Update on Tomosynthesis

May 17, 2022

Article in Auntminnie

Reminder: Tomosynthesis (or 3D mammography) is a radiological imaging technique that reduces the effect of superimposition of breast tissue as it reconstructs a three-dimensional image of the breast from several low-dose X-rays acquired from different projection angles.

This technique was heavily promoted about 10 years ago. Therefore, a review is done after 10 years of hindsight in the media "AuntMinnie.com."

This is a community website for radiologists and professionals in the medical imaging industry. According to this rather collaborative media that connects radiologists, business managers, and industry professionals to "meet, do transactions, research and collaborate," tomosynthesis has clearly disappointed.

Many questions and doubts about the benefit of using this technique have been raised previously:  https://pubmed.ncbi.nlm.nih.gov/30816931/

- tomosynthesis does not reduce false alarms
- the additional use of tomosynthesis does not reduce interval cancers
- tomosynthesis would increase overdiagnosis
- the benefits of tomosynthesis are not clear

1° Cancer detection

Digital mammography alone has been compared with digital mammography + tomosynthesis (a higher-radiation combination): matched studies* have shown that the addition of tomosynthesis made it possible to find more cancers: 8.8 per 1000 women compared with 6.4 per 1000. But in other unmatched studies*, the difference was narrower, 5.7 cancers detected per 1000 women versus 4.5.

* Matching consists of setting up pairs (1 case and 1 control) with the same characteristics (e.g., age) to compare the results while avoiding potential confounding factors. The groups are thus "balanced" on these characteristics.

2° Recall rates

What about recall rates? The recall rate refers to false alarms during screening, i.e., suspicions of cancer that will not be confirmed, but only after recalling the patients who will need to have other complementary explorations before deciding on these suspicions. Here again, the data vary according to the study conducted.

Based on the March 2022 study summarized here, repeated breast cancer screening with 3D mammography only modestly decreases the risk of having a false-positive result compared with standard digital mammography.

What can we learn from this study?

The risk of a false-positive result was lower when screening was performed every two years instead of every year and in the case of non-dense breasts and older women.
However, the difference was modest, and the reduction in false positives by using 3D mammography was only 2.4% compared to standard mammography.

3°How effective are synthetic mammography images?

In 2012 an opening was made for 'synthetic imaging,' which records a single radiological acquisition and therefore delivers a single dose of radiation, thus avoiding the over-irradiation caused by 3D mammography**.

But are the synthesized images an effective alternative to digital mammography images? Clinical results of effectiveness tests of synthesized mammographic images are unfortunately mitigated. Overall, the results between synthesized images are equivalent to digital mammography, although the latter has a better resolution.

**Classically, 2D mammography and 3D tomosynthesis acquisitions are used in combination. This results in a significant increase in the X-ray dose delivered. The X-ray doses delivered by combining 2D mammography and tomosynthesis are about twice the dose of 2D mammography alone.
Synthetic 2D tomosynthesis is an alternative, obtained by reconstruction from 3D acquisitions only; it avoids the joint use of 2D mammography and thus reduces the delivered dose.

4° Does tomosynthesis reduce mortality?

Does tomosynthesis result in a reduction in mortality? According to this article in Autminnie.com, a survey of eight studies conducted between 2016 and 2021 investigated whether tomosynthesis reduces rates of interval cancers (cancers not caught by screening because they occur between two mammograms) compared with digital mammography alone. Interval cancers are often very aggressive and occur quickly, thus missed by screening. They are correlated with mortality because their intrinsic aggressiveness endangers the survival of women, often because of their metastatic potential.

It was found that tomosynthesis does not impact the rate of interval cancer.

In conclusion

Ten years after its use, the benefits of tomosynthesis may be much more modest than clinicians initially expected. In conclusion, this technique is finally similar to digital mammography with no proven advantage.

Even if the detection rate of tomosynthesis seems slightly better, the benefit of this technique remains an open question. If this moderate improvement in cancer detection is gained at the cost of increased overdiagnosis, we cannot conclude that the benefit/risk ratio is favorable.

As usual, the major concern is the information provided to women, as tomosynthesis is sometimes performed in radiology offices without the knowledge of the patient who comes for a routine mammogram, who does not benefit from it and is exposed to unnecessary over-irradiation.

Also read: https://www.bmj.com/content/366/bmj.l4506




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


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

When marketing, finance, lobbying, and advertising invite themselves into the health care sector

Commercial determinants of cancer control policy (Eurohealth)

https://eurohealthobservatory.who.int/publications/i/commercial-determinants-of-cancer-control-policy-(eurohealth)
European Observatory on Health Systems and Policies (downloadable)

27 April 2022, Journal article
Summary by Dr. Cécile Bour - 30 April 2022

In this Eurohealth report, the authors focus on the negative influence of private interests on prevention, screening, and healthcare policies.

Cancer control, as defined by WHO and also often referred to as "cancer prevention and care," consists of a continuum from prevention, early detection (i.e., screening and early/rapid diagnosis of symptomatic patients), diagnosis, and treatment, to palliative/supportive care and survivorship

A definition of "the commercial determinants of health" was presented to the United Nations (UN) General Assembly 2017: "The commercial determinants of health are those conditions, actions, and omissions that affect health. Commercial determinants arise in the context of the provision of goods or services for payment and include commercial activities, as well as the environment in which commerce takes place.
Generally, private sector activities that impact population health."
This issue of the commercial determinants of cancer, referred to as the "dark side of health," has not yet been thoroughly explored.

According to the World Health Organization (WHO), 30-50% of all cancer cases are preventable, with tobacco use being the leading preventable cause of cancer in Europe. Other important risk factors are alcohol consumption, overweight and obesity, poor diet, and insufficient physical activity.
Added to this are sources of radiation and other chemical carcinogens, including from the cosmetics industry. These sources also increase the risk of developing various forms of cancer.

Europe is one of the largest markets for alcohol sales and is also the region with the highest proportion of alcohol-related diseases and premature mortality.
Europe has the highest average current tobacco use among adolescents. The evidence for a causal link to cancer is indisputable.
Of course, various behavioral and environmental factors account for the increased incidence of cancer. Many are preventable, but corporate interests and actions undermine public health efforts to combat them.

The response to industry criticism takes many forms. It ranges from threats of legal action for infringement of the industry's commercial rights, including intellectual property and economic freedom, to concerns that constraints on the industry will have a disproportionate impact on the economy and employment.
Other examples of industry tactics include enhancing corporate reputation (the concept of corporate social responsibility (CSR)*), denying the impact of their products or diverting attention from the harms caused by their products, and attempts to build an "evidence" base and then divide the public health community.
The bottom line is that the impact of tobacco and alcohol industry players on the cancer continuum includes a range of effective tactics that undermine public health, including recent direct marketing** to consumers.

* Companies consider environmental, social, economic, and ethical issues in their activities.

** Direct marketing is a communication and sales technique that consists in broadcasting a personalized and inciting message to directly reach a target of individuals to obtain an immediate and tangible reaction.

Deceptive drifts

A-Innovation as a panacea

It is striking that most of the articles reviewed in this report raise a particular concern, namely a blind and deceptive faith in "innovation."

Innovation has great appeal to policymakers, clinicians, the public, and donors, but all authors caution against launching new preventive, diagnostic, or therapeutic innovations without a rigorous evaluation of their basic safety and benefit to the population and call for an adequate evidence base to demonstrate their effectiveness and cost-effectiveness.
They also remind us of the rapid growth in pharmaceutical revenues generated by the sale of cancer drugs, despite a lack of return in terms of survival or cure during the same growth period.

B- Screening

The Council of the European Union still recommends screening for cervical, breast, and colorectal cancers, but with more nuanced information, and has published a guide to the proper use of systematic screening.

Since then, research continues to evaluate the advantages and disadvantages of screening, particularly for other types of cancers (lung is under study).

Despite an evidence base that does not support such practices, much "opportunistic" (i.e., off-recommendation, requested by a public demanding more medical care) screening occurs across Europe.
Managers and sales representatives play an essential role in promoting systematic testing practices that can do more harm than good (see the massive sponsorship at Pink October).
Commercial drivers can work through financial incentives, creating a "culture" that promotes rapid adoption of new technologies, lobbying, and marketing to clinicians and consumers.

The report says that many people may be included in irrelevant screenings, and resources may be diverted from those most in need of medical attention and treatment.
Overdiagnosis, in particular, is currently a specific problem. Since, at the individual level, it is not possible to determine whether cancer will progress or not, healthy people may be subjected to potentially unnecessary diagnostic procedures and treatment, with a consequent risk of adverse effects.

For example, thyroid screening has no benefit for the population but provides considerable evidence of massive overdiagnosis and unnecessary therapeutic procedures.

The first wave of cancer screening tests was developed mainly in the public sector and promoted by charities and professional bodies. There is a new wave of innovation in cancer screening, and much of this innovation comes from the private sector, often supported by professionals.

Diagnostic companies have become essential players in promoting new screening technologies, private laboratories and clinics may seek to expand the market for screening services by offering new technologies (such as 3D mammography) or expanding into disease areas not covered by national programs, which could increase public demand and intensify political pressure for their adoption within public health systems.

There has been a lot of commercial enthusiasm for cancer screening (such as predictive software, see for example here and here), industry analysts predicting the potential for "drug-like blockbuster revenues."

Companies developing new cancer screening technologies based on liquid biopsy have attracted huge billions of dollars in private investment. The technology has been very disappointing in screening, clinical studies that lack the rigor to assess the harms and benefits of this technology fully and accurately have been published to great media hype, and a phenomenon of "capture" of key opinion leaders has been added, through research collaboration with industry.

There is evidence, according to the report, that the new generation of molecular testing is being marketed using strategies that come directly from the pharmaceutical industry: recruitment of key opinion leaders, direct-to-consumer advertising, direct-to-physician advertising, and funding of NGOs, including patient organizations, to engage in ostensibly independent lobbying for government adoption of new technologies.
The commercial drive to generate revenue leads to distorted messages that present a partial view of the scientific evidence, biased towards claimed health benefits but obscuring potential harms, resulting in unnecessary public expenditure.
Carefully crafted public relations strategies can ensure media coverage that reinforces this unbalanced image, such as liquid biopsy molecular tests, 3D mammography, and artificial intelligence-based detection, which are heavily geared toward declaring tremendous benefits to populations and generally fail to report conflicts of interest.

C-Hyper-technology

Da Vinci Robot: this device is put forward in the report as the archetype of NPT (non-pharmaceutical technology).

Few technologies better represent the commercialization of the so-called NPT than the Da Vinci Robotic Surgical System.
This device, which allows surgeons to perform surgery remotely, sitting at a console to operate remote-controlled arms for micro-invasive surgery, was first approved by the U.S. Food and Drug Administration (FDA) in 2000.
Despite the lack of clear evidence of its superiority over open and laparoscopic techniques and its enormous costs, the method has been widely adopted throughout Europe, even in countries with lower living standards. Its inherent benefits, including improved visualization of the surgical field, greater range of motion of the robotic arms, and improved ergonomics for the surgeon, were expected to translate into improved patient outcomes. However, in the case of prostate and rectal cancer, no improvement in functional or oncologic outcomes was observed.

This is even though guidelines have been created to improve the rigor of evidence collection, particularly for medical devices.
Regulatory approval of a new medical device or technology requires clinical data and a demonstration of its safety before bringing the device to market.
In comparison, systemic therapies must go through a more complex process of demonstrating efficacy beyond current standards of care. This partly explains the lack of randomized controlled trials for medical devices.

However, the recent Cumberledge review highlighted the devastating impact of integrating drugs and devices without rigorous and thorough evaluation of the implications for patients, especially in terms of safety and health benefits. Unfortunately, the design of studies used to evaluate new technologies often lacks rigor. However, it can form the basis for clinical implementation, with less reliable single-center retrospective series still dominating the literature.

D-Lack of balanced media coverage

This drift can influence public perceptions and those who make decisions about funding biomedical research and clinical care, exacerbating general support.

We refer here to the enormous enthusiasm for innovation and, in particular, the idea of personalized or precision medicine, rooted in the long-standing belief that genomics will revolutionize the practice of medicine, a view now reinforced by faith in the transformative potential of digital technologies, including artificial intelligence

Public policymakers are prone to this form of buy-in, which can have two potential adverse effects on public health, including:

- a willingness to adopt new technologies because they are believed to represent the future of health care, without solid evidence that they improve clinical outcomes;

- misallocation of research resources, as funding goes to the discovery and development of new technologies, at the expense of simpler incremental improvements in care delivery, such as improved rapid clinical diagnosis for patients with actual potential symptoms of cancer

This can be a waste of resources, but in countries that lack qualified technicians in areas such as imaging or endoscopy, it exacerbates these shortages and delays in diagnosis for symptomatic individuals. It also exacerbates growing inequalities in access to medical care.

The landscape of commercial screening offerings is being transformed by innovation in diagnostic technologies and the broader development of the Internet as a new mechanism for consuming health care. In recent years, various consumer biological testing services sold over the Internet have been the subject of regulatory action.

In conclusion, and as Ioannides noted, medicine and health care waste society's resources because "we" as clinicians have allowed evidence-based medicine in cancer to be diverted by using technologies with marginal effectiveness but maximum cost.

The commercial determinants of cancer remind us that both governmental and whole-of-government approaches (combining vertical and horizontal management while partnering with organizations outside of government) are essential to meeting the challenge facing our society and that health decisions remain a political choice.

Range of ways in which private interests influence public health

1. Financial incentives affect all areas of health

- Economic incentives are misaligned with the promotion of overall quality of life.

- There is a misrepresentation of clinical information and public health data. (For example, in breast cancer, read here and here)

Economic incentives drive the development of new drugs with increasing applications, leading to trials over weak comparators (e.g., non-inferiority studies) and approvals based on modest effects in new settings.
In discussing the development of new screening technologies, diagnostic tools using molecular biomarkers, new precision therapies, or targeted drugs, all authors of the WHO report raised concerns about whether a drug or device efficacy measures were validated correctly.
Measures of benefits may or may not track in parallel outcomes that matter to patients, such as data on reduction in overall (all-cause) mortality or parameters such as quality of life; several of the report's authors expressed concern about how social factors and economic incentives have shaped clinical care, advertising, and investments in ways that do not promote the health and well-being of patients overall.

2° Lobbying

On behalf of the industry, and with the complicity of physicians and opinion leaders, the promotion of cancer screening research and technology development has led to an overemphasis on the benefits of these tools and technologies. It underestimates the harms of false positives or overdiagnosis.

3. Advertising

Many authors have drawn attention to the misleading nature of advertising and media communication about cancer risks and treatments.

They have raised concerns about the overselling of cancer drugs and new and unproven technologies.

4° Economic factors

Economic factors influence the rising costs of care, which disproportionately affect the most disadvantaged. For example, the uncritical press for new drugs and "technomania" has contributed to the increasing costs of new drugs and screening technologies, making access to care even more difficult for many patients, particularly those in developing countries.

Regulatory tools could encourage investment in actual prevention measures (alcohol, tobacco, obesity, physical inactivity), better palliative care, and more integrative care.

There is also a need for improved medical education on the roles of commercial interests in shaping cancer care, which may already mitigate tendencies toward "technomania" among physicians so that medical students have a better appreciation of the costs and benefits of new treatments and technologies, as well as the importance of palliative and end-of-life care with better patient integration.

How can we do better?

In summary, there are ethical and justice issues everywhere, and these issues have to do with respect for patient autonomy, equity, and beneficence.
Autonomy, with strong patient support and transparent communication about the benefit-risk balances of health devices.
Equity and justice about risk identification and prevention, early detection, alternative solutions, therapeutic solutions, and palliative care appropriate to the patient's real need.

Regulatory tools need to be developed to improve medical education, emphasizing transparency. Public administrations, national governments, and international agencies can do, and civil society can demand to mitigate the harms associated with conflicts of interest.

The authors also note a clear need for high standards, both at the level of the European Medicines Agency and through more robust health technology assessment mechanisms, with more sophisticated pricing and reimbursement systems at the national level.

The inadequate quality of research and regulatory standards and the critical lack of correlation between economic incentives and what is sought in terms of overall patient quality of life is a critical issue.



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


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

Cancer Screening—The Good, the Bad, and the Ugly

JAMA Surg. Published online April 6, 2022. doi:10.1001/jamasurg.2022.0669
https://jamanetwork.com/journals/jamasurgery/article-abstract/2790973

H. GilbertWelch,MD, MPH-Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts.

In clinical practice to say that a person has cancer gives as little information about the possible course of his disease as to say that he has an infection. There are dangerous infections that may be fatal and there are harmless infections that are self-limited or may disappear. The same is true of cancers. Cancer is not a single entity. It is a broad spectrum of diseases related to each other only in name. George Crile,MD, cancer surgeon 1 (p128)

Dr Crile’s recognition of the heterogeneity of cancer growth

Dr Crile's recognition of the heterogeneity of cancer growth in a 1955 issue of LIFE magazine presaged why early cancer detection might defy simple intuition. It is tempting to think that cancer screening can only help individuals and that all survivors of cancer detected by screening provide powerful evidence that it saves lives. However, cancer screening is counterintuitive. It turns out that the harms are more certain than the benefits; the survivors are less likely to be evidence of its benefit and more likely to be evidence of its harms.

Dr Criles uses an analogy of a barnyard pen :

The bird is a very fast cancer (missed by screening). The bear is a slow cancer, caught by the screening but which, not screened, would have manifested itself just a little later by a clinical symptom without loss of chance. The turtle and the snail represent very slow and stagnant cancers, for which screening is useless, because they would never have manifested. The patient dies with her cancer but not because of it.
The birds have already escaped the barnyard: they are the fastest growing and most aggressive cancers, those that have already spread by the time they are detectable. Screening cannot help with the birds.

Editor's note, another representation:

Limited (or Uncertain) Benefit

The goal of cancer screening is to reduce cancer mortality. Screening tends to miss the fastest growing cancers (the birds) because these cancers have such a short time window during which they are detectable by screening, but they are not clinically evident. Furthermore, effective screening requires not only earlier detection, but also treatment initiated earlier is reliably better than treatment initiated later.
Now we can notice that as cancer treatment improves, the benefit of screening decays. If clinically detected cancer can be routinely treated successfully, the utility of cancer screening naturally falls to zero.

Poorly Recognized (or Hidden) Harms

From an individual’s perspective, overdiagnosis is the most consequential harm of screening.
Overdiagnosis is so rarely confirmed in an individual (ie, a patient with a cancer that is detected by screening but is not treated, never develops symptoms, and dies of some other cause), so there was considerable debate about whether the problem really existed.
However, overdiagnosis can be easily confirmed at the population level. Thus, debates about the existence of overdiagnosis are now largely settled and have rightly moved to the question about its frequency— and how much it matters. In the case of breast, prostate, skin, and thyroid cancer screening, patients are more likely to experience the harm of overdiagnosis than they are the benefit of screening—avoiding a cancer death.

Problem is: many individuals must be screened to potentially benefit a very few. Roughly 1000 people must be screened to avert 1 cancer death in 10years.2 Thus, questions about what happens to the other 999 individuals become relevant.

Another issue apart from overdiagnosis: false alarms affect many: there are as many as 600false-positive results in a 10-year course of mammography.3 However, the bigger problem is that many people with false-positive test results are not told that the test was wrong, but rather that something is wrong with them.

Misleading Feedback, Financial Incentives, and Distraction

These harms might be acceptable were they accompanied by substantial and certain benefit. Unfortunately, screening itself provides misleading feedback that always suggests it is more beneficial than it really is.

As shown in the example in panel B of the Figure, the proportion of late-stage cancers detected falls from 50% to 25%, despite no change in late-stage incidence. Over time, 5-year survival rises owing to the combined association of lead time and overdiagnosis bias, even if the age of death is unchanged. Survivor stories are particularly pernicious: the more overdiagnosis from screening, the more people there are who believe that they owe their life to the test—and the more popular screening becomes.4 (click on the picture below)

Editor's note: In fact, if overdiagnosis could be completely eliminated, the proportion of advanced cancers would appear to be greater in the total number of cancers minus overdiagnosis, which usually amplifies the total number of cancers. The proportion of advanced cancers is diluted in the total cancer count when the proportion of overdiagnoses is added to this total. See the screening paradox:

Pr Welsch's conclusion

Dr Crile believed that medical care should be driven by patient needs, not surgeon needs (or now, system needs). He recognized there was a price to be paid for getting ahead of symptoms. Although cancer screening may make sense in selected high-risk individuals, I believe general population screening, as currently practiced in the US, has become a huge distraction to our core work.  It distracts the system away from acutely ill and injured patients: as physician performance is measured in terms of how frequently they test the well and not how well they care for the sick. General population screening distracts patients and policymakers away from the genuine determinants of human health. The tremendous resources involved in screening—in terms of money, people, and effort— would be better directed elsewhere.

References

1. Crile G Jr. A plea against blind fear of cancer. Life. 1955;128-142.

2. Welch HG. Evidence on cancer screening efficacy in randomized trials & effectiveness in US practice. Accessed March 2, 2022.
https://csph.brighamandwomens.org/wp-content/uploads/2021/12/Evidence-on-Cancer-Screening-Efficacy-in-Randomized-Trials-Effectiveness-in-United-States-Practice.pdf

3. Hubbard RA, Kerlikowske K, Flowers CI, Yankaskas BC, ZhuW, Miglioretti DL. Cumulative probability of false-positive recall or biopsy recommendation after 10 years of screening mammography: a cohort study. Ann Intern Med. 2011;155(8):481-492. doi:10.7326/0003-4819-155-8- 201110180-00004

4. Raffle AE, Gray JM. Screening: Evidence and Practice. 2nd ed. Oxford University Press; 2019.

Read more: https://cancer-rose.fr/en/2020/12/17/are-small-breast-cancers-good-because-they-are-small-or-small-because-they-are-good/

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


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

Dual-energy angiomammography

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

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


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

October, the cruelest month?

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.


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


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

BOOK “IM-PATIENTE”

NOVEMBER 2, 2021 BY CANCER ROSE

BOOK “IM-PATIENTE”, a feminist exploration of breast cancer

Publisher First Editions

By Mounia El Kotni and Maëlle Sigonneau

Mounia El Kotni is an anthropologist specializing, among other subjects, in health issues.

Maëlle Sigonneau was an editor. She disappeared in 2019 due to metastatic breast cancer. We hear her speaking in a podcast of Impatientes for Nouvelles Ecoutes in 2019 (a series of podcasts was then produced around the theme of breast cancer to tackle the injunctions addressed to women more globally by the medical profession and society).
The book is a continuation of the podcast, and it addresses the social and feminist impact of the disease through the eyes and experience of Maëlle. It talks about medical mistreatment and administrative violence. It highlights the sexist injunctions aimed at not harming society and masking this disease, disguised in pink and glamorized in October Rose campaigns.

This powerful book goes beyond the sole theme of cancer to resonate with all those who suffer from chronic illness.

Injunctions to femininity

"Are you having chemotherapy? Then the most important thing is to moisturize your skin, ok ?"

Is this really a caring concern of the pharmacist? Or is it the reflection of a society afraid of disease that the image of a sick woman sends back to it? The patient just wants to live, survive, and grow old...like the rest of us.

"It's important not to let go!" Are men told not to let themselves go after an illness?

What if we told women that there are certainly available moisturizers, wigs, breast prostheses, but only if they want them. And they have the right to be tired, makeup-free, bald, and refuse breast reconstruction.

Injunctions to procreate

A visit to a fertility clinic is one of the first steps in the process for young women. Although oocyte preservation is not compulsory, the book explains how years of preparing women to be mothers push them to save their oocytes "just in case," even if they do not plan to have children.

This oocyte conservation project is offered within days of the announcement. The book underlines to what extent specific accesses in health (here fertility preservation) are made fast, fluid, and obvious when society considers it legitimate. At the same time, some categories of people (homosexual couples) encounter many obstacles and exclusions in their medically assisted procreation process.

Injunction to breast reconstruction

The deletion of the sick body also involves breast reconstruction. The prosthesis is often a way for women to return to "normal" to go back to the condition of "before cancer." This wish is encouraged by society; the presence of breasts in pairs seems indispensable.

However, 70% of patients abandon breast reconstruction for various reasons, including a lack of surgical options or budgetary constraints.

Injunction to screening, injunctions by Pink October

The book also talks about how women are solicited during the Pink October campaigns without giving them easier access to more measured and objective scientific information.

When a woman questions the relevance of this screening in societal, media, or medical messages, she is constantly criticized, either for being imprudent or inconsequential. On the other hand, she is called stupid or "indoctrinated" and uncritical when she strictly follows official recommendations.

Women's interests are frequently put second; for the manufacturers of screening tests and mammography machines, medicine is just a market, and the people who persuade politicians to make public health decisions are those who have something to sell and a stake in the pursuit of those public health policies.

Finally, women become permanent subjects of medical surveillance and disease and cancer detection, making them "walking" risk factors...
They do not benefit sufficiently from decision-making tools with balanced information, which our collective Cancer Rose continues to denounce.

Pink October has become a market; there is no real national campaign of information. There, too, the image of a naked woman is used to promote a product, even if it is a medical examination.
We always hear the same stories about women who have beaten cancer, but do we hear about women who have serious cancers from the start, metastatic cancers for which medicine is still rather helpless?
Behind the pink mask hides concealment of less pleasant and less "glamorous" facts.

Pink October is a marketing tool that allows products to be sold under the pink label, but the amount of money collected and donated to research and its use is rather obscure.

Injunction to beauty

Are the "beauty workshops" offered to women after their treatments of real benefit to patients, or is it a lucrative business? Often, the workshops are free, but as the saying goes, "when it's free, you're the product to sell."

The products are, most of the time, completely conventional. It is not because the product is offered that it is necessarily without ulterior motive. It is necessary to be cautious of what is proposed; the products are not necessarily "organic" or "natural," as one might expect.
The cost of these products adds up to a loss of income for many patients. Half of the people have an out-of-pocket expense; some dental care for dental conditions secondary to treatment are not covered.

30% of women over 50 years old do not return to work within two years, and 20% of those who return to work only return part-time.

Earnings drop

Within two years of being diagnosed, three out of every ten women lose or quit their job. Women who become ill are frequently concerned about being perceived as underperforming, and their self-esteem suffers as a result.

Despite financial support, 60% of women experience a drop in income at the end of a labyrinth of procedures.

Information about administrative procedures is also difficult to obtain, and there are numerous bureaucratic obstacles. This also causes a lot of stress for the patients.

Injunction to perform, including in the context of sexuality

Women with breast cancer must continue to fulfill their societal roles. They are not always supported at home or work. The cancer survivor is portrayed as a fighter, a warrior.
This puts a tremendous amount of pressure on women because this is frequently how she is portrayed: as a woman who has overcome the disease, returns to work, grows out of it, and resumes a normal love life.
These are significant injunctions that deprive women of being simply individuals, sick human beings who need the care of others.

After illness, a woman is six times more likely to be abandoned by her partner.
After two years, 21% of ill women had been abandoned by their partners, while only 3% of ill men had been separated.

Injunction to sexuality

To recover its "life as a woman "is a way of saying "to regain her sexuality. "And this injunction, the women are the ones who receive it.

"Do not let yourself go and remain desirable." The book asks the question, "...who are the real beneficiaries of these injunctions: the women or their (supposed) partner? Does "maintain sexuality" despite cancer suit women, or does it rather suit society?"

Making women feel guilty

The current discourse on cancer prevention is based on making women feel guilty, blaming their lifestyle. The fight against cancer is oriented, on the one hand, towards an injunction addressed to women to make "the right choices" and to live healthily, and on the other hand, towards a technological approach in early detection by mammography.

However, a third option is being overlooked: the implementation of ambitious environmental health policies.

In 2017, cancers represented the second largest health care expense for Social Security.  These changes and progression cannot be explained solely by aging or demographic change. Addressing real environmental problems is critical. However, prevention through environmental cleanup is costly, whereas so-called prevention, based on early cancer detection, is highly profitable for the imaging and pharmaceutical industries.

The charities

Maëlle denounces the sometimes clumsy and misplaced charity of organizations.

She feels that people in these organizations essentially solve their problems by making believe that they are helping. Maëlle denounces this intrusive and infantilizing help that she experienced, with the distribution of daffodils, for example, in the hospital's vicinity, at the end of her chemotherapy treatment...

Maëlle explains a need for adapted social care; the emergency is not the cancer that everyone talks about, with a good prognosis, curable. The priority for research should be on these serious, immediately metastatic cancers.

Feminism

For Maëlle, the fight is also a feminist one.

Men had succeeded in attracting the attention of public officials in the fight against AIDS. Metastatic breast cancer has less visibility in Maëlle's opinion because it affects women, who have less space to express themselves.

To break free from compassionate behaviors and the glamorization of cancer, we would need to boycott Pink October, replacing pink messages with large posters on endocrine disruptors; we could imagine a month where conferences on advanced and metastatic breast cancer would be organized, and where we would raise awareness about the carcinogenic effects of pesticides, for example...

Instead of covering up this disease with pink, we must demand ambitious public policies, mobilize research (more on the risks of dying from cancer than on the risks of knowing a cancer in one's life, on the genetic determinants and the association with obesity and with certain atypical breast hyperplasias, Editor's note), improve the difficult daily life of the sick women.

The theme of this courageous book goes beyond metastatic breast cancer. Chronic diseases are a silent epidemic that should push us all to get involved in the real issues of public health.

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


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

INCa still outrageously dishonest and unethical

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/

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


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

Health screening needs independent regular re-evaluation

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

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


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

Screening campaigns: a move toward greater caution?

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

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


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

Mammo or Not Mammo ? A book for women (in French)

Cécile Bour, MD, Radiologist

August 4, 2021

Mammo or Not Mammo ?

Should I have a breast screen ? 

Book published on August 28, 2021

The media, health insurance, and doctors make all women aware of the benefits of breast cancer screening... but how many know that having a mammogram every two years involves risks, some of which have a negative impact on women's health and lives?

In this book, I will give you all the information you need to make an informed decision about whether or not to participate in breast cancer screening.

For this, I started with questions from patients that I collected during my consultations and answered as didactically as possible because a screening process is not an obligation but rather a personal choice that should be considered, provided that one is appropriately informed.

Editor's website

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


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