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)

https://publichealth.ku.dk/staff/?pure=en%2Fpublications%2Fcategories-of-systematic-influences-applied-to-increase-cancer-screening-participation(2cfeab86-5b7c-47db-be7b-bdf04436a71f).html

https://academic.oup.com/eurpub/article-abstract/31/1/200/5902144?redirectedFrom=fulltext

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).

Results

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 participating, (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: https://cortecs.org/2016/05/ (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 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

https://www.e-cancer.fr/Professionnels-de-sante/Veille-bibliographique/Nota-Bene-Cancer/Nota-Bene-Cancer-460/Categories-of-systematic-influences-applied-to-increase-cancer-screening-participation-a-literature-review-and-analysis

"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: https://cancersdusein.e-cancer.fr/infos/pourquoi-les-autorites-de-sante-recommandent-de-realiser-un-depistage/ : "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,

Here: https://www.ameli.fr/assure/sante/themes/cancer-sein/depistage-gratuit-50-74-ans

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%. " 

https://www.e-cancer.fr/Professionnels-de-sante/Depistage-et-detection-precoce/Depistage-du-cancer-du-sein/Les-reponses-a-vos-questions 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 really 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."

https://www.e-cancer.fr/Expertises-et-publications/Catalogue-des-publications/Depistage-du-cancer-du-sein-2018-Affiche-sans-zone-de-repiquage

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 perceived 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:

https://www.ameli.fr/seine-saint-denis/medecin/exercice-liberal/remuneration/remuneration-objectifs/medecin-traitant-adulte

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 on 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: https://cancer-rose.fr/en/2020/12/17/manipulation-of-information/

CONCLUSION

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.

ANNEX: 

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).

Table here:

https://cancer-rose.fr/wp-content/uploads/2021/04/tableau.pdf

We can also see the strong preferential communication on mammography screening (blue highlighting).

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

https://publichealth.ku.dk/staff/?pure=en%2Fpersons%2Fjohn-brodersen(0f06ffbd-c5c4-4560-aac7-f0bfdf8e86e7).html

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.

https://apps.who.int/iris/bitstream/handle/10665/330852/9789289054799-fre.pdf

He is also a co-author of the 2012 Cochrane booklet on mammographic screening.https://www.cochrane.dk/sites/cochrane.dk/files/public/uploads/images/mammography/mammografi-fr.pdf

He is a member of the Board and Scientific Committee of the non-profit organization "Preventing Overdiagnosis "https://www.preventingoverdiagnosis.net/?page_id=6

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

REFERENCES

[1] European Network for Prevention and Health Promotion in Family Medicine and General Practice. Available at: http://europrev.woncaeurope.org/

[2] Nordic Risk Group. Available at: http://nordicriskgroup.net/

[3] Preventing Overdiagnosis. Available at: http://www.preventingoverdiagnosis.net/

[4] Wiser Healthcare. Available at: http://wiserhealthcare.org.au/

[5] https://cancer-rose.fr/en/2020/12/18/perception-and-reality-2/

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

[7] https://cancer-rose.fr/en/2021/04/02/screening-propaganda/ (part OPINION LEADERS AND MEDIA)

[8] http://www.concertation-depistage.fr/wp-content/uploads/2016/10/depistage-cancer-sein-rapport-concertation-sept-2016.pdf

  • 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] https://cancersdusein.e-cancer.fr/infos/un-livret-sur-le-depistage-pour-sinformer-et-decider/ ou https://www.e-cancer.fr/Expertises-et-publications/Catalogue-des-publications/Livret-d-information-sur-le-depistage-organise-du-cancer-du-sein

[10] https://cancer-rose.fr/en/2021/01/01/critical-analysis-of-the-new-inca-information-booklet/

[11] https://cancersdusein.e-cancer.fr/

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

[13] https://cancersdusein.e-cancer.fr/infos/les-benefices-et-les-limites-du-depistage/

[14] https://cancer-rose.fr/en/accueil-english/

[15] https://cancer-rose.fr/wp-content/uploads/2019/07/Droit-dopposition_Mammos.pdf

[16] https://cancer-rose.fr/en/2021/04/02/screening-propaganda/

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

[18] https://cortecs.org/wp-content/uploads/2016/03/CorteX_mammo_sophie_davant.png

[19] https://www.youtube.com/watch?v=y7widbIFUb8

[20] https://cancer-rose.fr/2020/04/20/la-nouvelle-rosp-quel-changement-pour-le-medecin-concernant-le-depistage-du-cancer-du-sein/

[21] https://www.ameli.fr/seine-saint-denis/medecin/exercice-liberal/remuneration/remuneration-objectifs/medecin-traitant-adulte

[22] https://cancer-rose.fr/2020/12/17/la-concertation-citoyenne-de-linca-sur-le-futur-plan-cancer-une-mascarade/

[23] https://cancer-rose.fr/en/2021/02/14/getting-paid-to-be-screened/

[24] https://www.e-cancer.fr/Expertises-et-publications/Catalogue-des-publications/Depliant-d-information-en-langues-etrangeres-sur-le-depistage-organise-du-cancer-du-sein

 

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Screening propaganda

Marc Gourmelon, MD, November, 1st, 2020

"1 lie repeated 1000 times becomes the truth”.

This is one of the well-known principles of propaganda. (1)

It has been well studied in political field and more particularly in dictatorships. The sentence in the title is historically attributed to Joseph Goebbels, who headed the Ministry of People' s Education and Propaganda under the Nazi regime.

But propaganda is not a prerogative of totalitarian regimes, whether of the right or the left. As Noam Chomsky writes, "Propaganda is for democracies what violence is for dictatorships. "Propaganda is a concept designating a set of persuasion techniques, implemented to propagate with all available means, an idea, an opinion, an ideology or a doctrine and to stimulate the adoption of behaviors within a target public. These techniques are exercised on a population in order to influence it, even to indoctrinate it. " (2)

Clearly, the insistence on promoting breast cancer screening by mammography is propaganda. Indeed, there is an intention to "propagate a doctrine" according to which screening saves lives and this is in total contradiction with what independent scientific studies tell us.

The goal: "adoption of behaviors within a target audience", in this case, to perform a screening mammogram within the women target population. It is noteworthy that the desire to promote breast cancer screening by mammography has been a steady feature over the past 20 years, and has been accentuated with the adoption of the organized screening program in 2004, following the 2003 cancer plan. (3)

However, as early as 2015, following the consultation of French citizens on the topic, organized screening should have been stopped in France. However, this was not the case because conclusions of this consultation were "confiscated" to allow the continuation of this screening. (4)

All means are good to promote it. The Pink October campaigns that come back year after year are proof of this. All means are good to promote it.

But the propaganda goes farther.

PUBLIC AGENCIES

The latest report of the IGAS-General Inspection of Social Affairs, an independent organization, recommends "encouraging the use of screening, regardless of the methods used". (5)

OPINION LEADERS AND MEDIA

But also, any "open mic", any offer to speak in the media, be it radio or television or the written press, allows many doctors to spread the propaganda for screening.

We recently heard Professor Axel KAHN, a medical expert and president of the Ligue contre le cancer (League against cancer), sounding the alarm on France Info radio channel, in favor of this screening (6).

Many techniques of propaganda are therefore found in this " call " (2)

- fear

- call to authority

- false statement: "Covid-19 is much less serious than cancer”

- “Media influence: radio, television, press, advertising, internet " is also present because this call is relayed by : the newspaper Sud Ouest (7), Yahoo actualité (8), Europe 1 (9) Top Santé (10) La Croix (11) France Soir (12), and this a non-exhaustive list.

Here, the COVID19 crisis, although far from being related to the problem of breast cancer, is used to promote screening. In a similar way, we read in an article in Le Monde on 26 October 2020 (13) the following comments:

"The figures are also worrying when it comes to screening, which has stopped for twelve weeks. The number of mammograms within the framework of organized breast cancer screening for 50 to 74 year olds has totally collapsed. On the Ile de France and Hauts¬ de France regions alone, their number went from about 14,000 and 9,000 respectively from mid-March to early May 2019 to zero during the lockdown, according to the French Society of Radiology."

This collapse of screening, which worries Prof. Axel Kahn so much, allows a national daily newspaper of large edition to affirm once again a lie: there is nothing to worry about if a screening which has not shown its benefit, is not carried out anymore.

MEDICAL ACTORS

It should be noted that many of doctors promoting screening have very strong ties of interest with it.

The French Society of Radiology finds it disturbing that the number of screening mammograms has totally collapsed. But is the health of women their concern? Or are there other, non-medical concerns that are preoccupying this learned society? (14)

CONCLUSION

We should not let ourselves be "blinded" by propaganda. We must remain lucid and recognize in these repetitions, carried by media more concerned by " buzz " than by a critical work, a propaganda effect, again and again.

Will this propaganda and disinformation ever stop? One can doubt it considering the last news. (5)

Yet the well-being and health of women are at stake.

Références

(1) https://nospensees.fr/mensonge-repete-mille-se-transforme-t-verite/

(2) https://fr.wikipedia.org/wiki/Propagande#Techniques_de_propagande

(3) https://cancer-rose.fr/2020/10/19/histoire-du-depistage-mammographique/

(4) https://formindep.fr/cancer-du-sein-la-concertation-confisquee/

(5) https://cancer-rose.fr/2020/10/21/ligas-recommande-le-maintien-de-la-promotion-du-depistage-du-cancer-du-sein-par-mammographie-en-lintensifiant/

(6) https://www.francetvinfo.fr/sante/maladie/coronavirus/video-octobre-rose-axel-kahn-implore-les-femmes-de-se-faire-depister-le-covid-19-est-beaucoup-moins-grave-que-le-cancer-du-sein_4154331.html

(7) https://www.sudouest.fr/2020/10/24/cancer-du-sein-axel-kahn-lance-un-cri-d-alarme-pour-inciter-au-depistage-8000781-4696.php

(8) https://fr.news.yahoo.com/octobre-rose-axel-kahn-implore-085353145.html?

(9) https://www.europe1.fr/societe/debut-doctobre-rose-axel-kahn-alerte-sur-les-retards-de-diagnostic-des-cancers-du-sein-3995432

(10) https://www.topsante.com/medecine/cancers/cancer/covid-19-depistage-cancer-639344

(11) https://www.la-croix.com/Sciences-et-ethique/Deprogrammation-doperations-Linquietude-immense-malades-cancer-2020-10-27-1201121508

(12) http://www.francesoir.fr/opinions-tribunes/chronique-covid-ndeg34-le-geneticien-axel-kahn-president-de-la-ligue-contre-le

(13) https://www.lemonde.fr/planete/article/2020/10/26/cancers-infarctus-avc-ces-pathologies-victimes-indirectes-du-covid-19_6057437_3244.html

(14) https://www.cairn.info/revue-les-tribunes-de-la-sante1-2016-3-page-21.htm#

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


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

The anguish of pink advocates in the face of declining participation in screening

October 6, 2020

Cécile Bour, MD

https://www.lequotidiendumedecin.fr/specialites/cancerologie/face-une-baisse-du-depistage-du-cancer-du-sein-linca-lance-une-campagne-loccasion-doctobre-rose

and

https://mobile.francetvinfo.fr/sante/cancer/covid-19-les-retards-de-depistage-du-cancer-de-sein-vont-entrainer-une-augmentation-de-la-mortalite-entre-1-et-5-dans-les-dix-ans-qui-viennent-selon-la-fondation-arc_4124525.html#xtref=https://mobile.francetvinf

The anxiety-provoking communication of Pink October tries to surf on the wave of concern that the epidemic has caused among oncologists, and now tries to emphasize screening. The world of pink is worried, women who have long been manipulated[1], shamelessly incited[2] all of a sudden seem to be less enthusiastic about running and even less about running for screening.

"We need to encourage everyone to continue with screening campaigns", assures Mr. Pr. Eric Solary, president of the scientific council of the ARC foundation for cancer research. "Models indicate that the increase in breast cancer mortality will be between 1 and 5% in the next ten years."

"Faced with a decline in breast cancer screening, INCa is launching a campaign on the occasion of Pink October," proclaims the Quotidien du Médecin.

What's going on? Is the pink house burning?

Analysis

Let's analyze calmly the ever feverish messages of our institutes and health authorities, anxious, tormented, frightened and in a perpetual trance that women may turn away from their precious pink toy.

1. Assuming that there is indeed an excess of cancer deaths linked to COVID, in the years to come, it is obvious that the cause will not only be the lesser adherence to routine breast cancer screening but above all a delay in therapeutic management (by cancelling non-urgent interventions, by fear of patients being contaminated by going to the hospital or in doctors' waiting rooms), as Mr Solary admits in the article.

2. The main argument in opposition to the view of Mr. Solary is that the same model announces an increase of 2 to 5% in cancer mortality, this announced increase will concern all cancers, not only breast cancer [3].

This is the Grouvid study:

"Delays in diagnosis and treatment of cancers, linked to the first wave of coronavirus, could result in an excess of cancer mortality of 2 to 5%, five years after the start of management, according to a French study made public on Friday, September 18. These are the delays and postponements of patients' visits that have the most consequences, shows the research presented by statistician Aurélie Bardet of the Gustave-Roussy Institute in Villejuif (Val-de-Marne)."

"These delays could result in a "minimum 2% increase in cancer deaths" five years after diagnosis. This excess mortality would mainly affect liver, sarcoma and head and neck cancers. This research is based on a mathematical model that allowed an assessment of the effects of the Covid-19 pandemic on the organization of cancer care and the consequences on prognosis, taking into account the lags related to lockdown." (Grouvid study)

https://mobile.francetvinfo.fr/sante/maladie/coronavirus/coronavirus-une-surmortalite-par-cancers-de-2-a-5-liee-a-la-premiere-vague-de-l-epidemie-de-covid-19-selon-une-etude_4110821.html

Mr. Solary maintains that "The models indicate". But here we are, as far as screening and the Pink October campaign are concerned, we are mostly in communication and very little in science.

Which models, with which data in input?

"The models indicate", it ends up sounding like Kaa's song from the Jungle Book: " trust me, believe me...".

And that is difficult, because after all the misinformation of women we become doubtful to be able to trust blindly anyone...

Références

[1]https://cancer-rose.fr/en/2020/12/17/manipulation-of-information/

[2] https://cortecs.org/2016/05/

[3] https://mobile.francetvinfo.fr/sante/maladie/coronavirus/coronavirus-une-surmortalite-par-cancers-de-2-a-5-liee-a-la-premiere-vague-de-l-epidemie-de-covid-19-selon-une-etude_4110821.html

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. 

https://pubs.rsna.org/doi/10.1148/radiol.2021203935

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:

https://www.medscape.org/viewarticle/933105

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.

NEW BILINGUAL MEDIA LIBRARY

Cancer Rose, 31 March 2021

Cancer Rose launches new bilingual media library

Cancer Rose launches a new media library for general public and professionals who want to learn more about breast cancer and its screening, as well as about our activities on information and education. You will find it integrated in the menu, among the other categories of the website Cancer Rose.

The new design of our bilingual media library provides improved navigation to help our visitors find information easily.  Visitors can conveniently browse content, read and download all open-access documents, and view videos.

For general public, the media library offers posters, brochures, information videos, as well as an excerpt from Dr. Bernard Duperray's book "Dépistage du cancer du sein - la grande illusion".

For professionals, the media library offers the courses of Dr. Bernard Duperray, lecturer at the Faculty of Medicine Paris Descartes, within the inter-university diploma of breast pathology, as well as a library of clinical cases.

In addition, the media library provides access to Cancer Rose press releases and articles, as well as to presentations given at various events and conferences in France and abroad, since the Association was founded.

Links to Cancer Rose's social networks and the possibility of sharing any content you wish on your favourite social network are present at all times when you browse the media library.

Enjoy your visit on https://cancer-rose.fr/en/media-library/ !

Cancer Rose collective

Cancer Rose is a Non-Profit Organization under French law made up of independent Medical Doctors, a Doctor in Toxicology and a patient representative, with the goal of providing fair, transparent and objective information for women on mass screening for breast cancer, based on scientific evidence. Members of Cancer Rose have no sponsorships, honoraria, monetary support or conflict of interest from any commercial sources. They dedicate their time to this activity on a voluntary basis. The funds necessary for the functioning of this website and production of information materials (educational videos, brochures, posters) are generated by individual donations and members contributions.

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.

Pandemia and Screening – Short summary of what you’ve been told

March 16, 2021 C.Bour MD

October 2020

The anxiogenic communication of Pink October campaign tries to surf on the wave of anxiety caused by the epidemic, through oncologists, and now attempts to put emphasis on screening. The world of pink is worried, women who have long been manipulated, shamelessly incited, suddenly seem to be less enthusiastic to run and even less to run for screening.

Decryption here: https://cancer-rose.fr/en/2021/04/02/the-anguish-of-pink-advocates-in-the-face-of-declining-participation-in-screening/

November 2020

The pro-screening propaganda is intensifying in the middle of the Covid pandemic, however, with a privileged targeting of women: https://cancer-rose.fr/en/2021/04/02/screening-propaganda/

A study models an increase of cancers to be expected in the next years due to delays in cancer treatment, there is no mention of screening in this study, yet the media and opinion leaders make a false amalgam and present the delays in screening as main factor of an expected excess of mortality: https://cancer-rose.fr/en/2021/01/18/covid-19-pandemic-and-cancer-management/

February 2021

What if it would be the other way around? What if holding off on screening would be beneficial by reducing over-diagnosis and unnecessary treatment? What if we would study this?
A project is emerging: https://cancer-rose.fr/en/2021/02/26/drop-in-cancer-screening-during-covid-19-may-aid-research-on-overdiagnosis/

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.

Blind and Deaf

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

L’attribut alt de cette image est vide, son nom de fichier est aveugle-1-300x272.jpg.
Cliquer sur image pour version française/click on image for french version

Here this article translated

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But what about the real effectiveness of this screening?

The effectiveness of cancer screening is defined by : 

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

- a reduction in incidence of advanced cancers, 

- a lightening of treatments.

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

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

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

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

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

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

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

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

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

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

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

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

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

The citizen consultation on breast cancer screening by mammography in 2015

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

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

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

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


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

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

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

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

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

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

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

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

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

And since 2015?

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

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

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

What are the observations arising from these facts?

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

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

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

Several possibilities can be evoked. 

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

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

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

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

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

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

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

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

Conclusions

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

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

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

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

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

References

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

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

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

Recommendations :

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

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

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

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

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

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

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

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

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

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

The results of this 2015 study : 

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

- No reduction in breast cancer mortality. 

- No reduction in the number of advanced breast cancers. 

- No reduction in mastectomies.

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

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

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

The strong points :

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

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

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

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

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

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

Conclusions :

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

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

22% over-diagnosis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.


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Cancer and the frightening abyss of death

The tree that hides the forest

Annette Lexa, PhD Toxicology

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

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

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

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

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

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

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

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

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

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

The fear of the nothingness of death

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

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

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

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

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

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

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

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

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

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

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

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

Bibliography guide: 

Bertrand VERGELY , Entretien au bord de la mort , 2015

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


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

Mass screening for breast cancer disregards ethical values and fundamental principles of radiation protection system

By ANNETTE LEXA, Toxicologist PhD

OCTOBER 20, 2019

Mass screening for breast cancer is a technocratic monster inscribed in the law by ministerial order.

It is supposed to be based on the 9 pillars of public health policies. In its wording itself, it flouts the principle of knowledge [1] according to which objectives and actions must take into account the best available knowledge and, conversely, knowledge must meet the need for information to enlighten decisions. However, to date no study has confirmed the effectiveness of screening, based exclusively on the dogma "the earlier a cancer is detected, the better it is cured", which has not been validated in reality as mortality has not decreased since the system was introduced more than 25 years ago.

But it is even worse. The ministerial decree strongly encourages healthy women aged 50 and over to be regularly exposed to ionizing radiation from medical imaging (mammography and synthetic tomography).

The International Commission on Radiological Protection (ICRP) has established principles and values of radiation protection in order to protect populations and individuals [2]. These major principles and values are based on the regulatory use of the linear no-threshold model, which remains a conservative but contested basis [3] in view of recent discoveries in radiobiology. This probabilistic model is based on the dose-response relationship, which postulates that the number of radiation-induced cancers varies linearly with the dose received in an irreversible and cumulative manner and "without threshold" below which an exposure could be considered as having no effect.

Each ionizing particle passing through an organism has a certain probability of hitting the DNA; each impact causes a mutation that has a probability of moving to a stage leading to the initiation of cancerous proliferation. Therefore, overall probability of observing a cancer can only increase linearly with the dose received. Today we know that there is a fundamental inequality between individuals. Each individual has his or her own specific threshold of tolerance to ionizing radiation. Delivering the same dose to all while a non-negligible fraction (5 to 20%) of population has a risk of radiation-induced cancer 10 times higher than the norm is not acceptable. [4]

What are the currently recommended doses?

The recommended doses were enacted in 1991 by the International Commission on Radiological Protection (ICRP). They are valid for entire human population and do not take into account invidual susceptibilities. The commission estimates natural irradiation (radon, telluric, cosmic) at 2.5 mSv/year, average medical irradiation at 1.2 to 2 mSv/year and civil nuclear at 0.2 mSv/year.

Not everyone is equal because there are radon regions and others are not, with radon alone representing 1.2 mSv/year.

In addition, the consumption of medical imaging procedures is exploding with 70 million procedures in France per year (3), and, again for France, the annual dose received for medical diagnosis is 1 mSv/ inhabitant/year on average but can reach 20 mSv/year according to the Academy of Medicine itself, which does not hide its concern [5]. Women undergo more than men, due to the societal obsession with the breast, an accessible but sensitive organ. In the context of breast cancer screening, a woman who is not ill and is still young can also receive a much more radiant tomosynthesis exam, in a doctor's office without being warned of the risk involved. And many women are exposed from the age of 25-30 years by careless practitioners.

For the population, the dose is limited to 5 mSv per year, the maximum tolerable lifetime dose is 70 mSv.

However, doses received during medical imaging exams can lead to an excess of this limit, without taking into account individual susceptibility. For example, the monitoring of scoliosis in young girls in the past generated a dose of 0.11 Sv to the mammary gland.

Perez A-F, et al. Low radiation doses: towards a new reading of risk assessment? Bull Cancer (2015), http://dx.doi.org/10.1016/j.bulcan.2015.03.019

Mammography generates 2 x 2 mGy images spaced 3 minutes apart. Double-strand breaks (DSB) - a source of gene instability leading to the development of cancer - appear as early as 1mGy and the effect is significant around 100-300 mGy. Radiosusceptible individuals with delayed transit of the ATM repair protein simply cannot repair or poorly repair these DSBs in less than 3 minutes, and thus DSBs accumulate during mammography. The risk is all the higher the younger woman is, the more she is unaware of her radiosusceptibility status, and the more the examination is repeated every year or every 2 years. 6] (see the bibliography of Nicolas FORAY's work).

THREE MAIN PRINCIPLES OF THE RADIATION PROTECTION SYSTEM

- The rationale that states that any decision to subject a person to even the weakest possible source of ionizing radiation should do more good than harm. A sufficient benefit must be obtained to offset any costs or negative consequences. Ionizing radiation sources should not be used if there are other alternatives (e.g., no radiography if similar results are obtained with an ultrasound, it is up to physician and radiologist to make the trade-off between benefit and risk, the benefit a person receives from examination must outweigh radiological risk). Practitioners remain primarily responsible for justifying procedures they request or perform.

- The optimization of exposures to these radiations which must be at the lowest possible level;

- The limitation stating that individual exposures must not exceed dose limits recommended by the ICRP in order to avoid occurrence of stochastic (= random) effects. Each country defines regulatory limits based on ICRP recommendations.

ESSENTIAL ETHICAL VALUES UNDERLYING THE RADIATION PROTECTION SYSTEM (2) [7] [7]

Beneficence and non-maleficence 

Beneficence means doing good, and non-maleficence means not doing harm. These two related ethical values have a long history in moral philosophy, going back to the Hippocratic Oath, which requires a physician to do good and avoid harm. The use of radiation, although coupled with certain risks, can undoubtedly have desirable consequences, such as improved diagnosis and cancer therapy in medicine. But these must be weighed against harmful consequences. One of the main challenges in beneficence and non-maleficence is how to measure  benefits versus harm and risks involved. Moreover, such an assessment must be done in a transparent manner.

Prudence

Prudence is the ability to make informed and carefully considered choices in full knowledge of the implications and consequences of actions. It is also the ability to choose and act on what is in our power to do and not do.

Justice 

Justice is generally defined as fairness in distribution of advantages and disadvantages: fair compensation for losses (reparation), fairness of rules and procedures in decision-making processes. First, the principle of fairness in situations reflects personal circumstances in which individuals are involved. This is the role of regulatory dose limits, of compliance with protocols in order to reduce exposures in individuals subjected to the same radiation exposure (see the Toul irradiated persons case).

Inequality can also be seen as the inequity between the doses received by screened non-sick women, especially the youngest, compared to non-sick and unscreened women who are therefore less irradiated.

Dignity

Dignity is an attribute of human condition. It means that every individual deserves unconditional respect, regardless of age, gender, health, social status, ethnic origin, and/or religion. It is the principle of the Universal Declaration of Human Rights which states that all people are born free and equal in dignity and rights.

Personal autonomy is a corollary of human dignity: individuals have the capacity to act freely in order to be able to make informed decisions. This principle is found in "informed consent" in medicine, a principle that states that a person has the right to accept risk voluntarily and has an equal right not to accept it. This informed consent is of paramount importance when it comes to patients who are not seriously ill but are still young and healthy and who are being incited to be screened for cancer and the likelihood of  being affected is very low.

PROCEDURAL VALUES OF THE RADIATION PROTECTION SYSTEM

- Responsibility: individuals responsible for making decisions are accountable for their actions to all those who may be affected by these actions. In terms of governance, this means the obligation of individuals or organizations to account for their activities, to take responsibility and to be prepared to be accountable.

==> The sponsors of the MyPebs study, which aims to recruit women aged 40 and over to compare mass screening with a personalized form of screening, will be accountable in terms of radiation protection and will assume their responsibility when the time comes (and we will make sure they do).

- Transparency means "openness to decisions and activities that affect society, economy, and environment and willingness to communicate them clearly, precisely, quickly, honestly".

Transparency does not simply mean communication or consultation, it means accessibility to information about activities, deliberations and decisions involved and honesty with which this information is conveyed. This transparency implies that all relevant information is provided to persons concerned.

Thus, informed consent has been developed in the context of medical ethics. The prerequisites of informed consent include :

- information (which should be appropriate and sufficient)

- understanding

- volunteering (avoid undue influence)

- all of this associated with the right of refusal and withdrawal (without any prejudice such as the idea that had germinated in the sick brains of a few in the 90s, to withdraw the social rights of women who would not get screened).

For vulnerable people with limited or diminished abilities (people with disabilities, in prison, interned in psychiatric hospitals, etc.), for weak people under the influence of extorting or threatening doctors, for pregnant women, additional protection both in terms of consent and strict evaluation of the benefit/risk ratio is doubly necessary.

However, the 2006 Order [8] (7) went so far as to incite territorial officials to recruit, without information on the radio risk involved, women living in the Guyanese forest, handicapped, in prison, in order to increase the percentage of participation in mass screening for breast cancer, which is an obvious abuse of weakness.

==> By not communicating with women concerned in an honest and transparent manner about the radiation-induced risk and the intrinsic inequality of associated individual risk, mass screening for breast cancer does not respect this ethical value.

Worse, the My Pebs study (https://cancer-rose.fr/my-pebs/), funded by public money at the European level, does not respect this elementary ethical value, since it is to date impossible to freely dispose of the protocol and  women recruited are not informed of the radio-induced individual risk, all the more so as they are younger (inclusion planned from the age of 40).

-Inclusivity 

This is stakeholder participation, which involves all parties concerned in the decision-making processes related to radiation protection.

==> The 2016 citizens' consultation obviously did not respect this fundamental value of radiation protection.

CONCLUSION

By exposing women who are not ill, to ionizing radiation (mammography, tomosynthesis...), mass screening flouts the principles of justification, optimization and limitation of the radiation protection system as they currently exist, i.e. without taking into account individual inequality.

So obsessed with the promise of a fantasized benefit, screening has become blind to the inconsiderate risk it poses to non-ill women by subjecting them to unnecessary examinations, dangerous technologies (tomosynthesis) and without taking into account other possible doses received during the year.

Mass screening - and its uncontrolled extension to young women - flouts the fundamental ethical values of the radiation protection system, which are non-maleficence, prudence, justice (individual inequality in relation to radiation), transparency (lack of communication about individual risk) and inclusiveness in the participation processes.

The same is true of the My Pebs study, which intends to recruit 85,000 so-called "volunteer" women without informing them faithfully of the radiation risk involved, in defiance of the most elementary values of the radiation protection system.

  - But why so much malevolence and so little ethics, we can ask?

    - Because nature hates emptiness,

    - Because idea of doing nothing is unbearable in our mercantile society,

    - Because France hates the idea of citizens having  ability to act freely in order to make informed decisions,

    - Because  lure of gain ignores the principle of non-maleficence, prudence, dignity and equality regarding radio-induced risk.

    - Because there are lobbies (Europa Donna, etc.)

    - Because women have a propensity to subordinate themselves to medical authority from which they are struggling to emancipate themselves, and the market knows it.

Bibliography

[1] Plaidoyer pour l’abrogation de l’arrêté ministériel du 29 septembre 2006 encadrant le dépistage du cancer du sein , Annette LEXA, 2016.

[2] ICRP, 201X. Ethical foundations of the system of 37 radiological protection. ICRP Publication 1XX. Ann. ICRP XX(X), 1–XX.

http://www.icrp.org/docs/TG94%20Draft%20for%20Public%20Consultation%20(20April2017).pdf

[3] https://fr.wikipedia.org/wiki/Lin%C3%A9aire_sans_seuil

   - Argument in favor of the linear no-threshold model: Epidemiological studies have shown an increased risk of cancer at doses of 10 mGy. The carcinogenic effect of doses of the order of 10 mSv is proven in humans. From 10 mGy, the linear no-threshold relationship correctly reflects the dose-response relationship in the Hiroshima and Nagasaki cohort. At doses below 10 mSv, the irradiated cells are crossed by only one trajectory and the effect of each trajectory is an independent stochastic event. The nature of the lesions thus caused and the probability of repair and elimination of the damaged cells do not depend on the dose or the flow rate. The probability that an initiated cell will give rise to cancer is not influenced by lesions in neighboring cells or adjacent tissues.

- Some of the arguments in its favour have lost some of their value, in particular due to numerous results from radiobiology laboratories: Even if ionizations are independent, there may be group effects via cellular communication mechanisms; The efficiency of chromosomal damage repair is directly dependent on the dose rate, with the possibility of hypersensitivity to very low rate radiation; The development of cancer depends not only on an isolated cell but also on the surrounding tissues, which may contribute to its evasion of the immune system; The effects of one irradiation at a given time may depend on previous irradiations (adaptive response).

To these arguments against, we must now add individual susceptibility (genetic and epigenetic) leading a non-negligible part of the population (about 20%) to a risk of radio-induced cancer according to its own tolerance threshold, previously neglected in studies mixing radio-induced and spontaneous cancer with age.

[4] MODULE NATIONAL D'ENSEIGNEMENT DE RADIOPROTECTION DU DES DE RADIOLOGIE, Principes et mise en œuvre de la radioprotection, Drs J.F. Chateil, H. Ducou Le Pointe et D. Sirinelli, 2010. http://www.sfrnet.org/data/upload/files/10_objectifs_et_principes.pdf

[5] De l’usage des Rayons X en radiologie (diagnostique et interventionnelle), à l’exclusion de la radiothérapie. Rapport et recommandations. Dubousset J., Académie Nationale de Médecine, 2016. http://www.academie-medecine.fr/de-lusage-des-rayons-x-en-radiologie-diagnostique-et-interventionnelle-a-lexclusion-de-la-radiotherapie-rapport-et-recommandations/

[6] https://cancer-rose.fr/en/2020/12/29/predictive-test-for-radiotherapy-reactions-women-at-high-risk/

[7] https://cancer-rose.fr/en/2020/12/15/radiotoxicity-and-breast-cancer-screening-caution-caution-caution/

[8] Arrêté du 29 septembre 2006 relatif aux programmes de dépistage des cancers

https://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000000460656

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.


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

April 23, 2020

Randomized clinical trial by "cluster" (cluster)

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2764100

 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: https://cancer-rose.fr/en/2020/12/18/perception-and-reality-2/

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.

References

[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

https://www.ncbi.nlm.nih.gov/pubmed/14559757

[2] https://www.nejm.org/doi/10.1056/NEJMp1401875

[3] https://boris.unibe.ch/51602/7/Biller-Andorno%20NEnglJMed%202014.pdf

[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/

[5] 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/

[6] https://cancer-rose.fr/2020/03/14/recommandations-pour-une-prise-de-decision-partagee-avec-le-patient/

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

[8] https://cancer-rose.fr/2019/05/02/lettre-au-conseil-national-de-lordre-des-medecins-concernant-la-campagne-du-cngof/

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