Cancer screening for older adults; a bad idea

Patient-Reported Factors Associated With Older Adults' Cancer Screening Decision-making: A Systematic Review
https://pubmed.ncbi.nlm.nih.gov/34748004/

Jenna Smith 1 2Rachael H Dodd 1 2Karen M Gainey 2Vasi Naganathan 3Erin Cvejic 2Jesse Jansen 1 2 4Kirsten J McCaffery 1 2

  • Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
  • 2Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.

Objective of the study: 

To summarize the patient-reported factors associated with older adults' decisions regarding screening for breast, prostate, colorectal, and cervical cancer.

Method:

21 studies were included.

Factors associated with decision-making were synthesized into 5 categories: demographic, health and clinical, psychological, physician, and social system.

The most commonly identified factors included personal or family history of cancer, positive screening attitudes, routine or habit, gaining knowledge, friends, and a physician’s recommendation.

Results:

Although guidelines suggest incorporating life expectancy and health status to inform older adults’ cancer screening decisions, older adults’ ingrained beliefs about screening may run counter to these concepts.

Consequently, communication strategies are needed that support older adults to make informed cancer screening decisions by addressing underlying screening beliefs in context with their perceived and actual risk of developing cancer.

Cancer Rose commentary

We analyzed the CNGOF (CNGOF-French national college of obstetricians and gynecologists) campaign of 2019, a stunning "cry of alarm" for breast cancer screening in older women, with spectacular media coverage in a clear sky, while no country practicing screening recommends screening beyond the age of 74, nor even the WHO...

Why is this campaign, still relayed on this learned society's homepage, a danger to the elderly?

A study from the University of Leyden provides an answer.

Read here: https://cancer-rose.fr/2019/04/07/la-campagne-pour-le-depistage-de-la-femme-agee-par-le-college-national-des-gynecologues-et-obstetriciens-de-france-cngof/

Few trials have focused on screening women in old age. The study by researchers from the University of Leyden on data from the Netherlands, published in 2014 in the BMJ, makes up for this lack.

According to the authors, after the age of 70, organized breast cancer screening would be useless. Indeed, at this age, screening does not significantly improve the detection of advanced cancers but instead increases the number of overdiagnosis and, therefore, overtreatment.

In the Netherlands, breast cancer screening has been offered to women up to 75 since the late 1990s. "Yet there is no evidence that screening older women is effective," the study authors explain, citing that few trials have been conducted specifically on these age groups.

For the Dutch researchers, systematic screening after 70 years of age would mainly lead to the detection and treatment of lesions that would not have developed into disease during the life of the patients.

These unnecessary treatments have a considerable impact on health, and the co-morbidity of these older adults is too high, as they are less able to tolerate the side effects of treatments, such as surgery, radiotherapy, and chemotherapy.

For this reason, they recommend that generalized screening not be extended to those over 70 years of age and recommend an individualized decision based on life expectancy, breast cancer risk, general condition, and preference of the women concerned.

It should also be remembered that the immune system weakens with age. This means that we contract more cancers and infectious diseases.  All the organs become exhausted and function less well, and the healing and tissue regeneration faculties are lessened, all of which must be considered when administering heavy treatments.

Conclusion

A point of view published in the JAMA in 2019 raised the question of the relevance of screening for older adults. While all recommendations stop this screening at 74 years of age, it is unfortunately not uncommon to see people beyond that age being sent for screening and "check-ups."

The authors argue that the evidence of benefits for older adults is unclear, and the chance of harm becomes greater (e.g., overdiagnosis, burdens of additional testing, false-positive results, and psychological impacts).

Although aging-related concepts are challenging to communicate, older people must be counseled about the reduced benefit and increased chance of harm from screening associated with limited life expectancy and worsening health to make better quality screening decisions. Communication strategies are needed that support older adults in making informed cancer screening decisions.

The principle of non-maleficence implies not harming people, a principle that even a learned society like the CNGOF must adopt.

Glasgow-communication

The Australian author reported at this week's ICCH2022 INTERNATIONAL CONFERENCE ON

COMMUNICATION IN HEALTHCARE (September 5-9, 2022, Glasgow), the results of an interview-based study involving general practitioners regarding cancer screening in older adults.

General Practitioners' Approaches to Cancer Screening in Older People, A Qualitative Interview Study
https://each.international/eachevents/conferences/icch-2022/programme/

Session Description:

Background: Older adults continue to be screened for cancer with limited knowledge of the potential hams. In Australia, general practitioners (GPs) may play an important role in communication and decision-making around cancer screening for older people. This study aimed to investigate GP’s attitudes and behaviours regarding cancer screening (breast, cervical, prostate and bowel) in patients aged ≥70 years (as screening programs recently began targeting ages 70-74). Methods: Semi-structured interviews were conducted with GPs practising in Australia (n=28), recruited through multiple avenues to ensure diverse perspectives (e.g., practice-based research networks, primary health networks, social media, cold emailing). Transcribed audio-recordings were analysed thematically. Findings: Some GPs initiated screening discussions only with patients younger than the upper targeted age of screening programs (i.e., some thought 69 or 74 years). Others initiated discussions beyond recommended ages. When providing information, some GPs were uncomfortable discussing why screening reminders stop, some believed patients would need to pay to access breast screening, and detailed benefit and harms discussions were more likely for prostate screening. When navigating patient preferences, GPs described patients who were open to recommendation, insistent on continuing/stopping, or offended they were not invited anymore, and tailored their responses accordingly. Ultimately the patient had the final say. Finally, GPs considered the patient’s overall health/function, risk, and previous screening experience as factors in whether screening was worthwhile in older age. 

Discussion: There is no uniform approach to cancer screening communication and decision-making for older adults in general practice and limited understanding among both older people and GPs around why screening has an upper targeted age. Tools to support effective communication of the reduced benefit and increased chance of harm from cancer screening in older age are needed to support both older people and GPs to make more informed cancer screening choices.

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.

Overdiagnosis, the silent pandemic of the West?

May, 25th

http://www.publichealthtoxicology.com/Overdiagnosis-The-silent-pandemic-of-the-West-,145733,0,2.html

The use of so-called "preventive" medicine to maintain good health is an intense and widespread phenomenon in modern Western societies. Although this appears logical and may have a solid scientific basis because it reflects medical community recommendations, several questions that require further investigation arise.

The authors believe that the most serious issue with this behavior in relation to modern medicine is overdiagnosis.

"What is good health?" and "What is a medical problem?" "What exactly are we looking for in medical examinations?" and "What is the relationship between medicine, society, and its practices?"

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.

Potential benefits, as well as harms, from the COVID-19 disruption on cancer screening

May, 28th

Online early publication https://doi.org/10.17061/phrp32122208
https://www.phrp.com.au/wp-content/uploads/2022/04/PHRP32122208.pdf

During the Covid pandemic, some scientists and journalists from various fields predicted that disruptions in cancer screening programs would result in a "tsunami" of advanced breast, prostate, colon, and cervical cancers and deaths.

This prediction is strongly challenged by several scientists in this April 27 publication by Australian authors, who even consider the period of screening cessation as a "natural experiment" to finally accurately assess the benefits and harms of routine health care.

In some cases, it may be possible to identify where healthcare costs can be cut, particularly for low-value-added healthcare devices, because these decreases during the pandemic were not harmful or even beneficial.

Both short-term and long-term consequences must be evaluated.

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.

Why don’t we change our vocabulary?

May, 31th

https://philarchive.org/archive/LARCDS

This article argues that the phenomenon of overdiagnosis is linked to both our increasing knowledge of cancer and the fact that this new knowledge causes bias in cancer screening, but also to our approach to cancer and the associated medical vocabulary.

The authors selected two types of cancer as particularly exemplary: papillary thyroid cancer and carcinoma in situ of the breast.

The often militaristic semantics and abusive designations of "cancers" for lesions that are not life-threatening contribute to both an increase in societal anxiety and overdiagnosis, a real scourge of post-modern 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.

Awareness of breast cancer overdiagnosis among women with breast cancer

June, 22

Effects of awareness of breast cancer overdiagnosis among women with screen-detected or incidentally found breast cancer: a qualitative interview study

This is a study conducted by an Australian team from the University of Sydney (Prof. Alexandra Barratt's team) that consists of qualitative research conducted through international interviews with women diagnosed with breast cancer who are aware of the concept of overdiagnosis.

The majority of the women who were followed became aware of overdiagnosis after their own diagnosis and felt impacted.

The discovery of overdiagnosis or overtreatment has had a negative psychosocial impact on the women's self-image and the quality of their interactions with health care professionals. For some, it has triggered deep remorse about their past decisions and actions.

The experiences of this small group of women provide unprecedented insight into the serious consequences of overdiagnosis after a breast cancer diagnosis.




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 effect of breast cancer screening is declining

JULY 1, 2022 BY CANCER ROSE

https://academic.oup.com/eurpub/advance-article/doi/10.1093/eurpub/ckac047/6609838?login=false

By Søren R Christiansen, Philippe Autier, Henrik Støvring

The effect of breast cancer screening is declining

A new study raises the debate about the progressive decrease in the benefits of breast cancer screening which would be at a too low level compared to their consequences in terms of overdiagnosis and overtreatment.
Researchers from the University of Aarhus, Department of Public Health, Denmark, and the International Prevention Research Institute (IPRI), Lyon, France, are the authors of the study.
They state that breast cancer mortality has decreased over the past three decades due to improvements in patient management and better therapies, while the number of women needed to be invited to mammography screening in Denmark to prevent one cancer death in 10 years has doubled.

"As the beneficial effects of mammography screening declines ever more, we should consider abandoning the current mammography screening program with biennial mammograms for everyone aged 50-70. Perhaps a more targeted, high-risk screening strategy could be an alternative, if studies showed the strategy's beneficial effects," Støvring, associate professor in the department of public health at Aarhus University declared in an interview.

"I think we are approaching a point where just continuing might become untenable from an ethical point of view, as fewer and fewer women will experience gains due to screening (they would not die from breast cancer anyway due to improved treatment), but the number of women harmed due to overdiagnosis and overtreatment remains constant," he noted.

H.Støvring believes that for breast cancer the evidence for mammography screening is not convincing. He declared: "I think it is critical that we reassess screening programs as new evidence becomes available”. 

In conclusion, improvements in cancer therapy over the past 30 years have reduced mortality, which may erode the benefit-harm balance of mammography screening.

In addition, future improvements in the management of patients with breast cancer will increasingly reduce the benefit-risk ratio of screening.

The benefit of mammography in terms of reduced mortality declines while the harms such as overdiagnosis are unaffected. Screening leads to both overdiagnosis and overtreatment, which has a cost both on a human level and in terms of the economy.

Interview with the main author, June 24, 2022 by Helle Horskjær Hansen

https://health.au.dk/en/display/artikel/effekten-af-brystkraeftscreening-bliver-mindre-og-mindre-1

Screening for breast cancer has a cost. This is shown by a Danish/Norwegian study that analysed 10,580 breast cancer deaths among Norwegian women aged 50 to 75 years. 
"The beneficial effect of screening is currently declining because the treatment of cancer is improving. Over the last 25 years, the mortality rate for breast cancer has been virtually halved," says Henrik Støvring, who is behind the study.
According to the researcher, the problem is that screenings lead to both overdiagnosis and overtreatment, which has a cost both on a human level and in terms of the economy. 

Overdiagnosis and overtreatment

When the screening was introduced, the assessment was that around twenty per cent of the deaths from breast cancer among those screened could be averted. While this corresponded to approximately 220 deaths a year in Denmark 25 years ago, today the number has been halved. 

The study shows that in 1996 it was necessary to invite 731 women to avoid a single breast cancer death in Norway, you would have to invite at least 1364 and probably closer to 3500 to achieve the same result in 2016. 
On the other hand, the adverse effects of screening are unchanged.

"One in five women aged 50-70, who is told they have breast cancer, has received a 'superfluous' diagnosis because of screening – without screening, they would never have noticed or felt that they had breast cancer during their lifetime," says the researcher. 

One in five corresponds to 900 women annually in Denmark. In addition, every year more than 5000 women are told that the screening has given rise to suspicion of breast cancer – a suspicion that later turns out to be incorrect.

Peaceful, small nodes – but in who?

Henrik Støvring notes that the result is not beneficial for the screening programmes.

According to the researcher, the challenge is that we are not currently able to tell the difference between the small cancer tumours that will kill you and those that will not.

Some of these small nodes are so peaceful or slow-growing that the woman would die a natural death with undetected breast cancer, if she had not been screened. But once a cancer node has been discovered, it must of course be treated, even though this was not necessary for some of the women – we just do not know who.

"The women who are invited to screening live longer because all breast cancer patients live longer, and because we have got better drugs, more effective chemotherapy, and because we now have cancer care pathways, which mean the healthcare system reacts faster than it did a decade ago,” says Henrik Støvring.

Abstract of the study

Source:

Søren R Christiansen, Philippe Autier, Henrik Støvring, Change in effectiveness of mammography screening with decreasing breast cancer mortality: a population-based study, European Journal of Public Health, 2022;, ckac047, https://doi.org/10.1093/eurpub/ckac047

Background

Reductions in breast cancer mortality observed over the last three decades are partly due to improved patient management, which may erode the benefit-harm balance of mammography screening.

Methods

We estimated the numbers of women needed to invite (NNI) to prevent one breast cancer death within 10 years. Four scenarios of screening effectiveness (5–20% mortality reduction) were applied on 10,580 breast cancer deaths among Norwegian women aged 50–75 years from 1986 to 2016. We used three scenarios of overdiagnosis (10–40% excess breast cancers during screening period) for estimating ratios of numbers of overdiagnosed breast cancers for each breast cancer death prevented.

Results

Under the base case scenario of 20% breast cancer mortality reduction and 20% overdiagnosis, the NNI rose from 731 (95% CI: 644–830) women in 1996 to 1364 (95% CI: 1181–1577) women in 2016, while the number of women with overdiagnosed cancer for each breast cancer death prevented rose from 3.2 in 1996 to 5.4 in 2016. For a mortality reduction of 8.7%, the ratio of overdiagnosed breast cancers per breast cancer death prevented rose from 7.4 in 1996 to 14.0 in 2016. For a mortality reduction of 5%, the ratio rose from 12.8 in 1996 to 25.2 in 2016.

Conclusions

Due to increasingly potent therapeutic modalities, the benefit in terms of reduced breast cancer mortality declines while the harms, including overdiagnosis, are unaffected. Future improvements in breast cancer patient management will further deteriorate the benefit–harm ratio of screening.

Key points

Assuming a relative effect of mammography screening at 20% on breast cancer mortality, the number of women who needs to be invited to save one life has increased by 87% from 1996 to 2016. (Editor's note: this means that it is currently necessary to screen an ever increasing number of women in order to have a breast cancer death that would be prevented by screening, so it is more difficult to find a woman who has benefited from screening, while the adverse effects do not decrease (overdiagnosis)).

The number of women overdiagnosed with breast cancer per woman saved from dying of breast cancer has increased substantially from 1996 to 2016.

The deterioration in benefit-to-harm ratio of breast screening will continue due to steady improvement in therapies.

This study supports the need for re-evaluation of national screening programmes in high-income countries.

Tables

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“A cost both on a human level and in terms of the economy... “

...According to the lead author.

Another recent study raises the issue of additional costs associated with declining screening effectiveness: https://www.sciencedirect.com/science/article/pii/S0277953622003793

In this paper, the authors exploit a natural experiment resulting from the phased geographic rollout of a national mammography screening programme in Ireland to examine the impact of screening on breast cancer outcomes from both a patient cohort and a population perspective. 

Ireland is one of the few countries where, for operational reasons, the rollout of screening has resulted in a cohort of unscreened women that has existed long enough to serve as an appropriate comparison group.

Using data from 33,722 breast cancer cases diagnosed between 1994 and 2011, the authors employ a difference-in-differences research design using ten-year follow-up data for cases diagnosed before and after the introduction of the programme in screened and unscreened regions. 

They conclude that, although the programme produced the intended intermediate effects on breast cancer presentation and incidence, these failed to translate into significant decreases in overall population-level mortality, though screening may have helped to reduce socioeconomic disparities in late stage breast cancer incidence.

Highlights of the study

  • Screening increased detection of asymptomatic and early stage cancers.
  • There was no significant effect on population breast cancer or all-cause mortality.
  • Screening may have reduced socioeconomic disparities in late stage incidence.
  • Results call in to question the overall effectiveness of this common intervention.

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.

Preventing Overdiagnosis Conference-2022

Presentations

Dr. Jean Doubovetzky, a senior editor at the independent journal Prescrire, and author of the AntiDrKnock blog, presented on June 10 on the topic of unnoticed harms of breast cancer screening, "Under the radar: unnoticed harms of breast cancer screening."

Her is the presentation

Download / Télécharger

Dr. C. Bour was a speaker on June 11 on a panel discussing "Promotional versus neutral messages - impact on individual breast cancer screening decisions when information is suppressed."

Here is the presentation: 

Download / Télécharger

Our abstracts

All our abstracts are published in BMJ Evidence Medicine in the links below:

Under the radar

Dissemination of shared decision support knowledge...

Call for an international platform....

Better information of women

Socio-cultural environment

Posters

Dr. Jean Doubovetzky presented his innovative project of an international collaborative information website to inform the public about overmedication. "Call for an international platform of collaborative websites to fight "the harms of too much medicine."

La Maison de la Culture et de la Médecine  (The House of Culture and Medicine of Nice) in collaboration with Cancer Rose, presented a poster concerning the dissemination of medical knowledge for a medicine integrating more the patient.

"Dissemination of shared decision support knowledge in popular education and medical training regarding cancer screening "
Abstract

Cécile Bour, Md1, Jean-Michel Benattar, Md 2 3, France Légaré, PhD. 4, David Darmon PhD. 3 5 6, Luigi Flora PhD. 3 6

  1. Citizens’ association (NGO) (ONG) Cancer Rose
  2. Citizens’ association (NGO) Maison de la Médecine et de la Culture (MMC)
  3. Patient and Public Partnership Innovation Center (CI3P), Côte d’Azur University, France
  4. Shared Decision-Making Knowledge Translation, Laval University, Québec, Canada
  5. Department of Teaching and Research in Family Medicine (DERMG), Côte d’Azur University, France
  6. Interdisciplinary Research Laboratory RETInES, Côte d’Azur University, France

Keywords: Shared decision making, patient partnership, cancer screening, informed information, popular education, medical education.

Two citizens' associations, Cancer Rose and the Maison de la Médecine et de la Culture (MMC), have addressed, in their respective roles, the expectations of the citizen consultation on breast cancer screening in France (2016). Based on the work of Cancer Rose, which included the publication of a decision-aid based on French data, enriched by a small illustrated decision-aid, it was decided to offer monthly webinars on medical education in the health sciences, which would also be open to citizens.

Since 2015, Maison de la Médecine et de la Culture has specialized in this type of event, a project that has been carried out in collaboration with the Center for Innovation of Partnership with Patients and the Public (CI3P), an entity of the Department of Teaching and Research of Family Medicine DERMG at the University of Côte d'Azur since late 2019. The MMC is an association of citizens, not healthcare system users, that proposes through artistic works, meetings-films-debates that raise questions among citizens, whether they are relatives, patients, future decision-makers, or practicing healthcare professionals, on health issues that affect us all.

Since its first year, this activity has caught the attention of the Department of Family Medicine. Since 2015, MMC has been able to give additional teaching hours to family medicine interns for their participation in ethical reflections on health beyond peer-to-peer, physician-to-physician discussions.

At the same time, MMC has advocated for introducing a new approach initiated in Quebec with the current patient co-director of CI3P in France. MMC has co-designed a training program in collaboration with the Faculty of Medicine and the DERMG and commissioned by the Dean of the Faculty of Medicine: a university diploma course in the Art of Care in Partnership with the Patient. A training course recognized by the Ministry of Higher Education and Research as a pedagogical innovation in its first year of application in 2018. (Prix Passion Enseignement et Pedagogie in Higher Education in the " life-long education ").

This first partnership between citizens and academics resulted in the creation the Center for Innovation in Partnership with Patients and the Public (CI3P) within the Université Côte d'Azur's Faculty of Medicine, as announced by the program's founders at the award ceremony.

Cancer Rose and the MMC will host monthly webinars between the autumns of 2021 and 2022, between two Pink October campaigns dedicated to organized screening in France. These webinars provide free and informed information that is likely to foster critical thinking and shared decision-making for citizens, patients, health professionals, and medical students.

This webinar series is enhanced by the participation of a collaboration between CI3P and the Canadian Research Chair on Shared Decision Making and Knowledge Translation. A partnership that strengthens the historically strong links between these francophone universities, Laval University from Canada and Université Côte d'Azur from France.

Thus, CI3P and the Canadian Research Chair in Shared Decision Making and Knowledge Translation contribute to a long-standing collaboration between these two universities, France and Quebec, and thus between Canada and France.

These monthly participatory webinars, which were initially co-designed by members of the two associations and citizens (consisting of patients, health science students, and doctors), propose an exchange initiated by a work of art, which can be a work or an excerpt from a film or documentary, a literary work or a comic strip, a graphic illustration, or a theatrical or performance work. These works are mainly narrative, but not exclusively so. This artistic approach is proposed as an introduction to the theme.

The topics addressed then enable the development of a critical mindset among citizens because each person is mobilized singularly in their sensitivity and the unique interpretation that emerges from it. This approach opens up the Art of Care in partnership with the patient, which provides the means to reach a shared decision, within the framework of the doctor-patient relationship, following the ethical values of a medical practice adjusted to the patient.

This is the proposed cycle represented by this poster.

It's Discussed:

Article du CanadianTaskForce

Annonce dans la revue Prescrire

Photos

Editorial in the BMJ

Editor's Choice

A system reset for the campaign against too much medicine

BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1466 (Published 16 June 2022)

By Kamran Abbasi, editor in chief

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.

POD-CONFERENCE

Preventing Overdiagnosis Conference 2022-Calgary

Click on the image to access Preventing Overdiagnosis website

We are invited to Preventing Overdiagnosis Conference in Calgary (9 - 12 June) as speakers for the theme: Promotional messaging vs neutral messaging – impact on individual breast screening decisions when information is suppressed.

Keynote speakers: https://www.preventingoverdiagnosis.net/?page_id=2354

Presentation from Jean Doubovetzky MD, Under The Radar

Download / Télécharger

Presentation from Cécile Bour MD, Censorship In France

Download / Télécharger




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.

Update on Tomosynthesis

May 17, 2022

Article in Auntminnie

Reminder: Tomosynthesis (or 3D mammography) is a radiological imaging technique that reduces the effect of superimposition of breast tissue as it reconstructs a three-dimensional image of the breast from several low-dose X-rays acquired from different projection angles.

This technique was heavily promoted about 10 years ago. Therefore, a review is done after 10 years of hindsight in the media "AuntMinnie.com."

This is a community website for radiologists and professionals in the medical imaging industry. According to this rather collaborative media that connects radiologists, business managers, and industry professionals to "meet, do transactions, research and collaborate," tomosynthesis has clearly disappointed.

Many questions and doubts about the benefit of using this technique have been raised previously:  https://pubmed.ncbi.nlm.nih.gov/30816931/

- tomosynthesis does not reduce false alarms
- the additional use of tomosynthesis does not reduce interval cancers
- tomosynthesis would increase overdiagnosis
- the benefits of tomosynthesis are not clear

1° Cancer detection

Digital mammography alone has been compared with digital mammography + tomosynthesis (a higher-radiation combination): matched studies* have shown that the addition of tomosynthesis made it possible to find more cancers: 8.8 per 1000 women compared with 6.4 per 1000. But in other unmatched studies*, the difference was narrower, 5.7 cancers detected per 1000 women versus 4.5.

* Matching consists of setting up pairs (1 case and 1 control) with the same characteristics (e.g., age) to compare the results while avoiding potential confounding factors. The groups are thus "balanced" on these characteristics.

2° Recall rates

What about recall rates? The recall rate refers to false alarms during screening, i.e., suspicions of cancer that will not be confirmed, but only after recalling the patients who will need to have other complementary explorations before deciding on these suspicions. Here again, the data vary according to the study conducted.

Based on the March 2022 study summarized here, repeated breast cancer screening with 3D mammography only modestly decreases the risk of having a false-positive result compared with standard digital mammography.

What can we learn from this study?

The risk of a false-positive result was lower when screening was performed every two years instead of every year and in the case of non-dense breasts and older women.
However, the difference was modest, and the reduction in false positives by using 3D mammography was only 2.4% compared to standard mammography.

3°How effective are synthetic mammography images?

In 2012 an opening was made for 'synthetic imaging,' which records a single radiological acquisition and therefore delivers a single dose of radiation, thus avoiding the over-irradiation caused by 3D mammography**.

But are the synthesized images an effective alternative to digital mammography images? Clinical results of effectiveness tests of synthesized mammographic images are unfortunately mitigated. Overall, the results between synthesized images are equivalent to digital mammography, although the latter has a better resolution.

**Classically, 2D mammography and 3D tomosynthesis acquisitions are used in combination. This results in a significant increase in the X-ray dose delivered. The X-ray doses delivered by combining 2D mammography and tomosynthesis are about twice the dose of 2D mammography alone.
Synthetic 2D tomosynthesis is an alternative, obtained by reconstruction from 3D acquisitions only; it avoids the joint use of 2D mammography and thus reduces the delivered dose.

4° Does tomosynthesis reduce mortality?

Does tomosynthesis result in a reduction in mortality? According to this article in Autminnie.com, a survey of eight studies conducted between 2016 and 2021 investigated whether tomosynthesis reduces rates of interval cancers (cancers not caught by screening because they occur between two mammograms) compared with digital mammography alone. Interval cancers are often very aggressive and occur quickly, thus missed by screening. They are correlated with mortality because their intrinsic aggressiveness endangers the survival of women, often because of their metastatic potential.

It was found that tomosynthesis does not impact the rate of interval cancer.

In conclusion

Ten years after its use, the benefits of tomosynthesis may be much more modest than clinicians initially expected. In conclusion, this technique is finally similar to digital mammography with no proven advantage.

Even if the detection rate of tomosynthesis seems slightly better, the benefit of this technique remains an open question. If this moderate improvement in cancer detection is gained at the cost of increased overdiagnosis, we cannot conclude that the benefit/risk ratio is favorable.

As usual, the major concern is the information provided to women, as tomosynthesis is sometimes performed in radiology offices without the knowledge of the patient who comes for a routine mammogram, who does not benefit from it and is exposed to unnecessary over-irradiation.

Also read: https://www.bmj.com/content/366/bmj.l4506




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.

Evaluation of information on screening, the situation in Italy, French parallel, and hope…

Synthesis Dr. C.Bour, May 11, 2022

https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-022-01718-w

According to the authors of this Italian study published in BioMed Central (BMC, a scientific journal) on April 22, 2022, information about overdiagnosis showed a notable increase in 2021 compared with 2014. However, the frequency of this information in the documents aimed at women was still low, probably because it is both the most recent and harmful risk for women. Therefore, not all health operators are aware of overdiagnosis. If they are aware of it, they might avoid reporting the information in public documents for fear of dissuading women from undergoing screening. Moreover, many reports of overdiagnosis are unclear.

It is difficult not to find a parallel with the situation regarding information in France.

This situation of insufficient information for women persists for many reasons.

One of the most frequently reported justifications is that providing information on potential harms could reduce adherence to screening.

Method and results

As information provided to women on the benefit-risk balance is still highly biased, F. Atténa (Department of Experimental Medicine, University of Campania "Luigi Vanvitelli") and her collaborators have decided to evaluate documents addressed to the general female public and published on the Internet by the Italian national and regional public health services.

Information on false positives and false negatives, biopsy-proven false positives, interval cancer, overdiagnosis, radiation exposure, and mortality risk reduction was analyzed. In addition, quantitative data were investigated.

The 2021 situation was compared with the 2014 situation.

Overdiagnosis and biopsy-proven false-positive results were the least reported risks of screening (20.1% and 10.4%).
Compared to the 2014 information, the 2021 information showed some improvements. The most marked improvements concern overdiagnosis. The declarations of this adverse effect increased from 8.0 to 20.1%.
Concerning the number of false positives proven by biopsy, there is also an increase in the information from 1.4 to 10.4%.
But quantitative data remained scarce in 2021.

The authors conclude with the evidence of moderate improvements in information observed from 2014 to 2021.

However, information about breast cancer screening in materials for women published on Italian websites remains too sparse.

A previous shocking Italian study from 2020

A study published in September 2020 by Italian authors moved us: this economic study explained how to effectively manipulate women to make them participate ever more in organized breast cancer screening by mammography. The authors then congratulated themselves with confusing cynicism on the effectiveness of manipulation techniques: by withholding information from women in the invitation letters, insisting on a negative effect and a potential danger of not participating in screening, by "limiting the cognitive overload of women" (sic), it would be possible to increase participation in screening significantly.

This kind of unethical study can explain, among other things, the persistence of misinformation of women and biases in the information, which are constantly renewed, as seen in this BMC study mentioned above.

A problem common to many countries, including France

Danish authors analyzed how health authorities can subtly influence citizens to participate in cancer screening programs: https://cancer-rose.fr/en/2021/04/20/methods-of-influencing-the-public-to-attend-screenings/

The researchers identified and analyzed several "categories of influence," i.e., several methods that can be used to push the public to undergo screening.

In a systematic table, we find that information bias is used in many countries, among which we find European countries like Italy, corroborating the finding of this BMC study, Spain, and also France, where biased information from the National Cancer Institute (INCa) is present in two of the systematic categories. See the table: https://cancer-rose.fr/wp-content/uploads/2021/04/Supplementary-Tables-Rahbak-et-al-210421.pdf

The INCa's disregard for information to women culminates with the qualification of the scientific controversy of screening as "fake news ." (Cf https://cancer-rose.fr/en/2021/06/24/press-release-cancer-rose/)

Hope for improvement and consideration of overdiagnosis

A position of French sociologists on the "health projects" of the next government can be read in the article "The main topics for the next Minister of Health" published in the media 20Minutes; they are alarmed by the overdiagnosis of organized screening (in the section "Prevention").

We can read:

 "We must be wary of organized screenings; it can generate overdiagnosis, criticizes Frédéric Pierru (doctor in political science, a sociologist at the CNRS, research fellow (CR-CNRS), works at the Center for Political and Social Administrative Studies and Research (CERAPS), attached to the University of Lille). This is an individualistic, medicalized, and poor vision of prevention". He believes that it would be more effective to put resources back into maternal and child protection centers (PMI), school medicine, occupational medicine...

"Effective prevention would mean addressing diet, stress, alcohol..." says Daniel Benamouzig (sociologist, Director of Research at the CNRS, holder of the Health Chair at Sciences Po, and researcher at the Centre Sociologie des Organisations (CNRS and Sciences Po)). We know that this President is not very inclined to oppose the alcohol or pesticide lobbies. Health, particularly public health and the ecological transition, is a long-term task. It is not easy to prove oneself in five years..."

Let's hope that these far-sighted scientists are heard...


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.