Blind and Deaf

In the journal “Pratiques”, Dr Marc Gourmelon reviews the history of breast cancer screening in France, from the launch of organized screening campaign, through citizen consultation, until the current situation with the new 2021/2025 cancer plan endorsed by President Macron, in a climate of deafness of authorities to citizen demands and despite the failure of this screening. All of this is against women's right to fair information on the risk-benefit balance of this screening.

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Here this article translated

Marc Gourmelon, Medical doctor, member of the Cancer Rose collective

Where are we today in France, regarding breast cancer screening by mammography in women aged 50 to 74 years old without an increased risk of breast cancer?


Historical reminder of the introduction of breast cancer screening by mammography in France

Mammography (breast X-ray) is a radiological examination for diagnosis of any abnormalities detected in breast. It became common practice in the late 1960s with the arrival of the first mammograph in 1965. [1] [2]

Two randomized screening experiments are believed to have proven the effectiveness of mammography on mortality reduction.
These are the New York HIP trial (1963) and the study of two counties in Sweden (1985, 1997).

The published results were identical: a 30% reduction in mortality in the screened group compared to the control group in women over 50 years of age. This resulted in great enthusiasm leading several countries (United States, Sweden, Finland, United Kingdom, the Netherlands and others) to the decision to launch systematic screening campaigns by mammography.

In France, systematic breast cancer screening by mammography was first launched in ten pilot departments in 1989.

Thanks to this screening, it is believed that women would no longer have to die of breast cancer and the disease would be defeated on the basis of an a priori intuitive concept: the smaller or "in time" a cancer is caught, the less serious it is and the quicker it can be removed, thus the more advanced forms of cancer will be averted for women.

Starting in the 1990s, an increasing number of doctors began offering this imaging technique to detect breast cancer, and many studies were carried out in parallel on the subject.
A report from the French National Agency for Health Accreditation and Evaluation (ANAES) dated March 1999 assesses relevance in general population. It recommends the breast cancer screening for all women between 50 and 69 years of age, to be performed every two years. [3]

Based on this recommendation, the cancer plan 2003-2007 in its measure 21, notes:  "Fulfilling the commitment to generalize organized breast cancer screening by the end of 2003".[4] Organized screening of breast cancer by mammography, under the impetus of President Chirac, will then be generalized in France in 2004.

However, voices of national and international scientists have been raised, as early as 1987, urging caution, but inaudible in the climate of general euphoria. [5]

In 2001, the independent Nordic collective Cochrane published a meta-analysis, updated several times [6], which questions benefits of this screening.

Nevertheless, the French High Authority for Health (HAS), which evaluated this study in early 2002, refused to question the relevance of organized breast cancer screening. [7]

Despite the accumulation of studies and evaluations in recent years, today the organized screening of breast cancer by mammography is still recommended by the health authorities ( French High Health Authority, National Cancer Institute) on the basis of 2004 guidelines.
The objective is even to intensify it, because the participation targets for eligible women (50 to 74 years old) set at 70 or 80% have still not been reached.

In fact, participation in the organized breast cancer screening program represents only slightly more than 50% of women.

At the same time, the number of mammographers is constantly expanding and cutting-edge technology, such as tomosynthesis, a type of 3D imaging, is being studied to track down more and more small lesions, contributing to a surge in incidence of cancers without a significant reduction in mortality. (still 12,000 deaths/breast cancer/year).

Proponents of EBM (the concept of tripod-based medicine - scientific studies, physician's professional experience, and patient preferences and choices) advocate enlightened information and shared decision-making with the patient, who must be informed of the uncertainties of screening. This concept is defended in France by the independent journal Prescrire. In the United Kingdom and Canada, very detailed brochures are issued to patients, while in France this is not the case.

But what about the real effectiveness of this screening?

The effectiveness of cancer screening is defined by : 

- a drastic and significant reduction in mortality from the disease, 

- a reduction in incidence of advanced cancers, 

- a lightening of treatments.

The meta-analysis of the Cochrane collective that we have just mentioned above alerts us of an unexpected guest of screening, namely overdiagnosis. This concerns the discovery of cancerous and pre-cancerous lesions which, undetected, would not have endangered the woman's health or life, but which will all be treated with the same determination.

Together with false alarms, that is, suspected cancers that are not confirmed after further examinations of the patients, the risk-benefit balance of screening does not appear to be favorable. For the Cochrane, for every 2,000 women screened over 10 years, for one life saved, there will be 10 overdiagnosed and overtreated women and 200 false alarms. In the years following this publication, international and national studies on the benefit/risk of breast cancer screening by mammography have multiplied and have highlighted an important issue: an increasing overdiagnosis of small lesions (<2 cm) and precancerous lesions responsible for overtreatment, and a parallel reduction in mortality that is very minimal, little or not perceptible.  [8] [9] [10]

Indeed, when comparing populations of women subjected to different screening intensities, we find that among women screened, more cancers are found for identical survival in both groups. [11]

Overtreatment is the materialization of overdiagnosis for women, and it has destructive effects.

Women are doubly victims, in their body and in their illusions, convinced that they have been "saved" while they are suffering the stress of a ruined life and the potentially major adverse effects of treatment.
Treatments are primarily surgical, with an increase in total and partial mastectomies since screening, contesting the widespread myth of therapeutic lightening through screening. [12]
Women also undergo unnecessary radiation therapy with cardiac risks and an increased risk of hemopathy. [13] [14]
The quality of their lives is diminished; after being diagnosed with cancer, women suffer from anxiety and depression syndromes, some lose their jobs and become poorer. Their sexuality and self-image are altered, sometimes leading to suicide. [15]

Thus overdiagnosis leads to a number of deaths that are not reliably measured but which, when taken together, could be major, as a British study suggests. [16]
This problem of overdiagnosis took a long time to be recognized by health authorities in charge of organized screening.

Today, this has been done, but this crucial issue, which must be taken into account when assessing the risk-benefit balance of screening, is greatly minimized.
In the 2015 HAS document [17], overdiagnosis is well mentioned, but, taking up only a few lines of the nearly one hundred pages of the report, it is completely drowned out in explanations of the value of screening; therefore, it goes unnoticed.

Furthermore, when it comes to independent scientific studies questioning the value of screening, the HAS document uses the terms "controversy" and "polemical", which inexpensively discredits the debate on the subject.

The document is still in force today, and is very poor in terms of bibliography supporting the interest in pursuing organized screening.
This makes it a very partial document, contrary to what should be expected from a state agency.

The INCa (National Cancer Institute) has also continued throughout these years the same shortcomings in the information provided to women on the subject.

We have just seen that for health authorities, for politicians who decide on successive cancer plans, the question regarding effectiveness of breast cancer screening by mammography is not raised.

They do not question the effectiveness of this screening and they are aiming to intensify it, even though independent meta-analyses, international studies and epidemiological data from the countries where screening takes place tend to show that the objectives of screening effectiveness are not being met : 

- Not only does screening significantly increase the incidence of cancer without significantly decreasing the risk of dying from breast cancer,  -but also does not make it possible to treat less aggressively, or to reduce advanced forms of cancer that desperately remain at an unchanged rate, in all countries where screening is in place.

The citizen consultation on breast cancer screening by mammography in 2015

Several observations prompted the Minister of Health at the time, Marisol Touraine, to initiate in 2015 a scientific and citizen consultation on breast cancer screening:

- The stagnation of the participation rate of women, which does not exceed 50% instead of the initial 70% objective.

- The variability of participation according to territories and socio-economic groups.

- The growing extent of the debate on benefits and risks of screening, both within scientific and medical spheres and among general public, regularly covered by mass media.


The Cancer Rose collective, of which I am a member, was auditioned during two round tables, one with citizens and the other with health professionals.
Our collective, made up of doctors and a toxicologist, came together with the objective of providing women and healthcare professionals with all independent and recent scientific information available.
Thus, we have developed and launched an website that aims to convey information that will allow women to make an informed decision on the stakes of screening, in an objective manner, without being influenced by media and promoters of the pink campaign.
This collaboration has already led to the development of an information brochure as well as various informative and educational materials.

The report of the scientific and citizen consultation was published at the end of 2016. [18]
The conclusion is very clear: the organized screening program should be stopped based on the two proposed scenarios (see page 132 of the report [19]):

Scenario 1: discontinuation of the organized screening program, relevance of mammography being assessed in the context of an individualized medical relationship.

Scenario 2: Cessation of organized screening as it exists today and implementation of a new organized screening, profoundly modified.

Following the release of this report, INCa sent a letter to Minister Marisol Touraine, dated September 16, although we only became publicly aware of the report on October 2. Professor Ifrah, President of INCa, calls Scenario 1 in this letter a "textbook case" and dismissed it out of hand, thus reducing half of the work to a negligible amount. [20]

Voices were raised, scandalized by such a denial of health democracy. [21]

An action plan is then published by Mrs. Marisol Touraine who entrusts the renovation of the screening to... INCa, the same institute whose lack of information for women was heavily criticized throughout the consultation report.

Currently, in 2020, the citizens' demand of 2015 to stop the current screening is still unheard, the pink campaigns are going well, and this public health program is therefore continuing according to the 2004 plan.

The implementation of a "new, profoundly modified organized screening" based on individual risk is underway with the launch of the MyPeBS study [22].
This is a randomized, non-inferiority study comparing women randomly divided into two groups. One group will consist of women who are routinely screened according to current official recommendations, and the other group will consist of women who are individually screened based on an assessment of their personal risk of developing invasive cancer during their lifetime.
This study poses many problems, ethical (consent form given to women omitting overtreatment and minimizing overdiagnosis), and methodological (absence of a "no screening" arm of the study, recruitment of women as young as 40 years old with annual mammograms for risk groups without information on radiotoxicity), software for calculating individual risk without scientific validation .

And since 2015?

Nothing has happened, apart from continuity in the promotion of organized screening.

Breast cancer screening is still included in the Public Health Objectives Remuneration ( ROSP), but it must be recognized that the objective asked to the general practitioner (between 60 and 70% participation of patients) is very difficult to reach in order to get the maximum of this remuneration.

Every year, October month turns pink with multiple incentives for women to be screened. 2020 was no exception to the rule.
Broadcasts for general public (Stars à nues) on TV channels are making an unbridled and uncontrolled promotion of the screenings without any authority being concerned, nor the CSA Higher Council for Audiovisual that we had alerted.

What are the observations arising from these facts?

It was decided by the authorities to set up organized breast cancer screening by mammography in 2004 when already early warners were expressing their doubts. Fifteen years later, knowledge on the subject has been enhanced. A large number of studies have been published that are consistent on a perceptible lack of benefit from breast cancer screening by mammography, and on the presence of risks whose reality is tangible and accountable. According to the most recent studies, overdiagnosis now concerns one-third to one-half of the cancers detected by mammography [23].

According to the journal Prescrire, for every 1,000 women over the age of 50 participating over a period of 20 years, there are approximately 1,000 false alarms in France, leading to 150 to 200 biopsies, sometimes several on the same woman during her successive screenings [24].

So why is it important for the French authorities to continue this screening, since women who undergo it do not gain any conclusive benefit from it?

Several possibilities can be evoked. 

- After having literally conjured up women, for three decades, to get screened, through slogans and media campaigns, it seems difficult for the health authorities and opinion leaders promoting it to disregard it. 

- Conflicts of interest among certain actors in the field of screening cannot be denied and weigh heavily on the omerta that reigns over the scientific debate in France [25] [26]. 

- Beliefs based on intuitive concepts are often easier to anchor ("sooner is better", "finding earlier saves lives") than explanations of the much more complex natural history of cancers in real life. This requires a longer pedagogy and explanatory development, to make people understand why some cancers remain indolent for a lifetime, why people can die with their cancer but not because of it, why others are fast and kill their host no matter is done, screened or not. 

- Obvious laziness in tackling true prevention contributes to the persistent buzzing of well-oiled pink campaigns. 

- Primary prevention remains the weak side of public health in France. Smoking, alcohol, but also obesity and a sedentary lifestyle are among the risk factors for cancer in general.

In addition to many other social factors, such as poverty, night work, certain professional environments are well known as risk factors for developing breast cancer and other cancers.
But few resources are invested in massive campaigns to combat smoking, alcoholism, obesity and these socio-professional factors.

They would certainly be more relevant than Pink October campaigns or health fair shows that are inflicted on women with coercive and scary messages.

In this respect, the latest cancer plan 2021/2025 announced by President Macron on February 4, 2021 is symptomatic: even if it talks about tobacco and alcohol, it largely confuses prevention and screening, giving the latter a clear advantage at the expense of prevention policies worthy of this name [27].

Conclusions

It is particularly difficult for the public, faced with opposing opinions and a highly technical debate, to get a clear idea of realities at hand.
The health sector has seen in this year 2020, during the coronavirus crisis, medical "clashes" with diametrically opposed opinions.

How can one cope as a layperson who has no expertise on the subject?
This is exactly the problem that every woman who is asked to get screened has to face.
This is all the more difficult for her, since the authorities are "Blind" with regard to the scientific knowledge they have acquired, and "Deaf" to all questions on the subject.

This is why I think it is necessary that all women be aware of this simple infographics, based on the evaluation of the Cochrane review, in concordance with other audited evaluations, whose results have never been contested by the international scientific community [28].

This simple visual, summarizing the entire issue of screening, must be given to women BEFORE they undergo the organized screening test for breast cancer.

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

References

[1] Tabar L, VitakB, Chen HH et al.The Swedish Two-County Trial twenty years later. Updated mortality results and new insights from long-term follow-up, Radiol Clin North Am 2 000 ; 38:625-51.

[2] Efficacy of screening mammography : Kerlikowske K, Grady D, Rubin S M, Sandrock C, Ernster V L. Efficacy of screening mammography : a meta-analysis. JAMA 1995 ; 273(2) : 149-154.

[3https://has-sante.fr/upload/docs/application/pdf/mamo.pdf

Recommendations :

Routine screening is recommended in the 50-69 age group.

In the general population, the benefit of breast cancer screening in terms of avoided mortality is demonstrated in the 50-69 age group. Therefore, in this age group, routine screening is recommended.

In the 70-74 age group, the incidence of breast cancer is high, but data on mass screening are scarce. Taking into account the large-scale organizational difficulties, extending screening to this age group currently seems premature in France. On the other hand, it is logical to recommend the continuation of screening between the ages of 70 and 74 for women previously included in the systematic screening program between the ages of 50 and 69.

[4https://www.e-cancer.fr/content/download/59052/537324/file/Plan_cancer_2003-2007_MILC.pdf

5] In 1998, Professor Paul Schäffer of the Bas-Rhin Laboratory of Epidemiology and Public Health (faculté́ de médecine de Strasbourg), in charge of the evaluation of screening, published an article in the French Medical Council's Bulletin 19.

"Tumour screening campaigns: caution is needed. "Screening should not be harmful. If it can bring health benefits, its potential to harm individuals should not be forgotten.For reasons of efficiency and ethics, preventive action should not have major disadvantages.

[6https://www.cochrane.org/fr/CD001877/BREASTCA_depistage-du-cancer-du-sein-par-mammographie

7] "Gotzsche and Olsen's meta-analysis challenges the consensus on the effectiveness of breast cancer screening. "and : "The evaluation of Gotzsche and Olsen's meta-analysis, carried out by ANAES with the help of a multidisciplinary group of experts, concludes that it is not legitimate to question ANAES' recommendations in favour of breast cancer screening. »

(https://www.has-sante.fr/jcms/c_433803/fr/depistage-du-cancer-du-sein-par-mammographie-evaluation-de-la-meta-analyse-de-gotzsche-et-olsen)

[8] Breast Cancer Screening, Incidence, and Mortality Across US Counties,Charles Harding, AB ; Francesco Pompei, PhD ; Dmitriy Burmistrov, PhD ; et alH. Gilbert Welch, MD, MPH ; Rediet Abebe, MASt ; Richard Wilson, DPhil, JAMAIntern Med. 2015 ;175(9):1483-1489. doi:10.1001/jamainternmed.2015.3043

The results of this 2015 study : 

- An increase in the number of breast cancer diagnoses (+16% for a 10% increase in screening participation), mainly by tumors smaller than 2 cm. 

- No reduction in breast cancer mortality. 

- No reduction in the number of advanced breast cancers. 

- No reduction in mastectomies.

[9RevuePrescrire 2006 https://www.prescrire.org/aLaUne/dossierKcSeinDepSyn.php

"In terms of total mortality, a benefit of mammographic screening in the general population has not been demonstrated. If there is an effect (positive or negative) on total mortality, it is small. »

10] Mammography screening: A major issue in medicine, Philippe Autier, Mathieu Boniol, Eur J Cancer, 2018 Feb ;90:34-62. doi : 10.1016/j.ejca.2017.11.002.

The strong points :

- After 20 to 30 years of mammography screening, the incidence rates of advanced and metastatic breast cancer have remained stable.

Breast cancer mortality rates have not declined more rapidly in areas where screening mammography has been in place since the late 1980s.

- One-third to one-half of breast cancers detected by mammography are estimated not to be symptomatic during a lifetime (overdiagnosis).

- Randomized trials of breast cancer screening have adopted distinctive methods that have led to exaggerated screening effectiveness.

- The influence of mammography screening on mortality decreases with the increasing effectiveness of cancer therapies.

11] Twenty year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial, Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA, The BmJ, 2014 Feb 11;348:g366.

Conclusions :

- No difference in mortality between the two groups (mortality = number of deaths relative to the total number of people screened).

- Survival rates are identical, regardless of the stage of the tumour at the time of detection (by screening for some, by a symptom for others).

22% over-diagnosis

- No difference between the two groups in the rate of fatal cancers.

[12] Le dépistage organisé permet-il réellement d’alléger le traitement chirurgical des cancers du sein ?, Vincent Robert, Jean Doubovetzky, Annette Lexa, Philippe Nicot, Cécile Bour, Revue Médecine, Volume 13, numéro 8, octobre 2017.
https://www.jle.com/fr/revues/med/e-docs/le_depistage_organise_permet_il_reellement_dalleger_le_traitement_chirurgical_des_cancers_du_sein__310529/article.phtml

[13] Causes of death after breast cancer diagnosis : A US population‐based analysais, Ahmed M. Afifi MBBCh, Anas M. Saad MD, Muneer J. Al‐Husseini MD, Ahmed Osama Elmehrath, Donald W. Northfelt MD, Mohamad Bassam Sonbol MD, ACS Journal, 16 December 2019
https://doi.org/10.1002/cncr.32648

[14] Evaluation of the Incidence of Hematologic Malignant Neoplasms Among Breast Cancer Survivors in France, Marie Joëlle Jabagi, PharmD, MPH, Norbert Vey, MD, PhD, Anthony Goncalves, MD, PhD, Thien Le Tri, MSc, Mahmoud Zureik, MD, PhD, and Rosemary Dray-Spira, MD, PhD, JAMA Netw Open, 2019 Jan ; 2(1) : e187147.
Published online 2019 Jan 18. doi : 10.1001/jamanetworkopen.2018.7147

[15] Bouhnik AD et Mancini J, « Sexualité, vie affective et conjugale » In La vie deux ans après un diagnostic de cancer - De l’annonce à l’après cancer, collection Études et enquêtes, INCa, juin 2014, 454 pages.

[16] Harms from breast cancer screening outweigh benefits if death caused by treatment is included, BMJ, 2013 ; 346 doi : https://doi.org/10.1136/bmj.f385 (Published 23 January 2013). Cite this as : BMJ 2013 ;346:f385 - https://www.bmj.com/content/346/bmj.f385
Michael Baum, professor emeritus of surgery, Division of Surgery and Interventional Science, University College London, London WC1E 6BT, UK

[17https://www.has-sante.fr/jcms/c_2024559/fr/depistage-et-prevention-du-cancer-du-sein

[18https://www.e-cancer.fr/Institut-national-du-cancer/Democratie-sanitaire/Concertation-citoyenne-sur-le-depistage-du-cancer-du-sein

[19http://www.concertation-depistage.fr/wp-content/uploads/2016/10/depistage-cancer-sein-rapport-concertation-sept-2016.pdf (read: https://cancer-rose.fr/en/2020/12/14/final-report-of-the-citizen-consultation-report-of-the-steering-committee/)

[20https://www.atoute.org/n/IMG/pdf/Courrier-Ministre-concertation-depistage-cancer-sein---.pdf

[21https://formindep.fr/cancer-du-sein-la-concertation-confisquee/

[22https://cancer-rose.fr/my-pebs/ (read: https://cancer-rose.fr/my-pebs/2019/06/13/argument-english/)

23] Mammography screening : A major issue in medicine, Philippe Autier, Mathieu Boniol,
Eur J Cancer, 2018 Feb ;90:34-62. doi : 10.1016/j.ejca.2017.11.002.

[24Revue Prescrire, février 2015/Tome 35 N°376.

[25https://www.atoute.org/n/article308.html

[26] MitcHell ap, BascH em, Dusetzina sB. Financial Relationships With Industry Among National Comprehensive Cancer Network Guideline Authors, JAMA Oncology, 2016 Dec 1 ;2(12):1628-1631.

[27https://cancer-rose.fr/2021/02/08/nouveau-plan-cancer-2021-2030-une-planification-sovietique/

[28https://www.hardingcenter.de/en/early-detection-breast-cancer-mammography-screening

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Cancer and the frightening abyss of death

The tree that hides the forest

Annette Lexa, PhD Toxicology

It is easy to see in this frenzy of screening and explosion of patient recruitment in clinical trials a fool's game that primarily serves industry.
However, it is almost certain that reality is more complex, and this angle of analysis is not only one that can explain this situation, it is only a consequence and not the primary cause.

It seems more and more certain that this much promoted early detection indiscriminately detects cancers with good and poor prognosis. The problem is just that treatments which follow don't discriminate either ("We are going to cure you of a disease that you don't have yet", says a doctor in the France 5 documentary, « In the name of all breasts »).

This leads to over-treating a number of patients with new supposedly "innovative" anti-cancer drugs, extremely expensive and no more effective than those already on the market and whose serious side effects (death, second cancer) are largely unknown to general public.

In terms of public policy, cancer is receiving a great deal of attention, with a certain tropism for women's cancers, partly due to a captive and docile clientele (see on this same site "Breast cancer screening, the latest avatar of medical misogyny").

There are equally serious deadly diseases such as multiple sclerosis, cardiovascular disease, AIDS, diabetes that do not receive the same attention as cancer through its major National Cancer Plans.  And we are not talking about nosocomial and iatrogenic diseases. It is not a question here of a silence of the body but of a societal silence or even of an indifference or a kind of fatality difficult to explain, assuming that the State' s vocation in health care is to reduce premature mortality and increase life expectancy of its citizens.

Unlike other pathologies, even the most serious and deadly, cancer is treated apart as if it was " the devil, the invincible predator ". Because cancer is more than a disease, it is a symbol of extraordinary power.

It replaced plague of the Middle Ages, tuberculosis and syphilis of our ancestors. It represents the devious evil, the silent killer, it seems to arise without any obvious cause (except the proven cases of smoker's cancer). For experts, it remains extremely difficult to prove causal link between exposure to a substance and appearance of a cancer, as environment and genetics seem to interfere and create favourable conditions for its development until metastasis and death.

Medical imaging tools have only been available for a few decades to confirm diagnosis. In the past, we would die without really knowing what caused the death. Now we still die, but we know from what, and the prognosis is even announced with a staggering techno-scientific coldness ("you only have 6 months to live").

Medicine has made great progress in oncology, that is not the point. What is important here is to recognize that this progress had little impact on what we modestly call cancers with a poor prognosis (lung cancer, gliomas, sarcomas, acute leukemia, certain skin cancers...). .

So why do we continue to focus so much on the "fight against cancer" all around? There are many equally deadly diseases where we could make huge progress through prevention alone or simply by focusing more on research and national plans.

The fear of the nothingness of death

Cancer collectively crystallizes all our thoughts and taboos about death. Yet our societies have "killed" death by killing God.
Existentialism and atheism (with secularism, which became the state religion in France) have become modern philosophies, markers of progress in the flow of History.

In a materialistic vision, when we consider that there is nothing after death, this death having lost all meaning; all that remains is the fight against this absolute "injustice". And the fight against cancer has become the latest eschatological fight (concerning the ultimate destiny of  human race) of the postmodern crusaders in a society that has lost any project and common sense.

There are even post-humanist currents of thought that promise disappearance of death (cloning, freezing, transfer of thought from brain to hard disk...).

The discussion about death is therefore now reduced to the "right to" and not to existential questions about meaning of death, whether individual or collective. The individual, the new Man, necessarily emancipated, is supposed to be sent back to himself in the name of his personal convictions about death. And the individual has not necessarily acquired the psychic tools enabling him to take up this personal challenge. He is alone and he is afraid, very afraid and wherever he turns, he no longer finds a satisfactory answer.

If he finds a religion that offers him a turnkey life path, he sometimes signs without hesitation. Is he right? Is he wrong? In any case, we can't blame him too much in front of sidereal void.

In a completely different vision, which we will call "spiritual" (and not religious) of existence, death is a passage and this deep conviction is lived serenely, calmly, with much less anguish. It creates another relationship of trust in relation to life and death. We may feel sorrow at no longer seeing those we love, of course, but we are convinced that something of ourselves survives beyond the disappearance of our body and our self and we attach extreme moral importance to it, for example. It is a 360° vision of Life from birth to death.

Today, terror, fear is no longer in front of the Last Judgment, like our ancestors from the Middle Ages to 19th century, but in front of the void, the nothingness of death: contemporary funerals are the result (absence of rites, ...). This is an unprecedented situation knowing that burial rituals, the first sepultures date back 100,000 years and are the first markers of civilization (even Neanderthal buried his dead).

Asserting that death is nothing like Epicurus, is not true collectively. Individually and collectively it has been the stumbling block to all human life on Earth since Man became aware of his own death. As long as our societies have not transcended this drama that death has become in contemporary societies, we will not be able to get out of this teenage individualism that wants everything right away and especially not to die. There will be no turning back (with the return of traditional religions as they are) but it will be necessary that our societies include and transcend the great monotheistic religions and the other world visions transmitted by the first peoples.

If we are in a position to make this observation, we have no collective answer to date, each one being sent back to himself in front of this dizzying existential question. Death has become a personal matter to which society tries to respond as best it can. And frantic screening for cancer is a technocratic and economic societal response to calm the fear of death.

Biomedicine is still a combat medicine that works on "masculine" war premises. The exorbitant price of anti-cancer drugs, the major cancer plans and their share of "innovative" actions tinged with totalitarian desires that sometimes become ridiculous through obstinacy in reality of death, are result of this vision of the world.

The excesses of obsessive screening aimed at tracking down the slightest allegedly cancerous cell in everyone and by all means of medical imaging in order to "fight" it; are the result of the domination of the small self of the possessive individual, who wants to control everything, anguished by death he cannot control. Worse, like immature teenagers, we have wrapped this too warlike, too virile "fight against cancer" in a dripping pink emotional and regressive marshmallow, aiming to mask the lack of preparation of individuals in the face of death, their daily occupations having totally exempted them from having to reflect on the meaning of their life and death.

Our lives, our distant descent from our Cro-Magnon ancestors, the challenges that await tomorrow's humanity on a planet that will soon reach 10 billion people, deserve better than that. If, instead of turning inward and allowing ourselves to be taken over by a paternalistic state and a monopolistic economy, each of us starts to find the meaning of our lives, the courage to live, common sense in the face of individual and collective destinies, our Western societies will emerge stronger and will know how to restore meaning in the face of death. Otherwise, scenarios such as The Best of the World await us. We still have the choice, it is up to us to choose today and without delay.

Bibliography guide: 

Bertrand VERGELY , Entretien au bord de la mort , 2015

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


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

Breast Cancer Screening, the Latest Avatar of Medical Misogyny

ANNETTE LEXA - August 21, 2015

Value of breast cancer screening is not scientifically proven

Breast cancer screening seems obvious to women and we have all been lulled by these "evidences": breast cancer is the first cause of death in women, cancer is a horrible disease that threatens us all, the earlier a cancer is detected, the more it is cured, screening can detect small cancers that can be treated, if we do it early we will have fewer mutilating ablations.

However, contrary to what is asserted everywhere, and even on institutional sites when they intend to promote DOCS (organized breast cancer screening), women die much more in France from cardiovascular diseases 1. While breast cancer mortality has decreased slightly (from 4% to 3%), colon and lung cancer deaths have not changed over the same period [1] .

This small decrease is mainly due to the fact that women have become more attentive and better informed and that surgical and radiotherapy treatments have made great progress.

Since 2009, a scientific controversy (here, here, here, here) has developed around the risk/benefit balance of breast cancer screening, presented as the medical examination of choice that is supposed to reduce this mortality. This controversy has arisen from large epidemiological studies in various Western countries (not in France where epidemiology is a politically incorrect science to be avoided). This controversy is currently heating up with this recent American study (here) which demonstrates more masterfully that early detection not only did not reduce mortality that had become stable, but also did not reduce breast ablations.

Screening's 'assets' continue to be praised with its double reading (in France) in case of a negative result, which would be the top of the top of scientific rigor. Whereas no one seems to matter this simple question of common sense: "why not double reading in case of a positive result? ». What an arrogant and asymmetrical confidence in the infallible reading of the specialist! The risk of false positives (false cancers) with its heavy and disabling prescriptions and the risk of false negatives (with the recurrent discovery by women themselves of the famous "interval cancers" between two examinations) are systematically underestimated. And finally, the risk of developing cancer through an excess of examinations and radiotherapy (here) is most certainly underestimated, whereas recent work (here) should on the contrary incite the greatest caution with radiosensitive women.

But, obviously, the sacrosanct principle of precaution - especially when the risk-benefit balance is not proven - is much more scrupulously applied for chickens, steaks or cereals than for bodies of healthy women (not to mention the use of contraceptive pill, hormone treatment for menopause, breast prostheses, caesarean sections, periodical tampons, etc.).

Manipulative techniques to impose screening on a docile and captive female audience

 But then why have we been witnessing for years this veritable military operation of quasi-Stalinist national recruitment [2] of women to the depths of the most remote campaigns and by all means?  Doctors, institutions, associations, politicians, all enlisted for the Great National Cause with the numerical objective of bringing recruitment ideally to 70 or even 80%.  We go so far as to use "mammobiles" that travel around the Hérault department in the most remote villages to overcome the "reluctance" of "vulnerable" women and "women with a bad self-image" (I'm not exaggerating, go read here) and offer a free "useful" exam to women as early as 40).

Every year, we are entitled to the trickery of the Pink October campaign with the surge of indecent, manipulative, guilt-ridden, infantile messages, to reach women through the emotional supposed to be their main vector of communication and aiming to turn them all into cancerous ninnies ignoring themselves. Even if it means crushing individual lives, intimacy, and fulfilled sexuality, destroying couples and families (overtreating cancer is not a trivial event without risk, it is a personal drama) and leaving women in insurmountable financial difficulties because they are definitively labeled ex-cancerous (job loss, credit insurance...).

Treasures of imagination will be deployed to improve the self-image of the healthy women who are to be recruited by all means. But this does not really seem to be a priority anymore for a ex-cancer patient over 50 years old who must consider herself lucky to still be alive.

You will tell me that men also have their Movember to "fight prostate cancer". The PSA blood screening campaign was a failure and its interest was quickly questioned. It's true that men (including doctors), who care about their virility more than anything else, quickly understood the risk of overdiagnosis and overtreatment with its share of impotence and incontinence.... don't touch my virility.

Women's body control through medicine: a long history 

I will answer that this relentlessness to control women's bodies is not new in French medicine:

- The 19th century saw the invention of Charcot's hysteria, all feminine, which became the sexual neurosis of women who were believed to be deprived of a penis according to Freud.

André Brouillet, Dr. Charcot at the Salpêtrière

- With the praiseworthy aim of fighting syphilis, Pasteurian hygienism led to the control of captive prostitutes in brothels who had to undergo monthly degrading medical visits that clients never had to undergo, even though they were themselves just as vectors (of  transmission) of bacteria.

The medical visit , Toulouse Lautrec

- The control of childbirth by men from beginning of the 19th century resulted in a hecatomb of deaths in labour caused by the excessive hubris of hospital doctors who had taken over the childbirth. This hecatomb lasted until the 1930s. While 80% of pregnancies are normal, we then witnessed the increasing medicalization of pregnancy and childbirth, whose anxiety-provoking, cold and dehumanized nature did not escape any woman who experienced this event. In addition, there was an obsession with the control and normalization of this natural act with its share of episiotomies, epidurals and caesarean sections. It should be noted that this medical hypertechnicalization has not been accompanied by a decrease in maternal mortality in France.

- The invention of the oral contraceptive "pill" for women (why not for men?) became the symbol of female emancipation, of sexual liberation. However, for 4 decades, the medical profession has minimized and under-informed women about the side effects of this drug taken by women who are not ill. Yet this drug is a real endocrine disruptor classified as a group 1 carcinogen (definite carcinogen) by the IARC in 2012. The list of side effects that women docilely accept the risk of is as long as a poem à la Prévert: weight gain, cellulite, acne, headaches, depression, decreased libido, fatal venous and thrombo-embolic problems, slight increase in breast cancer and uterine cancer, etc. 

Yet no feminist, after the euphoria of the 70s and 80s, seemed to see the symbolic violence of this medicalization of women's bodies and sexuality.  In a terrible relational asymmetry, men were thus able to dispose of the bodies of women and very young girls brought by their own mothers in a irresponsible manner, and regularly complied with the medical visit to "their" gynecologist, demanding for the most scrupulous among them regular blood tests to monitor their cholesterol levels, accepting without flinching this control of their bodies and their sexuality, and sometimes serious undesirable effects of this constraining intake.

How can we speak of women's liberation ("my body belongs to me") with this passage from patriarchal submission to medical submission and to the desire of men since they are supposed to be 100% "available" from now on, and in case of a decrease in libido caused by taking the pill, they will blame themselves near their doctor-trust-sexologist? Recently, there has been concern about the urinary discharge of pill metabolites (17β-estradiol) present in aquatic environments at a concentration of around ng/L and responsible from this dose for fertility disorders and hermaphrodism in fish.

French society has not ceased to be worried about the impact of certain pesticides, brominated flame retardants, phthalates, glycol ethers, nonylphenol, Bisphenol A (a molecule that mimics estrogenic hormones) in food plastics, phytoestrogens, etc..,  on the reproductive system of humans and animals) but it continues to authorize the sale of oral contraceptives "under medical supervision" when it does not give them free of charge to teenagers who have just reached puberty in secondary school, prepared by official Natural Sciences classes where the pill is presented as a simple means of having regular periods [4] ... figure it out. Finally, how many women, struggling to start a pregnancy after 10 years or more of oral contraception, without asking themselves more than that, are complying with heavy methods of medically assisted procreation (MAP) whose violence and constraint have nothing to envy to what has just been described? What is to be thought of a Ministry of Health that advertises oocyte donation[5] without mentioning the heaviness of hormonal treatment and its possible consequences? What about companies such as Facebook and Google that encourage their employees to freeze their oocytes to fight against the biological clock by trivializing hormonal treatments of retrieval and reimplantation?

- In the aftermath, women were convinced that menopause was a pathology and medicalization of menopause was invented with hormone replacement therapy which was supposed to have a preventive role against a host of future diseases. Still today, TSH is too often given to treat simple transitory disorders sometimes felt at this time like hot flashes, night sweats, low libido or vaginal dryness, or even it is given (and claimed by some women) as a "preventive" with the promise of staying young.  Let us recall all the same that the treatment of menopause is classified as carcinogenic and that even  health authorities today encourage the greatest caution in its use.

Women were made to believe that, now that they lacked hormones, it was natural for them to suffer all sorts of inconveniences that needed to be corrected if they wanted to continue to appear socially young and sexually desirable (unless they naturally questioned at that age about their emotional life, the departure of their children, their desire and sexuality, etc.) . As each woman is unique and is her own witness, none of them can boast of the real effectiveness of TSH on her menopause and it is more than likely that a good part of effectiveness felt is a kisscool effect.

- As soon as craze for TSH waned, we witnessed the mass submission, sometimes from the age of 40, to mammography screening, a painful and anxiety-provoking examination of uncertain benefit to reduce mortality, and which only resulted in a dizzying increase in the number of small cancers that would not have developed, or very slowly or would have regressed, and the number of unnecessary and traumatic breast ablations.
It should be noted that these last two acts of violence against women's bodies concern the "not so-youngest" who no longer represent the ideal of youth and fertility of the young woman, the eternal object of male fantasy, and to which the 50+ woman must comply.

- The trivialization of heavy, painful and sometimes dangerous surgical procedures to have silicone breast implants in order to improve their self-image, to conform to a totally constructed social norm (the very thin woman with very large breasts) and to respond to male fantasies. Would we imagine for one moment 400,000 men in France undergoing surgery to inflate their penis or testicles?

- The submission to cervical cancer vaccines of uncertain benefit, with great reinforcement of campaigns blaming the mothers of young teenagers. Here again, why should women be the main vector of the papillomavirus in question? Why has a mixed campaign not been launched targeting both young heterosexual boys - and homosexuals particularly concerned - and young girls, if not because the medical world has a captive market with women and their daughters, docile, easy to make feel guilty and educated to obey?

Social control and submission to standards 

This docility of women with regard to medical world has changed little in spite of women's emancipation. And corporations and advertisers in charge of promotional campaigns are well aware of this, when they illustrate the importance of breast cancer screening by using images of young women with perfect bust, when they are not using guilty messages depicting family and "good friends". They continue to go running "against breast cancer" (who would be for, I ask you??) wearing a pink pin, dreadful gendered color, and don't hesitate to attend Tupperware meetings stamped Pink October to convince their reluctant girlfriends to go to the nearest mammobile.

Why this excessive relentlessness of medicine with the complicity of highest authorities of the State and their squads of civil servants in Regions to want to control the normality of breasts of women and to submit them down to their intimacy?

Why can we not find the beginning of an equivalent such control of the male body and such submission in men? Why doesn't medicine strive with same deployment of means to reduce mortality from cardiovascular disease in women, which represents almost 7 times more deaths per year than from breast cancer?  Or to lower female mortality from lung and colon cancer?  It is true that the heart, lung and colon are organs that are much less sexed. Women, contrary to what they claim, have not emancipated themselves from society's control over their bodies and sexuality. They have swapped one Master (father, husband, priest...) for another, representing the Promethean techno-scientific power supposed to watch over their bodies, which are inevitably disturbed, easily maladjusted, and which, if they are not careful, are the seat of all sorts of frightening feminine pathologies, this submission obscuring the perspective of a life as a woman, as a lover, as a mother in full bloom. Worse, women are women's worst enemies: making a daughter take the pill, recruiting her good friends is tantamount to making themselves accomplices in their submission, just as women are accomplices in the excision of the youngest in other cultures.

Some (here and here) have recently questioned the misogyny of the French medical profession, but paradoxically these theses have not seduced our journalists from women's magazines, who are nevertheless quick to liberate the sexuality of their readers.  This thesis did not seem to please the various feminist movements either, refusing to see in this pseudo-emancipation another form of alienation, as Marc Girard has very well demonstrated. There is in this submission an absolute unthought, a taboo, a blind spot that the struggle for women's emancipation has been unable to see.

Still today, the majority of women are not very curious and critical of recommendations that are made to them: submissive, constrained or outright exalted followers of the Church of Depistology (Europa Donna and other Pink October with the support of Sephora, Tupperware and Esthé Lauder), they do not go to critical blogs (to those previously mentioned, I will add here and there) to have another point of view and to reflect by themselves.

Control by Church 

Even though we live today in a secularized society, the past influence of the Church still unconsciously permeates our morals and mentalities. For centuries, the Catholic Church - like all monotheistic religious institutions - has sought to insist on the inferiority of women. She has sought to control the bodies and minds of women, for whom she has always had contradictory feelings: at once docile, submissive, modest and maternal, women remain for Church also a whore temptress, a witch or a fool incapable of judgment and decision by herself. Without going back very far, let's go back some 150 years. The few progressive women of the time are often put forward, but this is to forget that in the 19th century, while the predominantly male republican minds attacked the Church, the vast majority of women continued to be kept apart from the world, confined to their role as mothers, consolers, and social workers. Fear, restraint, modesty, devotion, virtue, these were the main qualities demanded of women who had only to please God and their husbands. Education was forbidden or very limited, and it was believed that she was incapable of intellectual life. Put aside from leisure, sport and study, women were considered weak and society had to protect them from themselves.

The adulterous woman was guilty when the man could act the most natural way in the world.  The woman was excluded from any religious function, unable to relate to transcendence and easily perverted by the Devil. For a long time, menstruation, the mystery of gestation, seduction and sexual attraction, the power of women over domestic life (where she had been locked up) frightened men terribly.

Still at the beginning of the 20th century, priests questioned young teenage girls about their violently prohibited masturbation practices (testimony of my own mother who lived through this in the 1930s at the age of 10).

Since the weakening of warlike societies and religious power, women have gradually been emancipated and immense progress has been made in recent decades. Has misogyny disappeared for all that? Nothing is less certain. Today, women study, divorce, work, have children they want, can have abortions, vote and know in theory the same rights as men. But differences still exist, reminiscent of a past, paternalistic, misogynistic world that still survives in the medical world where difference in treatment between men and women, although having taken a less coercive and more inciting form, remains glaring.

Medicine and Church  

For a long time medicine and religion were confounded, in the same fear of death .

The Age of Enlightenment saw the seeds of a new medicine that was meant to be rational. Did not the doctor with his new rites of medical examination replace the priest in his immense faith in medical progress and science, his interest in so-called ethical questions, his obsession with the control of female bodies from birth to death, whether in physiological, psychological, psychiatric or psychoanalytical field? Church saw woman of the 19th century as a layer, constantly pregnant or nursing. For the past 50 years, she has been put in a chemical straitjacket in a state of constant artificial sterility, now required to live a permanent sexual life where any drop in libido is experienced as suspect. She is also told not to complain about adverse effects ("it's in their head"). Any progress? In a sense yes, of course, but it is not certain that woman has not swapped her dependence for another alienation. And that male body of society is not yet consciously or unconsciously trying to control these bodies, so different from that of men, by their formidable cyclical capacity to seduce, to engender life.

Saint, whore, witch and Ninni, the four women of God, isn't that what contemporary diktats demand of women? At the same time to be a submissive and ignorant virgin, but also a temptress and seducer.

The era of biopower

Today we have entered the era of biopower, of state control of bodies from birth to death. Public health is a vast operation of planning, a series of recommendations that seeks to control any form of epidemic (with its vaccine obsession) or the development of aggressive factors (such as cancer); for this, it must also control medical power, doctors.

By necessity of management, the biopower has equipped itself with performance tools. There are no longer individuals, there are only medical images, protocols, populations, statistics. Worse, this biopower is tainted by cynical and soulless consumerism and it knows perfectly well how to talk to "health care consumers" under the guise of simplistic, soft and guilt-ridden arguments mixing fear, security and precaution and enjoining individual well-being as the only eschatological horizon.

The right to say "NO" 

Yet, no, we are not condemned to live our lives as women under a medical sword of Damocles, tetanized by fertility and menopause disorders, female cancers and medicalized pregnancies.

No, we are not condemned to live our lives after 50 years cahin-caha, depressed and petrified with anxiety between a mammogram and a biopsy, with the fear of one day finding ourselves mutilated (and rebuilt?), while swallowing our TSH with a glass of alcohol to pass.

We can re-appropriate our bodies in all their beauty and their fertile and erotic power.

We have the freedom not to accept to be a pre-cancerous woman who ignored herself, not to accept to give in to fatalism, fear and control, to the overbidding of long, painful, sometimes humiliating, sometimes dangerous tests, and we can build our lives with our companions in a complementary, responsible and respectful relationship without relying on misinformed doctors who have been trained only to answer our questions as normal and healthy women with tests and prescriptions.

We can demand respect for our values and preferences, in a dignified and respectful relationship with doctors.

For this, there is a wonderful natural remedy called trust in Life.

References

1] In France (latest available source: INSEE, 2011), where the life expectancy of a woman is 85 years, the main causes of mortality in women are as follows:

73,842 of cardiovascular diseases (28% compared to 36% in 1996)

16,106 lung diseases (6% compared to 8% in 1996)

10,286 of digestive diseases (4% versus 5% in 1996)

5,800 of infectious and parasitic diseases (2% compared to 2% in 1996)

and for cancers :

7,734 in respiratory tract and lung cancer (3% vs. 3% in 1996)

8,113 of cancer of the colon, rectum, anus (3% compared to 3% in 1996)

11,623 women died of breast cancer (2% compared to 4% in 1996).

2] the suppression of the Individual Screening has even been imagined by the High Authority of Health in 2011 (here)

3] France, with its 2.3 deaths per 1000 births is in 17th position in Europe in 2013.

4] http://svt.ac-creteil.fr/IMG/pdf/4emecauseregles-.pdf

5] Campaign of the Biomedicine Agency "Become a Happiness Donor".

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.

Cancer chemotherapy: a fool’s market

ANNETTE LEXA , PhD in Toxicology

MARCH 8, 2016 

A priori, if we believe official messages communicated through the national cancer plan 2014-2019 (1) , we are witnessing real progress in the domain of anti-cancer therapies, and society (via patient associations) is ready to make it possible for everyone - in the name of the sacrosanct "equality of opportunity" - to have access to the best treatments, especially experimental ones. Otherwise, society and patient associations will even consider that this would be a "loss of opportunity".

Faced with the boom in oral chemotherapy, the 2014-2019 national cancer plan - which is silent on the origin of this boom - gives great importance (much more than to prevention) to improving "compliance (adherence to treatment) and management of adverse events" of new "innovative" anti-cancer therapies.

The term "compliance" (page 16 of the report) is scary and says a lot about the managerial necessity to make them accepted at all costs to the body and psyche of reticent patients by "securing" their care "pathway".

For the past 10-15 years, we have been witnessing an almost frenetic rush to bring new anti-cancer molecules to market. At the same time, the price of these new molecules is exploding. Patients are almost constrained to be enrolled in therapeutic trials.

What patients don't know is that there is no correlation between price, cost to market and efficacy in terms of survival rates. Moreover, these new molecules are not subject to rigorous clinical trials or to the search for proof of efficacy. Their efficacy - if it exists - is purely statistical and it is the standardization of treatments that prevails by type of cancer and not by type of patient. A careful reading of the scientific articles published on this subject in recent years even suggests that it is more important to put them on the market than to ensure their effectiveness and safety (3).

These drugs benefit from a fast-track marketing procedure. However, it has been proven that these drugs placed on the market prematurely have more serious adverse effects than those placed on the market more rigorously. Worse, once a molecule is placed on the market (such as bevacizumab), it is difficult to withdraw it from the market.

In the United States, of the 71 compounds approved by the FDA (Food and Drug Administration) between 2002 and 2014, the improvement in survival for all cancers combined is 2 months (5). For solid tumors, a review by the EMA (European Medicines Agency) shows an improvement of 1.5 months (3).

Currently, in Europe and in the USA, the regulatory agencies accept non-randomized trials, trials without controls, biased protocols, phase III trials when phase II was not convincing and they turn a blind eye to the quality of publications of these trials.
Worse, they accept as proof of "efficacy" new "innovative" molecules, "surrogate end points", measurements of biochemical sub-parameters, which are less costly to implement and which replace the only criterion that should prevail in oncology, survival, as a criterion of efficacy. It doesn't matter if you die in 10 days, the oncologist will look with satisfaction at your biomarkers rising.

The sky is getting a little darker when we learn (9) that a serious setback is announced in the new health law in the USA (21st Century Cures Act) whose stated objective is to make the best possible return on investment by reducing the time and number of patients in clinical trials, or even to abolish all clinical trials and replace them with "surrogate end points" (biochemical sub-parameters), in vitro and in silico studies. The USA is paving the way for a regression that is all the more serious since currently, in the USA, one third of drugs are approved after trials lasting less than 6 months and the average number of patients is 760. Underhanded negotiations around the future transatlantic treaty make this scenario increasingly likely as far as we are concerned.

In the USA, a number of oncology experts even believe that the moral red line between reasonable profits and profits has been crossed (3, 6). Partly because the poorest cannot afford to pay, as they no longer have medical insurance (a cancer treatment costs the insured about 20,000 to 30,000 dollars).

In France, costs are the same but we don't realize it because we are all covered by health insurance and optimal reimbursement.

In terms of "fight against cancer", it is also important to remember that 85% of the research is public and therefore financed by taxpayers and donations, the oligopolistic market (which relates to the oligopoly, a market characterized by a small number of sellers against a large number of buyers) of these pharmaceutical companies spending only 1.5% of its revenues on this research, between 5 to 13% on clinical trials and between 20 to 45% on marketing.

After this little clarification, we have a very different reading of the latest 2014-2019 cancer plan: the explosion of patient recruitment in early phase clinical trials of "innovative" drugs (do they really have a choice?), the public financial participation in this forced march, which is duly praised, leaves a strange bitter taste: is it the health of patients or the market that takes precedence? Not only are patients being lied to, but it is seriously damaging to both patients and research. For their safety alone, patients and physicians must demand greater rigour. Balanced health care budgets are also at stake.

Finally, it is questionable whether health agencies are serving the interests of patients or laboratories: in light of the appointment of Professor Agnès Buzyn as head of the Haute Autorité de Santé, it is reasonable to wonder (7, 8). Health agencies should regain their primary vocation, which is to ensure the protection of the public, and they should provide clear and transparent information to the public.

REFERENCES 

1. Plan Cancer 2014-2019 , LE RAPPORT AU PRÉSIDENT DE LA RÉPUBLIQUE , Février 2016

2. Au nom de tous les seins, documentaire France 5

3. Light D.W., Lexchin J., Editorials, Why do cancer drugs get such an easy ride? Rushed approvals result in a poor deal for both patients and cancer research , BMJ 2015;350:h2068

4. Prasad V et coll., The Strength of Association Between Surrogate End Points and Survival in Oncology: A Systematic Review of Trial-Level Meta-analyses. JAMA Intern Med. 2015 Aug;175(8):1389-98

5.Fojo T, Mailankody S, Lo A. Unintended consequences of expensive cancer therapeutics

- the pursuit of marginal indications and a me-too mentality that stifles innovation and

creativity, JAMA Otolaryngol Head Neck Surg 2014;140:1225-36.

6. Hagop Kantarjian et coll., High Cancer Drug Prices in the United States: Reasons and Proposed Solutions J Oncol Pract 2014 Jul 6;10(4):e208-11.

7. Les petits arrangements de la nouvelle présidente de la Haute autorité de santé (7 mars 2016) https://www.mediapart.fr/journal/france/070316/les-petits-arrangements-de-la-nouvelle-presidente-de-la-haute-autorite-de-sante

8. Le professeur Agnès Buzyn nommée Directeur de la HAS. La victoire de big onco (8 mars 2016) http://docteurdu16.blogspot.fr/2016/03/le-professeur-agnes-buzyn-nommee.html 9. Avorn J and Kesselheim A.S., The 21st Century Cures Act — Will It Take Us Back in Time? N Engl J Med 2015; 372:2473-2475

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.

Loss of scientific rigor and scientific misuse, poor quality medical research

Cécile Bour, MD, May 14, 2020

In the era of EBM (proof-based medicine), the headlines of last few weeks during the Covid 19 pandemic have highlighted the drifts that undermine this approach of a modern medicine.

We should not only blame the recent context; over the last decade and perhaps more, there are three main problems in modern medicine that Jeanne Lenzer, an investigative medical journalist, and Shannon Brownlee, Vice President of the Lown Institute, « a nonpartisan think tank advocating bold ideas for a just and caring system for health in the United States », have denounced in "Issues" column of their site.

These three drifts seriously weaken evidence-based medicine and jeopardize the benefits owed to patients, and they are currently exacerbated in this period of crisis.

Three main drifts of today's medicine

  • The main drugstore in the city where I practice has the motto "primum non nocere" above the counters. But, according to Lenzer and Brownlee, doctors are insufficiently trained to discern good science from poor studies, and prefer to use molecules they know and whose effect appears biologically plausible. Fear and haste have sounded the death knell for the Hippocratic maxim, a pillar of medicine. Beliefs and unproven faith in medications used for other medical conditions have been considered, without concern for their real usefulness against an emerging and unknown virus, or their possible harmfulness.
  • The second pitfall identified by the authors is the prominent role of the media today. On the one hand,  convictions and opinions of non-physicians are following in the footsteps of politicians, to whom the floor is widely and generously given. On the other hand, many of media that echo this are ignorant and incompetent in scientific method or in search for evidence, and also have a commercial interest in hype around these well-known and popular, but null, town criers.

We can only agree with this observation, having ourselves been confronted with a very unpleasant episode of attacks from a TV host, who mediated his experience of prostate cancer at will to convince people who asked him nothing, to undergo prostate screening test, in spite of all the non-recommendations of such screening [1].
The naive crowds that "follow" these characters, fan clubs generally very well supported on social networks, do not facilitate the expression of cautious doctors or independent collectives like ours, which are inevitably a killjoy in the general hope. The word of the Cassandras is hardly a media-friendly one...

●The third calamity denounced by Lenzer and Brownlee concerns poor quality studies that do not include what is called a "control arm", i.e. inclusion in the study of a comparison group that has not been given the drug being tested. The control arm is the cornerstone of a strong randomized controlled trial. It aims to formally establish the true efficacy of a product, highlighting possible biases in the tested protocol. For example, a drug may appear to be effective in reducing the risk of a given disease when the population to which it was administered is already naturally less at risk, because they are younger, healthier or have easy access to medical care. A control arm with a wide range of subjects can show ineffectiveness of the test drug in certain groups of  population and thus point to errors in reasoning or biases that would go unnoticed. In hastily constructed studies, on the other hand, potential harms may be underestimated. 

But even outside of critical health periods, such as in the field of cancer for example, proclamation of "miracle" drugs has been legion in recent years, with questionable studies, selling hope of so-called "revolutionary" chemotherapies. On this subject read the post of Annette Lexa, our toxicologist.

We add to this last point on the poor quality of medical researchn a particular type of study that is currently spreading, it is the "non-inferiority" test, all the more fraudulent and perfidious that nobody understands a drop.

Doshi and all. 2] studied informed consent forms from non-inferiority studies on antibiotics. Their observations are generalizable, however, because there are many applications of this type of study, in diabetes, cardiology, infectiology and cancerology. Doshi et al. found that often neither the methodological experts nor the members of personal protection committees were able to define the true objective of the study from the information forms given. For the methodologists, only 1 out of 50 trials, according to them, correctly restituted the objective of the study; for the patients, 7 out of 50 studies succeeded in doing it. These results raise the question of whether consent is truly an informed one, and thus whether the trial is even ethical.

But what are we talking about?

Non-inferiority trials

We have given a summary explanation about the MyPEBS study for personalised breast cancer screening which concerns the theme of our site, a study that we have analyzed in depth here: https://cancer-rose.fr/my-pebs/.

In the non-inferiority trial it is a question of comparing two elements (two medical devices or two procedures, or two drugs) to check whether the device or procedure or treatment being tested would not be worse than what is already in use, accepting a certain loss of effectiveness within a certain tolerated margin, known as the non-inferiority threshold.

It is not a question of verifying whether the system, procedure or drug tested would be superior to former one. This is often how the press reports it and how doctors and public understand it, but it is not the case!

For example, for breast cancer screening, intended purpose is normally to reduce severe forms of cancer. In the MyPEBS non-inferiority study, if the new personalized screening tested does not appear to favor a rate above 25% (arbitrarily set threshold) for additional severe cancers, the trial will be declared a success. You have read correctly. There is no control group there either to test what would happen without screening, which would be legitimate though since recent studies on this screening no longer manage to demonstrate a positive benefit/risk balance.

It is true that in non-inferiority trials in cancerology the control arm is rarely considered, this being judged to be unethical given seriousness of disease, and patient cannot be deprived of any care. But here, in the MyPEBS study, healthy and non-complaining women are being tested, we should remember.

What must therefore be understood, in short, is that it is possible, with non-inferiority trials, that a new health procedure can be accepted as effective, even if its therapeutic or beneficial effect is slightly inferior to current standard. In a non-inferiority trial, the new procedure or drug is not supposed to make the participant healthier than she would have been outside the trial, since superiority of the procedure or drug is not sought.

The only assumptions are :

- In the best configuration, participants randomized into the study's test group could fare as well as if they had not participated in the trial,
-or then potentially worse within an arbitrarily accepted margin, in the wrong scenario.

And everyone is happy. The public because they are not well informed and believe that what was tested on them is 'superior', the journalists who did not grasp the subtleties of the methodology and write laudatory articles, and above all the designers of the study. Why is such an approach necessary? Because with this set-up, the study is subtly biased towards the result desired by the promoter, which is to obtain or safeguard a market share much more than to answer a scientific question whose stake is the well-being of the patient. For MyPEBS, the aim is to establish breast cancer screening, since women will only have a choice between two options: old screening or personalized screening, but screening in all cases.

To caricature, the patient or population will be worse or not less well, but the good news is that the study is a success..

Two interesting articles to help the practitioner in the critical analysis of the studies that published

Vinay Prasad, in an editorial in the JGIM[3] (Journal of General Internal Medicine) where he actually quotes the results of Doshi et al, refers to the publication of Aberegg, Hersh and Samore who analyzed 183 non-inferiority comparisons of 163 clinical trials published in the five major impact medical journals.

Aberegg and colleagues found that only 70% of the non-inferiority studies explicitly stated why new therapy would have an advantage, and in 11% of cases no advantage could be inferred. This suggests to these authors that many of these studies should not have been conducted.

What should the practitioner beware of and what trials of non-inferiority can he trust? According to V.Prasad, it is necessary to :

  • Consider whether new therapy is less expensive, more convenient, less invasive or less toxic than old one. If answer is no, stop looking, he says! There must be a positive compensation for the patient for loss of effectiveness of the new procedure or new drug being tested. If not, there is no point in learning about the "novelty".
  • Ask yourself how much loss of effectiveness of the new procedure or new treatment you would be willing to accept in order to adhere to it. 5% loss of effect, or 10%? More or less?
  • Be concerned about the margin of inferiority accepted. E.g. for MyPEBS the non-inferiority threshold is very generous. This means that if, at the end of the new screening, 25% additional serious cancers are found, the study is "successful". This margin would have to be justified, and this justification would have to appear at least in the study protocol, which is not the case.
  • Finally, consider whether the new intervention was in fact 'inferior', not 'non-inferior'.

The French independent journal Prescrire[4] examined  problems of these particular trials in 2006. Their advice is similar to that mentioned above. For the journal, one must be critical of the threshold of non-inferiority that is chosen a priori, arbitrarily by trial designers. For the patient, this threshold is equivalent to the loss that is consented to in relation to the reference treatment or device.  It is therefore necessary to be sure that the result is not in fact a true inferiority.

For Prescrire, in short, these tests are intended to simply exclude the possibility that a treatment or process is massively worse than what already exists. When the treatment or procedure is slightly less effective, and within a certain accepted margin, the new treatment or procedure is only of interest to the patient if it brings other benefits in compensation. And this is where the stick can hurt, as in this study we regularly criticize, and not just us.

To conclude:

The urgency and willingness to obtain results quickly justifies dispensing with well-conducted controlled studies and exposes us, because of flawed and poorly executed studies, to biased medical judgments and erroneous conclusions.

Improper, sometimes excessive, communication by lay people or ignorant media aggravates media coverage of drugs or procedures that we do not know what they actually induce, whether they do more harm than good.

These problems pre-existed before the context of the Covid19 pandemic which only brought them to light.

Research in science is important, yet it must meet quality standards, be done by scientists who are concerned about respecting proven methodologies and meeting standards, and this in a serene media environment.

This is currently not the case, as damage and physical inconveniences to health of populations are aggravated by misinformation and pollution of scientific debate by quarrels of opinion.

If we want to make good science that is useful to people, we must develop a critical spirit, constantly verify results of studies promoted as revolutionary by media, see by which methods conclusions have been reached.

We have come full circle; if we want to make good medicine we will always return to what is proclaimed at the front of the drugstore, the basic principle that must underpin our medical practice: "primum non nocere" .

References

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

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710221/

[3] EDITORIAL
Non-Inferiority Trials in Medicine: Practice Changing or a Self-Fulfilling Prophecy?

Vinay Prasad, MD, MPH

Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA; Department of Preventive Medicine and Public Health, Oregon Health and Science University, Portland, OR, USA; Center for Health Care Ethics, Oregon Health and Science University, Portland, OR, USA.

J Gen Intern Med 33(1):3–5
DOI: 10.1007/s11606-017-4191-y
© Society of General Internal Medicine 2017

[4] La Revue Prescrire avril 2006/Tome 26 N°271, page 249

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.

Myths in medicine, but does their rebuttal make it possible to install the facts in a lasting way?

Cécile Bour, MD, May 24, 2020

During the Covid-19 pandemic that we have just experienced, science based on facts has been severely mistreated... General panic, mediocrity of the media combined with incredible assurance of a single researcher sounded the death knell of the serene search for facts, proclaimed as miraculous a treatment without having the proof, stepped on the principle of primum non nocere, (first do no harm), which is the foundation of our medical practice.

Independently of fundamental questions, which is not our subject, we can see that the urgency of a health situation facilitates drifts, sloppy studies, but also statements made by personalities who are not aware of scientific constraints, but who want to impose their convictions.

The interesting question is: does even strong evidence that can bury doubts and polemics have the power to put an end to myths and beliefs that are deeply rooted in medicine?

And above all, will they be tolerated in a context of serious illnesses, where public is asking for hope and where  scientific community and public authorities prefer to persist in a benevolent ideology, however fallacious?

Parallel of the epidemic situation with the myths conveyed during screening campaigns

Being a group focused on issues of public medical information and interference of non-medical stakeholders in scientific controversies, as we regularly experience during pro-cancer screening campaigns, we can draw parallels with history of breast cancer screening, where economic stakes and beliefs have prevailed over reasoning.

The public does not like uncertainty, and the tremendous desire to overcome major health threats enables the appearance and immoderate expression of promises of salvation and healing.

How was it possible to impose the mantra that screening is a preventive act, and that regular mammograms can drastically reduce the risk of dying from this disease?

To understand, a bit of history

At the very beginning of the history of screening, between the 1970s and 1980s and in various cities, counties and countries (Norway, Denmark, Canada, New York, Swedish counties, Malmö in Sweden,) women were included in so-called trials, meaning studies that consisted of simply comparing the outcome of screened women against that of unscreened women.

At that time this could be done, as women had never received an X-ray of their breasts before; they were what can be called "pure cohorts". And these early comparative studies claimed a tremendous decrease in mortality through screening, up to 30% reduction in the risk of dying from breast cancer.

 Presented in this way, this performance seemed very pleasing. In view of these results, it seemed intuitively obvious that breast cancer screening would allow earlier diagnosis, earlier treatment and thus a drastic reduction in mortality by eradicating the most serious forms.

But science is sometimes a colossus with feet of clay, and while some erected convenient convictions, other researchers, more scrupulous and suspicious, drove the stings of doubt into this base of certainties.

Indeed, it became quickly clear, (this is no longer contested by the scientific community), that these first trials had many biases, such as irregularities in method, in distribution of women between the two groups and in statistical analyses. The methodology of trials did not meet current quality criteria. For example, some of women "screened" by mammography had tumors that were already clinically palpable! Even the published results of the so-called trial in the two Swedish counties were incompatible with the data in the Swedish national file. The best results had been obtained with the less good mammograms, none of the equipment used then would be approved for use today.

While victorious publications multiply between 1992 and 2000, along with an important media and social relay on women, physicians and governments, Gotsche and Olsen, two independent Nordic researchers, proceed, in 2000-2001, to a meta-analysis according to the methodology of the independent Cochrane collective to which they belong.

And then it's a shock.

(Meta-analysis is a scientific method of combining the results of a series of studies on a given problem according to a reproducible protocol, here: does screening reduce mortality from disease. It allows a more precise analysis of the data by increasing the number of cases studied in order to draw a general conclusion. By grouping together the previous trials carried out, data on 800,000 women were obtained).

Gotsche and Olsen quickly realized that none of conducted trials were of high quality and that they all had biases, sometimes significant. By combining the best trials (the so-called Malmö 1, and the Canada 1 and 2 trials), it appears that there is no statistically significant difference in mortality between screened and unscreened women. Obviously, this is a colossal turnaround while enthusiasm for this public health procedure, which was supposed to solve the cancer problem once and for all, was in full swing.

Unfortunately for the researchers, they did not get authorization to publish their results in Cochrane reviews, and the powerful Cochrane "breast cancer group" forced them to include even biased trials in order to improve the results; after long negotiations, and with inclusion of the poorest trials, the authors still found only a very meagre and hypothetical benefit. They added at the end of their publication that the best trials show no decrease in mortality, and that the indicator "mortality from breast cancer" is unreliable.

About these negotiations that took place, read here : Trouble in the world of evidence

But in the end, the press preferred to retain the beautiful story of a life-saving screening, as did savant societies, women largely influenced by a glowing press, doctors, health authorities....[1]

However, other meta-analyses, the American USPTTF* in 2000 and the French independent review Prescrire in 2006 corroborate these equally disappointing results, even with different age groups studied, different observation periods and different cohorts.

* U.S. Prevention Services Working Group of primary care and prevention experts who review evidence of effectiveness to develop recommendations in the area of prevention.

The conflicts of interest that have plagued the whole history of breast cancer screening are very well documented on the Formindep website [2] [3], and are reported in the very complete report of the citizens' consultation (starting on page 63).

Conclusion

Science applies a method of doubt to beliefs and superstitions, and to itself as well, in well-done studies.

Uncertainty in the face of health dangers encourages beliefs and reassuring hopes, all the more so as this uncertainty is strong, not only on the magnitude of the threat itself, but also on the means of countering it.

The first bearer of good news becomes a hero, a savior. Any reasonable protester who applies his method of doubt becomes a public enemy.

With the history of screening we see how myths and intuitive ideas, simple to understand but false, once established, have a long way to go.

For three decades now, the myth of "preventive" screening, "life-saving for women", has been firmly anchored in people's minds, regularly promoted by the public authorities, the National Cancer Institute and the health authorities, valorized by public personalities who are committed to its promotion. Evidence of its ineffectiveness and, worse, of its deleterious effects, is little mediatized, has no right to be quoted; those who want to evoke it and warn women are called conspirators, incompetents, evildoers for the cause of women and are inaudible during the pink October campaigns.

Current Covid-19 crisis has revealed the fragility of science in relation to belief, and has highlighted all the possible excesses once we move away from the search for facts, act in haste, and adhere to convictions justified solely by their comforting character.

References

1] All of this is documented in the report of the citizen and scientific consultation on screening in 2016, starting on page 51, see also https://cancer-rose.fr/wp-content/uploads/2019/07/depistage-cancer-sein-rapport-concertation-sept-2016.pdf.

As well as in Bernard Duperray book "Dépistage du cancer du sein, la grande illusion" published by Th Souccar, starting on page 26.

2] https://formindep.fr/les-cinquiemes-rencontres-du-formindep/

3] https://formindep.fr/?s=Tabar%2C+Lancet

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.

Blatant disregard for informed consent in screening

Summary by Cécile Bour, MD

September 18, 2020

BMJ: first published as 10.1136/bmj.m3592 on 17 September 2020.
Quote this as: BMJ 2020;370:m3592
Published: 17 September 2020
https://www.bmj.com/content/370/bmj.m3592

Hazel Thornton is a health science researcher at the University of Leicester.

She received her PhD in Science from the University of Leicester for her contributions to medicine and patient care. The award recognizes her work in advocating for patients and changing perceptions within the medical research and health care community.

The BMJ publishes her letter on the subject of patients' informed consent, which is often flouted, even though this is a right and a major ethical issue.

Hazel Thornton refers to a publication by Helen Haskell [1] [2], founder of Mothers Against Medical Errors, which reports the severe criticisms of the "Cumberlege Report" [3] on the British health care system, judged "disjointed, siloed, unresponsive, and defensive”.

The report points to the failure regarding the informed consent of healthy patients, whose non respect is a violation of human rights according to the Declaration of Helsinki [4].

What is of great concern is “the testimony from hundreds of patients reporting lack of informed consent.”

While health care professionals are supposed to work “in partnership with patients to make good clinical decisions," which is at “the heart of good medical practice".

Informed consent and screening

Hazel Thornton writes in her letter to the BMJ:

Asymptomatic people, too, are the target of health professionals in preventive medicine. Medical interventions used in screening are not without potential for harm, so properly informed consent must be sought. Not to do so is an abuse of human rights. Flouting the four basic principles of medical ethics—autonomy, beneficence, non-maleficence, and justice—must not go unchallenged. Incredibly, in the 21st century, blatant disregard for the right to proper consent is still occurring. Two examples clearly illustrate this.

The first is an experiment to determine the effects of manipulating invitation information provided to around 6000 asymptomatic women in the province of Messina, Sicily, “to increase uptake” into their breast cancer screening programme.[5] The second is the UK NHS breast screening programme AgeX trial, which was started in June 2009 and announced as “likely to be the largest randomised controlled trial ever undertaken in the world,” recruiting millions of women. Efforts to challenge this trial, with its flawed consent process, have met with “siloed, unresponsive and defensive” attitudes.[6] [7]

H.Haskell says, "How to change it is still an unsolved problem. There have been inquiries, reports, and recommendations over the years, but the fundamental issues around power, justice, and compassion are still with us. " What can be done to end these blatant abuses of the right to properly informed consent and tackle the lack of engagement ? 

Cancer Rose Reflections

Indeed, we have to draw a parallel with the European MyPEBS clinical trial on personalized breast cancer screening.

We have already reported its multiple shortcomings, which we denounced in a joint letter from 4 groups defending independence and integrity in health, a letter relayed among others in the BMJ.

Participants in this MyPEBS study are provided with a so-called consent brochure. The problem is that it does not comply with the law, which requires that this consent be based on fair, clear, complete and unbiased information.

We have summarized our concerns about the brochure for the MyPEPS study here (see point 3 ): https://cancer-rose.fr/my-pebs/2019/06/13/argument-english/

Over-treatment is not mentioned, with over-diagnosis indicated at its lowest range.

In conclusion, we have the same questions as Hazel Thornton:

After the French scientific and citizen consultation, which demands fair and complete information [8], how many laws, declarations, reports and investigations should we hope for in order to obtain the fundamental right to information and informed consent for the patient, and a firm and solid commitment from health authorities and governments to guarantee this right to the patient?

Références

References

[1] https://pubmed.ncbi.nlm.nih.gov/32763955/

[2] https://patientsafetymovement.org/advocacy/patients-and-families/patient-advocates/helen-haskell/Founder of Mothers Against Medical Error

[3] Haskell H. Cumberlege review exposes stubborn and dangerous flaws in healthcare. BMJ 2020;370:m3099.
doi: 10.1136/bmj.m3099 pmid: 32763955

[4] World Medical Association. Declaration of Helsinki. https://www.wma.net/fr/policies-post/declaration-dhelsinki-de-lamm-principes-ethiques-applicables-a-la-recherche-medicale-impliquant-des-etres-humains/

5] Italian study on the manipulation of women, we talk about it here :https://cancer-rose.fr/en/2020/12/17/manipulation-of-information/

[6] Bewley S, Blennerhassett M, Payne M. Cost of extending the NHS breast screening age range in England. BMJ 2019;365:l1293.
doi: 10.1136/bmj.l1293 pmid: 30971394

[7]We were talking about this trial

here : https://cancer-rose.fr/en/2020/12/29/cost-of-extending-the-nhs-breast-screening-age-range-in-england/ and here: https://cancer-rose.fr/en/2020/11/30/the-largest-clinical-trial-in-great-britain-on-breast-cancer-screening-was-halted/

[8] https://cancer-rose.fr/en/2020/12/30/citizen-and-scientific-consultation-on-breast-cancer-screening-in-france-steering-committee-report/

See at the end of the article the summary of the citizens' requests in red, first point being related to the quality of information

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.

Vegetarianism and cancer

By Cancer Rose

1 December 2020

The fact that eating habits have an influence on the risk of developing cancer, and that the incidence of cancer among vegetarians in particular is lower than among people having a meat diet, has already been the subject of scientific studies [1].

A more recent publication [2] than the above-mentioned one, analyzing 86 cross-sectional studies and 10 prospective cohort studies, reports a significant protective effect of a vegetarian diet on the incidence and mortality of ischemic heart disease (-25%), and on overall cancer incidence (-8%). The vegetarian diet was found to significantly reduce the overall risk (-15%) of developing cancer.

But a post by the physician essayist and novelist, Dr. Luc Perino, whose articles [3] we often relay, testifies to another aspect of the behavior of vegetarians and vegans that could have an effect on the reduced incidence of cancer among this group of people, namely the lower participation in screening.

Non-carcinogenic diet and participation in screening / opinion column by Luc Perino

We publish here, with the kind permission of Dr. Perino, the post that you can read, among many others, on the author's blog [4]:

There is no longer need to conduct studies in order to prove that lower meat consumption reduces the incidence of cardiovascular disease. The subject is no longer under debate since half a century. Decreased meat consumption and physical exercise have contributed to the new gains in life expectancy observed in recent decades. 

We also know that low-meat diets reduce the risk of colon cancer. In recent years, the large number of vegetarians has made it possible to carry out studies of greater statistical value on the effects of such diets on health. The question of cancers has obviously been addressed and it appears that in addition to colon cancer, the vegetarian diet also reduces cancers as unexpected like breast and prostate cancer. Generally speaking, all cancer risks are reduced to a greater or lesser extent.

Confounding factors such as tobacco have obviously been taken into account, and some studies went so far as to consider other confounding factors such as personality traits and other elements of a reasonable vegetarian lifestyle (excluding fanatical vegans). For example, vegetarian women take fewer hormone treatments during menopause and further reduce their risk of breast cancer.

The funny thing, if I dare to phrase it this way, is that vegetarians participate much less in organized cancer screening programs. Some will conclude that they are carriers of unknown cancers that will develop sooner or later. This hasty conclusion, somewhat tainted by pro-screening ideology, is contradicted by lower overall cancer mortality among vegetarians of all ages who are followed for a long time.

This is explained by the fact that many of the cancers detected are either false positives or cancers that would never have had a clinical manifestation before death from another cause.

Vegetarians therefore have fewer clinical cancers, fewer detected cancers and fewer virtual or sub-clinical cancers. The health benefit of this triple protection is even greater than that already observed in the reduction of mortality. Indeed, the anxiety associated with all screening and the biographical stigma associated with a cancer diagnosis aggravates morbidity and mortality. We know that all cancers, whether clinical, screened or virtual, have the same psychological and biographical repercussions.

We will not go so far as to encourage vegetarians in their diagnostic recklessness, as this could shock the academy. Nevertheless, we must congratulate them for their sanitary perspicacity and their serenity in the face of pathological destiny, without forgetting to praise their climatic altruism.

Study on participation in screening

In the bibliography of this post, cited by the author, we find a study published in the BMJ in 2017 on health behaviors according to population groups following specific diets [5].

31,260 participants were studied from four diet groups (18,155 meat eaters, 5,012 fish eaters, 7,179 vegetarians, 914 vegans) in the British EPIC-Oxford cohort [6]. 

Compared to meat eaters, vegetarian and vegan women reported lower participation in breast cancer screening, and vegetarian men were less likely to undergo PSA testing for prostate cancer. 

No difference was observed in women for cervical cancer screening. 

For women in all non-meat eating groups there was also a lower consumption of hormone replacement therapy for menopause compared to meat eaters. 

Less use was observed for any kind of medication in general among participants in all no-meat groups. 

Conclusion

Behavioral differences, rather in the sense of lower participation in breast cancer screening, prostate cancer screening, lower hormone replacement therapy and overall drug use were observed in the non-meat diet groups. Apparently these population groups are thus less exposed to the risk of developing cancers, less exposed to clinical cancers (revealed by symptoms), and to sub-clinical cancers (not symptomatic), whose over-detection unbridled by mass screening feeds over-diagnosis, and all this in a context of less anxiety, less morbidity and less premature mortality among vegetarians, observed even in the long term, probably in relation to a healthier general life behavior, and not only due to vegetarianism alone [7].

References

[1] https://academic.oup.com/ajcn/article/89/5/1620S/4596951?searchresult=1

[2] https://pubmed.ncbi.nlm.nih.gov/26853923/

[3] https://cancer-rose.fr/2017/07/04/les-billets-de-luc-perino/

[4] https://lucperino.com/715/vegetariens-et-cancers.html

[5] https://bmjopen.bmj.com/content/7/12/e018245

[6] The Oxford Component of the European Prospective Investigation into Cancer and Nutrition (EPIC) is a prospective cohort of 65,000 men and women living in the UK, many of whom are vegetarians.

[7] https://theconversation.com/les-vegetariens-vivent-ils-plus-longtemps-probablement-mais-pas-parce-quils-sont-vegetariens-72929

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.

Cancer diagnosis: the bone of death or symbolic effectiveness

Annette LEXA, PhD Toxicology (Eurotox)

Expert Regulatory Toxicologist-Environmental Health Risk Assessor

22 February 2016

In today's health care system, a cancer diagnosis can be the most traumatic announcement that a patient will ever experience. And for some people, the announcement will be even more deadly than the cancer itself or its treatment. This is what a cohort study published in 2012 in the New England Journal of Medicine has masterfully demonstrated. The follow-up of this historical cohort of 6 million Swedes between 1991 and 2006, examined the link between cancer diagnosis and the immediate risk of suicide or death from a cardiovascular accident. In the first week after the announcement, the relative risk of committing suicide was 12.6 and the relative risk of dying from a cardiac accident was 5.6 compared to the control group without a cancer diagnosis. This indisputable result is observed equally in men and women.

According to the authors, a negative attitude from the healthcare professional, his or her beliefs around a diagnosis, will cause a deep distress to the patient, especially for cancers with a poor prognosis, leading to death within a week of diagnosis.

The major public health campaigns, the health system and the health professionals themselves, who are part of this dreaded particular colloquium, should be better consider this syndrome in their decision-making process based on the benefit-risk analysis, this potentially fatal psycho-physiological stress induced by the diagnosis itself.

Marcel Mauss and the death bone 

This study, which followed the standards of Evidence Based Medicine, confirms what ethnologists such as Claude Levy-Strauss in 1946 or Marcel Mauss in 1926 had already studied in the 20th century. This fatal syndrome is better known as "bone-pointing syndrome". This ancestral practice has been described among the first peoples of Australia, New Zealand and Polynesia. It consists in condemning a person to die after pointing towards to him a few meters away, a thin bone (often a kangaroo or emu femur of about 45 cm). This ritual is still at use today in Australia where health professionals are trained to face these fearsome situations, where the strength of beliefs prevails to the point of making the victim die from panic fear that disrupts the instinct of conservation, life itself. It is not a death of starvation where the individual would have let himself die of hunger and thirst, no, it is a panic fear that leads to a very rapid death that is not a deliberate choice of the individual or a death due to pre-existing psychological disorders, which the researchers verified in the Swedish study.

Marcel Mauss (1872-1950) wrote the following in 1926: "The Australians consider to be natural only those deaths that we call violent . (...) All the other deaths have a magical or religious origin (...). Mr. Mac Alpine employed a young Kurnai in 1856-57. This young boy was very healthy. One day, he fell ill. He explained that he had done what he shouldn't have done. He had stolen a female opossum before having permission to eat it. The old men had found out about it. He knew that he would not grow any more. He went to bed, practically under the effect of this belief; he never stood up again and died within three weeks. 

(…) Two recent observers, one of whom is a doctor, tell how people die from the death bone among the Wonkanguru: they are very scared. If this bone is found, the bewitched one gets better; if not, he gets worse. European medicine does not inspire confidence. It can do nothing (...) "

Mauss quotes Sir Barry Tuke, a physician who attests to having known "a healthy individual with a Herculean constitution". He died of this "melancholy" in less than three days. Another, "in excellent appearance, and certainly without any lesions of the thoracic viscera, was grieved by life: he said he was going to die and died in 10 days". In most of the cases studied by the doctor, the period was two or three days.

Marcel Mauss reminds us that sociology, like psychology, is only part of biology. Ideas that haunt the social body (death by cancer) have an immense capacity for development and persistence in individual consciousness. It is at the level of biology, of the psychophysiology of the individual that the collective suggestion crystallizes; the consciousness is entirely invaded by ideas and feelings that associate cancer and inevitable death and that are entirely of collective origin. Individuals die "by enchantment". Our human societies are animal societies, highly evolved indeed, but animal societies above all. And man is only a symbolic social mammal for whom language and symbols are powers that sustain his impulse of life and death.

Claude Lévy-Strauss and symbolic effectiveness

Claude Levy Strauss (1908-2009) later formulated the concept of symbolic effectiveness, based on the work of the American physiologist Waler Bradford Cannon (1871-1935). Cannon theorized the famous principle of the fight-or-flight response. In the face of a threat, if fighting or fleeing is no longer possible, physiological stress puts the organism in danger (illness, death). "An individual conscious of being the object of an evil spell is intimately persuaded, by the most solemn traditions of his group, that he is condemned: parents and friends share this certainty. From then on, the community retracts: one moves away from the cursed one, one behaves towards him as if he were not only already dead, but a source of danger for all those around him...".

Of course, there has to be a belief in "magic". This symbolic power implies a macabre ballet of three: the sorcerer, the victim and the group, all must share the same belief, the same trust and the same requirement. The fundamental problem is the relationship of a certain type of individual that we might qualify as easily influenced by certain requirements and beliefs of the group (cancer is an inexorably deadly and horrible disease that threatens and terrorizes us all).

Announcement consultation or "the pink bone".

The passive patient-victim and the active doctor-shaman then engage in this macabre dance orchestrated by the health care system around the panic fear of cancer: the doctor must at all costs fight this modern-day plague that threatens the entire community. His feverishness in making appointments for further tests and treatments reinforces the idea of imminent death. Some patients are convinced that they are already, in a way, banished from the world of the living. Society as a whole is threatened by cancer (how else to explain this collective obsession to "fight against cancer"?) and each new diagnosis is threatened with expulsion from the social body (work, family, insurance, bank...). Her stress is such that some of them can lose control of their lives, all choice. Their metabolic, psychophysiological and even vital functions are in danger. The victim succumbs without having been able to fight or flee: they die of a heart attack if their constitution allows it, otherwise they commit suicide under the effect of the dramatic collapse of their neurotransmitter balance.

The obsession with breast cancer screening, with its lot of over-diagnoses, stems from this hysterized macabre dance, linking women, doctors and the social body: terrified at the idea of being socially banished, how many pre-cancerous or cancerous women have already been victims of this disastrous fate by the collapse of their vital defenses? Nobody knows it and nobody wants to know it, the important thing is to fight cancer at all costs, isn't it? Without going as far as to the death, the announcement of the presence of a cancerous tumor can trigger in some women the collapse of their psycho-neuro-immunological defenses, making even more difficult the medical fight to be carried out during heavy treatments sometimes engaged in excess (surgery, radio- and chemotherapy) and accepted because they seem to be the price to pay to continue to keep its place among the living.

The society tries to exonerate itself and save face by multiplying "empathic" campaigns aiming to give "tips and tricks" on how to "live well with cancer while remaining feminine and keeping one's morale, energy and smile", but some victims, once they have received the ACR4 mark, are not as fortunate as others to have a mind of steel when faced with the symbolic effectiveness of the pink bone.

Bibliography

Cannon W.C., Voodoo death, American anthropologist, 1942, 44(2), 169-181.

Gaudard P.Y.,  Suggestion of the idea of death in Marcel Mauss, acute fatal catatonia, phobia and symbolic modalities, Journal français de psychiatrie, 2010/4 (n°39)

Marcel Mauss, Definition of the collective suggestion of the idea of death. In Sociology and Anthropology, 313-320

Suicide and Cardiovascular Death after a Cancer Diagnosis, Fang Fang et al, N Engl J Med 2012;366:1310-8.

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 if you would benefit from stopping screening ?

Cécile Bour MD, 15 June 2020


The question was asked by Quebec scientists in the newspaper Le Devoir.
https://www.ledevoir.com/opinion/idees/580791/et-si-la-covid-19-vous-avait-sauve-e

Not everyone benefits from screening, especially if it is a screening whose risk-benefit balance is increasingly questioned in view of the cumulative risks, and in view of the benefit that is less and less proven with the hindsight we now have on breast cancer screening campaigns.
This pause in screening could be an opportunity for research, to reflect on information for women without alarmism or threats towards them, to ask the right questions about the use of financial resources in health care towards procedures and tools that are proven beneficial to populations, as the Quebec signatories conclude:
"The current context must be used to question more broadly our choices in the offer of clinical services in order to prioritize interventions that have demonstrated effectiveness and concrete benefits for patients.”

Read also the analysis of :
-Welsch/Prasad https://edition.cnn.com/2020/05/27/opinions/unexpected-side-effect-less-medical-care-covid-19-welch-prasad/index.html
-Judith Garber https://lowninstitute.org/reduced-cancer-screenings-in-covid-19/
-Susan Bewley https://blogs.bmj.com/bmj/2020/04/14/susan-bewley-things-should-never-be-the-same-again-in-the-screening-world/
-John Horgan https://blogs.scientificamerican.com/cross-check/the-cancer-industry-hype-vs-reality/

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.