Digital Mammography

Summary by Cécile bour, MD

April, 26, 2021

In the Journal of The National Institute Volume 113, Number 1, January 2021, is published an article of 2020 on an important meta-analysis. It discusses the contribution of digital mammography in breast cancer screening, a publication that we had relayed here:

Digital mammography, approved in 2000 by the American FDA, is also widely used in France. 

Studies suggested that the new technology is equivalent to the old analog film technology for cancer detection.

A short technical description

Analog mammography produces an image printed directly on silver film. 

Digital sensor radiography (CR), which has now completely replaced the analog one, is an indirect mammography technique that captures the image on a reusable plate. This receptor of image contains a photostimulated luminophore, the X-rays cause an excitation of luminescent molecules which convert the X-rays to light. An analog-to-digital converter then produces a digital image that can be archived.

Direct Digital Radiography (DR) does not use reusable plates. Sensors convert the X-ray stream directly into an electrical signal which is then digitized and transferred to the screen. The image is visible and can be analyzed on the screen directly by the radiologist. The image can then be enhanced if it is over or underexposed for a better visualization. In this case too, the images can be stored as digital files in a computerized archiving system.

The article

In the article published in the National Institute's journal, authors Otis W Brawley (oncologist and epidemiologist in Baltimore, USA) and Channing J Paller (oncologist and urologist in Baltimore, USA) first recall the results of this important meta-analysis.

Digital mammography is certainly justified by easier storage and handling of images. There is also a possibility of computer-assisted diagnosis and better performance for the exploration of dense breasts. Digital mammography also has a lower radiation exposure than film mammography, provided that the number of images is not increased unreasonably... More on this later.

For effective screening, the authors point out, three objectives must be met: more localized tumors found at the same time as a decrease in interval cancers (tumors diagnosed between two screenings), and a decrease in the incidence of advanced cancers.

Regrettably, the Australian meta-analysis by Faber et al. (Sydney School of Public Health, Australia) confirms the problem of increased overdiagnosis with this method, which allows more detection of small lesions, particularly carcinomas in situ, the vast majority of which do not affect the life of the woman diagnosed, but there is no difference in the detection rate of invasive cancers. 

The study suggests that 11% of cancers detected by digital mammography are overdiagnosed. However, other analyses cited in the article are much more pessimistic about the rate of overdiagnosis attributable to the digital system [1].

The digital technique also has no effect on interval cancers, which are not reduced.

In the United States, the age-adjusted incidence rate (new diagnoses) of breast cancer increased by more than 30% from 1975 to 2000, while the incidence of advanced breast cancer at the time of diagnosis was stable for the 25 years, instead of decreasing as expected.[2]

Most importantly, the recall rate is significantly increased with digital technology because of the increase in false positives, which means that the claim of less radiation with digital technology is questionable, since these women recalled because of false suspicion of cancer will undergo, among other examinations, new X-rays.

Highlights from the article

Two interesting points are made by Brawley and Channing in relation to the results that can be extracted from the Australian meta-analysis:

1. The true measure of the value of effective screening at the population level is a reduction in cancer mortality and unnecessary treatment. 

Screening should not justify its apparent success on the discovery of more and more cancers, many of which are unnecessary detections, but rather on the detection of more cancers that are important to find because they are clinically dangerous to the women who develop them. But digital mammography is not more discriminating for these forms and overdetects a large number of cancers that would not have caused any consequence.

2. It is human nature to think that the new technology is always the best, and many experts felt that digital mammography would lead to better health outcomes. 

Sometimes we have to face the fact that the truth is different from what experts have put forward. These results demonstrate, according to the authors, the importance of post-marketing evaluation and open-mindedness. 

These results also show the biological variations of breast cancer, and confirm a non-linear natural history of the pathology: some cancers are useless to find because they regress or do not progress, others are immediately aggressive and develop between two screening mammograms without any possibility of stopping their occurrence.

Our commentary

We invite our readers to read the work of Bernard Junod and Dr Bernard Duperray on overdiagnosis. The natural history of cancer is of paramount importance, without this knowledge we will never be able to understand the problem of overdiagnosis and interval cancers.


[1] "One-third to one-half of breast cancers detected by mammography would not have been Clinical over a lifetime (overdiagnosis)."

[2]Welch HG, Gorski DH, Albertsen PC. Trends in metastatic breast and prostate cancer–lessons in cancer dynamics. N Engl J Med. 2015;373(18):1685–1687.

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.

Media coverage of screenings

Global Media Coverage of the Benefits and Harms of Early Detection Tests

Mary O’Keeffe, PhD1Alexandra Barratt, MD2Alice Fabbri, MD3,4Joshua R. Zadro, PhD1Giovanni E. Ferreira, PhD1; Sweekriti Sharma, MPH1Ray N. Moynihan, PhD5

Synthesis by Cécile Bour, MD, April 22, 2021

This "researchers' letter" is from Australian scientists including Prof. A. Barratt, Professor of Public Health at the University of Sydney and Dr. Ray Moynihan, Australian researcher at Bond University and health journalist, focuses on the media coverage of screening tests. It was published in JAMA on April 5, 2021. The authors of the publication study the way in which the balance of benefits and harms of 5 tests are treated in the media.

Media is key to promoting testing of asymptomatic individuals in the population, and might play an important role in encouraging realistic reporting of the benefits and harms of screening, including unnecessary diagnoses.

But data suggest that medical media coverage tends to exaggerate benefits, minimize harms, and ignore conflicts of interest.


The authors studied all English-language narratives from 2016 to 2019 in LexisNexis (a publishing and professional information company), ProQuest (a global company providing tools for content search and management from dissertations, theses, books, newspapers, periodicals, etc.) and Google News.

All types of non-fiction articles from newspapers, blogs, magazines, and broadcast transcripts were included as long as they mentioned or implied benefit or harm from medical testing, with or without disclosure of conflicts of interest of the narrators involved.

The stories were reviewed for health benefits (early treatment, saving lives) and harms (false positives, overdiagnosis), and reflected views expressed by the commentators according to their agreement or disagreement.

Five early detection tests were targeted by this review: liquid biopsies, tomosynthesis also known as three-dimensional mammography (discussed on this site [1] [2]), electrocardiogram recording using the Apple Watch Series4 app, blood biomarkers for dementia, and artificial intelligence technology in dementia.


Overall, media coverage focuses much more on the benefits of early detection testing than on the harms, and the risk of overdiagnosis was poorly covered.

Overall, 97% of the narratives reported benefits, 37% reported harms, and only 34% reported both benefits and harms.

63% of stories reported only benefits, while only 3% reported only harms.

Overdiagnosis was mentioned in only 57 of the 432 stories, making only 13% of all content that mentioned harms, or 5% of stories in the entire set.

In total

This study confirms the results of other similar studies on the subject of health media coverage[3] [4] [5].

The authors suggest that improved media communication would encourage a healthier skepticism about the health options available to populations, and reduce the problem of overdiagnosis (or overdetection).

They argue that strategies are urgently needed to improve media coverage so that professionals, patients and the public receive more balanced information about early detection tests.


In the past, we have repeatedly expressed our alarm at the biased reporting of scientific facts in the media.

In the case of screening mammography, easy slogans are used, facilitated by the impossibility for women to make an informed decision since they are fallaciously informed, as shown in a previous study[6].

A commentary published following the Australian study in JAMA was of particular interest to us[7].
It is that of Dr. Diamandis[8], head biochemist of the University Health Network and 'Toronto Medical Laboratories' and also division head of clinical biochemistry in the department of pathobiology at the University of Toronto in Ontario, Canada.

Indeed, we can remember the unbridled media hype and enthusiasm, as early as 2015, about "liquid biopsies"[9]. The "woman who would beat cancer", "the heroine of modern times" was presented on many television platforms and several more or less glamorous media. She was Mrs. Patrizia Paterlini-Bréchot, a scientist who worked on the development of liquid biopsies. [10][11] [12] [13] [14] [15] [16] [17]

But studies and publications that are less media-friendly[18] [19] dampen this enthusiasm about the possibility of using liquid biopsies more widely as routine population-based screening.
Indeed, in addition to its high cost and complexity, these tests on circulating tumor DNA seem to suffer from the same problems of low sensitivity and specificity as traditional biomarkers if we try to use them for screening in an asymptomatic and a priori healthy population. This means that we are heading for over-diagnosis, large numbers of false positives, with panic in the population and cascades of additional examinations for those who test positive (for a better understanding of these notions, see here:

In his commentary to the Australian team's study, Dr. Diamandis writes:

"More recently, as the authors pointed out, we have seen a strong push by academic researchers and companies for DNA tests of circulating tumors for early cancer detection. However, our calculations showed that this test will only be able to detect large symptomatic tumors. We further stressed the need for newspapers to provide a space for healthy debate on such controversial issues. Since: biased reporting favoring the good news, but not the bad news..."




[3] MoynihanR,BeroL,Ross-DegnanD,etal.Coveragebythenewsmediaof the benefits and risks of medications. N Engl J Med. 2000;342(22):1645-1650.

[4] MoynihanRN,ClarkJ,AlbarqouniL.Mediacoverageofthebenefitsand harms of the 2017 expanded definition of high blood pressure. JAMA Intern Med. 2019;179(2):272-273.

[5] Walsh-ChildersK,BraddockJ,RabazaC,SchwitzerG.Onestepforward,one step back: changes in news coverage of medical interventions. Health Commun. 2018;33(2):174-187.




[9]Liquid biopsy consists, schematically, in taking a blood sample to detect as early as possible material released into the blood by cancerous tumors. Three tools can be used: detection of circulating tumor DNA, circulating tumor RNA, circulating tumor cells.

For the moment, this is considered to be an interesting avenue for research. But a person who does not have cancer and is simply concerned about his or her health cannot, today, benefit from this type of blood test.









[18] Fiala C, Diamandis EP. Utility of circulating tumor DNA in cancer diagnostics with emphasis on early detection. BMC Med. 2018 Oct 2;16(1):166. doi: 10.1186/s12916-018-1157-9. PMID: 30285732; PMCID: PMC6167864.


"The use of CTCs or tcDNA as tools for early detection of primary tumor or recurrence remains a very active area of clinical research, but is not, in the absence of clinical evidence, routinely applicable."

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.

Methods of influencing the public to attend screenings

Categories of systematic influences applied to increase cancer screening participation: a literature review and analysis

Joseph Rahbek , Christian P. Jauernik, Thomas Ploug, John Brodersen
(more about the authors ==> see at the bottom of the article)

April 20, 2021; 

Summary Dr C.Bour, with the help of our referent patient Sophie

Under this title the authors aim to analyze how health authorities can subtly influence citizens to participate in cancer screening programs.
The researchers identified and analyzed several "categories of influence", i.e. several methods of pushing the public to undergo screenings.
They point out that when influences become too severe, this is at the expense of citizens' ability to make a personal choice.

Methods of study

Two methods were chosen:

  • A systematic literature search was performed on three databases listing scientific articles and publications which are: PubMed, Embase and PsycINFO. In addition, a review of the so-called "grey" literature was carried out, i.e. information brochures and website content from regulatory authorities and patient organizations targeting general public.
  • Relevant experts were contacted via international email lists and asked to provide examples of systematic influences in cancer screening. These experts are members of independent groups and have expertise in cancer and the collateral damage of screening.

These include the following groups: EuroPrev (18 members),[1] Nordic Risk Group (24 members),[2] Preventing Overdiagnosis (27 members),[3] a Google group (breast-cancer-screening google group) with a special interest in screening mammography (42 members), and Wiser Healthcare (21 members).


From the 19 articles included and the expert survey, six main categories of systematic influence were identified: (a) misleading presentation of statistics, (b) misrepresentation of harms versus benefits, (c) opt-out, (which consists in considering as passive consent the fact that a solicited patient does not object to the invitation to screen), (d) recommendation of participation, (e) fear appeals, (f) influence on general practitioners and other healthcare professionals. 

The authors provide examples for each category.

a) Misleading presentation of statistics

This involves presenting mortality reduction data in an embellished way by using percentages of relative reduction in the risk of dying, instead of raw figures.

Editor’s note : For example, in the case of breast cancer screening, a mortality reduction of 20% is presented. This is a reduction in the risk of dying when comparing two groups, i.e. one group against another.
With this kind of presentation, one might think that 20 out of 100 people screened would die of cancer. This is not the case, explanation:
If out of 1000 screened women 4 die of breast cancer, and out of a group of unscreened women 5 die of breast cancer, the passage from 5 to 4 constitutes mathematically a reduction of 20% of mortality, but in absolute figures it only makes a difference of one woman... This is why it is important to always require a presentation in real data, and not in percentages, which embellishes the situation.

Often physicians and patients have a limited understanding of the statistics, and exposing risk reductions in relative numbers is likely to increase participation especially because citizens overrate the benefits of screening.[5]

b) Misrepresentation of harm compared to benefits:

This method of influence can be applied by presenting the benefits in relative figures, as we have just seen, and the harms in absolute figures. Alternatively, certain types of harms can be minimized and even omitted altogether.

The authors cite as an example a British information brochure on mammography screening in which the reduction in breast cancer mortality was emphasized, but a major harm such as overtreatment was omitted [6]. In addition, the same British brochure showed the risk of overdiagnosis after one round of screening, and the cumulative reduction in mortality after five rounds of screening, thus minimizing the harm while exaggerating the benefit.

Failure to inform correctly also addresses the omission of harms such as overdiagnosis and overtreatment.[6]

Editor's note: We will detail in a dedicated paragraph the very same shortcomings in the information given to women in France, which were denounced in this study, and which were also mentioned during the public consultation on screening in 2016 in France. We will come back to this.

c) Opt-out systems

This consists of assigning citizens a pre-booked appointment at the point of the invitation. If the person does not wish to participate, he/she must actively opt out. The non-refusal of the patient is considered de facto as acceptance to participate.

Editor's note: In France, we do not have this system of prebooked appointments, but the system of reminders is widely used if a patient does not show up for a screening mammography appointment (reminders by mail and sometimes SMS).

d) Recommendations of participation

A recommendation to participate in a health procedure does not provide evidence about the effectiveness or appropriateness or benefit of a screening program. Instead, it promotes one option (to participate) as the smartest or best, based on the authority of the source from which the injunction emanates. This is the argument from authority.[7]

Celebrity staging is also widely used in different countries to increase participation. Humorous examples are given in the article by Rahbek et al. In an Icelandic government video, after examining a citizen's rectum, the doctor slaps him on the bottom and exclaims, "More men should follow your example and take care of their own ass" - a recommendation, unaccompanied by factual data.

e) Fear appeals

This is a well-tried lever. By relying on the uncertainty of life and emphasizing the human fear of dying, it is easy to convince.

All of the above levers are illustrated in an excellent and pictorial way in the Cortecs media article: (Editor's note)

f) Influence on general practitioners and other healthcare professionals

The most obvious one is the system of reward by remuneration when the professional encourages a patient to participate, called P4P (Pay for performance) or ROSP (Remuneration on public health objectives) in France.

g) Others

It is not used in France but is in force in Uruguay, and it was almost introduced in Germany: it is the legislative influence.

In Germany, in 2007, a law proposal suggested that if an individual did not participate in a cancer screening program and was subsequently diagnosed with the type of cancer for which he or she had been called for screening, then that individual would have to pay double the health tax - a law proposal that was finally rejected.

In total

The authors' analysis shows that there is a common point between the six main categories of influence detailed in the article: they work through psychological biases and personal costs (i.e. time consumption or financial) on non-participation.

The article here focuses essentially on "nudging" populations, a term that refers to anything that predictably changes people's behavior by pushing them into what you want them to do, without any scruples, and even to the point of financial incentives.

Insofar as patient autonomy and informed choice are important, the authors say, the use of such influences is ethically questionable in cancer screening programs where the benefit/harm ratio is complex and scientifically contested.

Therefore, they argue, there is a need to find better ways to facilitate participation by willing citizens, without pushing reluctant citizens to participate. Instead of evaluating cancer screening programs on the basis of participation rates, programs should be evaluated on informed decision rates, regardless of participation or non-participation.

Key points

• This study finds six categories of systematic influences applied to increase participation in national cancer screening programmes.

• The categories of influences work through psychological biases and personal costs of non-participation and might not be compatible with the citizens’ informed choice.

• Research on how to properly implement informed decision models as not to complicate participation for otherwise willing citizens are needed.

Methods of pressure and manipulation by the sanitary structures in France, in particular for breast cancer screening by mammography

We will take up the six methods of influence described and analyse their application in France, specifically concerning breast cancer screening which is our subject of concern. The shortcomings of information in France have been very well identified and described in the report of the citizen and scientific consultation on breast cancer screening (2015/2016) which, let us remember, called for a halt to this screening[8] (observations of multiple failures in the information given to women).

It is important to underline the incredible cynicism of the National Cancer Institute which uses this same publication to improve the participation rate in screening!

Indeed, on the Institute's website, in the section intended for doctors (thematic access "health professionals") this publication is quoted as a basis for improving the participation rate, ignoring the denunciation of the unethical character of the influence techniques by the authors of the study.

"Conducted on the basis of a systematic review of the literature (19 articles) and with the help of experts, this study identifies different types of influence allowing to improve the participation rate in screening programs." 

The critical analysis of the Rahbek et al. study is not mentioned at all...

Let's look at the information given to women according to the 6 categories of influence analyzed in the article.

a) Misleading presentation of statistics

Rahbek et al. cite the INCa booklet[9] in Table 5 of the supplements section of their study (TABLE 5. GREY LITERATURE SEARCH RESULTS) as an example of misleading presentation of statistical data, and they denounce the French booklet's presentation of mortality in terms of relative risks. In fact, in the French booklet, the reduction in the risk of dying from breast cancer (this so-called gain in mortality) is announced by INCa to be between 15 and 20%. We have also analysed this booklet and made the same observations about the misleading and embellishing information concerning the supposed gain in mortality from breast cancer screening [10].

When we visit the INCa website[11], which is supposed to guarantee proper information to the population, we immediately come across the same flaw denounced by the publication, here: : "International studies estimate that these programs can prevent between 15% and 21% of deaths from breast cancer."

The same presentation can be found again and always on the French Health Insurance website, in spite of the citizens' requests to avoid this pitfall, superbly ignored and scorned by these authorities, which are nevertheless heavily pinned for their failings, as can be seen on the website,


b) Misrepresentation of harms versus benefits

On the French Assurance Maladie website, it is impossible for a patient to obtain information on overdiagnosis or overtreatment. In the search box there are no hits.

But in the tab "organized breast cancer screening" you will find a video made by the INCa and a reference to the page of the Institute.

The benefits, on the official site of the INCa, are largely developed, and the harms are called here modestly the "limits of screening". In the small paragraph 'DIAGNOSIS AND TREATMENT OF SLOW PROGRESSIVE CANCER', overtreatment, a direct consequence of overdiagnosis for women, is never mentioned.

Overdiagnosis is indicated at a percentage of 10 to 20%, figures that are completely obsolete and have been revised upwards for a long time[12].

Even lower numbers appear on the page for professionals: "Based on published studies, overdiagnosis could be in the range of 1-10% or even 20%. " The same observation can be made on the site dedicated to breast cancer screening (Prevention and screening of breast cancer) where you will find exactly the same wording[13].

We had also carried out ourselves a quantitative evaluation of the informative value of this site where the inciting for screening is obvious[14].

The French brochures are again cited in the "supplements" of the Rahbek et al study, item 'MISREPRESENTATION OF HARMS VS BENEFITS'; the authors denounce the omission of overdiagnosis in the official brochures. To be more accurate, overdiagnosis is mentioned in the booklet but very much minimized, and the description of overtreatment, a corollary of overdiagnosis, is completely missing.

Still in the same section, Rahbek et al. denounce the omission by the official French brochures of the risk of exposure to ionizing radiation. We had also noted this point in the analysis of the booklet (reference 11). But in fact this point is mentioned on page 12 of the INCa booklet, which states that: "the risk of death from radiation-induced cancer is of the order of 1 to 10 per 100,000 women who have had a mammogram every 2 years for 10 years."

This is true, but it should be pointed out that this risk increases with the repetition of examinations and incidences. Let us recall that 3 mSv are received on average with a mammography (between 2 and 3 images per breast depending on the needs), which corresponds to already 9 months of annual irradiation (which is 4.5 mSv per year for a French person). 

c) Opt-out system

As mentioned above, this system is not used in France. However, if a woman does not go for screening, she will be reminded several times, sometimes even by text message, giving women the impression that screening is mandatory. However, this is not the case, screening is not mandatory  and we have provided a pre-filled form on the home page that women who do not wish to undergo mammography screening can send to their departmental screening structure. 15]

At the end of the INCa booklet, it is clearly stated "You cannot or do not wish to be screened. Fill in the questionnaire in the invitation letter and return it to the address indicated. Please be aware that you can change your mind at any time. "

d) Recommendations for participation

The argument of authority is widely conveyed by opinion leaders, a radiologist speaks on the home page of the "breast cancer prevention and screening" website.

In the midst of the Covid pandemic, we saw a renowned oncologist calling on women to continue screening, scaring them and arguing loudly that breast cancer would kill more than the pandemic. When we read that the 100,000 mark was passed in one year (breast cancer causes 12,000 deaths/year), we realize how sordid these counts seem and especially how some media doctors do not hesitate to exaggerate in order to convey inciting and frightening messages.[16]

The stars in France are not to be forgotten, as shown by the TV show " Naked Stars " where celebrities unveil themselves for " the good cause " with messages that are intellectually indigent and insufficient in terms of scientific information.[17]

In 2011, Marie-Claire published multiple photos of French stars who let themselves be photographed naked to "raise awareness" of breast cancer screening, allowing this media a considerable and profitable increase in its sales.[18]

e) Fear appeals.

The organization Pink Ribbon, formerly 'Cancer-du-Sein-Parlons-en' , broadcast a spot in 2015 based on messages related to death (breast cancer, the most common, the most deadly).[19]

The INCa is not lagging behind and in 2018 was published this poster: "This cancer is at the same time the most frequent and the most deadliest in women. Yet if it is detected early, the treatments are generally less burdensome and the chances of recovery greater."

Cancer is constantly associated with a verdict of death, so much so that the medical, societal and media messages are based on a military and bellicose jargon: cancer is an enemy that will inexorably invade the body. The patient either wins or succumbs, despite the "therapeutic arsenal" or the "fight" led by the patient. As soon as a cancer is diagnosed at the mammogram, the feverishness that the doctor shows in making appointments for his patient for other examinations and surgery reinforces the idea of imminent death for the patient. Each newly diagnosed woman feels banished from the world of "normality" and threatened with expulsion from the social system (work, family, insurance, bank, etc.). The stress that some women feel after the announcement is such that they lose all control over their lives, professionally, emotionally and in their families. And this is very well recognized by the other women in the family, friends or professional environment.

f) Influence on general practitioners and other health professionals

In France this is the ROSP system (remuneration on public health objectives)[20].

See here:

Note that on the site dedicated to professionals [21], the risk of "unnecessary mutilation of women screened by excess" is well recognized, the controversy and the consultation of 2016 are mentioned, nevertheless the premium is maintained (according to web page of December 29, 2020).

But even worse is the financial incentive offered to the women themselves. Indeed, in 2020 the INCa organized a masquerade of consultation[22] where one item caught our attention, as it proposed to pay women this time in order to bring them to screening.

A citizen has expressed her concern in an article published in the JIM, denouncing the lack of ethical consideration in this proposal for "paid participation"[23].

The manipulation of women is a real scientific topic

To read here:


Rahbek et al have perfectly identified the shortcomings of the information provided to the public on screening in general, information that remains globally often inciting, which goes against the ethical objectives that we owe to the patient.

The shortcomings and failings of the official French brochures were noted, including those of the INCa, an institute that is supposed to protect the patient.

The booklet of the INCa, already quite imperfect, is sent to women eligible for screening only once at the time of their first convocation when they are 50 years old. In 2017, when the booklet was published, women aged 50 who were first called for screening received it, but women over 50 at that time will never receive it.

And what can be said about the INCa's multi-language brochure, which is even more succinct?

From our point of view, we can only be dismayed and distressed to see to what extent the demands of French citizens, who had, during the 2016 consultation, identified the same problems, have remained unheard and scorned by the French authorities.


You will find here a table annexed with the original publication, showing the research of the so-called 'grey' literature (brochures and information websites). French brochures are named in several items of misleading communication of data (yellow highlighting).

We have selected for presentation in our article only the examples concerning breast cancer screening, by mammography.

We found that these examples account for about 60% of the total number of examples for all cancers combined: prostate, breast, cervical and colorectal. We can conclude that there is a preferential communication, a hype around breast cancer screening, compared to other cancers.

Table here:

The authors

Joseph Rahbek

Master student Department of Public Health, Section of General Practice
Research Unit for General Practice, Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen K, Denmark

Christian P. Jauernik

The Research Unit for General Practice, Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen K, Denmark

Thomas Ploug

Thomas Ploug is Professor of ICT (Information and Communication Technology) Ethics at the Department of Communication and Psychology at Aalborg University in Copenhagen. He holds a Master of Philosophy from the University of Copenhagen and a PhD in ICT ethics from the University of Southern Denmark. His research interests and projects cover topics in different areas of applied ethics, such as ICT ethics, medical ethics and bioethics. He is currently involved in projects on online and offline consent behavior in the health context, and nudging in the health sector. He is head of the research group on communication and information studies, director of the Centre for Applied Ethics and Philosophy of Science, member of the Danish Council of Ethics and the clinical ethics committee of Rigshospitalet, Copenhagen.

John Brodersen, Professor, University of Copenhagen

John Brodersen, the senior author of this article, is a general practitioner with more than ten years of experience in clinical practice. Dr. Brodersen holds a PhD in public health and psychometrics and works as an associate research professor in medical screening at the University of Copenhagen, Department of Public Health, Research Unit and Section of General Practice.

His work was used in the development of the 2020 WHO Screening Guide, which builds on the background papers written by John Brodersen for the 2019 WHO European Technical Consultation on Screening.

He is also a co-author of the 2012 Cochrane booklet on mammographic screening.

He is a member of the Board and Scientific Committee of the non-profit organization "Preventing Overdiagnosis "

His research focuses on the development and validation of questionnaires to measure the psychosocial consequences of false positive screening results. Dr. Brodersen has published numerous articles in peer-reviewed journals.

In the area of self-diagnosis and screening, Dr. Brodersen specializes in the areas of sensitivity, specificity, predictive values, overdiagnosis, informed consent, and psychosocial consequences for healthy individuals when tested.

He also teaches nationally and internationally on evidence-based medicine.

PhD thesis:Brodersen, J 2006 , Measuring the psychosocial consequences of false positive screening results - breast cancer as an example, PhD thesis, Månedsskrift for Praktisk Lægegerning, Department of General Medicine, Institute of Public Health, Faculty of Health Sciences, University of Copenhagen. Copenhagen


[1] European Network for Prevention and Health Promotion in Family Medicine and General Practice. Available at:

[2] Nordic Risk Group. Available at:

[3] Preventing Overdiagnosis. Available at:

[4] Wiser Healthcare. Available at:


[6] Gotzsche PC, Hartling OJ, Nielsen M, et al. Breast screening: the facts–or maybe not. BMJ 2009;338:b86.



  • page 125, le constat d'une information inadaptée.
  • page 57 : les incitations financières
  • pages 85, 92, 93, 115 : la communication "lacunaire" de l'INCa
  • pages 95, 96 jusqu'à 100 : la communication 'simpliste' de l'Assurance Maladie
  • page 133 : les deux scénarios proposés par le comité de pilotage pour l'arrêt du dépistage mammographique.

[9] ou

















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.

Self-selection bias, a study that illustrates it

March 21, 2021

Cécile Bour, MD

One of our faithful and wise readers, whom we thank, asked our opinion on a study by Tabar and Duffy, recently published but we had not mentioned.

According to this publication, there would be a significant reduction in mortality from breast cancer in patients who were monitored.

Here are our comments. We did not mention this study because there is a huge and well-known selection bias, namely that women who do not participate in screening are very different from those who do; and this bias can explain the results as well as the screening itself in this population.

On Medscape we can read:

One of the experts who was approached by Medscape Medical News to comment on the new study, Philippe Autier, MPH, MD, PhD, from the University of Strathclyde Institute of Global Public Health at the International Prevention Research Institute, Dardilly, France, questioned the methodology of the study. "This method is incorrect simply because women attending screening are different from women not attending screening," he said. "The former are more health aware and have healthier behaviors than the latter, and this is a well-known fact and supported by the literature."

Dr Autier emphasized that it is practically impossible to control for that bias, which is known as confounding by indication.

"The statistical methods used for attenuating the so-called self-selection are very approximate and based on unverified assumptions," he said. "For this reason, the Handbook on Breast Cancer Screening produced by the International Agency for Research on Cancer clearly stated that 'observational studies based on individual screening history, no matter how well designed and conducted, should not be regarded as providing evidence for an effect of screening,' and the methodology in this paper has never been recommended by the [agency]."

A better way of conducting this type of study would have been to show the incidence trends of advanced-stage breast cancer in Sweden for the entire female population aged 40 years and older, he asserts. Dr Autier used that methodology in his own study in the Netherlands, as previously reported by Medscape Medical News.[4]That study foundt hat in the Netherlands, screening mammography over a period of 24 years among women aged 50 to 74 years had little effect on reducing rates of advanced breast cancer or mortality from the disease.

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.

Secondary hematological cancers after treated breast cancer

September 19, 2019

Article from January 2019, Summary by Cécile Bour, MD

Evaluation of the Incidence of Hematologic Malignant Neoplasms Among Breast Cancer Survivors in France

JAMA Network Open. 2019;2(1):e187147. doi:10.1001/jamanetworkopen.2018.7147

download PDF 

Authors :

Marie Joelle Jabagi, PharmD, MPH; Norbert Vey, MD, PhD; Anthony Goncalves, MD, PhD; Thien Le Tri, MSc; Mahmoud Zureik, MD, PhD; Rosemary Dray-Spira, MD, PhD

About this study

This is a cohort study. All French women between the ages of 20 and 85 years who were diagnosed with breast cancer and did not die (referred to as "survivors"), between 2006 and 2015, were included and were followed up until the onset of hematological cancer, or until death, or until loss of follow-up, as the case may be. Comparisons were made with all French women in general population enrolled in general health insurance plan each year from 2007 to 2016. Data from the SNDS (containing data from the PMSI and the CepiDC) were analyzed.


The different types of hematological neoplasia considered were acute myeloid leukemia, myelodysplastic syndrome, myeloproliferative neoplasms, multiple myeloma, Hodgkin's lymphoma or non-Hodgkin's lymphoma, acute lymphoblastic leukemia, lymphocytic lymphoma. The incidence (number of new cases) of these different types was estimated and compared to the incidence in women in general population.

In this study of 439,704 French women, women with a diagnosis of breast cancer who had not died from it, had a statistically standardized higher incidence of acute myeloid leukemia and myelodysplastic syndrome compared to women in general population. There was a slight increase in the incidence of multiple myeloma and acute lymphoblastic leukemia.

French women participating in the study who had breast cancer in the last decade were 3X more likely to develop acute myeloid leukemia and five times more likely to develop myelodysplastic syndrome than women in  general population. Several previous studies have linked these pathologies to chemotherapeutic agents, radiotherapy, and taxotere therapy (adjuvant treatment of breast cancer, see HAS 2015 advisory). (See studies [1])

It cannot be ignored that hematological risk of malignant neoplasm reaches peaks within specific time frames after breast cancer.

The annual incidence of acute myeloid leukemia in these patients from this study, increased during the first few years following diagnosis of breast cancer, with an early peak around year three and a subsequent peak around year eight. This finding is consistent with previous studies indicating the presence of 2 types of acute lymphocytic leukemia associated with treatment.

The authors suggest that the latency of onset may depend on the age of the patient at diagnosis, type of therapy and dosage regimen, and also on the limited time of follow-up in the study (even later cases may occur that have not been reported here).

The majority of secondary leukemias are of the myeloid type, but it is estimated that acute secondary lymphoblastic leukemias account for 10% to 12% of all secondary leukemias, with breast cancer being the most common cancer causing these secondary pathologies. In this study, there was a two-fold increase in the incidence of acute lymphocytic leukemia in breast cancer "survivors". Some studies showed that irradiation and chemotherapy were associated with pathogenesis [2], while other studies suggested that prior therapy plays a less important role in secondary acute lymphocytic leukemia than genetic predisposition [3].

A 50% increase in the incidence of multiple myeloma was observed in breast cancer survivors in this study. This slight increase has not been reported and needs to be further investigated, particularly the role of susceptibility due to heredity in BCRA1 and BCRA2 mutation carriers. [4]


This study reveals that acute myeloid leukemia, myelodysplastic syndrome and acute lymphoblastic leukemia are more common in treated women who do not die from breast cancer than in women in the general population; this is of concern and according to the authors, ongoing surveillance of hematological malignancies and further research into the underlying mechanisms of these diseases is needed.

This study is intended to better inform practicing oncologists; patients with a history of breast cancer should be informed of the increased risk of developing certain hematologic malignancies after their first cancer diagnosis.

Recent discovery of genetic signatures that guide treatment decisions in early stages of breast cancer could reduce the number of patients exposed to cytotoxic chemotherapy and its complications, including hematological cancers[5].

It is therefore necessary to continue monitoring trends in the occurrence of hematological cancers, especially as approaches to cancer treatment are evolving rapidly. Further research is also needed to evaluate  treatment modality in cases of genetic predisposition to secondary malignancies.

Comments :


Concerns about overdiagnosis are all the more justified because women, some of whom are at high risk and unaware of it [6], may be receiving radiation therapy that they would not have needed, and are being precipitated by screening for a disease they would not have had in its absence, with potential risks inherent in treatment, including secondary hematological diseases.

This has been shown in studies that suggest that risks of treatment may outweigh the expected benefit of screening. [7]

As our dotted poster on the home page of the site (bottom of the page, "poster") shows, the benefit/risk balance in screened women is far from being in favor of benefit, due to overdiagnosis, radiation-induced cancers, radiation-induced coronaritis, surgical and anesthetic accidents, post-treatment thromboembolism, and secondary hematopathies.

The Cancer Rose Collective regrets that these elements are not explicitly detailed in the information brochure given to women who are part of the new study on personalized screening, the MyPebs study. Overdiagnosis is minimized at rates that are currently obsolete, overtreatment, a tangible consequence resulting from overdiagnosis for women, is not stated, and consequences of treatment are not mentioned[8].


[1] Studies about relation between breast cancer treatment and Hematologic Malignant Neoplasms:

  • SmithRE,BryantJ,DeCillisA,AndersonS;National Surgical Adjuvant Breast and Bowel Project Experience. Acute myeloid leukemia and myelodysplastic syndrome after doxorubicin-cyclophosphamide adjuvant therapy for operable breast cancer: the National Surgical Adjuvant Breast and Bowel Project Experience. J Clin Oncol. 2003;21 (7):1195-1204. doi:1200/JCO.2003.03.114
  • PragaC,BerghJ,BlissJ,etal.Risk of acute myeloid leukemia and myelodysplastic syndrome in trials of adjuvant epirubicin for early breast cancer: correlation with doses of epirubicin and cyclophosphamide. J Clin Oncol. 2005;23(18):4179-4191. doi:1200/JCO.2005.05.029
  • BeadleG,BaadeP,FritschiL.Acute myeloid leukemia after breast cancer:a population-based comparison with hematological malignancies and other cancers. Ann Oncol. 2009;20(1):103-109. doi:1093/annonc/mdn530
  • Le Deley M-C, Suzan F, Cutuli B, et al. Anthracyclines, mitoxantrone, radiotherapy, and granulocyte colony- stimulating factor: risk factors for leukemia and myelodysplastic syndrome after breast cancer. J Clin Oncol. 2007; 25(3):292-300. doi:1200/JCO.2006.05.9048
  • Galper S, Gelman R, Recht A, et al. Second non breast malignancies after conservative surgery and radiation therapy for early-stage breast cancer. Int J Radiat Oncol Biol Phys. 2002;52(2):406-414. doi:1016/S0360-3016 (01)02661-X
  • RenellaR,VerkooijenHM,FiorettaG,etal.Increased risk of acute myeloid leukaemia after treatment for breast cancer. Breast. 2006;15(5):614-619. doi:1016/j.breast.2005.11.007
  • CurtisRE,BoiceJDJr,StovallM,FlanneryJT,MoloneyWC.Leukemia risk following radiotherapy for breast cancer. J Clin Oncol. 1989;7(1):21-29. doi:1200/JCO.1989.7.1.21


  • HsuW-L,PrestonDL,SodaM,etal.The incidence of leukemia,lymphoma and multiple myeloma among atomic bomb survivors: 1950-2001. Radiat Res. 2013;179(3):361-382. doi:1667/RR2892.1
  • AndersenMK,ChristiansenDH,JensenBA,ErnstP,HaugeG,Pedersen-BjergaardJ.Therapy-related acute lymphoblastic leukaemia with MLL rearrangements following DNA topoisomerase II inhibitors, an increasing problem: report on two new cases and review of the literature since 1992. Br J Haematol. 2001;114(3):539-543. doi:1046/j.1365-2141.2001.03000.x

[3] GanzelC,DevlinS,DouerD,RoweJM,SteinEM,TallmanMS.Secondary acute lymphoblastic leukaemiais

constitutional and probably not related to prior therapy. Br J Haematol. 2015;170(1):50-55. doi:10.1111/bjh.13386

[4] StruewingJP,HartgeP,WacholderS,etal.The risk of cancer associated with specific mutations of BRCA1and

BRCA2 among Ashkenazi Jews. N Engl J Med. 1997;336(20):1401-1408. doi:10.1056/NEJM199705153362001


  • CardosoF,van’tVeerLJ,BogaertsJ,etal;MINDACTInvestigators.70-Gene signature as an aid to treatment decisions in early-stage breast cancer. N Engl J Med. 2016;375(8):717-729. doi:1056/NEJMoa1602253
  • SparanoJA,GrayRJ,MakowerDF,etal.Adjuvant chemotherapy guided by a21-gene expression assay in breast cancer. N Engl J Med. 2018;379(2):111-121. doi:1056/NEJMoa1804710




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.

Heart disease is the biggest killer of breast cancer survivors

Summary by Cécile Bour, MD

 January 12, 2020

Causes of Death After Breast Cancer Diagnosis: A US Population-Based Analysis

original article Cancer journal


The longer  women are followed up after being diagnosed with breast cancer, the more likely it is that a cause of death unrelated to the original cancer would be found. The most common cause of death is heart disease, according to the authors of the study published at the end of 2019 in the journal "Cancer".

The study is based on a population of more than 750,000 American women diagnosed with breast cancer over the past 15 years since the beginning of the century.

The proportion of deaths from non-cancerous causes increased from about 28% in the first year after diagnosis to just over 60% among women who lived for more than 10 years after their breast cancer diagnosis.

These women, having survived their cancer longer, had a significantly increased risk of heart disease and Alzheimer's disease compared to general population.

Results according to monitoring

  • For deaths within 1 to 5 years after diagnosis, breast cancer itself is the responsible cause in the most frequent cases.
  • Among women who died 5-10 years after diagnosis of breast cancer, breast cancer was the cause of death in 38.2%, followed by other cancers in 13.4%, and non-cancerous causes in 48.4%. Heart disease was the most common non-cancer cause of death (15.7%), followed by cerebrovascular disease (stroke) and chronic obstructive pulmonary disease (3.9%) and Alzheimer's disease (3.4%).
  •  In a more distant follow-up, the cardiovascular cause prevails.

Evoked causes

As discussed above, deaths from heart disease and stroke are leading causes of death unrelated to cancer during the post-diagnosis follow-up periods.

But other important causes of death unrelated to breast cancer include chronic liver disease, sepsis, infectious and parasitic diseases. Suicide must also be considered, as it is a significantly higher cause of death than in the general population in all women but particularly among young women.

The high rates of death from heart disease are probably related to the toxicity of chemotherapy (especially anthracyclines) and radiation therapy (especially left breast).


According to Dr. Sonbol, co-author of the article,

1°Some women could be cured of breast cancer and then die of other intervening causes.

2°For other women breast cancer, e.g. metastatic cancer, may have been transformed into a chronic disease, it may be under control through systematic therapy, and then other causes contribute to death.


According to the authors, these findings provide considerable insight into how patients treated for their breast cancer should receive warnings about future health risks.

Hospital physicians who follow up women that have had breast cancer must work closely with general practitioners to ensure optimal long-term follow-up and prevent various pathologies that may occur during the lifetime of these patients after their treatment.


We would add that overdiagnosis, in this context, must become a major concern, all the more so since it throws healthy women into an illness they should not have known about, and exposes them to these other, potentially serious pathologies which are also likely to seriously impact their lives and lead to death.

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.

Effect of a mammography screening decision aid for women 75 years of age and older

April 23, 2020

Randomized clinical trial by "cluster" (cluster)

 Authors: Mara A. Schonberg, MD, MPH; Christine E. Kistler, MD, MASc; Adlin Pinheiro, MA et al.

A cluster randomization trial is a trial in which subjects are randomized not individually but by randomization unit or groups of subjects, known as "clusters".

Here 546 women aged 75 to 89 years, who received a decision aid on mammography screening prior to a health care visit with their practitioner, constitute the randomization unit.

Purpose of the study :

To investigate how the use of a screening decision aid for women 75 years of age and older affects their decision to participate in mammography screening.

Study Results

Providing these women with a mammography screening decision aid prior to their medical visit helps them make informed decisions and leads to fewer women undergoing mammography screening.

Study Conclusion

Therefore a decision support tool can help reduce overscreening.

Our analysis

Cécile Bour, MD

Such a study could be of interest on younger age groups, although an assessment of what concerned women perceive and the impact of the lack of balanced information has already been carried out [1].

How do women perceive the benefits of screening according to what has been conveyed about it, and according to the information they have received, and which has forged their convictions on the subject?
This is the question posed in this study by Domenighetti et al, according to which the table below was drawn up by Nikola Biller-Andorno, a bio-ethics researcher who collaborated on the work of the Swiss Medical Board. [2] [3]

In this comparative table we can find, in part A, data from Domineghetti's American Women's Perception Survey, and in part B, actual data from the most likely scenarios, found from the most convincing and reliable studies. [4]1-3)

The authors (Biller-Andorno et al.) were stunned by the significant discrepancy between women's beliefs about the benefits of screening and the reality, and legitimately asked the question: how could women make an informed decision if the benefits of the procedure were overestimated?

See our article with the detailed results of this work here:

For the moment, the decision-making tool for women requested by the citizen consultation is completely absent in France, since 2016 when the consultation took place.

There is indeed a question of establishing one " in the French way ", which will hardly be possible given the deficient epidemiological data in our country [5].

Recently in JAMA a viewpoint was published on recommendations for shared decision making with the patient [6].

Unfortunately at the moment it seems that the shared decision is more a medical " dream " than a reality.

Indeed, recommendations from learned societies always have more weight than the values and experiences of the patient, and are sometimes imposed in the media and on patients with great virulence and authoritarianism, as we saw in 2019 with the abusive campaign of the French national college of obstetricians and gynecologists (CNGOF)[7], advocating the extension of screening to the elderly, without any national or international recommendation. The Council of the Order, which we had alerted, did not react ,[8] even though it regularly calls to order those who violate the communication of verified medical notions, as is currently the case in the Covid context.

To conclude

There is still an enormous amount of work to be done so that the values and reality of each patient's life, including her age, can guide the practice of every physician. There is also a long way to go, to ensure that physicians have the practical means to contribute to shared decision making, so that women, both older and younger age groups, finally have access to real tools made on a correct and independent scientific basis.

The development of such tools implies admitting the possibility of women's refusal to participate in screening, as the performance of mammography screening has proven over the decades and in the course of modern studies to be increasingly disappointing.

The real problem is that neither health authorities nor politicians are prepared to accept the possibility of women refusing to be screened for political and ideological reasons, thus depriving them until now of true autonomy in health.


[1] Domenighetti G, D'Avanzo B, Egger M, et al. Women's perception of the benefits of mammography screening: population-based survey in four countries. Int J Epidemiol2003;32:816-821 CrossRef | Web of Science | Medline



[4] 1. Gotzsche PC, Jorgensen KJ. Screening for breast cancer with mammography. Cochrane Database Syst Rev 2013;6:CD001877-CD001877 Medline/

  • Independent UK Panel on Breast Cancer ScreeningThe benefits and harms of breast cancer screening: an independent review. Lancet 2012;380:1778-1786 CrossRef | Web of Science | Medline/
  • Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ 2014;348:g366-g366 CrossRef | Web of Science | Medline/





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.

High risk of breast cancer and mammography, in practice

JANUARY 18, 2021

(We have addressed this specific topic in two articles, below is a practical summary at the request of one of our readers. [i] [ii])

The first problem is to define a woman who is at high potential risk of developing breast cancer during her lifetime. And what is a "family at risk".
A family history alone, even a direct one, does not constitute the proof of being a person "at risk", contrary to what is often presented as a scarecrow to women.
We receive plenty of testimonials from young women who are unnecessarily alarmed and above all incited to unnecessary and dangerous over-medicalization.

What about the search for genetic mutations in women? When should it be done? 

This is the question that the independent French medical journal Prescrire addressed, Volume 36 N°388/February 2016.

Genetic mutations in the BCRA1 and BCRA2 genes are autosomal dominant, and women with these mutations are at higher but earlier risk of breast and ovarian cancer than the general population.

-The median age of onset is 40 years and the cumulative risk of cancer at age 70 is 51% to 75% for the BRCA1 mutation, 
-The median age is 43 years and the estimated cumulative risk is 33% to 55% for the BRCA2 mutation.

The journal Prescrire proposes the following criteria as significant backgrounds for proposing an onco-genetic consultation:

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

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

-A person who has had ovarian cancer

-A person with breast cancer with a diagnosis before the age of 40, or a bilateral form, the first one before the age of 50, or a hormone receptor negative cancer that occurred before the age of 60.

Eisinger Score

The Eisinger score is a decision aid for requesting an onco-genetic consultation.(Click below to download) :

Several situations can arise in families with multiple cases of breast cancer:

A- Mutation identified in a woman in the family, presenting a breast cancer.

This search for genetic mutation brings valuable information to the women in the family: women who are carriers have a higher risk, women in the same family who do not have it, end up with the risk of the general population.

If a woman in the family decides to do a mutation search on the BCRA1 or BCRA2 genes because of a loaded genealogy, and finds herself carrying a deleterious mutation on these genes, then her risk of developing breast cancer appears to be high, and this risk is also very high for relatives.

B- No mutation found in women with breast cancer.

Either there is really no mutation and the patient has developed a form of cancer without a genetic cause, or there is a mutation, but it may be due to an unidentified genetic cause.

Therefore, there will be uncertainty for the women in her family regarding the hereditary nature or not of this cancer, the risk of the familial nature of this cancer is not as high as in the case of an identified mutation such as BRCA but probably slightly higher than in the general population.

Uncertainty makes it necessary to analyze genealogy, which also has its share of uncertainties and imprecisions…

C- The person with breast cancer has not done any genetic research.

For the women among the relatives, this gives useless information: either the ill person may have had a mutation that was not researched, or she is free of a mutation but the mutation possibly exists in the family members.

All overall, the following points should be kept in mind:

  • Either the person presents a family case carrying a mutation but she is free of any mutation herself, her risk will be close to that of the general population. 
  • Or the person has the mutation and can be estimated to have a higher risk of breast cancer than the general population.
  • But for other women there are still uncertainties about their family's risk of breast cancer:

-In women whose family members have had breast cancer but without a mutation found in only one of the family cases,
-In women with a personal genetic research of a mutation that is negative, with a genealogy presenting several cases of breast cancer, but without research done on the ill persons.

Proposals of conduct to be followed, different options depending on the situation

Who are the individuals with the highest theoretical risk?

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

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

-Male relative with breast cancer in the family of the first or second degree

-First or second degree female relative with ovarian cancer.

Summary according to the Prescrire dossier published in the Revue Prescrire May 2016/Tome 36 N°391-p.355 to p.361

Here is a table summarizing the proposed courses of action according to the presence of mutation or not, and proposals for complementary imaging (downloadable table, click below):



1°In 2014, the French National Authority for Health (Haute Autorité de Santé) issued recommendations that are still in force:

2° The recommendations of the National Cancer Institute, click (table p.10 of the doc)

As you will read, early and annual mammography is recommended, ignoring the greater risk of radiation-induced cancer, which can occur, depending on mutations, as early as the first mammogram. iii] [iv]

For these women at particular risk, recommendations are made without any objective data on the impact of different screening strategies, on overall mortality data, breast cancer mortality, mastectomies, treatment effects, over-diagnosis and false alarms for this at-risk population. In absence of data, these women and their caregivers are unsure of what to do and are struggling empirically.

While assessments are conducted on the general population, it is equally important to do them in these special populations, but they are not available.

General cautions

A thorough discussion should be undertaken with the patient because the knowledge of this high risk will condition for her, in addition to an important psychological burden:

-Permanent anxiety

-Numerous false alarms (false positives)

-Over-diagnosis is highly probable but not evaluated since no studies have been carried out to quantify it.

To quote the May 2016 issue of the journal Prescrire: "To ensure that screening has a favorable benefit-risk balance, it is not enough to determine the most effective detection method: earlier diagnosis does not always change the burden of treatment for patients, nor necessarily the prognosis of the disease".

"It is also necessary to establish the conditions where this translates into tangible clinical benefits for the people screened. It is also important to measure the undesirable effects to which all screening exposes people: over-diagnosis and over-treatment, sources of serious undesirable effects sometimes; iatrogenicity of the tests; false positives causing anxiety and useless tests; medicalization of the healthy person's existence. »

And further on, on the ethical aspect:

"Ethics. The magnitude of the risk of breast cancer in these higher-risk women compared to the general population does not make it unethical to conduct randomized clinical trials, on the contrary. Clinical trials comparing the effects of various screening strategies on clinical criteria such as total mortality, breast cancer specific mortality, frequency of breast amputations, frequency of cytotoxic treatments, would provide the answers that are lacking, instead of leaving women and caregivers without solid evidence for these important decisions". 

According to the journal Prescrire, a U.S. evaluation reports 125 cases of radiation-induced breast cancer per 100,000 women between 40 and 74 years of age screened by mammography every year, 16 of which are fatal. And for high-risk women, it has been shown that breast cancer was twice as frequent in women exposed to x-ray examinations before the age of 30 than in those not exposed.

Other complementary exams

Other exams than mammography, each having its limits, and an adapted follow-up can be proposed.


This exam has a higher sensitivity compared to mammography and is less radiating.

MRI + Mammography:
84% of cancers found

MRI alone:
75% of cancers found

Mammography alone:
32% of cancers found

These proportions are almost identical for women at high risk, but here the problem is the same, we do not know the proportion of overdiagnosis. It is not known whether there is a gain in survival for these women who are followed in this way, or whether, on the contrary, they are exposed to more overdiagnosis and invasive treatments.

The long-term effects of Gadolinium injected annually are also unknown. The assessment of this potential risk is all the more necessary as these women will be integrated into heavy surveillance protocols, with multiple repeated MRI scans.

This product has possible side effects during injection and some cases of allergic reactions have been described.


this examination increases overdiagnosis and exposes to false positives and multiplies unnecessary biopsies.

Clinical examination by a professional:

The authors of the Prescrire dossier did not find any study evaluating the performance of breast self-examination.

But according to all the studies examined by the authors, it seems that at least half of the cancers discovered by an imaging examination were not diagnosed by the clinical examination carried out at the same time. It is not known if a delay in clinical diagnosis would be life threatening, as this has not been evaluated.






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

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

Additional MRI screening for women with extremely dense breast tissue
Bakker, M. F.; de Lange, S. V.; Pijnappel, R. M.; Mann, R. M.; Peeters, P. H. M. and all, Supplemental MRI screening for women with extremely dense breast tissue. N Engl J Med. 2019;381(22):2091–2102 , DOI: 10.1056/NEJMoa1903986

Synthesis Cécile Bour November 28, 2019


Extremely dense breast tissue is believed to be a risk factor for breast cancer, a factor that is especially limiting for cancer detection by mammography.

The aim is to test whether the use of MRI would reduce the occurrence of interval cancers, i.e. cancers appearing between two mammograms, the previous mammogram having been considered normal.


This is a randomized controlled trial (study subjects randomly assigned to either group), multicentre (conducted in two or more centers with the same protocol and a coordinator responsible for processing all data and analyzing the results).

It is carried out by van Gils and his colleagues in the "DENSE" trial group.

The researchers divided 40,373 women between 50 and 75 years of age with extremely dense breast tissue and negative screening mammogram results, into two groups: either the "additional MRI" group or the "screening mammogram only" group; specifically 8,061 women in the "MRI-invitation" group and 32,312 women in the "mammogram-only" group.

A control mammogram was then performed after two years for both groups to compare the results in terms of the number of cancers found.

The main finding was the difference between the groups in the incidence of interval cancers over a two-year screening period.

The researchers stated that “Such patients may benefit from a tailored breast-screening strategy, supplemented with more sensitive imaging methods. The benefit of supplemental imaging is the subject of a worldwide debate. In the United States, a federal law directs breast-density reporting,but supplemental screening is not recommended in American guidelines. “

Although complementary imaging increases the rate of cancer detection in women with dense breasts, the question that remains is whether it improves health outcomes. Read about it:

Conclusion of the study

Additional MRI screening appears to be associated with fewer interval cancers compared to mammography alone in women with extremely dense breast tissue and normal mammography results. It appears that for dense breasts, the risk of interval cancers is reduced by half in women with negative mammograms and MRI screening.

Specifically, the researchers found that the interval cancer rate was 2.5 per 1,000 screenings in 4,783 women in the MRI-invitation group compared to 5 per 1,324 women in the mammography-only group.

Overall, 59% of women in the MRI group really attended this additional screening. Of the 20 interval cancers diagnosed in the group that was invited for MRI, 4 were diagnosed for women receiving MRI, and 16 were diagnosed for those who did not receive MRI.

Limitations of the study

  • False positives : Supplemental MRI scans were associated with a cancer detection rate of 16.5 per 1,000 screens and resulted in a false positive rate of 8.0% (79.8 per 1,000 screens). Among women who had a breast biopsy based on an MRI indication, 26.3% had breast cancer and 73.7% did not.
  • Sample not large enough.  To examine the effect of MRI screening on breast cancer specific mortality or overall mortality, the study would require a larger sample size and a longer observation period.

The lower rate of interval cancers observed in MRI participants may have an effect on mortality, but it would also be necessary to see a reduction in the number of advanced cancers in order to demonstrate a benefit on mortality reduction, which has not yet been demonstrated for mammography screening alone.

Reservations expressed 

In an accompanying editorial, Dan L. Longo, Associate Editor of the New England Journal of Medicine, and Professor. of Medicine at Harvard Medical School, (Boston), praised the high quality data from this unprecedented randomized trial: « It appears to show that among women with dense breasts, the risk of interval cancers is halved by following a negative mammogram with MRI screening ».

But the problem of over-diagnosis and the usefulness of additional screening in asymptomatic women, in whom lesions will be detected and be treated, without any evidence of survival or reduction in mortality, continues to be raised.

Dan Longo writes :

« But is a reduction in interval cancers an appropriate surrogate for improved overall survival? It appears that most of the cancers that were detected on supplemental MRI screening were found at an early stage. Ductal carcinoma in situ was 10 times more frequent among patients undergoing MRI, and these diagnoses were likely to lead to treatments. What remains unclear is whether the tumors would never otherwise have been detected or threatened the patient’s survival. »

« The ultimate test of the value of MRI screening in women with extremely dense breast tissue will be whether its use improves survival — an answer that we will not have for a very long time. In the meantime, we now have a trial showing that MRI screening can lead to a lower rate of interval cancers. The cost is that 74% of the biopsies that are subsequently performed will not lead to a cancer diagnosis, and we do not know whether the cancers that were detected needed to be found or treated. »

« So the dilemma remains. Women with dense breasts and a negative mammogram who undergo MRI have a very low risk of having breast cancer (16.5 per 1000 screenings in this trial) and an increased risk of a false positive scan. The findings of this trial are likely to reinforce the idea that MRI screening is important in women with dense breast tissue. But will we be putting these women at increased risk of procedures without contributing to their eventual survival? »

In addition, another study :

The concern about additional MRI screening is addressed in another controlled study of MRI screening for contralateral breast cancer patients in the United States. (Wang SY, Long JB, Killelea BK, et al. Preoperative breast magnetic resonance imaging and contralateral breast cancer occurrence among older women with breast cancer. J Clin Oncol 2016;34:321-8.)

Although the incidence of invasive breast cancer in the contralateral breast after the screening period was lower with MRI screening than without screening, the overall incidence of breast cancer in the MRI group was twice as high as in the no MRI group, with no change in the incidence of advanced cancer throughout the five-year follow-up period. However, it is the incidence of advanced breast cancer that tells us whether or not screening is effective.

The researchers concluded :

“An increased synchronous contralateral breast cancer detection rate, attributable to MRI, was not offset by a decrease of subsequent contralateral breast cancer occurrence among older women with early-stage breast cancer, suggesting that preoperative MRI in women with breast cancer may lead to overdiagnosis.”


Bakker, M. F.; de Lange, S. V.; Pijnappel, R. M.; Mann, R. M.; Peeters, P. H. M. and all, Supplemental MRI screening for women with extremely dense breast tissue. N Engl J Med. 2019;381(22):2091–2102 , DOI: 10.1056/NEJMoa1903986

Longo, D.L, Detecting Breast Cancer in Women with Dense Breasts-Editorial, N Engl J Med 2019; 381:2169-2170 DOI: 10.1056/NEJMe1912943

Wang SY, Long JB, Killelea BK, et al. Preoperative breast magnetic resonance imaging and contralateral breast cancer occurence among older women with breast cancer. J Clin Oncol 2016;34:321-8.

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.

Digital mammography not more effective in reducing the most serious cancers, according to Australian meta-analysis

by Cécile Bour, MD, June 28, 2020

This is a meta-analysis of 24 studies of more than 16 million screening mammograms (10,968,843 film and 5,614,900 digital mammograms) by Australian researchers, which reported the following results :

With digital mammography is observed :

  • A statistically significant increase in recalls and false positives; bearing in mind that false positives can generate considerable anxiety in women who are misidentified as having breast cancer. After the transition to digital mammography, which began around the year 2000, a recall increase rate of 6.96 per 1,000 screens was  reported.
  •  No impact on the rates of interval cancers, these cancers not being anticipated by screening because they are often very rapid and progressive and appear between two screening mammograms, despite a previous negative mammogram. Their rate is not lowered by digital technology.
  •  A modest but statistically significant increase in the cancer detection rate, however this improved detection rate is largely due to a higher detection of carcinoma in situ, the great majority of which are of unnecessary detection, with little difference in the detection of invasive cancers.

 Precisions and some reminders

1° Transition from analog to digital

Initially, mammography was analogical, i.e. using films that had to be developed. The radiological signal, to make it simple, is  transformed into a 'visual' signal, which involves technical uncertainties that can alter the quality of the film to be interpreted (film artifacts, quality and fragility of the films, problems with developing baths, etc.). With the digital process, used in screening since 2008, sensors retrieve the image, store it in memory, there is no transformation of the signal and the image is projected in real time on the computer screen (or console). The diffusion of the signal is limited to the maximum ('photon counting' technique) to keep only the useful information. This technology has been acclaimed for its better detection rate compared to the analog system, especially in case of dense breasts, and for its lower irradiation.

This last aspect is certainly not negligible, but should be relativized, since radio-biologists have made us understand the mechanisms of radio-toxicity, which is much less dose-dependent than subject-dependent. See:

2° The impact of digital in terms of benefits

 In 2010, questions were already being raised about the real impact for women in terms of mortality reduction, because the interest of screening is to detect the cancers that endanger the most women's lives, and thus reduce mortality, a fact that is difficult to prove with breast cancer screening (reduction in breast cancer mortality since the 1990s, thanks to therapeutic advances, a reduction well before the advent of screening campaigns).

However, an increase in detection rate ranging from 20 to 28% with the digital technique (in fact according to the Australian study, there is 25% more detection for carcinoma in situ and only 4% more for invasive carcinoma), this represents only one additional cancer detected thanks to this new technique per 1000 women, and it does not mean that one more life is saved.

Screening performance is measured by mortality and not by the detection rate. The problem is that it preferentially detects a cancer that will be little or not life-threatening, and that would have been detected by analog mammography one year later anyway, or even in the absence of any screening by the appearance of a clinical symptom, without changing the therapeutic result. More cancers that would never have manifested themselves are also detected. The problem of overdetection by preferential detection of cancers with little or no evolution thus causing overdiagnosis, has already been raised.

3° The problem of over-detection of carcinoma in situ (CIS)

Below is a reminder of what we explained about in situ carcinoma of the breast:

In situ carcinoma of the breast is defined by the proliferation of cancer cells within a galactophoric duct without the cells protruding beyond the wall of the duct to invade the rest of the breast.

It is essentially a mammographic finding, as 90% of women diagnosed with DCIS had microcalcifications on mammography.

The vast majority of these lesions do not threaten women's lives if they are not detected, their prognosis is very good, the 10-year survival rate, a parameter widely used by health authorities, is over 95%. There is the ductal form and the lobular form considered rather as a risk factor for breast cancer.

CIS contributes to overdiagnosis. Tests and studies show that the increasing detection of CISs has not contributed to the reduction of breast cancer mortality. Before the introduction of screening, CIS accounted for less than 5% of all breast cancers, rising to 15-20% in all countries where screening campaigns exist. They are not counted in the incidence figures (rate of new cases) given by the National Cancer Institute, as they are considered separately and not as "true" cancers.

In addition, there is a lack of real consensus among pathologists for the classification of these lesions in the analysis of the biopsies they receive, with a tendency to outclass them in poorer prognostic categories, for fear of underestimating a "disease".

Most CIS are considered as non-mandatory precursor lesions to invasive cancer; paradoxically, the dramatic increase in their detection followed by their surgical ablation has not been followed by proportional decreases in the incidence of invasive cancers.

The major problem is that these particular breast cancer entities are treated with the same severity as breast cancer.

In November 2016, a study carried out by University of Toronto reported  the following results:

- Their treatment makes no difference in women's survival.
- Women with CIS are heavily treated (sometimes by bilateral mastectomy) and have the same likelihood of dying from breast cancer as women in the general population.
- Treating CIS does not decrease their recurrence.
- Preventing recurrence by radiation therapy or mastectomy would also not reduce the risk of mortality from breast cancer.

Similarly, our study of mastectomies in France showed a steady increase in surgical procedures, our first hypothesis being the overtreatment of lesions that are not invasive cancers, but so-called pre-cancerous lesions and CIS [3] [4].

The long-term consequences of overtreatment can be life-threatening. For example, radiation therapy on these lesions appears to be unable to reduce the risk of death from breast cancer, but is associated with a dose-dependent increase (10-100% over 20 years) in the rate of major coronary events. [5]

In several countries, clinical trials are being conducted to test a simple active surveillance, especially for low-grade CIS, rather than aggressive treatment:


For Philippe Autier [6], from the International Prevention Research Institute (IPRI), the problem is undoubtedly inherent to routine mammography, in particular digital mammography, which is too efficient for the detection of small calcifications; these are the most frequent radiological sign of these forms, and mammogaphy has an excellent sensitivity for the detection of these microcalcifications.

You will find in our media library several clinical cases of carcinomas in situ, abusively called carcinomas.

Conclusion of authors of Australian meta-analysis

The increase in cancer detection after the switch to digital mammography did not result in a reduction in interval cancer rates. Recall rates were increased.

These results suggest that the transition from film to digital mammography, primarily motivated by reasons of better technological performance, did not result in health benefits for screened women.

This analysis reinforces the need to carefully evaluate the effects of future technological changes, such as tomosynthesis [1] [2], to ensure that the new technologies lead to better health outcomes, beyond the gains in technical performance alone.

[1] Read :[2] Read also  :

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.