Category: News headlines

An article published on February 11 in the journal STAT tells us about a study project that consists of examining a "natural experiment" to evaluate data such as mortality or overdiagnosis in cancer screening. 

This natural experiment concerns the decline in screening tests during the pandemic. We could then examine and gauge the overdiagnosis of cancers, the real burden of screening, since it throws healthy people into the hell of the disease.

This examination would thus be done at the end of the pandemic, which seems more ethical than a prospective study where patients would have to be randomized in order to be subjected to screening or not.

(Editor's note: however, such a study seems to us to be quite feasible with good information for participants, but more costly and more complicated to set up[1]. It can just be considered that conducting a randomized study on overdiagnosis with two groups of people, perfectly informed before participation in the study, is certainly more ethical than subjecting entire populations, as is currently the case, to highly controversial screenings as to their effectiveness, without any fair information on the benefit-risk balance. This is the case for prostate cancer screening (many men are prescribed a PSA dosage without any explanation) and for breast cancer (many women, uninformed, believe that breast cancer screening is mandatory and will save their lives)).

The author of the article, Ms. E. Cooney, is a general assignment journalist at STAT, a journal of biotechnology, pharmaceutical, policy and life sciences analysis, which she joined in 2017. Previously, she was a blogger at the Boston Globe, before moving to the science editor at the Broad Institute of MIT and Harvard (a biomedical and genomics research center located in Cambridge, Massachusetts, U.S.A.).

Background

Ned Sharpless, current director of the U.S. National Cancer Institute (NCI) and professor of medicine and genetics, was alarmed by the sharp drop in the number of screenings by colonoscopies, mammograms and other cancer screening tests. His concern was motivated by models predicting an explosion in cancer rates if screening was not performed. (In France, we also had our national cancer centres forecasting the worst consequences in the event of non-screening[2]).

However, it will be the delays and postponements in the arrival of patients that will have the most consequences, according to the Grouvid study[3] presented by the statistician Aurélie Bardet of the Gustave-Roussy Institute in Villejuif (Val-de-Marne).

But in January of this year, Mr. Sharpless questioned the downside of early detection: overdiagnosis, when asymptomatic cancers that may not develop and harm the patient are detected, and the overtreatment that accompanies it. The pandemic, he says, could be an opportunity to resolve a long-standing controversy over the extent to which the disadvantages of cancer screening outweigh its benefits. "Knowing the extent to which overdiagnosis and overtreatment actually occur during cancer screening is a very complicated subject," he said. For him, the pandemic has provided an interesting natural experiment, where we could examine some of these tumours, diagnosed later. Is the fate of patients really less favorable because of a later diagnosis of their tumor?

If delays in screening - depending on the cancer and the screening test - do not lead to worse outcomes for most patients, then they could provide valuable information when we will emerge from the pandemic. To demonstrate that non-use of screening is not detrimental, the decline in screening rates should lead to a decrease in overdiagnosis, and not concomitantly result in a significant increase in the number of patients developing disabling or fatal cancers.

(Editor's note: Caution, raw rate data should be examined. In fact, if overdiagnosis could be completely eliminated, the part, i.e., the proportion of serious cancers, would then appear to be greater in the total number of cancers minus overdiagnoses, which usually amplify the total number of cancers. In fact, the proportion of serious cancers is diluted in the total cancer figure when the contribution of overdiagnosis is included in the total cancer figure. 

It is therefore necessary to look at the crude rate and not at the percentage of serious cancers in the total number of cancers identified).

For Mr. Sharpless, the time has come to examine more closely the natural history of cancers during the postponement period, and overtreatments.

Observations already available

For Clifford Hudis, a breast cancer specialist and CEO of the American Society of Clinical Oncology, tests such as colonoscopy are clearly useful. But for other cancers, the impact on survival has been less obvious.
Mr. Hudis emphasizes the difference between screening a person with no symptoms and diagnosing a person with clinical signs. ( It is obvious that under no circumstances consultation should be postponed in case of a clinical symptom).
For him, the evidence is irrefutable: Pap smears and HPV tests to detect precancerous cells in the cervix have significantly reduced mortality rates. Colonoscopy and other screening tests for colorectal cancer in adults have been similarly successful, to the point where an expert panel is recommending screening for colorectal cancer in younger people.
(Editor's note: this opinion is much more nuanced according to experts and studies [4] Perhaps we are still lacking hindsight).

There is much less certainty about the effectiveness of mammography and CT screening for lung cancer, while the use of PSA screening for prostate cancer continues to be controversial[5]. Yet we have "natural experience" with this screening.
Routine PSA testing opened the door to a sharp increase in the incidence of prostate cancer diagnoses, which rose by about 16% per year from 1988 to 1992, then by 9% per year until it stabilized in the late 1990s.
After the U.S. Preventive Services Task Force (USPSTF) changed its recommendation in 2012 to advise men against routine PSA testing, the incidence of prostate cancer has finally stabilized, in contrast to what was happening before widespread testing. And mortality has not changed!

Cooney also relates the position of Barnett Kramer, former director of the NCI's Division of Cancer Prevention: "It's not just prostate cancer where over-diagnosis and over-treatment are a concern," he says. « There are other slow-growing cancers that would never cause suffering during a patient's natural lifetime, and there are also cancers that never progress ».
“You introduce a screening test, in this case for thyroid cancer, kidney cancer, and melanoma, and you dramatically increase the incidence of cancer and prevalence of those cancers,” he declared in front of an association of health journalists.
“There are more and more people that are diagnosed with cancers, and yet you make very little impact on the mortality. They are cured. But they never would have gone on to die of the cancer anyway.”

For instance, while Mr. Kramer sees real harm in overdiagnosis, he does not want this message to encourage people to avoid seeking medical care for symptomatic cancer. “People should be alerted to making sure they seek medical attention at the earliest signs of symptoms,” he said. « We do know that ignoring advancing symptomatic disease is harmful.”

The author also quotes Otis Brawley, former Medical and Scientific Director of the American Cancer Society and now a professor at Johns Hopkins University: “There are cancers that don’t need to be cured. And that’s at least 60% of all prostate cancers and maybe 20% of breast cancers don’t need to be cured.”
(Editor's note: the 20% estimate concerns invasive carcinoma according to the first randomized studies on Canadian trials for example [8], but on the one hand these estimates are now being revised upwards, and on the other hand, if we add carcinomas in situ, 80% of which would not need to be treated, the over-diagnosis of breast cancer is estimated at almost 50%, which means that it could concern one cancer in two detected by mammographic screening [9]).

According to Dr. Sharpless, most cancers are discovered following the appearance of symptoms.
Nevertheless for him “there are plenty of people alive today because they had an asymptomatic lesion detected on some screening exam that was removed, resected, treated, and they’re cured of what would’ve been a very symptomatic cancer. The opposite argument is true, too.”, meaning: many of the living people treated by removing, resecting lesions that would never have become symptomatic.

Another factor to consider is that cancer therapies have improved. Some may be diagnosed at a later stage with delayed screening, but they are curable with effective therapies," says Sharpless. So the higher grades can be apprehended by new therapeutic approaches.

(Editor's note: P. Autier's study noted: The influence of mammography screening on mortality declines with the increasing effectiveness of cancer therapies.)

Which method for evaluation?

Eric Feuer, founder and leader of the NCI Cancer Surveillance Modeling Network Evaluation Project, has worked on NCI models predicting excess mortality from breast and colorectal cancer due to delayed screening. 
He stated that the widespread use of the PSA test was also a natural experiment.
“When screening goes up rapidly, you’re taking cases from the future,” Feuer said. « Some of those cases never would have caused symptoms, but they made incidence rise. The problem is that the PSA test doesn’t accurately predict which cancers, with or without symptoms, will be harmful and which won’t. »

For breast and colorectal cancer, Dr. Feuer will examine data from the Surveillance, Epidemiology, and End Results program (SEER) and other NCI data to see if the decline in screening rates has been followed by a decline and then an increase in incidence. He will monitor rates of positive screening tests, the stage of confirmed cancer diagnosis, and mortality data.
In addition to the SEER, the Population-based Research to Optimize the Screening Process (PROSPR) observational database will also be used to discern the effects that decreased cancer screening may have on the stage at which cancer is diagnosed, among other measures.

All this is supposed to allow the estimation of overdiagnosis, if the data return is powerful enough.

Mr. Kramer (former director of the NCI's Division of Cancer Prevention) has requested that PSA be removed from his usual blood test panel.

Professor Brawley (Johns Hopkins University professor) thinks Covid-19 is the imminent danger we should consider now. His hospital has cancelled elective operations, including radical prostatectomies.

The natural experiment on screening tests will take some time to show results.

“We’ll know in 10 years,” NCI’s Feuer said.

Meanwhile....

The director of the Canadian Breast Imaging Society said her group already has a study underway. The full transcript of the interview can be found at this link: https://www.cbc.ca/radio/thecurrent/the-current-for-feb-9-2021-1.5906730/february-9-2021-episode-transcript-1.5907645

MATT GALLOWAY: Tell me more about that. I mean, in the six months that this pandemic would have perhaps derailed or slowed down or stopped screening, what would be the change in that in terms of, you know, where cancer might be, but also, as you say, survival rates?

JEAN SEELY: Well, it's too early for us to know. And we're starting a study to look at this because we believe that this is a factor that's happening across the country. There was a modelling study done by the group at Sunnybrook, and they used a mathematical model called OncoSim, where they estimated that a six-month delay in screening would lead to 670 more advanced breast cancers in Canada and 250 more breast cancer deaths in the next 10 years. And delaying that even more than six months, which may happen with people stopping or naturally not referring themselves, would lead to an even higher number of deaths. So we are seeing this across the country.

So we can easily imagine how breast medical imaging experts will design the research to their advantage, and how they will promote it. The debate will never end, and a battle of "models" will be engaged.

Opinion of Dr. Vincent Robert, our medical statistician :

"Apart from the fact that this is only a model (and with another model we would certainly find something else), which statistician, and with which tool, would be able to spot an increase of 250 deaths among the random fluctuations of the annual number of deaths (with 12000 deaths per year on average, the confidence interval of the annual number of deaths in France has an amplitude of about 500 deaths, i.e. the annual number of deaths naturally fluctuates by much more than 250; or, if you prefer, an increase of 250 deaths will not appear to be statistically significant). "

To be continued..…

References

[1] https://cancer-rose.fr/my-pebs/methodologie/ - choose article: "l'étude dont on rêvait"

[2] https://cancer-rose.fr/2020/10/06/langoisse-des-thuriferaires-du-rose-face-a-la-decroissance-de-participation/

[3] https://cancer-rose.fr/en/2021/01/18/covid-19-pandemic-and-cancer-management/

[4] https://bmjopen.bmj.com/content/9/10/e032773

[5] https://cancer-rose.fr/en/2021/02/11/parallel-to-breast-screening-prostate-screening-overdiagnosis-as-well/

[6] https://cancer-rose.fr/en/2021/02/01/overdiagnosis-of-thyroid-cancer-another-womans-concern/

[7] https://www.youtube.com/watch?v=068KMIe-gys&feature=emb_logo
Dr. Adewole Adamson's observation is frightening: no reduction in mortality and massive overdiagnosis due to the fact that the tolerance thresholds of dermatologists and anatomo-pathologists are lowered in front of skin lesions.

Dermatologists are increasingly and rapidly asking for biopsies, while anatomical pathologists prefer to upgrade their diagnosis of lesions examined under the microscope (i.e., when in doubt, classify as malignant lesions that are simply dubious and that could only be monitored), giving rise to an apparent melanoma epidemic with even more artificial "survivors".The vicious circle is endless, prompting patients and doctors to do more and more routine skin examinations.

[8] https://cancer-rose.fr/en/2021/01/06/miller-study/

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

Lung cancer screening by low-dose CT scan, or the history of a pre-announced disappointment.

In February 2020, a medical imaging  journal[1] triumphed in publishing the results of a clinical trial on lung cancer screening by low-dose chest CT, which was then widely reported in press, promoting this high technology as a systematic screening method in smoking population.

This is a scanning technique using low doses, similar to those delivered by a simple chest X-ray (in two incidences, face and profile, equivalent to 20-40 µSv, instead of 5.8 mSv for a standard chest CT), giving a slightly more degraded image, not very efficient for the analysis of interstitial pneumopathies, but sufficient for a diagnosis of small nodules.

The article in this review concluded as follows: "This study therefore seems to be in favor of organized lung cancer screening, at a time when the procedures have reached very low irradiation levels".

But what is it actually about?

Essentially two trials (there have been several studies) are supposed to provide evidence of a significant decrease in specific mortality from bronchopulmonary cancer. These are the US National Lung Screening Trial (NLST), and the NELSON trial conducted in Belgium and the Netherlands.

Already in 2014, in a guidance brief, the HAS [2] noted: ".... it is likely that the low specificity of low-dose CT screening will remain a major obstacle to the implementation of screening in clinical practice and of a screening program".
"Disadvantages and risks associated with low-dose CT screening include radiation exposures ranging from 0.61 to 1.5 mSv, a certain degree of over-diagnosis that varies between studies, and a high rate of false positive tests, usually explored with more imaging".

When we examine the study published in the NEJM [3] on the NELSON trial, the last line of Table 4 reads as follows: All-cause mortality - deaths per 1000 person-yr 13.93 (screening group) 13.76 (control group) RR 1.01 (0.92-1.11).
This clearly means that there is no impact on all-cause mortality, and this is the only data that should be of interest to the public and the media when reporting the results of such a study.

Remember that the "overall mortality" data includes everything, cancer, its treatment and its non-treatment, and reflects more adequately the "real life" data.
This information is rarely put forward, as the promoters of screening preferentially report the gain in terms of specific mortality, i.e. by the disease alone [4].

But the Academy of Medicine has retained it, and in a published report it expresses its concerns [5] [6]. The Academy notes several problems that prevent this screening from being generalized:

    - The two main trials on lung cancer screening with low-dose CT scans greatly underestimated potential harmful effects (false positives, over-diagnosis, false negatives, irradiation and over-treatment). The magnitude of  benefit and risks are unknown, and even if a 25% cure rate is achieved among subjects included in the study, the majority of patients will die early from other smoking pathologies (other cancers, heart disease, emphysema etc...) without increasing their life expectancy.

- For a screening to be effective, it is necessary to have cancers with a sufficiently long latency to be caught during a screening test (therefore as few interval cancers as possible); yet the proportion of cancers with a long latency in the lung is low.

-"These cancers are mainly due to active smoking and, marginally, to passive smoking: more than 85% of cases can be attributed to tobacco. The progressive decrease in smoking among men (from 60% of smokers in the 1960s to 33% currently) is reflected in the decrease in incidence and mortality due to these cancers", which is equivalent to saying that this cancer is simply accessible to effective primary prevention campaigns and incentives to stop the main risk factor, tobacco.

"The natural and evolutionary history of the disease must be known and the various forms defined"." Between ages of 50 and 74, lung cancers are therefore mainly composed of adenocarcinomas, which seem to be the most easily detectable. For example, in the European NELSON trial, 61% of cancers in the screened group are adenocarcinomas compared to 44% in the control group, which could explain a better effect of screening in women," explains the Academy.

    - Unknowns: on target population, on appropriate participation rate, frequency of scans, therapeutic indications for cancers discovered during the scan, acceptability by patients, motivation and compliance with smoking cessation, etc...

    - People who participate in the trials are not representative of entire population eligible for screening at a later date, which may lead to an overestimation of efficacy in the Nelson study.

    - Economic evaluation is also necessary, with the Academy correctly pointing out that primary prevention is certainly more effective and less costly.

To rebound on the arguments of the Academy of Medicine, it is necessary to bear in mind economic stakes of this screening, not only of the initial examination but also the high cost of iterative examinations in case of intermediate nodules (which must be followed over years to monitor their evolution). Bronchial cancer screening by CT would be 4 times more expensive than breast cancer screening and 10 times more expensive than colorectal cancer screening.

Specifically concerning women

The results on the effectiveness of low-dose CT screening at 10 years are more variable and difficult to interpret in women. The Academy also has reservations, particularly in the NELSON trial, pointing out that they are not significant because of the small number of women included in the two trials and followed up in 10 years.

For our part, we emphasize that this screening, if it is launched in the female smoking population, will be superimposed on the biennial mammography, again in total ignorance of the effect of cumulative doses of iterative examinations [7] [8] for an unproven reduction in mortality [9].

Irradiation draws attention again

Once again, and just as for breast cancer screening, let's keep in mind that we are inflicting radiation, even in low doses, on people who have no complaints, who are a priori healthy, and this radiation will be repeated.

For suspicious (5 to 10 mm) and undetermined nodules, a check-up will be carried out at 3 months. Nodules that increase in volume (+ 25% in volume in 3 months) and nodules larger than 10 mm must be investigated immediately (biopsy or surgery). Stable nodules will be controlled for 3 years.

Some semi-solid nodules may be slow-growing and will be followed for a longer period of time, for 5 years.

All this for a zero gain in terms of overall mortality.

Ionizing radiation induces two types of effects: "deterministic effect", i.e. conditioned directly and with certainty according to the dose of radiation received, for example if a certain threshold is exceeded as in the case of a nuclear catastrophe or during radiotherapy treatments.

The other effect is "random" (appearance of cancers with a certain probability for an individual but without certainty, without a known threshold, depending on individual radiosensitivity).

For diagnostic radiology, the doses used are certainly much lower compared to radiotherapy, but the exposure, especially repetitive, could be harmful in a "probabilistic" way, by an accumulation of alterations of cellular DNA and individual sensitivity. Since most estimates are based on extrapolations of risks observed from nuclear and atomic accidents, long-term effects of even minimal and repeated doses are certainly very variable depending on the individual, and definitely still unknown at the present.

On this subject, read the work of N. Foray, radiobiologist, INSERM.

: https://www.sfmn.org/drive/CONGRES/JFMN/2016%20GRENOBLE/SCIENTIFIQUE/CommunicationsOrales/N._FORAY_MembreWeb.pdf

et https://its.aviesan.fr/getlibrarypublicfile.php/cd704e89988a4e3bcf2e1217566876cf/inserm/_/collection_library/201800012/0001/J1-098ITS-2017.foray.lyon.ITMO.TS..21.nov.2017.pdf.pdf

To conclude

For academics, the most important thing is the fight against the main risk factor: smoking, and acceptance of its reduction is the very condition for candidates selected for eventual regular screening.

Chest CT scans could then serve as a motivation for smoking patients to make a decision to quit.

It will then no longer be a matter of systematic screening of an entire population, but rather of using imaging as part of a smoker's health check-up, and as part of the singular colloquium within the medical consultation.

Finally, in the context of recognized occupational exposures, low-dose chest CT scans could be a method of monitoring exposed subjects.

Reactions

They were not long in coming, an APM dispatch of February 24, 2021 informs us that three learned societies are taking a stand.

"The three learned societies are the Francophone Thoracic Cancer Intergroup, the French Lung Society and the Thoracic Imaging Society.

In this text, which updates previous recommendations, the learned societies reaffirm their position in favor of individual screening by low-dose thoracic CT scan without injection of contrast agent, for which they specify the modalities." ......
" Contrary to the Academy of Medicine, which proposes a low-dose scanner once, during a smoker's health check-up, learned societies envisage a recurrent examination. They believe that there should be 2 CT scans one year apart and then one every 2 years, except in the case of risk factors or a previous exam with an intermediate result or it should continue every year.
And this screening should be continued "for a minimum period of at least 5.5 to 10 years".

Again, we note the regrettable and not very scientific reaction of the president of the National Federation of Radiological Doctors:

"Incompetence or senility? The National Academy of Medicine has rendered a verdict against the use of low-dose CT scanners for the detection of bronchopulmonary cancer. The scanner would contribute to the health assessment of smokers and help them quit smoking."

A new study

https://pubmed.ncbi.nlm.nih.gov/35040922/#:~:text=Conclusions%20and%20relevance%3A%20This%20population,indolent%20early%2Dstage%20lung%20cancers.

This population-based ecological cohort study found that screening for low-dose CT scans of low-risk Asian women, mostly non-smokers, was associated with significant over-diagnosis of lung cancer. Five-year survival is biased by the increased detection of indolent lung cancers at an early stage.
Unless randomized trials can demonstrate some value for low-risk groups, low-dose CT screening should remain targeted only at heavy smokers.

References

[1] http://www.thema-radiologie.fr/actualites/2592/l-etude-nelson-promeut-le-depistage-du-cancer-du-poumon-par-scanner.html

[2] https://www.has-sante.fr/upload/docs/application/pdf/2014-12/note_de_cadrage_cancer_du_poumon.pdf

[3] https://www.nejm.org/doi/full/10.1056/NEJMoa1911793

[4] This "gain" is often expressed as a relative reduction in the risk of dying, i.e. by comparing a screened group with an unscreened group.

In the case of breast cancer, the manipulation is to express this gain repeatedly, in particular in the media, in percentages. Thus you are told that breast cancer screening reduces mortality by 20%, everyone understands that 20 people out of every 100 screened die of this cancer, but this is not the case, in absolute figures there is only one life saved. Out of a group of 2000 women screened in 10 years, there is one death from breast cancer, out of a group of 2000 women not screened in 10 years, there are 5 deaths, the reduction from 5 to 4 is indeed a reduction of 20%, but in real life, it is only one person.…

[5] https://www.academie-medecine.fr/le-depistage-du-cancer-du-poumon-par-scanner-thoracique-faible-dose-stfd-reste-non-justifie-mais-peut-etre-utile-pour-un-bilan-de-sante-des-fumeurs/

[6] https://cancer-rose.fr/wp-content/uploads/2021/02/RAPPORT-Académie-de-médecine.pdf

[7] http://agora.qc.ca/documents/radiation_des_depistages_aux_accidents_nucleaires

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

[9]https://cancer-rose.fr/2019/10/20/le-depistage-de-masse-du-cancer-du-sein-bafoue-les-valeurs-ethiques-et-les-principes-fondamentaux-du-systeme-de-radioprotection/

Cécile Bour, MD, February 13, 2021

That is the question asked in the JIM[1] of February 13 by a citizen, a participant in the INCA[2] citizen consultation organized to " put an end to cancers".

This woman gives here her opinion on an item proposed by the INCa which seemed to her to be particularly unethical.
She is an agri-food engineer with a PhD in Life and Health Sciences. 
She speaks jointly with two other scientists, Dr. Theodore Bartholomew, a physician at the Royal Surrey County Public Hospital in Great Britain and holder of a Master's degree in Bioethics, and Dr. Harald Schmidt, Assistant Professor at the Department of Medical Ethics and Health Policy and Research Associate at the Center for Health Incentives and Behavioral Economics, at the University of Pennsylvania, in the United States.

We have already expressed our concern about this citizen consultation supposed to support the next ten-year cancer plan, through two articles [3] [4] published at the time of its launch where we denounced the collusion with pharmaceutical industry and very low citizen participation despite the dithyrambic presentation of the INCa communicators.

Not only citizens have been able to vote just for fallaciously formulated items (see our articles), without prior information on the ins and outs of certain proposed measures, but the participation rate is in no way representative of the French population (2478 effective participants for 3. 8 million people affected by cancer in France, and 47 million French citizens registered on the electoral rolls...), thus denying the "adequacy" that would exist between "the objectives and measures presented and the expectations of our fellow citizens" proclaimed by the INCa communicators.

And we were already astonished by this item[5] in particular, which also retained attention of the three authors in the JIM :

Experimenting with material incentives to facilitate people's participation in screening :

Incentive mechanisms such as financial motivation or payment of expenses (transportation, childcare, work), which have been very little used to date, will be experimented with in order to evaluate their contribution to the development of participation in the program.

Adherence to screening programs or procedures also requires the mobilization of professionals, whether in the carrying out of the act or in the informing and raising awareness on screening, otherwise by incentivizing.

This is not without recalling similar measures already in place in the United States, where many private health insurance companies incentivize women to perform screening mammograms by offering compensation in various forms.

What do the authors denounce in the article?

This French citizen and the two co-authors denounce together the cynicism of this financial incentive measure proposed by the INCa, which ignores the demands of the true citizen consultation [6] dedicated to breast cancer screening and organized in 2016, that called, in addition to the cessation of this screening, for better information given to women on the benefit-risk balance of this breast cancer screening ("Taking into consideration the controversy in the information provided to women and in the information and training of professionals").

This is the point made by the three authors, who recall that the issue at stake is to inform women about the risk-benefit balance of screening, in particular the risks of overdiagnosis, in order to enable them to make a better choice, one that is optimal for each of them: "The risk of these incentives is that the decision-making process is short-circuited, that women make decisions they will regret and that they would not have made in the absence of incentives".

The authors point out the unethical nature of this item: "... the choice of screening should be made by properly informed women and not by their physicians, nor by health insurers, public health policy makers or other actors. This initiative should not be promoted, but rather ensuring that women have access to truly useful information on the advantages and disadvantages of screening. Rather, we advocate encouraging active and informed choice by encouraging women to use evidence-based decision support tools".

At the beginning of the article, the authors recall the Cochrane Collaboration review[7] and the risk of overdiagnosis inherent in this screening, which should be known by each woman before engaging in screening. And they ask a very logical question:  "Instead of trying at all costs to strengthen screening as foreseen in the new ten-year cancer plan, why not mobilise more resources for equal access for all women to informative materials and documents on the risk-benefit balance of this screening, to enable them to make a conscious decision on whether or not to participate in mammography screening"?

 Citizen's demands heard? Is informing the population a concern of the new plan?

No, not at all.

The proposed measure on financial incentives for women to increase their participation is further proof that the National Cancer Institute is doing just what it wants to do, promoting the pursuit of its obsolete objectives, formulating the items in such a way that citizens can only approve due to lack of explanation, and burying the demands of the citizens of 2016 in anti-democratic brutality.

We also noticed that in the small group of 24 people who concocted these items of the consultation, we find the representative of the drug companies (LEEM) Mr. Eric Baseilhac, director of economic affairs.

The sad consequence of all this is formulated in the new European cancer plan, published shortly after this "citizens' consultation" supposedly based on citizens' opinions but in advance elaborated a long time ago, and which proclaims the intensification of screening:

https://ec.europa.eu/commission/presscorner/detail/en/ip_21_342

« ...ensuring that 90% of the EU population who qualify for breast, cervical and colorectal cancer screenings are offered screening by 2025. To support achieving this, a new EU-supported Cancer Screening Scheme will be put forward ».

The pharmaceutical and medical imaging industry can rub their hands :

« In addition, to support new technologies, research and innovation, a new Knowledge Centre on Cancer will be launched to help coordinate scientific and technical cancer-related initiatives at EU level. A European Cancer Imaging Initiative will be set up to support the development of new computer-aided tools to improve personalised medicine and innovative solutions »

Everything continues as planned, all is going well in the best of all worlds.

Références

[1] https://www.jim.fr/medecin/debats/e-docs/des_incitations_financieres_pour_le_depistage_du_cancer_du_sein_sont_contraires_a_l_ethique_186433/document_edito.phtml?reagir=1#formulaire-reaction

[2] https://consultation-cancer.fr/

[3] https://cancer-rose.fr/2020/12/15/inca-une-consultation-citoyenne-pourquoi/

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

[5] https://consultation-cancer.fr/consultations/axe-1-ameliorer-la-prevention/consultation/consultation/opinions/12-ameliorer-lacces-aux-depistages/mesures-proposees/experimenter-des-incitatifs-materiels-pour-faciliter-la-participation-des-personnes-au-depistage

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

[7] https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001877.pub5/full

February 7, 2021
Cécile Bour MD

Emmanuel Macron has just launched on Thursday 4 February a decennial national strategy (for 2021-2030)  in fight against cancer, with a funding of €1.74 billion over 5 years, i.e. 20% more than for the three previous cancer plans. The aim is to reduce the number of so-called "avoidable " new cancers by 60,000 cases per year from now to 2040.
Several media are talking about it, but we rely on the rather exhaustive report made by the newspaper Le Monde [1] on February 4, 2021 and on the 6th report to the president elaborated by the INCa[2].

We are going to review the "plans" from their origin until today, and we will see the evolutions through ages, from great demagogic objectives of past times to ...great demagogic objectives of nowadays, complemented by the intrusion of drug manufacturers. Already in 2013, Roche laboratory was not far away from breast cancer screening and watchful when analyzing "women's compliance" with screening through the EDIFICE[3] study. And when a pharmaceutical company takes such a close interest in a controversial measure, it is often to find out how to protect its interests...

The more patients there are, the more pharmacopoeia is sold.

Focus on screening

Main axes of this new cancer plan are deployed in the article published in Le Monde newspaper and we will focus on screening, our core target, which the president promises to strengthen in the first axis called "prevention". 

• "Every year in France," the article says, "9 million people participate in one of the three organized screening programs (breast, colorectal and cervical cancers). The goal is to increase this number to 14 million in 2025". "Every year, more than 157,000 people die of cancer in France. In total, 3.8 million people live with the disease. Four out of ten new cancers would be avoidable. That represents 153,000 new cancers per year that would be prevented if the population adhered to organized screening programs, had a balanced diet and regular physical activity".
• The "urban legend" of "preventive" screening, so precious to the INCa correspondents, comes up against the very definition of prevention, which is to ensure that the disease does not occur. Yet screening aims to detect, to track down a disease, which is already there. Screening procedures, whether for colorectal, breast or prostate cancer, do not anticipate the disease but detect a lesion that is already present in the body.

This misleading confusion between "prevention" and "screening" is found in the "improving prevention" axis[4] of citizen consultation that the INCa (National Cancer Institute) proposed at the end of last year[5] [6].
However, French women citizens, during the 2016 citizen and scientific consultation on breast cancer screening, pointed out this dishonest confusion between the two terms.[7]

       Page 5 : The committee also noted dysfunctions, abnormalities in the current organization of screening and consequences it generates: inequalities of access, lack of understanding of stakes, confusion between primary prevention, screening and early diagnosis, lack of information on risks and uncertainties of screening in invitation letter sent every 2 years,

      Page 125 " Moreover, information provided about organized screening maintains confusion between prevention and early diagnosis. "

Difficult to admit a simple awkwardness this time, on the contrary, this amalgam of terms is maintained deliberately, serving to falsely attribute to screening a preventive power that it obviously does not have.

Review of previous cancer plans

We review what has been previously designed in different successive cancer plans, while following evolution of lung and breast cancer.[8]

1° Plan 2003-2007[9]

Heading

"The Plan allows to reduce tobacco consumption through a comprehensive tobacco control strategy combining price increases, a ban on sales to minors under 16 years old, information campaigns and actions targeted at youth and women, and the development of aids to help people stop smoking"."The organized breast cancer screening program was generalized in 2004, while the organized colorectal cancer screening program was the subject of an experimentation from 2002 to 2007 in 23 pilot departments".

Epidemiological results of the 2000s

Lung (Remontet Report 2013 page 79)[10]

"The incidence of lung cancer has been steadily increasing over the past two decades. This trend is more pronounced in women, although both incidence and mortality remain much higher in men. ... At the same time, mortality follows a similar trend.... The number of deaths has increased from 15,473 to 22,649 in men and from 1,997 to 4,515 in women".

Page 84 tables 5 and 6

Breast (Page 99 of the report)


"The incidence of breast cancer has increased dramatically over the past two decades. Between 1978 and 2000, the average annual rate of change in incidence was +2.42%. The number of new cases has almost doubled in 20 years, from 21,211 cases in 1980 to 41,845 cases in 2000. 
At the same time, mortality has remained stable (slight annual increase of 0.42%). The number of deaths rose from 8,629 in 1980 to 11,637 in 2000".

Table 5 page 104

All in total : What should be concluded from a review of these data? Duperray notes[11]: "For breast and prostate cancer, there is a stable mortality and an incidence that escalates as the screening intensifies, whereas for lung cancer which is not routinely screened, the number of deaths is proportional to the number of diagnoses.  Incidence of lung cancer increases in parallel with the real cause of the disease, tobacco consumption.

Table page 155

"Indeed, for cancers that are screened, such as breast and prostate cancer, the overdiagnosis generated by screening is expanding, resulting in a sharp increase in the incidence of cancer in 2005, with no impact on mortality, which remains comparable to previous years without screening. In comparison, lung cancer, which does not benefit from any screening, shows a comparable rate of death and diagnosis.

In this graph, we see that the rate of serious cancer remains unchanged, whereas it was expected to decrease with the introduction of screening.(Figure 9 in the book, page 121 [11] ).

Unbridled and ideological enthusiasm for screening, despite the warnings made by whistleblowers as early as 2000, makes this fact inaudible and encourages the continuation of programs, especially given the disappointing participation of women.

2° Plan 2009-2013 [12] [13]

Heading

P.56: "The actions taken have not led to increased participation in organized screening programs for breast and colorectal cancer. The "Pink October" and "Blue March" information and mobilization campaigns have been renewed annually by adaptation of messages... Participation in organized screening programs is not progressing for breast cancer (national participation rate of 52.7% in 2012 for a target of 65% set by the Plan) as well as for colorectal cancer (31.7% in 2012 for a target of 60%)".

In the face with this observation, it would seem important for health technicians to intensify participation, as we can read in the following pages; therefore, recommendations of the High Authority for Health (HAS) are aimed at maintaining the objective of organized screening while at the same time strengthening the conditions that allow women who are not at high risk of developing breast cancer to limit individual screening practices (page 81 of the report).

On the tobacco smoking aspect, the report states on page 47 :

Thus, while 76% of people surveyed consider the risks associated with tobacco smoking to be "certain", the prevalence of smoking is still 32% among 15-85 year olds. Sixty-five per cent of respondents also continue to believe that "breathing city air is as bad for your health as smoking cigarettes".

Results of epidemiological data

Lung[14]

We can read in the Remontet report on solid tumor incidence and mortality, page 176  "Lung cancer incidence and mortality are still twice as high in men as in women in 2018".

The report states:

"The evolution of mortality from lung cancer mortality is closely linked to the evolution of incidence in both sexes and for all ages...Mortality is still increasing in women for all ages and more significantly for those in the 50-60 age group..."

Breast

Remontet Report Page 204 tables 4 and 5

In relation to incidence, a slight inflexion of the specific mortality from breast cancer can be noted, but this, as we can see below, takes place as early as the 90s, well before the generalization of screening, and cannot be attributed to it.

The report states (page 207): "The introduction of organized screening is generally accompanied by a temporary increase in incidence and to some extent by overdiagnosis (cancer that would not have developed before the patient's death and which is more likely to be in situ cancer not included in this study)".

Regarding mortality, the report states:

"A decrease in the mortality rate has been observed since the mid-1990s, linked to major therapeutic advances (hormone therapy, taxanes, targeted treatments adapted to the molecular profile of the tumor) and an increase in the proportion of cancers diagnosed at an early stage, notably through screening. "

But this last point is strongly contested by several international researchers who object that overdiagnosis is increasing with more and more screening in an almost proportional way.[15]

Others suggest that screening may be providing unaccounted for excess mortality due to the effects of overtreatment. [16]
Disturbingly, there is no difference between screened and unscreened groups of women. [17]
And in any case, mortality from all causes is not reduced.

All in total :
When looking at and comparing all the data on lung cancer and breast cancer, we can see that tobacco consumption, the leading cause of cancer-related death in France, has not decreased and it contributes to inequalities, by progressing among women and unemployed. It is clear that measures banning the sale of cigarettes to minors under 18 years of age and graphic warnings on packages are largely insufficient.

Meanwhile, despite the observation of a marked increase in the incidence of breast cancer, still without a massive impact on the reduction in mortality expected from successful screening*, the Pink October campaigns for awareness and promotion of breast cancer screening, are going well and without saving resources  (city lighting, races organized by municipalities, placarding of slogans), without any questioning or reflection on the overtreatment generated in population.

*PS: (When there is such a marked discrepancy between increasing incidence (number of new cases) and non-proportionally declining mortality), this case inflation is due to one thing: unbridled screening activity).Once again, we can see that despite overabundance of resources for the Pink October campaign, breast cancer mortality, particularly in women, is only on the increase. And smoking alone kills more than breast and prostate cancer combined![18]

The fight against tobacco smoking is clearly not meeting its stated intentions, probably because tobacco generates a lot of revenue in the form of taxes[19]. It is clear that  emphasis on intensifying screening makes us forget that the fight against smoking and alcoholism is not up to what would be possible if politicians, instead of sparing lobbies, really intended to reduce cancers.

3° 2014-2019 Plan[20] [21]

This plan focused on facilitating access to breast cancer screening for women who are farthest away and by any means possible. 

As the women who were easily accessible seemed to be recalcitrant to this screening, the authorities decided that it was necessary to stimulate participation of women who were usually little solicited or geographically inaccessible.

And there is no shortage of ideas:

-To set up regional training courses for women to relay awareness of cancer screening (organized breast cancer screening) targeting women in precarious situations (partnership with IREPS2 ) (Picardie). 

-Favor access to screening for women furthest away from screening sites by organizing the payment of transportation costs for a mammogram in Cayenne (French Guiana) and fight against inequalities in access and recourse (Martinique). »

-Carry out an inventory of access to organized breast cancer screening for disabled people in social and medico-social establishments (Franche-Comté). 


-Facilitate access to screening for detainees by raising awareness among the teams of the Consultation and Ambulatory Care Units (Indian Ocean)

Pages 72 and 74:

"the objective of achieving 75% coverage of organized or spontaneous breast cancer screening for women aged 50-74 by 31/12/2018" "to increase the effectiveness of organized breast cancer screening programs".

There is a need to increase women's participation, again and again; this 2014-2019 cancer plan only addresses the technocratic side of the system and anticipates in its terms what the high authorities want to promote, in defiance of the information to which the female population is entitled and which it has demanded in the meantime during the citizen and scientific consultation on breast cancer screening and its harms[22]. The aim is to keep this screening program on the tracks set in 2013, directed towards intangible five-year objectives.

Epidemiological results

In 2017 (see on the official website of the INVS), in France, among the causes of cancer deaths in women, breast cancer, responsible for 11,883 deaths, comes first, followed by lung cancer (10,176 deaths) then colorectal cancer (8,390 deaths).

 All in total

Observation is still indisputable: In France, the decline in specific mortality (from breast cancer) is not significant, despite the fact that breast cancer has been made a public health priority and that more resources have been devoted to it than to other pathologies.

Mortality from lung cancer, on the other hand, remains a major concern, especially among young people, which the current plan aims to address once again .

One plan followed another, and none of the problems have been solved: smoking continues to take its toll, and cases of breast cancer have risen alarmingly to 54,000/year with an overdiagnosis acknowledged by the authorities, but largely minimized and appearing to these authorities, in no way to question our medical practices, while we still record, despite organized screening, between 11,000 and 12,000 deaths/year, a figure that has been stable since 1996.[23]

Additional remarks before concluding

1°The illustrative image in the article from Le Monde published online, is a skin cancer screening case.

We relay here an interesting podcast[24] in English, on the overdiagnosis of melanoma, a cancerous skin tumor.

Dr. Adewole Adamson's observation is alarming: no reduction in mortality and massive overdiagnosis due to a lowering of the tolerance thresholds used by dermatologists and anatomo-pathologists regarding skin lesions.

Dermatologists request increasingly and more quickly the use of biopsies, while anatomical pathologists prefer to upgrade their diagnosis of lesions examined under the microscope (i.e. to classify as malignant lesions that are simply dubious and that could only be monitored), giving rise to an apparent melanoma epidemic with even more artificial "survivors".

The vicious circle is endless, prompting patients and doctors to do more and more routine skin examinations.

2° specifically on breast cancer

We read in the 6th report to the President of the Republic published in March 2020 by INCa, page 7, prelude to the 2021/2025 cancer plan presented on February 4, 2021 [25]:

A strengthening of the quality of organized breast cancer screening.

"In terms of organization, according to a decree published on February 22, 2019, only digital mammography facilities are now authorized in the program. The decree confirms that the radiologist, as the first reader, must analyze the images on an interpretation console. »

Looking back at the changes imposed to radiologists throughout the history of screening, it is interesting to note that decision-makers have always opted to improve the form, but never to question, the very substance of this system. 
In the course of my career as a radiologist, and since the 1990s, I have witnessed the transition from two to three breast images per breast, to compensate for the problem of interval cancers, which occur between two mammograms and escape screening.

Then we had to complete this "mammotest" with the addition of ultrasound and clinical examination. We therefore went from a "test" to an individual examination in the face of the method's failure!

Then we witnessed the advent of digital mammography, a technology that at first coexisted with analog mammography depending on the radiology office, and now imposed on everyone.

There is no doubt that we will soon see the arrival of tomosynthesis[26] [27],, which is highly radiant and often performed in addition to mammography without the patient's knowledge in some practices, with the prospect of a surge in false alarms and overdiagnosis.

Support for a study experimenting with personalized breast cancer screening.

"An international experiment in targeted breast cancer screening has been initiated. Supported by the French National Cancer Institute, the ARC Foundation for Cancer Research and the Ligue contre le cancer, and funded by the European Union, the MyPeBS (My Personal Breast Screening) study intends to evaluate whether personalized breast cancer screening could be a better screening option for women aged 40 to 70. »

The best proof of the failure of the current screening system is that we are now trying an "individualized" screening, a real trap for women, especially in the younger age groups, since, if deemed at risk, they will have mammograms that can be annual and from the age of 40....

What better way, by means of a study of an arrangement that is as hermetic as it is pernicious[28], to extend screening to age groups that have not been concerned until now because of a benefit-risk balance that has proved harmful for these young women.

These are the continuous "improvements" made to breast cancer screening, a veritable absurd race instead of an in-depth questioning on: rethinking the fundamental relevance of screening.[29]

3°For prostate cancer,[30]

we had already mentioned the problem of overdiagnosis, and had also talked about the problem of thyroid cancer[31], the latter with a predominant impact on women's lives.

Surprising to read in the article from Le Monde "Another challenge: to intensify research to find new screening tests, particularly for lung and prostate cancer. »

A new prostate screening? It's precisely because the old one wasn't very brilliant in terms of efficiency....

And since critical questions are not asked in any media, medical information can shamelessly continue through the show "Stars in the Nude" on French Television, where stars strip to "raise awareness" about screening and for the "good cause", without any respect for scientific data. The presenter, Mrs. Sublet, states in an interview in a feigned modesty that her show is "of public utility"[32].

Last year, in the week following this TV show, our radiology consultations were literally assailed by young men finding "balls" in their purses (absolutely true), and young women in tears who also found various swellings in their chests.No diagnosis was made, all of them were fortunately healthy. All this useless excitement mobilized the already scarce doctor's time, to the detriment of a patient in real need of care.

Conclusion :

A "Soviet" planning that makes a mockery of scientific data

There is no question of providing better information to women or of reducing the number of screenings, we still find objectives set in advance, pre-decided, and built up in minds of technocrats centered on an inventory of figures to be reached.

We see the unfortunate results of the failure of real prevention campaigns (tobacco, alcohol, obesity), with lung cancer inexorably on the rise and deaths in parallel.
     

Why not give priority to health education with real large-scale campaigns instead of a waste of resources to promote screening, most of which, it must be admitted, has no perceptible impact on overall mortality, and on the contrary leads to overdiagnosis in healthy populations, plunging them into pointless situations of ill people?

Why? In a opinion column Annette Lexa, toxicologist, gives some clues[33]:

-"Destructive behaviors have been valued for a long time; hygiene and prevention are supposed not to be hedonistic;

-Curative sector is economically more interesting;

-Occupational cancers continue to be neglected and minimized by the health funds themselves (CPAM, MSA), forcing long, improbable and costly procedures;

-Society, which is so promptly in controlling its citizens when the political and economic system is in danger, pretends to fear that this is an attempt to reduce individual "freedoms" (freedom to smoke, to drink, etc.);

-Tobacco, alcohol, industrial food marketed by advertising bring in a lot of VAT;

-Contraceptive pill, a symbol of female emancipation, yet cancerogenic and endocrine disruptive as proven by the IARC (http://www.cancer-environnement.fr/479-Classification-par-localisations-cancereuses.ce.aspx#Seins), is still and always presented as the most popular means of contraception while skillfully minimizing undesirable effects, so great is the collective stake in sexuality.

-How many young women buy "organic" cosmetics guaranteed free of bisphenol A and parabens presumed to be carcinogenic while taking the pill and smoking?

-Our modern societies have not been able to reinvent the ritual of passage to adulthood, trapping adolescents in risky behaviors (addiction to tobacco, alcohol, drugs, trivialization and precocity of risky sexual practices ...).

-Finally, opportunistic marketing aimed at developing a connivance with women (cosmetics, mutual insurance companies, e-health professionals, "sports" events) symbolizes the power of manipulation and misinformation as well as the cynicism of an entire society busy developing business by giving itself a virtuous endorsement and sometimes even sincerely thinking of clumsily repairing the damage it has itself created, while it should put all its energy (albeit less profitable) into cancer prevention and provide everyone, from a very young age, with the keys to optimal life and health. "

Finally, this new cancer plan was developed under the supervision of the pharmaceutical industry.

And here is our colleague Dr. Gourmelon who explains:

"What is immediately striking in the two press releases, in addition to the means implemented, is the place that the cancer "lobbies" have taken in the prospective group that drew up the 220 proposals with Pr IFRAH. (See Annex 3 of the 29-page press kit).  In this small group of 24 people, we find the representative of the drug companies Mr Eric Baseilhac. He is the director of economic affairs".

Full article available here: https://cancer-rose.fr/2020/12/15/inca-une-consultation-citoyenne-pourquoi/

Broadly speaking, the objectives vary little, and neither do the epidemiological data, demonstrating the inanity of these large plans, which are invariable from one five-year plan to the next, from one president to the next.

In the end, only the easy and demagogic causes remain, giving the illusion of "doing", of grasping the problems, to the great delight of the firms and their "innovations".

Read here: https://ec.europa.eu/commission/presscorner/detail/en/ip_21_342
"Early detection of cancer by improving access, quality and diagnostics and support Member States ensuring that 90% of the EU population who qualify for breast, cervical and colorectal cancer screenings are offered screening by 2025. To support achieving this, a new EU-supported Cancer Screening Scheme will be put forward.
......In addition, to support new technologies, research and innovation, a new Knowledge Centre on Cancer will be launched to help coordinate scientific and technical cancer-related initiatives at EU level. A European Cancer Imaging Initiative will be set up to support the development of new computer-aided tools to improve personalised medicine and innovative solutions."

Références

---

[1] https://www.lemonde.fr/planete/article/2021/02/04/une-nouvelle-strategie-nationale-pour-faire-reculer-le-cancer_6068728_3244.html

[2] https://www.e-cancer.fr/Presse/Dossiers-et-communiques-de-presse/L-Institut-national-du-cancer-publie-le-dernier-rapport-annuel-au-president-de-la-Republique-du-Plan-cancer-3-et-precise-les-echeances-de-la-strategie-decennale-de-lutte-contre-le-cancer

[3] https://www.roche.fr/fr/pharma/cancer/depistage-cancers-france.html

[4] https://consultation-cancer.fr/project/axe-1-ameliorer-la-prevention/consultation/consultation

[5] https://cancer-rose.fr/2020/12/15/inca-une-consultation-citoyenne-pourquoi/

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

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

[8] https://www.e-cancer.fr/Plan-cancer/Les-Plans-cancer-de-2003-a-2013

[9] https://cancer-rose.fr/wp-content/uploads/2021/02/Plan_cancer_2003-2007_MILC.pdf

[10] https://www.santepubliquefrance.fr/maladies-et-traumatismes/cancers/cancer-du-colon-rectum/documents/rapport-synthese/evolution-de-l-incidence-et-de-la-mortalite-par-cancer-en-france-de-1978-a-2000

[11] B.Duperray "le dépistage du cancer du sein, la grande illusion" Ed Thierry Souccar, page 155

[12] https://www.e-cancer.fr/Plan-cancer/Les-Plans-cancer-de-2003-a-2013/Le-Plan-cancer-2009-2013

[13] https://cancer-rose.fr/wp-content/uploads/2021/02/2009-2013.pdf

[14] https://www.santepubliquefrance.fr/maladies-et-traumatismes/cancers/cancer-du-sein/documents/rapport-synthese/estimations-nationales-de-l-incidence-et-de-la-mortalite-par-cancer-en-france-metropolitaine-entre-1990-et-2018-volume-1-tumeurs-solides-etud

[15] https://cancer-rose.fr/en/2020/12/29/analysis-of-harding-american-study-2015/

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

[17] https://cancer-rose.fr/en/2021/01/06/miller-study/

[18] http://www.unicancer.fr/le-groupe-unicancer/les-chiffres-cles/les-chiffres-du-cancer-en-france#:~:text=Cancer%20colorectal%20%3A%209%20294%20d%C3%A9c%C3%A8s,la%20prostate%20%3A%208%20207%20d%C3%A9c%C3%A8s

[19] https://www.who.int/tobacco/economics/taxation/fr/

[20] https://cancer-rose.fr/2016/10/10/a-propos-du-plan-cancer-2014-2019/

[21] https://www.e-cancer.fr/Expertises-et-publications/Catalogue-des-publications/Plan-Cancer-2014-2019

[22] https://cancer-rose.fr/2016/12/15/nouvelles-du-front-premiere-manche/

[23] https://cancer-rose.fr/2016/07/30/mortalite-donnees-de-la-base-cepidc-de-1996-a-2012/

[24] Podcast dermato https://www.youtube.com/watch?v=068KMIe-gys&feature=emb_logo

[25] https://www.e-cancer.fr/Expertises-et-publications/Catalogue-des-publications/Sixieme-rapport-au-president-de-la-Republique-Mars-2020

[26] https://cancer-rose.fr/2019/11/28/avis-de-la-haute-autorite-de-sante-sur-la-performance-de-la-mammographie-par-tomosynthese-dans-le-depistage-organise/

[27] https://cancer-rose.fr/2019/03/09/association-de-la-tomosynthese-versus-mammographie-numerique-dans-la-detection-des-cancers/

[28] https://cancer-rose.fr/my-pebs/2019/06/13/argument-english/

[29] l'étude dont on rêvait : https://cancer-rose.fr/my-pebs/2019/03/09/letude-dont-on-re%cc%82vait/

[30] https://cancer-rose.fr/en/2021/02/11/parallel-to-breast-screening-prostate-screening-overdiagnosis-as-well/

[31] https://cancer-rose.fr/en/2021/02/01/overdiagnosis-of-thyroid-cancer-another-womans-concern/

[32] https://m.youtube.com/watch?v=7NQOTNDeM1c

[33] https://cancer-rose.fr/2016/11/05/la-vraie-prevention-parent-pauvre-du-plan-de-lutte-contre-le-cancer-du-sein/