November 27, C.Bour MD

Angiomammography is a recent technology that is not useful for screening but in diagnosing lesions and for particular indications.

We're talking about it because it's a technique you've probably heard of, and the French Health Authority recently examined it.

What is angiomammography?

This procedure combines mammography with the injection of a contrast agent to analyze contrasting lesions. It is possible to differentiate benign from malignant tumors based on the tumor's vascular behavior, specifically the emergence and subsequent fading of the vascular enhancement.

Dual-energy approach

After injecting the contrast agent into the patient, mammography is conducted with two incidences (one frontal and one oblique per breast) in two acquisitions, one low and one high energy, as is usual.

The glandular tissue and fat can be separated by recombining the images produced with these two acquisitions, leaving just the contrast of the lesions of interest apparent on the recombined images.

The end result is a type of mapping that allows for visualizing highly vascularized lesions such as cancers.

However, the dose delivered to the gland is higher due to the repetition of the acquisitions, once at low and once at high energy. The additional irradiation is approximately 1.2 times the usual dose for each image.

Why no indication in screening for women at high risk of breast cancer?

This technology is more irradiating than conventional mammography; MRI appears to be more suited because we usually want to limit irradiation in this at-risk population, for whom ionizing radiation is a potential factor in cancer induction.

What is the advantage of this technique compared to MRI?

It is quick to perform. Because the same incidences are used, it is simple to analyze the images and compare them to earlier mammograms (faces, obliques).

It is, however, irradiating and is not recommended for women who are at high risk of cancer. There is always the potential of allergy to the injected contrast products, even if it is low.

HAS (French Health Authority) recommendations

Angiomammography could be used in the following situations:

• diagnostic impasses, to confirm the presence of a suspicious lesion or to rule out the presence of a lesion, although with necessary follow-up;
• when contrast imaging is required:
  - locoregional extension assessment (tumor size and search for additional lesions);
  - evaluation of response to neoadjuvant chemotherapy;
  - tumor evaluation before neoadjuvant chemotherapy, but experts noted that breast MRI is currently the reference examination in this indication.

Two situations to be considered:

Angiomammography is recommended in the following situations where MRI is contraindicated:

• diagnostic impasses;
• locoregional extension assessment of cancer;
• tumor evaluation before and after neoadjuvant chemotherapy.

In the absence of contraindications to MRI, angiomammography is recommended

• In assessing locoregional extension or before/after neoadjuvant chemotherapy, for evaluating the tumor size, particularly for its perfect correspondence with the mammography images.

According to HAS, a quality control policy should be implemented to ensure optimal doses are always used and that the facilities are monitored.
More robust performance studies and meta-analyses are needed to confirm the diagnostic efficacy of angiomammography.

The HAS recommends conducting clinical research studies to confirm diagnostic performance data, to demonstrate the clinical usefulness of angiomammography, define its role in the diagnostic strategy, and determine its impact on therapeutic management (number of biopsies, the relevance of the surgical decision, rate of reinterventions, etc.).

. 

References

https://www.edimark.fr/Front/frontpost/getfiles/24426.pdfhttps://www.has-sante.fr/jcms/p_3186760/fr/interet-de-l-angiomammographie-double-energie-dans-la-strategie-diagnostique-du-cancer-du-sein-rapport-d-evaluation

Summary Dr. Cécile Bour, November 15, 2021

About an article published on October 15 in The New York Times by Holly Burns, a San Francisco area writer who was diagnosed with breast cancer 4 years ago.

Holly Burns shares her experience, which is similar to that of other cancer "survivors," and which remains poorly expressed during the annual Pink October: "October is National Breast Cancer Awareness Month and I am a person who’s had breast cancer, which means for me October is basically 31 days of low-key PTSD.”

Pink October as a trigger for an "anniversary reaction"

Kathleen Ashton, a psychologist at the Cleveland Clinic Breast Center in Ohio, also testifies in the article, "Some do enjoy the opportunity to raise awareness, but the majority of my patients find the month distressing."

For some patients and former patients, the month of Pink October acts as a red flag that is waved and brings everything to the surface, with the procession of trauma that has often accompanied the patient's journey, from the announcement to the treatment.

Deborah Serani, a psychologist and professor at Adelphi University in New York, explains that anxiety at a particular time may be triggered because of a phenomenon known as the "anniversary effect" or "anniversary reaction," a unique set of thoughts or feelings that arise around the anniversary of a significantly traumatic experience.

Thus, explains the psychologist, anything that reminds us of the traumatic event experienced can provoke this "anniversary reaction".

A gap between marketing and real life

This month can be particularly difficult for those whose cancer is progressive and has progressed. "It can feel like only the happy stories are presented," testifies a 40-year-old woman, Emma Fisher, with stage 4 metastatic breast cancer.

"It's hard to see campaigns where "everyone is laughing and smiling and having bake sales and doing fun runs," she says. "It makes me feel invisible, it's almost like metastatic patients are this dirty little secret in the breast cancer world, because nobody wants to portray breast cancer as a killer."

In the book IM-PATIENTE, Maëlle, the young woman with advanced cancer who testifies, says something similar: "the hospital is decorated in pink for a month, all the nice grannies knit their little pink squares, and we make a pretty ribbon around the hospital, well, okay. Sure. But during Pink October, what stories are we talking about? We always tell the same stories. We talk about these warriors who started their enterprise while undergoing chemo and who have three children after their surgery.
It's always the same story. Have we ever heard during Pink October about women having metastatic cancer? I don't think so. Because it's not pretty, it's not glamorous, we don't talk about it. that's unacceptable." (June 2018)

Bri Majsiak, co-founder of a non-profit organization for people affected by breast and gynecological cancers, says, "Breast cancer lasts 365 days a year, not 31."

How do you get through the month of October with peace of mind?

Psychologist Dr. Ashton (Cleveland Clinic Breast Center in Ohio) advises women affected by breast cancer to limit exposure to things they might experience as upsetting, which can mean taking a break from social media, unsubscribing from as many marketing emails as you can, not being afraid to set boundaries with loved ones who don't understand why ex-patients and patients might find this month very painful to live with, or sharing with other women who may be feeling the same way.

While friends and family may assume this is a month of celebration for survivors, they "need to understand that a serious personal illness like breast cancer is a traumatic experience," Dr. Serani said.

A Charleston psychotherapist, Ms. Ilderton, also advises against making the survivor you know a 'case study,' she whose friend emailed a group using her as an example of why a mammogram was a must.

Bri Masiak advises that for those who wish to support Pink October, they should look carefully at where the proceeds go and consider whether it would be better to donate to a more focused local organization, or one that is helpful to women during their treatment, for example.

Indeed, the destiny of the funds collected is often very opaque, the marketing budget can represent an important part, and the part really devoted "to the cause" is not known by the donors. The stated purpose of the fundraising is often "research".

But....what research? Do we wonder which studies have really been financed, what are the results, what are the concrete advances for women while we have been running for decades and yet breast cancer still kills, and this since the 90s, 11,000 to 12,000 women/year? This leaves us wondering about the real impact of these costly campaigns.

Conclusion

During this great annual pink barnum, not very useful and in reality not very informative for women, we should at least be aware that it can be a vector of distress and painful memories for some of us.

We hope that future Octobers will be less pink, more discreet and less festive, more educational and more interactive with all women, the healthy ones, the survivors and the heavily affected ones, for a better information on breast cancer, in a neutral and objective way.

15th of October, 2021 

https://www.e-cancer.fr/Expertises-et-publications/Catalogue-des-publications/DEPLIANT-Depistage-des-cancers-du-sein.-Guide-pratique

In June 2021, the French National Cancer Institute (INCa) issued a new leaflet, in addition to the brochure published in 2017, sent to women one time for their first screening appointment at the age of 50. This new leaflet will be distributed to all women for the following appointments, beginning at the age of 52. 

here: PDF of the leaflet

 REMINDER: 

1) The 2015 citizen and scientific consultation [1] allowed for the expression of two scenarios: "Scenario 1: Termination of the organized screening program..."; "Scenario 2: Discontinuation of organized screening as it exists today [2],..." and the claim for women concerned by breast cancer screening to have "balanced and complete information." [3]

2) It took two years for the French National Cancer Institute to publish in 2017 a very insufficient brochure [4], barely mentioning the harms of screening (pain during the examination, overdiagnosis, etc.) but not detailing them, focusing mainly on the very meager benefits, which are advantageously put forward.

3) In an international study, INCa's lack of objective information and manipulative nature were questioned [5], as was already the case for the citizen and scientific consultation report.

Today, six years after the citizen consultation, INCa persists and signs.

The proof is this new leaflet, which will be included in future biennial invitations sent to women aged 52 and over.

Analysis

The poor informative content of this leaflet allows a rapid analysis: NONE of the adverse effects of screening are mentioned. 

Instead, it states:

"This early detection increases the chances of a cure: it allows 99 out of 100 women to be alive 5 years after diagnosis."

CAUTION: Being alive 5 years after a diagnosis does not imply that you have been "cured." 
What about this generously promoted survival? 
First and foremost, it would be more accurate to present the 5-year survival rates of 100 women who were screened and 100 who were not screened.

Here's an insightful article that explains what survival means and why it isn't a reliable indicator of screening effectiveness https://formindep.fr/cancer-des-chiffres-et-des-hommes/

This is what survival means:

 "Survival" measures the length of time the cancer is present or the length of time a patient lives with cancer, but it does not measure the longevity or life expectancy. 
Screening creates an optical illusion by anticipating the date of cancer onset by detecting it before any symptoms appear. While the result is the same, i.e., death regardless of the time of diagnosis, this creates the impression that the patient's life is being prolonged. In reality, screening does not affect t women's longevity; it simply shifts the "window of observation" in the disease's history.

A diagram from the WHO screening guide, page 47, illustrates this lead-time bias [6] :

Or in this diagram: [7]

"Lead-time bias occurs when screening finds cancer earlier than that cancer would have been diagnosed because of symptoms, but the earlier diagnosis does nothing to change the course of the disease" (National Institute of Cancer (NIH) USA).

To illustrate the situation differently, let's use an analogy: a train heading for Paris derails in Orleans at 3 p.m., causing the death of all passengers. If I boarded at Tours, I would have a survival of 30 minutes; if I boarded at Bordeaux, I would survive 2 hours. Artificially, we can say that people who boarded at Bordeaux have longer survival than those who boarded at Tours, even though they did the same thing: boarding the train at a given moment.

Thus, the extension of survival is the result of two phenomena: the efficacy of treatments that would extend the life of a cancer patient and the anticipation and detection of several lesions that would not have caused the death anyway. Nonetheless, not all over-diagnosed women die! As a result, there is an illusion of success in the case of breast cancer because we are diagnosing numerous lesions that would never have caused the death...

"Survival" is a poor indicator because it is used to describe something that it cannot: the effectiveness of screening.

The only indicators of the effectiveness of screening are the decrease in mortality and the reduction of advanced cancers. However, it is not enough to say: "THE EARLIER A BREAST CANCER IS SCREENED, THE GREATER THE CHANCES OF CURE," it is necessary to prove with data and the INCa, carefully omits this point in the leaflet...

Why is this leaflet outrageously dishonest and unethical?

1. Again, French women are not receiving the critical neutral information to which women in other countries are entitled. This is a serious breach of ethics.  Women citizens were indeed asking for easy-to-understand decision aids (pictograms). [8]

2. The information on the risks of screening is not directly available. The word "risk" is never even mentioned, which is a deceitful way to make this information as inaccessible as possible.

Indeed, we can read on one of the leaflet's pages, "To learn more, talk to your doctor or go to "cancersdusein.e-cancer.fr." 

If the woman invited to the screening wants to know the unfavorable effects, she must go to this website [9] and look for the section(s) dealing with these adverse effects herself. 

Overdiagnosis is never mentioned as a title on this website's home page; the risks of screening can be found by clicking on the inserts "the benefits and limits of screening" and "breast cancer screening, risk 0 or not?"

The word "limits" is misleading and not appropriate. In its French version of the guide, the WHO uses the term "effets nocifs" (in English: harms) of screening, which weighs against the benefits. [10]. 

For a woman to say that screening has limitations means that screening is not completely effective and that there are probably cancers that are missed. But this term does not imply that screening has risks.

3. Addressing citizens' requests does not mean that INCa can disseminate deliberately truncated, false, misleading, and incomplete information, embellishing the benefits and concealing the risks at the same time as the letter of invitation. This is yet another example of disregard for women who will never have access to the truthful information to which they are entitled.

4. This process, which is repeated every two years, is, of course, a strong incentive because of its repetition.

5. The initial brochure was incomplete and has not been modified since 2018 despite its shortcomings [4]. But at least it addressed the possibility of overdiagnosis. The 2017 brochure is aimed at women aged 50 who are invited to perform breast cancer screening for the first time. It is only sent for the first screening, so women who turned 50 before 2017, now aged 55 or older, have never received it and will have to rely on this misleading and incomplete leaflet issued in 2021.

6. This new leaflet is supposedly "based" on the 2017 brochure, misleading, as overdiagnosis is never mentioned.

7. The new leaflet says: "to know more, talk to your doctor or go to the website...". The general practitioner can certainly be contacted, but in reality, the woman makes an appointment directly with the radiology office, mainly because the information in the leaflet focuses all its communication on the benefits of screening, leaving the practitioner no opportunity to properly inform the patients before they go for mammography screening. In any case, what question would a woman ask her practitioner since the notion of "risk" does not appear anywhere in the brochure?

8. In the "key information" section, it is stated that mammography is "reliable." This information is again misleading since mammography exposes women to false positives (suspected cancers that are not confirmed) and false negatives (cancers that are hidden or develop between two mammograms and are, therefore, "missed" by screening).

Why is INCa so consistent in providing promotional information about mammography breast cancer screening? 

Why has INCa's biased promotional communication remained unchanged over the years? This is a question that everyone should ask.

Since the introduction of organized screening for breast cancer in 2004, scientific knowledge about mammography screening has advanced, but INCa's "communication" has not changed. INCa still presents screening as very beneficial to women, as it does in this leaflet, without mentioning what is debated in France and worldwide. The major benefit is still asserted even though it is increasingly being questioned.

Furthermore, many risks have been updated, but this brochure does not even use "risk," implying that they do not exist. The INCa replaces the term "risk" with "limit," which is never used in the scientific literature on the subject.

Why is this mode of communication being used? 

For all of its years, INCa has focused its communication on promoting breast cancer screening by mammography. This communication is very different from what is done in other countries. [8]

INCa's goal is not to correctly inform women about organized breast cancer screening by mammography but to intensify it to "win the European competition." And this is done blatantly, disregarding scientific knowledge on the subject. 

As proof: in its detailed report "Ten-year strategy 2021/2030 to fight cancer," we read INCa objectives on p20, "Achieve one million more screenings by 2025. It is up to us to exceed the coverage targets recommended at the European level in terms of screening and to join the leading group in terms of adherence (70% for the Organized Breast Cancer Screening ......., ". [11] 

The INCa appears to be only following orders from the authorities. On the other hand, citizens have the right to expect objective information from such a health authority rather than "propaganda." 

Why is it critical for citizens to have access to information that INCa does not provide?

INCa's role was defined at the time of its creation (article L1415-2 of the Public Health Code); it was given two contradictory missions: to inform (paragraph 3) and to promote screening (paragraph 6). 

"Informing" means providing unbiased information about the benefits and disadvantages of a public health system. "Promoting" means ensuring that the public is effectively influenced to adhere to it, which contradicts neutral information because it tends to conceal anything that dissuades people.

As a result, there is an irreconcilable incompatibility between these two missions, as well as a clear conflict of interest when, as with this unworthy leaflet, INCa can congratulate itself for responding to citizens' requests for information while ensuring that this information remains outrageously biased.

This is precisely what the INCa is doing with this brochure, which is akin to infantilizing women by maintaining them in ignorance, assuming their inability to make an independent choice.

According to a French publication, in order to increase screening participation, women who are called upon to undergo it should not be given information.[12]

Given this situation, doctors and patients will have to adapt and seek the information necessary for everyone to make informed decisions outside the communication of the French health authorities.

Example of a brochure

It is not surprising that this manipulative information comes from an institute that does not hesitate to label the scientific debate on screening as "Infox" or "Fake news." [13]

Our Cancer Rose collective began delivering more balanced information in a leaflet several years ago without any financial outlay. It is in A5 format, downloadable and foldable, and is intended for women and doctors to distribute to patients at the end of their consultation.

Our collective will make a point of informing the leaders of the INCa's International Scientific Council. We will notify international actors and groups fighting in many countries for women to be recognized as intelligent beings deserving of information to ensure their choices and autonomy in health matters within the framework of informed consent.

References

---

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

[2] page 132-133 du rapport https://cancer-rose.fr/wp-content/uploads/2019/07/depistage-cancer-sein-rapport-concertation-sept-2016.pdf

Two scenarios proposed, both contain the words "stopping screening".

[3] page 128 du rapport https://cancer-rose.fr/wp-content/uploads/2019/07/depistage-cancer-sein-rapport-concertation-sept-2016.pdf

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

[5] https://cancer-rose.fr/en/2021/04/20/methods-of-influencing-the-public-to-attend-screenings/

[6] https://apps.who.int/iris/handle/10665/330852?locale-attribute=en&

[7] https://www.cancer.gov/about-cancer/screening/research/what-screening-statistics-mean 

[8] https://cancer-rose.fr/en/2021/06/28/other-information-tools/

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

[10] https://apps.who.int/iris/handle/10665/330852

[11] https://solidarites-sante.gouv.fr/IMG/pdf/feuille_de_route_-_strategie_decennale_de_lutte_contre_les_cancers.pdf

[12] https://cancer-rose.fr/en/2021/01/24/objective-information-and-less-acceptance-of-screening-by-women/

[13] https://cancer-rose.fr/en/2021/07/13/the-national-institute-of-cancer-in-france-inca-relegates-the-question-of-the-benefit-risk-of-organized-breast-cancer-screening-to-the-fake-news-rubric/

October 2, 2021, Dr. C. Bour

BMJ 2021 ; 374 doi : https://doi.org/10.1136/bmj.n2049 (Publié le 27 septembre 2021)
https://www.bmj.com/content/374/bmj.n2049

Authors:

Fabienne G Ropers, consultant, Department of General Paediatrics, Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands Alexandra Barratt, professor, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia

Timothy J Wilt, professor, Minneapolis VA Center for Care Delivery and Outcomes Research and the University of Minnesota, Minneapolis, MN, USA

Stuart G Nicholls, researcher, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada

Sian Taylor-Phillips, professor, Warwick Medical School, Coventry, UK

Barnett S Kramer, consultant, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA

Laura J Esserman, professor, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA

Susan L Norris, doctor, Oregon Health and Science University, Portland, OR, USA

Lorna M Gibson, consultant, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK

Russell P Harris, emeritus professor, School of Medicine, University of North Carolina at Chapel Hill, NC, USA

Stacy M Carter, director, Australian Centre for Health Engagement, Evidence and Values, University of Wollongong, Wollongong, NSW, Australia Gemma Jacklyn, consultant, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia

Karsten Juhl Jørgensen, chief physician, Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark 

According to the authors (researchers, medical professors, physicians, etc.), new circumstances that differ from the initial context in which screening programs were implemented may alter the benefit and risk profile of screening programmes

From the early beginnings of screening, intended to detect disease or risk factors before symptoms appeared, there is evidence that screening delivers health benefits but also harms and costs. It is important to note that these outcomes are not constants: they change with new evidence, vary between contexts, and over time.

Screening practices (whether organised as programmes or not) tend to be slow to react to these changes; alterations are often resisted and controversial.

According to the authors, reasons for resistance to change in established and entrenched programs include both financial interests (of individuals, groups, or lobbies with a vested interest in continued screening), attention to sunk costs,[1] and lack of evidence of high certainty or proper evaluation of existing evidence. But there is also a problematic belief that early detection is always better, and simply inertia or preference for the status quo. 

Screening programmes are often financed within finite collective healthcare budgets. They target asymptomatic people, most of whom are not those who need healthcare most. 

Therefore, continuing screening in the face of changing circumstances deserves careful consideration, as it potentially leads to harm to healthy citizens and wastes scarce resources.

While there are well-established principles for starting screening, none exist for stopping it.

As experts who have worked on screening over many years, the authors see an urgent need for clear, agreed methods for actively re-evaluating existing practices.

Why screening practices need re-evaluation

The value of screening may be changed by several factors, including changes in disease incidence, advances in diagnosis and treatment, evidence from ongoing programmes, and preventive possibilities.

For example, in some cases, so-called primary prevention, i.e., prevention before the disease occurs, may decrease disease incidence and thus the absolute benefit from screening.

New data showing that therapeutic advances contribute more than screening to the reduction of mortality by the disease are, of course, essential.

In the context of breast cancer

This article is, of course, "up to date" at the dawn of the pink October wave. Since the year 2000, early whistleblowers, epidemiologists, for the most part, have been warning about the harmful effects of breast cancer screening, of which it is imperative to inform women.

According to several reviews, the adverse effects prevail when the harmful effects attributable to screening and overtreatment are included in calculating mortality and morbidity[2].

In all cases, and according to independent evaluations, the benefit of screening is always minimal compared to the added harms it exposes. As a result, several countries have decided to inform women through decision support tools [3]. At the same time, the French communication relentlessly continues its promotion in the media with untruths, as in the magazine Dr. Good where we also learn that mammography delivers UV [4]...

Or in the show 'Envoyé Spécial' where "awareness" of screening seems to be a major concern rather than objective information.

John Horgan, an American science journalist, wrote an excellent summary of the enormous gap between reality and the almost industrial promotion of screenings and certain treatments based on distortions of scientific data.[5]

We are now well aware of the problems of over-diagnosis[6] and over-treatment that screening at any cost leads to, in the face of a non-significant reduction in mortality[7], particularly for breast cancer. It is becoming urgent to consider this modern knowledge when questioning the relevance of low-contribution screening such as that for breast cancer.

Reactions to BMJ article

1° Reaction of Pr.M.Baum

Michael Baum

Professor emeritus of surgery and visiting professor of medical humanities UCL-London

He comments:

"Their mantra, "catch it early and save a life" has led to the wastage of huge human and technical resources, delayed the introduction of more valuable public health initiatives, and harmed countless asymptomatic individuals by over-diagnosis and over-treatment. As the ultimate reductio ad absurdum, there has been a very high profile of a screening programme using liquid biopsies to identify 30 different cancers in the last week. (see this link; https://www.annalsofoncology.org/article/S0923-7534(21)02046-9/fulltext ). It reaches the point of farce when they claim the highest sensitivity for metastatic cancers with unknown primaries. I hate to think how much damage was done to the patient in the frantic research for the primary. I would humbly suggest that the first agenda item for this new committee would be to nip this in the bud."

We talked about liquid biopsies, which quickly showed their limits in terms of screening. Indeed, finding a circulating cell does not make the individual a cancerous person in the future. What will we do with all these "findings" in people who complain of nothing and who will have to undergo heavy and repetitive complementary explorations to find something or nothing at all one day hypothetically? [8]

If applied to cancer screening in an asymptomatic population, these circulating tumor DNA tests will have the same problems of sensitivity and specificity as traditional biomarkers, in addition to their high cost and complexity.

2. Reaction of Dr. Shyan Goh

Orthopaedic Surgeon-Sydney, Australia

Dr. Goh cites the WHO document, a guide on screening programs that we also present in our webpages [9], which can be downloaded in French for interested readers [10].

This paper on population-based screening, Dr. Goh explains, is full of examples of how a screening idea does not necessarily work the same way in an international setting.
One important premise of population-based screening is that "the benefits of screening outweigh the potential harms."

The question here is, says the author, what are the "potential harms" of screening?

Many clinicians advocate various screening programmes based on the focus upon potential harms caused by the disease being screened, often in the form of mortality rates from the disease.

Others and much of the public looked at overall mortality and morbidities of the screening programme, including deaths from the diseases as well as of other causes including complications of screening (e.g., biopsy for mammography screening in case of false alarm, Editor's note)

Conclusion

We conclude with Dr. Goh's pertinent question: which viewpoint is more important, that of the clinicians focused on the search for more and more cases, or that of the public more interested in overall mortality and morbidity, the one that also captures the harms of screening?

In 2021, after several decades of errors and controversies, the current data no longer show the superiority of the breast cancer screening program.

When, but when, and after how many infantilizing pink campaigns will the public authorities and health authorities finally find the courage, with the support of the media, to inform women?

References

[1] In behavioral economics, sunk costs are costs that have already been paid definitively; they are neither refundable nor recoverable in any other way.

[2] https://cancer-rose.fr/en/2020/12/29/excess-mortality-due-to-treatment-outweighs-the-benefit-of-breast-cancer-screening-synthesis-of-several-studies/

[3] https://cancer-rose.fr/en/2021/06/28/other-information-tools/

[4] http://link.mag.nl.drgoodletter.com/m/view/200101/501233/kztFMyVWSJxvreVukpVatg==

Interview with Dr. Pierre-Yves Pierga "Finally, regarding exposure to UV rays, if we add up all the mammograms performed in a lifetime as part of the screening, it represents less than a CT scan. So the exposure remains reduced."

We have pointed out the error to the editors; it is indeed X-rays.

[5] https://cancer-rose.fr/en/2020/12/14/the-cancer-business/

[6] https://cancer-rose.fr/en/2020/11/30/what-is-overdiagnosis/

[7] https://cancer-rose.fr/en/2020/11/30/what-is-an-effective-screening/

[8] https://cancer-rose.fr/en/2021/04/22/media-coverage-of-screenings/

[9] https://cancer-rose.fr/en/2021/06/28/other-information-tools/

The WHO guide is the third decision support tool in the article, from the top[10]https://www.euro.who.int/en/publications/abstracts/screening-programmes-a-short-guide.-increase-effectiveness,-maximize-benefits-and-minimize-harm-2020

Analysis by

Sophie, referent patient,
Dr. M.Gourmelon,
Dr. C.Bour

September 2, 2021

We may be witnessing a shift in certain countries and the World Health Organization's standpoint on breast cancer screening campaigns. The example is given by Ukraine, which opts, with the help of the WHO, for an "early diagnosis" programme for breast cancer control plan rather than classical screening.

This more cost-effective policy is discussed in the following article “Better than screening: with WHO’s help Ukraine chose a cost-efficient policy to prevent breast cancer” https://www.euro.who.int/en/countries/ukraine/news/news/2021/3/better-than-screening-with-whos-help-ukraine-chose-a-cost-efficient-policy-to-prevent-breast-cancer

According to the WHO: « Given the major improvements in breast cancer treatment in the past decades, in cases when breast cancer is diagnosed at early palpable stage, the rates of secure cure are very high.”

Thus, an early and rapid diagnosis procedure for women with symptoms would be preferred rather than a mass screening that would indiscriminately target the entire healthy women population [1].

According to the WHO, this is an "inspiring story" about searching for the best way of fighting breast cancer. The WHO recognizes the effectiveness of this new approach and suggests taking it as an example as it will save thousands of lives and millions of euros in loans in Ukraine.

The concept of "early diagnosis”

But what does this "early diagnosis", put forward by the WHO, mean?

Early diagnosis is based on the rapid identification of cancer in patients who present symptoms of the disease to offer them a complete and rapid diagnostic follow-up.
In low-resource countries such as Ukraine, the problem is that symptomatic women, who already have a breast cancer symptom and do not seek medical attention early enough, present too late for care.
France was ready to lend Ukraine $24 million to equip it with mammography equipment for a screening program. Still, with WHO support, Ukraine chose a less expensive and more prudent strategy, claiming that the country already had enough mammography equipment to launch an effective early breast cancer diagnosis program.

A detailed explanation of this concept is given in the following document: https://apps.who.int/iris/bitstream/handle/10665/254500/9789241511940-eng.pdf?sequence=1, starting on page 8.

To summarize, the two procedures that are being weighed up here are as follows:

- early diagnosis, only for patients with symptoms  

- systematic screening: applied to the entire healthy population

According to the document:

“After consultation with WHO/Europe experts, Ukraine’s authorities became interested in another WHO-recommended cancer prevention strategy – the early diagnosis programme. It is based on the rapid identification of cancer in patients who have symptoms of the disease and rapid full diagnosis follow-up. Given the major improvements in breast cancer treatment in the past decades, in cases when breast cancer is diagnosed at early palpable stage, the rates of secure cure are very high.”

“In comparison to mammography screening programme, centralization of advanced centers providing high-quality early diagnosis of breast cancer is more efficient, economical and sustainable in a setting with limited resources,” said Dr Olga Trusova, a leading Belarusian mammography expert who took part in the BELMED project aimed at implementation of breast cancer screening in Belarus. BELMED was funded by the EU and implemented by WHO/Europe and IARC since 2016.

These quotes are meaningful because they implicitly acknowledge that screening:

1. carries risks that are inflicted on healthy populations,

2. has not been as successful as expected,

3. is very costly compared to the expected population benefits, and

4. once a disease is treated with significant efficacy in symptomatic forms, screening becomes obsolete. This is precisely one of the observations made by P. Autier, professor of epidemiology at IPRI: the ability to reduce breast cancer mortality attributable to treatment makes the ability to screen even more negligible and non-existent, and more women would have to be screened to achieve the number of deaths avoided that would be truly attributable to screening, with all the concomitant over-diagnosis and false alarms.
https://cancer-rose.fr/en/2020/12/17/mammography-screening-a-major-issue-in-medicine/
The more effective the treatments, the less likely screening will be useful.

Screening would be limited to cancers for which it appears to be effective, such as cervical cancer. “Early detection" seems to be a less expensive option with less negative impact for certain cancers, such as breast cancer. Early detection is effective for cancers that can be identified in early stages and cured with immediate treatment; this is true for breast cancer.

The WHO technical consultation on screening

To understand this shift toward a more measured and reasoned approach, we must go back a bit to the time of the WHO's technical consultation on screening for countries in the European region, which was held in Copenhagen in 2019:

https://www.euro.who.int/__data/assets/pdf_file/0017/408005/WHO-European-Technical-Consultation-on-Screening.pdf

The goal of this consultation, namely to limit the harmful effects of screening on the population, inconveniences that are frequently ignored and underestimated by the population, is clearly stated from the start:

“In recent years, countries in the WHO European Region have been introducing new screening programmes for conditions and health checks along the life-course. However, policy-makers, health professionals, and the public are not adequately aware of the potential harms of screening as well as the costs and requirements of implementing an effective screening programme. With this in mind, the WHO Regional Office for Europe held a Technical Consultation inCopenhagen on 26–27 February 2019 aimed at clarifying the harms and benefits of screening in the light of recent scientific evidence and countries’ experience. This Consultation constituted the first step in an initiative by the Regional Office to improve policy decision-making for screening. It was attended by 55 experts from 16 countries, including academics and observers from nongovernmental organizations.”

At the end of 2020, the WHO published the screening guide; concerning breast cancer in particular (page 38), the guide points out the harmful issues of screening (overdiagnosis and false alarms) and emphasizes informed information, an intangible ethical principle, before inciting populations to screening.
https://www.euro.who.int/fr/publications/abstracts/screening-programmes-a-short-guide.-increase-effectiveness,-maximize-benefits-and-minimize-harm-2020

In this logic, the WHO titles in March 2021:
“Better than screening: with WHO’s help Ukraine chose a cost-efficient policy to prevent breast cancer.”

Early diagnosis, why not in France?

Often the question is asked: "But what to do instead of the current screening?"

It is now recognized that mass screening causes more harms than benefits, it does not reduce mortality substantially and induces many overdiagnoses with their consequences of over-treatment, and leads to unnecessary illness. Although very much in favour of screening, the Marmot report alleges 3 overdiagnoses for a life lengthened by screening [2]. The Cochrane review mentions 10 overdiagnoses for one life saved [3].

In France, we have a sufficient number of mammography machines to be able to adopt this policy of early diagnosis, which is more respectful of women, while at the same time providing them with correct and neutral information on breast cancer and the means to fight it, as called for by the public consultation.

But, in practice, this is what we already know! In our country, women are generally vigilant about the health of their breasts; screened or not, women are made aware of breast cancer by the media and the medical profession, and they have the reflex to consult without delay when they perceive abnormal symptoms. Our health care system has vast economic and human resources and does not have the problems of under-resourcing that Ukraine and other European countries have. A symptomatic woman here receives prompt care and has all chances to be correctly treated and followed up.

Early diagnosis instead of costly mass screening procedures: an "inspiring story," says the WHO, an effective tool in the fight against cancer, allowing health resources to be allocated more appropriately.

So, instead of blindly and indiscriminately urging women to undergo routine screening in disregard of balanced information, a screening that is more likely to expose them to an unnecessary disease than to save lives, why don't we make this inspiring story our own?

Is there a necessity for mistrust?

« The early diagnosis approach for breast cancer was recognized as more appropriate for Ukraine than mammography screening. It is less resource-intensive and allows Ukrainian health system to better prepare for future screening measures if needed.”

This line from the first document we mentioned at the start of the post makes us wonder...

We must ensure that the concept of "early diagnosis" is not misused and that it does not serve as a "foot in the door" for pro-heavy imaging and pro-testing lobbies to rush into larger ambitions and to deploy insatiable appetites toward more and more medicine, directed at more and more individuals, many of whom would not have needed it and will not benefit from it.

References

[1] As a reminder, a basic notion of knowing the difference between screening mammography and diagnostic mammography:

Screening mammography is the routine mammography that women are asked to have every two years from the age of 50, even in the absence of any symptoms.

Diagnostic mammography is the one that is motivated by the appearance of a sign, a symptom in the breast (swelling, retraction, deformation, etc.). This symptom then requires a mammography exploration to identify and diagnose the problem in the breast.

[2] Marmot M.G., et al. The benefits and harms of breast cancer screening: an independent review. Br J Cancer. 2013 Jun 11; 108(11): 2205–2240
https://pubmed.ncbi.nlm.nih.gov/23744281/

[3] https://www.cochrane.dk/sites/cochrane.dk/files/public/uploads/images/mammography/mammografi-fr.pdf

Paris, Saturday, July 17 - The fight against fake news, especially in the health field, seems essential to reinforce the informed consent of everyone and the autonomy of people concerning their health. However, how to avoid that under the virtuous pretext of drawing attention to untruths, some focus first on their messages, sincerely convinced of their relevance and importance, omitting or denying the veracity of certain questions and controversies?

Wouldn't it be paradoxical and dangerous if those who present their work as a deciphering enterprise actually provide partial or even biased information?

On this subject the association Cancer Rose and the collective “Pour une inFormation indépendante en Santé” (Formindep) write to us today.

They alert to the way how the National Cancer Institute (INCa) would not always avoid a form of instrumentalization of the fight against fake news, by preventing by this means that comprehensive information on systematic breast cancer screening is provided.

By Cancer Rose and Formindep

Cracking down on fake news or hindering access to reliable medical information : What's new in France?

The facts

The French National Cancer Institute (INCa) conducted an internet-based "consultation" from September 22 to October 15, 2020. This consultation aimed for participants to vote "for" or "against" 220 proposals developed by the Institute for the new decennial Cancer Plan. Less than 2500 people took part.

One of the proposals is headlined "Set up a device to combat fake news ".

The text is as follows:

"A reactive anti-fake news system will be structured. It will enable people to be enlightened in the face of controversies likely to concern the various fields of cancer: primary prevention, screening, treatments, and complementary care. It is important to better inform public opinion, especially by using data that makes tangible the effects of prevention (international benchmarks, results of studies...). In addition, without being limited to the field of cancer, the creation of a "CSA Health" type system will be studied to implement rules for information in health, provided in a framework agreement with content hosts (media, social networks) to do a work of eliminating fake news identified by a college of experts."

CSA is the French acronym of “Conseil Supérieur de l'Audiovisuel », which is the French regulator of audiovisual.

Actualisation 2022

Project of an High Audiovisual Council of Health confirmed and published in the "Decennial Strategy to Fight Cancer 2021-2030", page 43

The reservations expressed by some citizens did not prevent INCa from adopting this proposal with great diligence, based on the 124 voters among the 47.9 million inhabitants registered on the electoral rolls and without any representative power.

The proposal has already been incorporated, in a simplified form, into Decree No. 2021-119 of February 4, 2021, which defines the ten-year national cancer strategy.

In the paragraph "Improving prevention", we read the following sentence, although it is somewhat imprecise: "New devices will be created to combat fake news".

And in June 2021, the INCa launched a new rubric on its website to denounce "fake news", under the title "The Enlightenments".

A fully assumed project to censor information

And there's a bad surprise there, because under the heading mentioned above, "The Enlightenments", the controversy over breast cancer screening is immediately qualified as "fake news", with the following surprising wording: "This scientific debate may have a negative impact on women and turn them away from the screening".

While skepticism is fundamental to any scientist worthy of the name, the INCa succeeds in both censoring all scientific debate and promoting itself in a partisan manner, minimizing overdiagnosis, the central problem of screening, and concealing its serious consequences for women, namely overtreatment, by publishing a pro-screening propaganda text.

Three major concerns

1° Possibility that the INCa will acquire, in future, the excessive power to force internet media and social networks to censor information which the Institute deems unilaterally "fake."

This is frightening because it implies the establishment of authoritarianism in health. Zealous and intolerant defenders of their self-justified "truth" will thus be able to impose their peremptory right-thinking  in a democracy, far from the interests of the population, affirming as an undeniable fact that "Breast cancer screening provides women with a benefit far greater than its risks."

This completely disregards the physical, psychological, and social suffering that women are experiencing due to overdiagnosis and its corollary, overtreatment.

2° Legitimacy of the INCa to provide information is questionable, as is that of taking a right to designate "fake news".

This institute was previously criticized for poor information quality in the 2016 report of the Citizens' Concertation on Breast Cancer Screening.

 It has also been pointed out in two academic studies. In the first study cited, the information disseminated by INCa is compared to that provided by Cancer Rose. Beyond the brief abstract, the study's findings show that the information provided by Cancer Rose is superior to that of the INCa in terms of the criteria for information that must be presented to the public.

The second study, published by Danish authors, denounces INCa's methods for influencing the public to increase screening participation, classified in following systematic categories: “Misleading presentation of statistics” and “Misrepresentation of harms vs. benefits” .

Is it, therefore, legitimate for this Institute to act as a censor and issue injunctions to "eliminate fake news”?

3° Ethical principle of non-maleficence is blatantly disregarded in the new rubric created by INCa

INCa affirms breast cancer screening as having "undeniable benefits for women" .  

The INCa article on breast cancer screening concedes that a certain percentage (though admittedly small) of women will be overdiagnosed and "treated unnecessarily".

Even if there were a massive overall benefit in the women's population, which is not the case, one of the limitations of breast cancer screening is that only some women will benefit, which is at the cost of harm to others.

Such a justification violates the fundamental principle in medicine: "first not harm", since individuals will obviously be harmed following the intervention of health professionals, at the instigation of the INCa, in search for a benefit that is neither certain nor proven. And not universal.

Will INCa's policy become censorship after a propaganda policy to develop screening? It is not possible to guarantee health democracy in our country, where freedom of expression and access to knowledge are fundamental rights, by acting in such an unworthy manner, both ethically and scientifically.

References

[1] About the title

https://fr.wikipedia.org/wiki/Cancel_culture

The expression Cancel culture has been variously translated as "culture of banishment", "of cancellation", "of ostracism" or "of ostracization", "of negation", "of annihilation", "of erasure", "of suppression", "of boycott" or "of boycott", "of public humiliation", "of interpellation", "of denunciation"

Thus, on July 7, 2020, in an article published in Harper's and translated in Le Monde, 153 artists, intellectuals and personalities denounced the culture of cancellation and the obstacles to the free flow of ideas and condemned the "intolerance towards divergent opinions".

[2] https://consultation-cancer.fr/pages/consultation-resultats-et-apports-citoyens

[3] https://consultation-cancer.fr/consultations/axe-1-ameliorer-la-prevention/consultation/consultation/opinions/2-prendre-ensemble-le-virage-preventif/mesures-proposees/mettre-en-place-un-dispositif-de-lutte-contre-les-fake-news

[4] www.legifrance.gouv.fr/eli/decret/2021/2/4/SSAP2100774D/jo/texte

[5] https://leseclairages.e-cancer.fr/le-depistage-du-cancer-du-sein-est-il-inutile-voire-nefaste

[6]       Reference 1 of the article on breast cancer screening in the rubric "The enlightenments” is nothing more than a report from ... the INCa! (1 National Cancer Institute, "Benefits and limitations of the organized breast cancer screening program," 2013)

[7]        “Améliorons le dépistage du cancer du sein-concertation citoyenne et scientifique-Rapport du Comité d’orientation,” September 1, 2016. Page 84 and 85 of the consultation report: http://www.concertation-depistage.fr/wp- content/uploads/2016/10/depistage-cancer-sein-rapport-concertation-sept-2016.pdf

"The public consultation.... highlighted the very inadequate information available to women on this screening. And, for those that are specifically intended for them, we note that this information makes no mention of the controversy that it has been the subject of for several years, nor of the existence of a real uncertainty as to the benefit/risk ratio, nor of its limitations, both in terms of its true purpose (in this case, "detection") and its financial coverage."

[8] https://www.sciencedirect.com/science/article/abs/pii/S039876201930522X?via%3Dihub

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

[10] https://cancer-rose.fr/2020/01/02/david-contre-goliath-qui-informe-mieux-les-femmes-cancer-rose-ou-linca/

[11] https://cancer-rose.fr/wp-content/uploads/2021/04/nouveau-tableau.pdf

[12] https://leseclairages.e-cancer.fr/le-depistage-du-cancer-du-sein-est-il-inutile-voire-nefaste/