Category: Informations (en)

Marc Gourmelon, MD, Cécile Bour, MD

September 8, 2020

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

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

Background and methods

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

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

The summary of his study indicates the following:

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

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

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

In introduction is explained :

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

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

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

The hypothesis of this study was as follows:

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

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

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

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

“The overall participation rate at 12 months (Table 2), was significantly higher in the control group: 42.13% versus 40.25% in the decision aid group (p = 0.02).”

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

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

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

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

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

Discussion and analysis

A-Analysis of the tool

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

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

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

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

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

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

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

The IPDAS criteria are very specific requirements that the tool must meet to guarantee a high quality of information.[2]

The mention of overdiagnosis and overtreatment is therefore an absolute must.

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

B-the ethical problem

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

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

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

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

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

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

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

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

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

Conclusion

This study went unnoticed.

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

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

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

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

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

We must then stop trying at all costs to persuade women to get screened. We have to stop manipulating at such a point the so-called decision support tools. Instead, we must inform women, so they can make an informed decision.

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

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

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

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

References

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

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

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

[4] Law on the obligation to provide information in the French public health code:
https://www.legifrance.gouv.fr/affichCode.do?idSectionTA=LEGISCTA000006196409&cidTexte=LEGITEXT000006072665&dateTexte=20180522

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

Identify recommendations for stopping or reducing unnecessary routine primary care

Summary by Cécile Bour, MD, September 15, 2020

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

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

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

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

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

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

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

What is EBM?

The EBM is based on a tripod:

1) external experience, basically scientific studies

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

3) patient preferences and values.

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

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

But...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Conclusion

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

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

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

References 

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

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

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

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

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

October 27, 2017

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

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

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

Setting

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

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

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

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

Conclusion of the authors

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

Miller's study, published in 2014, is a randomized controlled trial, which corresponds to the highest quality criteria for population-based studies. Data are analyzed from groups whose subjects are randomly selected and then compared.

Here, the study involves 90,000 women, 45,000 with screening, 45,000 without screening. In fact the trials (NBSS 1 and 2 , National Breast screening studys ) were conducted in Canada in the 1980s with women screened annually for 5 years with annual mammography and clinical examination, and then followed up for 10 years. Here Miller proposes a re-evaluation after 25 years of follow-up for these two groups.

What are the conclusions?

1°-No difference in mortality between the two groups (mortality = number of deaths in relation to the total number of people screened).

2° Survival rates are identical, regardless of tumor stage(survival = number of deaths in relation to the number of cancers diagnosed)

3° 22% over-diagnosis

4° No difference between the two groups in the rate of fatal cancers.

More precisely, Miller finds 22% overdiagnosis, or 1 overdiagnosis (and thus overtreatment) for every 424 women who received mammography screening, for a zero benefit regarding the reduction of mortality  from breast cancer.

The criticisms that have been made against Miller have been varied. First, it was argued that there could have been contamination of both groups because of the length of follow-up. In fact, some of the follow-ups stop after 7 to 10 years, which limits two drawbacks: some women in the non-screening group could still have had a mammogram one year or the other, while some women in the screening group could have "missed" a year of mammography. Waiting another 20 years would dilute or blur the results.

-First, the effect of non-compliance in the screening group and contamination in the non-screening group will rather lead to an underestimation of over-diagnosis.

-Secondly, the detractors of these studies argued that it would take a very long time to see the effectiveness of screening, as it would only be over a very long period of time that the danger of undetected cancers in the non-screened group would be seen. But here, even after 25 years, we still do not see this famous " dormant cancer " finally appearing, and no excess mortality of women who are not screened, perhaps because dormant cancer does not exist...

Miller was also criticized for not being representative of the French system, which screens every two years and begins at age 50 (whereas the Canadian trials targeted women aged 40-59). However, in the United States there was a debate about starting screening at 40 years of age.

It is clear that mammography was prematurely marketed to us as the ideal way to reduce the danger of cancer, particularly the killer one.

http://www.bmj.com/content/348/bmj.g366

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

October 17, 2017

Dr. Cécile Bour, MD

Dr. Jean Doubovetzky, MD

 Dr. Vincent Robert, MD

PREAMBLE

Our collective has conducted a study (see news release) to verify the assertion of defenders of systematic screening that, after implementation of generalized screening, there would be a decrease of surgical practices. As this postulate has not been verified in France, we are relying on the PMSI (program for the medicalization of information systems) which records hospital stays in an exhaustive manner. The findings of the article to be published in the October issue of the journal Médecine, and in open access by following this link, show that the de-escalating of surgical procedures has not occurred:

Study in Médecine/oct 2017

Or here : Researchgate

Our study on our website

Following the feedback and questions received from readers, we provide below some explanations to clarify the most frequently asked questions.

_____________

 WHAT DOES THE STUDY SAY?

 First of all, contrary to what our opponents say, the PMSI (program for the medicalization of information systems) is completely reliable. The rating errors that could occur here and there are not significant, in fact the quotation of mastectomy procedures does not change, the surgeons know them very well. If there were errors, they would be made in both directions. It should be noted in this regard that the figures put forward in studies other than ours on surgical procedures come from the same data source that surgeons use to report their data. In France, there is no other data base for epidemiological and statistical analyses due to the lack of a national cancer registry, an information system that exists in other countries. Any "cheating" on the quotations is highly visible, leads to severe sanctions by the national insurance fund against fraudsters, and is not credible, as the figures for total mastectomy procedures, which are more remunerative, would then be at the expense of those for partial mastectomies, but this is not the case, as all procedures are on the increase. Over the last four years, an average of 19,966 total mastectomies have been performed annually, compared with 18,351 annually in the four years preceding the generalization of organized screening (2000-2003), an increase of 8.8%.

Indeed, at the same time, the number of breast cancers diagnosed each year has increased. But, even in relation to this figure, the numbers don't add up.

In 2012, there are still practiced 4 total mastectomy procedures for 10 new cancers, as in the year 2000. And there are 15 partial mastectomy procedures for 10 new cancers compared to less than 13 in 2000.

In other words, the number of partial mastectomies is increasing faster than the incidence of invasive cancers. And the number of total mastectomies is increasing in parallel with the number of invasive breast cancers.

Under these circumstances, we should speak of a therapeutic escalation, not of a de-escalation.

-------------------------------------

Role of individual screening

Indeed, some patients have recourse to individual screening; the changes in breast cancer surgery that we have noted cannot be explained by the screening coverage that has remained stable (organized and individual screening added) in recent years.

On the other hand, while the lack of decrease in screening coverage may explain the lack of decrease in total mastectomies, it does not exonerate screening from any responsibility for the significant increase in the number of lumpectomies and partial mastectomies. This increase in the number of surgery procedures depends less on the number of women screened than on the sensitivity and specificity of the screening. With technical progress, double reading of mammograms, the switch to numerical mammography, and an improvement in the skills of radiologists, the sensitivity of mammography is steadily improving.

Therefore, it is rather the performance of screening in detecting increasingly small tumors that is responsible for the increase in the number of surgery procedures, as it leads to an increase in over-diagnosis, and consequently over-treatment.

Once again, the truth is that an unfulfilled promise was made to women, by announcing that the generalization of organized screening would result in "lighter" treatments.

_______

On the issue of total mastectomies

Click to enlarge

Some are satisfied with the decrease in the ratio of total mastectomies to partial mastectomies, or the ratio of total mastectomies to "total procedures". This apparent improvement is only due to the fact that partial mastectomies are increasing significantly compared to total mastectomies, which are also increasing, but to a lesser extent. However, this is not a good indicator of a de-escalating treatment. It would only be gratifying if the number of total mastectomies were reduced. Unfortunately, this is not the case.

The annual number of total mastectomies is not decreasing, neither the number of total mastectomies relative to the incidence of invasive cancers. How can these results be explained?

    - The re-intervention rate (partial mastectomies complemented afterwards) is only 3% and cannot account for the data; see page. 53 of the report: "Improving the quality of the healthcare system and controlling expenses: Health Insurance proposal for 2015" Report to the Minister in charge of Social Security and to the Parliament on the evolution of Health Insurance expenses and revenues for 2015 (law of August 13, 2014).

    - The recommendations requesting that conservative surgery be favored whenever possible are perhaps not followed, in such a way that the intended benefit of screening is cancelled out.

    - Or total mastectomies are performed for non-invasive tumors (notably CIS). These procedures represent an over-treatment associated with over-diagnosis. They would make lose the benefit of a general trend towards more conservative surgery for invasive cancers.

When the progression is considered without even considering the time scale, the general picture is one of an increasing trend, almost linear with a fairly high random variability.

We do not note any definite break in this linear trend and it would be impossible to locate the year when screening under invitation became generalized if the years on the x-axis were not indicated (2004). (This can be confirmed by a Davies test). Therefore, the trend in the annual number of total mastectomies has  not been modified by the generalization of organized screening. No reduction in this rate can be claimed.

concerning total mastectomies

In the statistics of cancer incidence presented by INCA (French National institute of Cancer) site, only the figures concerning invasive cancers are reported, since cancers in situ (CIS) correspond to a separate entity, wrongly referred to as 'cancer' and not considered as 'real' cancer, and they are not taken into account.

It has been shown that surgery does not improve the prognosis of in situ cancers. This is why we have studied the ratio of the number of mastectomies to the incidence of invasive cancers and not invasive + cancers in situ.

The number of mastectomies (of all types) is greater than the number of new cancers. It therefore seems that in situ cancers are surgically operated on "in doubt", not only by partial mastectomy, but also sometimes by total mastectomy.

QUANTIFIED APPROACH :

Our observation is as follows: for every 1,000 invasive cancers, 213 more surgical operations were performed  in 2012 compared to 2000 (a).

This is an excess of 10,387 interventions compared to what the incidence of invasive cancers indicates (b).

Another method of calculation can be used: in 2012 there are 71,916 interventions compared to 53,876 in 2000. There are therefore 18,040 additional interventions in 2012 (c). Of these 18,040 additional interventions, 7,663 can be explained by a rise in the incidence of invasive cancers (d).

The remaining 18,040-7,663 = 10,377 interventions cannot be explained by the rise in invasive cancers. To the nearest rounding errors, the 10,387 given by the other method of calculation are included.

Re-interventions have a limited part to play, since they account for just 3% of mastectomies. Our hypothesis is therefore that, for the most part, these 10,377 additional procedures are attributable to over-diagnosis leading to over-treatment.

a) (ratio of total acts in 2012 year x 1000) – (ratio of total acts in 2000 year x 1000) = (1.475 x 1000) - (1.262 x 1000) = 213

b) 213 x 2012 year incidence = 213 x 48,763 = 10,387

c) 71.916 - 53.876 = 18.040

d) 2012 year incidence x ratio acts/incidence year 2000 = number of acts related to the increase in incidence between year 2000 and year 2012 = (48,763 x 1.262) - 53,876 = 7,663

THE PART OF TOTAL MASTECTOMIES

Chart

There is a statistically significant decrease in the proportion of total mastectomies (p < 0.00001 in Spearman's rank correlation test). However, this decrease in the proportion of total mastectomies is not synonymous with a lighter surgical procedure. Indeed, as shown in the graph below, the decrease in the part of total mastectomies is not due to a decrease in total mastectomies but to a greater increase in partial mastectomies than in total mastectomies.

click on the image to enlarge :

CONCERNING THE AGING OF THE POPULATION

The increase in total mastectomies could be attributed to the increase and aging of the female population.

To test whether this hypothesis stands true, the annual number of mastectomies can be related to the annual number of new cases of breast cancer.

A mastectomy is performed because there is cancer and not because of being a woman.

In summary, two arguments allow us to claim that screening has not lead to a de-escalating in surgical procedure of breast cancer.

1. The trend towards an increase in the annual number of total mastectomies has not changed as a result of the generalization of the screening under invitation.

2. The number of total mastectomies per 1,000 new invasive breast cancers has not been decreased due to the generalization of screening under invitation.

Thanks to Dr Vincent Robert for all these analyses.

_____________

Our study was presented at the congress of the French Society of Breast Senology and Pathology, November 2017 in Lille.

Here is the presentation :  SFSPM Lille PC

Abstract

Poster

diaporama SFSPM Lille PC