this decision. More explanation here:
https://cancer-rose.fr/en/2021/02/11/parallel-to-breast-screening-prostate-screening-overdiagnosis-as-well/

Conclusion

The extension of screening to the younger age group is a step forward from 2019, when, regarding the 45-49 age group, the GDR (expert panel proposing the recommendations) suggested at that time a triennial or biennial mammographic screening in the context of an organized screening program, mentioning a low level of certainty.

In the meantime, the MyPEBS study has been set up to test the possibility of more targeted screening since it must be admitted that the current screening does not work as expected: "After analysis of all the components, the final objective of Mypebs is to provide the best recommendations for the best breast cancer screening strategy in Europe.
The MyPEBS promoters' argument also states: "A major challenge is to make women more informed and more active in their screening decisions, as clearly recognized by several international studies. Indeed, a major concern of national screening programs in all participating countries is to promote informed choices about decisions to participate in screening and subsequent treatment options. Informed choices require that good quality, relevant information be provided to women so that they can make decisions consistent with their values."

So it appears that the EU sees no contradiction in funding a €12M study to achieve more precise, risk-based screening and, on the other hand, expanding the age ranges for screening without evidence, even before MyPEBS has delivered its results...
Or else there is no contradiction, and the MyPEBS study is meant to achieve this, to finally impose screening to all women, with an extension of the age to younger age groups as early as 40 years old as we already figured...?

Read: https://cancer-rose.fr/my-pebs/2019/06/13/argument-english/

These new EU recommendations just jump to the front.
This current 2021 EU report states that for the 45-49 age range, "full details, including downloadable supporting documents for health professionals, will be available soon."

We hope these will be real scientific justifications and that the promise made to citizens after the French citizen consultation to provide support tools for an informed decision, including the decision not to be screened, will not be forgotten.

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.

Screening for cancer: the Good, the Bad and the Ugly

‘On the Shoulders of Giants’ is a series of educational talks hosted by NCITA where experts bring their perspectives to encourage and challenge wider thinking within the cancer imaging research community.

Here a video-presentation by Michaël Baum, Professor Michael Baum is Emeritus Professor of Surgery and Visiting Professor of Humanities at University College London.

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.