An unexpected side effect of the covid epidemic-19

The following is the view of two researchers regarding the long-term contribution of suspending cancer screening, to the advancement of cancer knowledge.


Gilbert Welch (Centre for Surgery and Public Health at Brigham and Women's Hospital and author of "Less Medicine, More Health")
And Vinay Prasad (oncologist, Associate Professor of Medicine in Oregon Health and Science University et auteur de "Malignant: How Bad Policy and Bad Medicine Harm People With Cancer")
https://edition.cnn.com/2020/05/27/opinions/unexpected-side-effect-less-medical-care-covid-19-welch-prasad/index.html


Synthesis by Cécile Bour, MD, 28/05/2020


We had already recently reported the views of Judith Garber, a political and health policy scientist at the Lown Institute, and also whose of Susan Bewley, Professor Emeritus of Obstetrics and Women's Health at King's College London and President of HealthWatch.

According to the authors, due to the fact that medical care services were overwhelmed by the epidemic, some patients certainly suffered harm on their health.
For others, though, the two authors suggest that the delay may have been beneficial.
In addition to the effect of the decrease in surgical interventions, emergency room admissions, requests for additional biological and radiological examinations, and the increase in telemedicine, the two researchers review the impact of suspending cancer screening.
Previous research on the global effects of physician strikes has suggested a decrease in mortality concomitant with reduced medical consumption. It therefore seems relevant to carefully study mortality trends in 2020 and to disentangle Covid-related deaths from other causes of death. It would be just as important to look at inequalities according to socio-economic background: the interruption of medical care may reduce mortality among the over-medicated wealthy, but the opposite phenomenon is feared among the poorest.

The screening area

Suspending cancer screening is one of the areas to be studied according to Welsch and Prasad. For them, there is no doubt that the decline in mammography will lead to a decrease in the number of breast cancers diagnosed. But is this a bad or a good thing?
This is a good opportunity to study what will happen in American cancer statistics when screening resumes, in the opinion of these authors.
They expect one of two observations:

  • Breast cancer rates might "catch up" with the delay in diagnosis, meaning the deficit in cancer diagnoses during the pandemic would be matched for by a surplus of cancers in subsequent years. In other words, any cancers not detected in patients during the pandemic would eventually be found afterwards.
  • The alternative would be that breast cancer diagnoses would never catch up…
    Why ?
    Years ago, researchers observed this phenomenon in Norway. Welsch and Prasad refer here to the famous Oslo Institute study of 2008: in a group, women aged 50-64 years had three mammograms in six years, and at the end of six years it turned out that they had more invasive breast cancers detected than women in the comparison group, who had only one mammogram after six years. If all breast cancers were expected to become symptomatic, there would have been as many in both groups. There is no reason why there should be fewer in the group that was not regularly screened, except that breast tumors that never expressed themselves and even regressed spontaneously were detected in excess in the group that had more frequently mammography. This study was at the origin of the demonstration and quantification of overdiagnosis. (See our brochure).

A mammographic procedure done later and less frequently therefore leads to fewer breast cancer diagnoses. It could be argued that this deficit eventually manifests itself in undetected tumors appearing within a longer time frame, around 5, 10 or 25 years. However, this is not the case; this deficit is never caught up even after 25 years of follow-up, as Miller's study shows.
The results of the 2008 Oslo study suggest that some small cancers regress on their own. Question: could this be happening now during the Covid-19 pandemic? And could it be highlighted?

In the article the authors also look at the decline in heart attacks and strokes observed during this period. These diseases were either under-diagnosed or there were actually fewer of them?
Who benefited from this period of less medicalization, and who lost?

Conclusion of the authors

We won't find the benefits unless we look for them, say Prasad and Welsch. We need physician-researchers who are willing to ask hard questions about the services they provide - questions that may threaten their own professional/financial interests.

Covid-19 provides a once in a lifetime opportunity to study what happens when the well-oiled machine of medical care downshifts from high to low volume in order to focus on acutely ill patients. It will be comfortable for physician researchers to study what was lost. It will be courageous for them to study what was gained.

Our opinion

Here, the two researchers present and highlight the question of overdiagnosis and discuss its causes (spontaneous regression of a slow-growing/null tumor), rather than trying to quantify it.
Indeed, the period of suspending screening is likely to be too short for examining its impact reliably. For that it would require that the interruption last two or three years or more (as in the Oslo study comparison group, where the time period for mammography non-examination in the comparison group was 6 years), and that this interruption concerns people who would have been eligible within that time period, according to the initial schedule, as well as that there be no attempt to catch up with the delay.
In our situation, only a few months of over-diagnosed cancers will disappear.
Already in our country the INCa has been rushing, although the epidemic is not yet totally behind us, to send a note to the ARSs (Regional Health Agency) asking to set up a timetable to catch up with the screenings not carried out! (Page 2)
"A plan to catch up on screening not carried out will be established by each CRCDC (regional coordination centers for cancer screening), depending on the estimated number of screenings not carried out and on the epidemiological situation in the territories, its own resources and the methods for resuming activity".
It should be noted that there is an obsessively technocratic concern about the activity indicators of the screening centers, there is no question of reflecting on the possibility of a study based on the data collected during the suspension of screening period, no, it is a question of catching up on indicators that would have lagged behind schedule for the last three months.
A Danish physician colleague confirms that in Denmark, as well, the reactivation has also taken place, and it is not lagging behind….


Another reflection is that if we will find only a slight reduction in incidence due to the short duration of suspending cancer screening, it will be very difficult to detect reliably the eventual compensatory increase mentioned by the authors, or on the contrary the absence of a compensatory increase, not to mention the fact that tumors that disappear by themselves (the over-diagnosed) need nevertheless at least several months, if not years, to disappear.

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.

What is metastasis ?

A metastasis is a secondary tumor site, originating from primary tumor cells that have become detached from it and then transported to nodes or secondary organs via the lymphatic and/or blood circulation. Breast cancer, whether it has pejorative biological characteristics, is likely to produce metastases.
The organs that may be secondarily affected are the bones, brain, liver, lung…..


The risk of developing metastases in the case of breast cancer depends on the molecular characteristics of the original tumor. According to several studies, aggressive, fast-growing breast cancer, which rapidly becomes large and metastatic from the outset, does not develop from every small lesion, but from a subpopulation of small lesions with biological factors that are pejorative from the outset.

Since being detected, the rates of metastatic cancer have not decreased over the past 20/30 years, although this is one of the objectives of screening, together with the decline in mortality.

Read: https://cancer-rose.fr/en/2020/12/17/mammography-screening-a-major-issue-in-medicine/

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.

What is My PEBS ?

Mypebs (my personal breast screening) is a European study that should last 6 years and recruit 80,000 women, aged between 40 and 70, in 5 countries (Italy, France, Israel, Belgium and the United Kingdom).
The defined objective of the study is to verify whether individualized screening, i.e. based on each woman's lifetime risk of developing breast cancer, would be more effective in reducing the number of advanced cancers (stage 2 and above) than current standard mass screening.


BUT IN REALITY, THE STUDY WILL SIMPLY BE LIMITED TO DETERMINING WHETHER INDIVIDUALIZED SCREENING WOULD NOT MISS TOO MANY SERIOUS CANCERS COMPARED TO STANDARD SCREENING.

This is called a "non-inferiority test". If the new screening, or individualized screening, miss less than 25% serious cancers more than in the standard screening, it will be arbitrarily considered as being " non-inferior ", and after all, the two methods would be considered equivalent.
In other words, the question is whether the new strategy is not less effective than the original one, assuming that if there are, for example, 24% (less than 25%) more serious cancers, the results are declared "non-inferior". The authors will argue that both types of screening are equally effective, and the study will be declared a success.

There are several methodological flaws on Mypebs study :

  • Incomplete and misleading brochure given to participants, minimizing the problem of over-diagnosis and omitting the problem of over-treatment.
  • There is no comparison group of "unscreened" women, which means that the over-diagnosis in the screened groups cannot be quantified compared to a group of unscreened women.
  • The software used to "calculate" the individual risk of each woman according to her age, her personal and family history, her breast density, has no scientific validity and will be "tested" during the study with possible readjustments.
  • Additional mammograms will be carried out for certain women included in the study from the age of 40 onwards, whereas the irradiation of the breast exposes them to a real risk of DNA chains breakage of the breast cells in this young age group.

To better understand the specificities and flaws of Mypebs, Cancer Rose has created a portal dedicated to studying and decoding the My PEBS study.
You can also find an analysis here, made by our statistician, Dr Vincent Robert: http://www.mypebs-en-questions.fr/index.php

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.

What is “high risk”?

FIRST

What is a "family at risk"?

Having a previous family history case, particularly a direct one, is not proof of being a "at-risk" person, despite what is commonly thrown at women as a scarecrow.

We receive frequent testimonials from young women who have been unnecessarily alarmed and, more importantly, compelled to undergo unnecessary and potentially dangerous over-medication.

What about genetic mutation testing for women? When should it be done?

The independent publication Prescrire, Volume 36 N°388/February 2016, presents this topic.

BCRA1 and BCRA2 gene mutations are autosomal dominant, and women with these mutations have a more considerable and earlier risk of breast or ovarian cancer than the general population.

-For the BRCA1 mutation, the median age of onset is 40 years, and the cumulative risk of developing cancer at age 70 is 51 percent to 75 percent.
-For the BRCA2 mutation, the estimated cumulative risk ranges from 33% to 55%.

According to the journal Prescrire, the following criteria should be considered when proposing an oncogenetic consultation: 

-Three people in the same branch with breast cancer before age 70,

-Two people in the same branch with cancer before age 50

-One person with ovarian cancer

-One person with breast cancer diagnosed before age 40, or a bilateral form, the first before age 50, or a hormone receptor-negative cancer that occurred before age 60.

The oncogenetic consultation will be requested in these circumstances, based on the score table below.

Eisinger score

The Eisinger score is a decision aid for requesting an oncogenetic consultation.

We present it below (downloadable):

In families where there are multiple cases of breast cancer, the following conditions may arise:

A- Mutation found in a woman of the family presenting breast cancer.

This genetic mutation search provides valuable information to women in the family

Women who are carriers have a higher risk, while women in the same family who are not carriers have the same risk as to the general population.
Suppose a woman in the family decides to search for a mutation in the BRCA1 or BRCA2 genes because of her genealogy and finds herself to be a carrier of a deleterious mutation in these genes. In that case, her risk of developing breast cancer appears to be high, which is also high for her relatives.

B- No mutation found in women with breast cancer.

Either there is no mutation, and the patient has a form of cancer without a genetic cause, or there is a mutation, but it may be an unidentified genetic cause.
As a result, the women in her family will be uncertain whether or not this cancer is inherited. This cancer's risk of inheritance isn't as high as it is when a BRCA mutation is found, but it is higher than in the general population.

Because of the uncertainty, it's necessary to look into the genealogy, which has its own set of uncertainties and imprecision.

C- The breast cancer patient has not undergone genetic testing.

This provides useless information to women's relatives. The sick person may have had an unknown mutation, she may be mutation-free, but the mutation could be present in family members.

REMEMBER THE FOLLOWING:

- Either the person has a family member with a mutation but is mutation-free, her risk will be similar to the general population.

- Either she is a carrier of the mutation, and her risk of developing breast cancer can be estimated, which will be higher than in the general population.

- However, for certain women, there may still be a lot of uncertainty about their family's breast cancer risk:

*In women who have had breast cancer in the family but have not had a mutation in one of the cases,
*In women with a personal negative genetic mutation search, with a genealogy presenting several breast cancer cases, but without any search performed on the sick members.

Summary of guidelines according to the situation, based on the Prescrire publication.

Published in "La Revue Prescrire" May 2016/Tome 36 N°391-p.355 to p.361

The authors provided different options based on the risk circumstance (carrying a mutation, no mutation but one case in the family, no mutation but a family 'history'); we tried to synthesize these situations in a table (below, downloadable).

First of all, who are the subjects at risk?

-a woman with a case of breast cancer in a first-degree relative (mother, sister, daughter) before age 40.

-two women with breast cancer in the first or second-degree family.

-affected male relative, first or second degree

-woman of the family in the first or second degree affected by ovarian cancer.

When no genetic mutations are found in these families, the family risk remains quite uncertain.

 For further explanation, see the article: https://cancer-rose.fr/en/2021/01/29/high-risk-of-breast-cancer-and-mammography-in-practice/

Who should be advised to have a prophylactic mastectomy (breast removal for the prevention of cancer)?

Synthesis of an article entitled "to whom to propose a prophylactic mastectomy" published in the journal 'Réalités en Gynécologie-Obstétrique- N°185_janvier 2017'; Authors: A.Kane, CH. Dehghani, E.Vincens from the Department of visceral and gynecological surgery, Groupe hospitalier Diaconesses Croix Saint-Simon, Paris

The conclusions are:

- For patients who are carriers of the genetic mutation (BRCA1 and BRCA2 mutation but especially BRCA1), unaffected, especially for young patients and those with a heavy family history, preventive mastectomy corresponds to the best means of prevention and must be discussed with them.

- For patients who carry a mutation or have a heavy family history and who have had breast cancer, preventive bilateral or contralateral mastectomy in the event of removal of the breast during first cancer seems to be of interest in terms of survival and reduction in the occurrence of second breast cancer. The HAS recommends it.

The benefit is very uncertain and highly overestimated for patients who have had breast cancer but without genetic risk or family history. The authors cite numerous risks, and it is NOT recommended.

Three cases are studied:

1.         Request for preventive mastectomy of patients with mutation or at high risk.
2.         Request for contralateral preventive mastectomy in these mutated or high-risk familial patients who have had first breast cancer.
3.         Request for preventive mastectomy in patients who have had breast cancer without genetic background.

Lesions referred to as "at risk"

These are "borderline" lesions found on microscopic examination after a breast biopsy, which are not benign, which are not cancers in the strict sense of the word, which are said to be "intermediate" and which present a more or less increased risk for the patient of turning into cancer later on.

Below are two tables of recommendations found in the literature that quantifies risk based on a biopsy result.
These two tables indicate the proposed course of action (abstention, surgery, or monitoring).

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.

Exit mobile version