What is a screening mammogram ?

There is a difference between a screening mammogram and a diagnostic mammogram.

  • A screening mammogram is the routine mammogram that you are asked to have every two years, even though there are no symptoms, upon screening invitation letter
  • A diagnostic mammogram is one that is prompted by the appearance of a sign or symptom in the breast. This symptom requires an exploration by mammography, among other imaging techniques, in order to identify and diagnose the problem in the breast.

What are the major signs that should lead you to consult?

  • Modification of the roundness, of the general shape of the breast (irregularities, distortions).
  • Retraction of the nipple
  • Recent lump or swelling, especially if there is little mobility when palpated.
  • Flat, i.e. the flatter area of the breast, which disrupt the roundness of the breast.
  • Bloody discharge
  • Unexplained redness
  • Lump in the armpit, persistent or increasing in volume
  • "Orange peel" with the appearance in the affected area of "pads", small blisters perceptible between two fingers.
  • Wound on the skin, due to ulcerative cancer
  • Swelling and firmness of the entire breast
  • Deeply palpable mass, occurring without visible external deformation
    Beware, not all of these signs are typical of cancer; they can also be indicative of benign breast disease! Nevertheless, they should motivate you to consult a doctor.

Screening mammography is not a prevention method.

-Preventing a disease means doing everything possible to ensure that it does not occur. For example, avoiding smoking is a good preventive attitude towards lung cancer.

-Screening is searching for a disease in a person who has no symptoms, and who does not complain about anything at all. Repeating mammograms can in no way prevent breast cancer. The mammographic image restitutes what is already present in the organ.

How does a mammography screening take place in France ?

In practice, the woman notified to attend makes an appointment at the radiology office of her choice. She will have a mammography exam followed by an ultrasound examination depending on necessity (dense breasts or radiological abnormality to be clarified). These images will be interpreted by the radiologist, who is the "first reader" of the examination. He will make a report and propose a classification of the examination (see below). This file (images and report of the first reader) is sent to the departmental structure in charge of managing the screening depending on the patient residence. The images will be reviewed there by another radiologist, the "second reader" , coming from another radiology office or medical imaging structure, and who does not know the woman patient. He will establish his verdict without having seen or questioned her, only on the available images. He will 'report' his verdict in the form of a classification, either in concordance with the first radiologist reader or, on the contrary, in discordance, which will imply a call back of the woman patient for further exploration.
Mammography classification is a radiological classification, depending on the greater or lesser degree of certainty that the imagery pleads in favour of a cancerous lesion. It is by no means a prognostic classification. The ACR (American College of Radiology) classification was developed in 1990. There are 5 stages.

ACR 1: normal, the breast is "nothing to report".
ACR 2: images which are just benign abnormalities, such as small axillary ganglions, micro cysts, benign calcifications, images which are not always known what they are but which have remained unchanged for ages, amorphous fibro-adenomas, or cysts which are already well known.
ACR 3: an image which is not worrying but whose outcome are wished to be checked, which has not been known before, or which was been known but has changed slightly compared to previous evaluations. The proposed conduct is a single monitoring at 4 or 6 months, depending on whether masses or calcifications are involved, and then eventually at one year.
ACR 4 means that there is a high probability of cancer, and in any case a suspicious anomaly, to be further investigated. ACR4 therefore automatically implies a biopsy, under ultrasound (micro-biopsy) or under radiographic control, by a mammotome procedure (macro-biopsy), or directly by biopsy-exeresis.
ACR 5: the anomaly is very strongly suspected of malignancy and the semiological criteria are quite representative and typical of malignancy.
ACR 0 designates an incomplete examination to which other imaging examinations must be associated.

For more explanations and details read here: https://cancer-rose.fr/en/2020/12/30/arc-classification/
Below is a diagram that illustrates the possible situations during a mammography screening.

Click to enlarge

You can see the so-called "false alarm" situation. This is the suspicion of cancer, on a mammographic image, but which will not be confirmed after further examinations. These additional examinations are sometimes heavy, and sometimes even result in biopsies, the number of which has greatly increased since the screening in place, this situation being favoured by the double reading. Experiencing a false alarm is often very stressful, as the woman has to wait sometimes several days or even weeks for confirmation of the absence of disease. For every 1,000 women over the age of 50 participating in screening for 20 years, there are an estimated 1,000 false alarms in France, leading to 150 to 200 unnecessary biopsies (Revue Prescrire, February 2015/Tome 35 N°376).

This is, along with overdiagnosis and radiotoxicity, the third harmful effect of mammographic screening.

False alarm and overdiagnosis aren't the same thing, don't confuse both !

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.

What is radiotherapy ?

Radiotherapy is the administration of radiation in order to destroy cancer cells and prevent them from multiplying. It must be targeted to avoid damage to the vital organs around.
Radiotherapy for breast cancer, which follows very frequently the surgical treatment, can nevertheless cause side effects, which may not be revealed until later. These effects may be local, directly affecting the irradiated organs, or general, and of variable expression depending on the sensitivity of the individuals.

-Local effects, more or less late :

Cutaneous effects, simple redness even radiodermatitis.

Pulmonary fibrosis causing the lung tissue to lose its elasticity.

Coronary heart disease, heart rhythm disorders, heart troubles, congestive heart failure.

Radio-induced secondary cancers, on the oesophagus, lung, skin, ribs.


-General effects :

Fatigue

Anaemia

Inappetence

Decrease in the number of blood cells

INDIVIDUAL RADIOSENSITIVITY

Another insufficiently addressed problem of radiotherapy for breast cancer is the uneven radiosensitivity among women. The breast is a highly radiosensitive organ, and repeated breaks in the DNA strands contained in breast cells can lead to mutations over time and can lead to secondary, treatment-induced cancers. However, this effect occurs in a variable way depending on whether one is radioresistant or moderate or hyper-radiosensitive.

The fact is that 25% of the population has this hypersensitivity to radiation which predisposes them, due to a deficit in their cellular repair mechanisms, to increased mutations and potential secondary radiation-induced cancers.

As explained above, radiotherapy treatments for breast cancer, which deliver repeated doses per session and over several sessions, are of course targeted at best, but there is a risk of radiation-induced cancer beyond the targeted area, especially if one belongs to the 25% of people who are particularly vulnerable to radiation. In spite of the very high individual variability, therapists continue to administer the same doses for all, without any testing to predict the individual radiosensitivity of patients. However, these tests do exist, and it would be urgent to inform patients about the existence of these tests to assess their own radiosensitivity, as not all tests are of equal value, and to obtain reimbursement for the scientifically proven tests.

Read more: Predictive Test for Radiotherapy Reactions: Women at High Risk

And: Radiotoxicity and breast cancer screening: caution, caution, caution…

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.

What is mastectomy ?

A mastectomy is a breast ablation. It can be partial (only the affected part is removed), or total (the entire breast is removed), when the tumor is too large in relation to the volume of the breast, when there are several lesions, or in the retro-areolar forms.
Advocates of breast cancer screening argue that with the detection of smaller lesions, there is less aggressive treatment on women's breasts, and therefore less heavy surgery is performed. However, several studies and particularly meta analysis have shown the opposite.
(A meta-analysis is a method of combining the results of several independent studies on the same topic in order to synthesize the results and draw an overall conclusion.) Furthermore, the independent review Prescrire, the meta-analysis by the Nordic Cochrane research group, the publication by Pr P. Autier and the american Harding study all report an increase in the number of surgical procedures. The more we detect, the more breasts are removed.


We have verified this ourselves with our study on mastectomies in France, which you will find in its completeness as well as the explanations on the site. Its results are indisputable: no reduction in mastectomies, total or partial, can be demonstrated after the generalization of organized screening.


Irrespective of this fact, what is at stake for women is not to promise them "lighter" surgical acts, but rather not to have them undergo any surgical treatment if they do not need it, while not exposing them unnecessarily to a disease which they should never have known in the absence of screening (over-diagnosis).

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.

What is metastasis ?

A metastasis is a secondary tumor site, originating from primary tumor cells that have become detached from it and then transported to nodes or secondary organs via the lymphatic and/or blood circulation. Breast cancer, whether it has pejorative biological characteristics, is likely to produce metastases.
The organs that may be secondarily affected are the bones, brain, liver, lung…..


The risk of developing metastases in the case of breast cancer depends on the molecular characteristics of the original tumor. According to several studies, aggressive, fast-growing breast cancer, which rapidly becomes large and metastatic from the outset, does not develop from every small lesion, but from a subpopulation of small lesions with biological factors that are pejorative from the outset.

Since being detected, the rates of metastatic cancer have not decreased over the past 20/30 years, although this is one of the objectives of screening, together with the decline in mortality.

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

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.

What is My PEBS ?

Mypebs (my personal breast screening) is a European study that should last 6 years and recruit 80,000 women, aged between 40 and 70, in 5 countries (Italy, France, Israel, Belgium and the United Kingdom).
The defined objective of the study is to verify whether individualized screening, i.e. based on each woman's lifetime risk of developing breast cancer, would be more effective in reducing the number of advanced cancers (stage 2 and above) than current standard mass screening.


BUT IN REALITY, THE STUDY WILL SIMPLY BE LIMITED TO DETERMINING WHETHER INDIVIDUALIZED SCREENING WOULD NOT MISS TOO MANY SERIOUS CANCERS COMPARED TO STANDARD SCREENING.

This is called a "non-inferiority test". If the new screening, or individualized screening, miss less than 25% serious cancers more than in the standard screening, it will be arbitrarily considered as being " non-inferior ", and after all, the two methods would be considered equivalent.
In other words, the question is whether the new strategy is not less effective than the original one, assuming that if there are, for example, 24% (less than 25%) more serious cancers, the results are declared "non-inferior". The authors will argue that both types of screening are equally effective, and the study will be declared a success.

There are several methodological flaws on Mypebs study :

  • Incomplete and misleading brochure given to participants, minimizing the problem of over-diagnosis and omitting the problem of over-treatment.
  • There is no comparison group of "unscreened" women, which means that the over-diagnosis in the screened groups cannot be quantified compared to a group of unscreened women.
  • The software used to "calculate" the individual risk of each woman according to her age, her personal and family history, her breast density, has no scientific validity and will be "tested" during the study with possible readjustments.
  • Additional mammograms will be carried out for certain women included in the study from the age of 40 onwards, whereas the irradiation of the breast exposes them to a real risk of DNA chains breakage of the breast cells in this young age group.

To better understand the specificities and flaws of Mypebs, Cancer Rose has created a portal dedicated to studying and decoding the My PEBS study.
You can also find an analysis here, made by our statistician, Dr Vincent Robert: http://www.mypebs-en-questions.fr/index.php

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.

How does a cancer develop ?

Cancer does not always develop as we imagine, in a linear and inevitable way from one cell toward generalization and then the death.
The model that has been taught for a long time was that of a cell which becomes out of control, multiplies in an uncontrolled way, becomes a tumor in an organ, spreads in a local-regional manner, and then generally leads fatally to the death of the organism if no intervention is made.

HOW DOES A BREAST CANCER DEVELOP?


Modern scientific evidence, epidemiological studies and autopsy studies enable us to design other models for the development of breast cancer. (click on pictures)

We have now learned that breast cancer does not develop in a linear manner, but that there are a multitude of possibilities, with slow, even nonprogressive cancers, which, if they are unknown, will not impact a person's life or health; some may even regress, while others may evolve quite fast, and are intrinsically immediately aggressive, due to their molecular characteristics, they are the ones that lead to a true cancer-disease.

The diagrams below explain why screening has failed, with several types of cancer developments.

  • Rapidly developing, intrinsically aggressive cancer has a high velocity and a short residence time in the organ, it will be missed by screening. Metastases are often present, even if not yet visible, in lymph nodes or distant organs. It is often big at the time of diagnosis, because it is fast, being found big does not mean late diagnosis.
  • Very slow, nonprogressive or regressive cancer, which would not have impacted the patient's life, has a very long residence time in the organ and will therefore rather be detected by repeated screening. Its diagnosis is useless for the patient, yet it will be treated with the same aggressiveness. It is small at the time of diagnosis because it is slow; small does not necessarily mean "early".
  • The cancer which develops progressively will one day be symptomatic and detected by the patient by the appearance of a clinical sign, this cancer can be treated in time, because the evolution towards the generalization stage takes a very long time (10, 20 to 30 years).

Click on pictures

Having a cancerous tumor does not automatically lead to a cancer-disease. However, this is what women are made to believe by telling them that they have been cured thanks to the detection of a tumor that would never have killed them. On the other hand, the rate of serious cancers has not decreased since the screening in place.

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.

What is chemotherapy ?

Chemotherapy is a therapy that uses chemical substances that have cellular toxicity, to affect sick cells in order to destroy them. Quite often several substances are combined to increase their effectiveness, especially if the cancerous disease spreads. The different drugs can be administered by intravenous injection (infusion) or orally (tablet). The molecules affect the diseased cells, but unfortunately also the healthy cells indiscriminately, which often causes more or less pronounced side effects, depending on the individual sensitivity of the person (loss of appetite, loss of hair, nausea, vomiting, severe fatigue).

Regarding breast cancer, since the screening was introduced, i.e. over the last thirty years, the percentage of patients undergoing chemotherapy has risen from 20% to around 80%. Chemotherapy for breast cancer also has effects on survival, comfort of life and other morbid effects for these treated patients.

Researchers warn on the over-detection of cancers that would never have impacted the lives of patients if they had not been discovered (over-diagnosis); the consequence is over-treatment, wherever screening is done, the number of mastectomies, radiotherapies (see relevant chapters) and chemotherapies have increased. All cancers that have been detected, real cancers as well as those that would not have progressed, are treated.
Scientists warn on the increased mortality due to over-treatment, and several studies suggest that the toxic effects of the treatments administered cancel out the hypothetical benefit of screening, which has already been widely questioned.

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.

What is overdiagnosis ?

Overdiagnosis is defined as the histological (i.e. by means of a microscope) diagnosis of a "disease" which, if it had remained unknown, would never have caused any inconvenience to the patient's health during her lifetime, or threatened her life.
It is not a misdiagnosis or a false alarm. It is really cancer in view of its current definition, which is based solely on the diagnosis under the microscope of a sample taken from an organ (the breast) .
The diagnosis is correct but needless to the patient. It is the medical practice that produces this excess of "diseases". Indeed, having cancer cells which were detected does not make the individual as being cancerous. But the more we detect, the more we find.
Its reality is absolutely irrefutable nowadays, its demonstration is based on epidemiological studies with a high level of evidence, it is an accounting reality, wherever screening exists; overdiagnosis is not identifiable at the individual level, because for the concerned individual, or for the doctor who detects the presence of cancerous cells, it is a diagnosis. Overdiagnosis is revealed by comparing populations subjected to different screening intensities.

Which evidence for overdiagnosis of breast cancer?

First of all, several comparative studies, including a fundamental study by the Oslo Institute in 2008 (Zahl P-H, Maehlen J, Welch HG. The natural history of invasive breast cancers detected by screening mammography. Arch Intern Med. 2008 Nov 24;168(21):2311-6).

Two groups of women were compared, one screened every two years, the other examined only once after six years. Result: 22% excess cancers in the screened group. Thus, if all the tumours evolved into perceptible cancers, we should have found the same number of cancers in these two groups of women with the same profile. Since more cancers are found in the group screened every two years, it means that there is an excess of diagnoses.

Autopsy studies further corroborate this result. Almost half of the women (the percentages vary according to age group), who died of causes other than breast cancer, had unexpressed breast lesions. The same phenomenon can also be observed in men in their prostate, which is why systematic screening for prostate cancer is no longer recommended by the High Authority for Health.
Read: https://cancer-rose.fr/en/2020/12/30/arc-classification/

The problem with over-diagnosis is that it is accompanied by overtreatment, all without any gain in survival for women, there is no difference in mortality figures between the groups of screened and unscreened women.
However, the presence of more and more diagnoses of breast cancer that would never have manifested themselves, makes it possible to justify the apparently positive results of this health system in the eyes of the promoters of screening and the health authorities.
By detecting "harmless" cancers, screening gives the illusion of contributing to cures. With the overdiagnosis generated, screening makes patients believe that it is effective when they present a cancer that has been proven by microscopic examination, but which will not impact their health (these overdiagnosed cancers remain quiescent, do not progress or progress only slightly or regress).
Thus, by selecting non-ill women, screening justifies a treatment and gives these women the illusion of curing them of a disease they would never have had without it.

Therefore it is the massive screening that generates overdiagnosis and "feeds" on it to convince the medical profession and public opinion of an effectiveness that is not proved.

Overdiagnosis is a source of considerable harm to women who undergo screening mammography. Recognition of the concept of overdiagnosis of cancer by the medical community has been slow, but today it is no longer acceptable to minimize its burden, nor its consequences, and continue to not inform the main interested parties.

Probably in 10 years' time, if we continue in this way, one woman out of six will be diagnosed with breast cancer during her lifetime, perhaps even more since a woman labelled "cancerous" represents herself a family risk factor for her offspring, who will be even more encouraged to be screened. With the certainty that the overall harm induced by screening will only increase

What are the consequences of overdiagnosis?


The consequences are those of an overtreatment. All lesions, overdiagnosed or not, will be treated.
Women will suffer the consequences of the side effects of treatment.
Mastectomies increase in all countries with screening-campaigns.
Radiotherapy presents the risk of causing secondary radiation-induced cancers and increases the risk of coronary artery disease when the left breast is irradiated.
Chemotherapy has known adverse effects on the blood lines, which can lead to nausea, vomiting, hair loss, induced menopause etc…
Hormonal therapy then administered for 4 to 5 years to reduce the risk of recurrence, in the case of hormone-receptor-positive cancers, can be well tolerated, but can also cause fatigue, arthralgia, thromboembolic complications and, in the case of Tamoxifen, increase the risk of endometrial cancer (uterine mucosa).
All of these effects have a profound impact on the emotional, social, professional and economic life of women and on their physical and mental health.

Click on picture to enlarge

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.

What is an effective screening ?

What is an effective screening?

An effective screening involves two criteria:

  • important reduction in mortality
  • reduction in the incidence of advanced cancers

Example of a screening that meets these criteria, cervical screening, images from a presentation by Pr P.Autier

Click to enlarge

What about breast cancer? Is screening for breast cancer effective?

1°Criterion, mortality

Since 1996, there have been approximately 11,000 to 12,000 deaths from breast cancer per year. We are therefore not seeing the massive and drastic reduction that we observe in medicine when strategies really work. (The discovery of tuberculosis antibiotic therapy led to the closure of the sanatoriums within two years, the sterilization of the scissors used to cut the umbilical cords has effectively eliminated mortality from neonatal infections).
Furthermore, it is misleading to come up with figures for specific mortality (mortality from disease, here breast cancer) without giving figures for overall mortality (all-causes mortality).
Deaths due to the consequences of breast cancer diagnosis and subsequently due to surgical or anaesthetic accidents, complications of chemotherapy and radiotherapy such as cardio-vascular damages and radiation-induced cancers are not included in breast cancer mortality.
To date, there are no clear signs of a decrease in overall mortality from mammography screening.

As far as the specific mortality from breast cancer is concerned, we can see that it has been decreasing since 1993. However, this decrease occurred before the generalization of screening in France (in 2004) and cannot be attributed to it. In the United Kingdom, the decline in breast cancer mortality was 11% between 1985 and 1993, while screening was only operational in 1988.
In an impact report, a comparison of eight countries in Europe and North America reveals no correlation between national screening penetration and chronology or the extent of breast cancer mortality reduction. The comparative approach in this study with 14 other types of cancer shows a similar decrease in the mortality rate of these cancers, while these other cancers are not the subject of screening campaigns.
The start of the decline in breast cancer mortality is correlated with therapeutic de-escalation at a time when there is better control of the therapies administered to women and of their adverse effects.

There is a decrease in mortality from breast cancer, on the one hand it is not correlated with the screening practice, and on the other hand, by the very confession of official authorities data, 12,000 women continue to die of breast cancer every year, not counting those who die from complications that are distant from their treatment (12 146 in 2018 in France)..
Another fact is that mortality rates and survival are the same in groups of screened women and in groups of unscreened women, at similar stage of the cancer at the time of its diagnosis, as shown by several studies, including A.Miller's in particular, with a long follow-up of the groups of women over 25 years.

2°Criterion, the rates of serious cancers

The accumulation of epidemiological data shows that in populations where mammography screening has been widely used for a long time, the incidence of advanced cancers has shown little or no decrease. Numerous studies confirm this fact [1].
A recent, large 2015 study of 16 million women in the United States corroborates this disappointing finding [2]:
- No significant reduction in mortality (red line in the graph on the left)
- No reduction in serious cancers (red line in the graph on the right)

Survival at 5 years

This data, which INCa and screening promoters often advantageously highlight, is an indicator of the lifetime of cancer and not of the effectiveness of screening.
Early cancer diagnosis gives the illusion of a longer survival.
This is an optical illusion: by anticipating the date of the occurrence of cancer, one has the impression of an extension of the life, whereas life expectancy has not improved in any way.
The prolongation of survival is the result of two phenomena: the effectiveness of therapies that prolong the life of a patient with his cancer, and screening that anticipates the date of appearance of cancer regardless of the outcome of the disease.
Survival is increased all the more as the over-diagnosis is greater. Indeed, by definition, all over-diagnoses cure!

Click to enlarge

A good counter-example is the cervical cancer: its 5-year survival is very poor, but mortality from this cancer has fallen dramatically.

Comparison of 6 different screenings

Click to enlarge

While the incidence increases without any impact on serious cancers or significant reduction in mortality due to screening, this increase is then the direct effect of medical intervention which over-detects lesions, which is of no use to people's health.

For one cancer, we see that the contract is being fulfilled: this is the cervical cancer. Anticipating precancerous lesions means that the incidence of this cancer, the rate of severe forms as well as its mortality decrease perceptibly and is relatively well correlated with the introduction of screening.
However for the breast, prostate and thyroid, the situation is much more disappointing, with an unresolved problem: increasing overdiagnosis, without a satisfactory decrease in serious cancers or a reduction in treatment.
For colon cancer, it is currently recommended that screening be reserved for high risk individuals.

Bibliography

[1].Autier P, Boniol M, Koechlin A, Pizot C, Boniol M. Effectiveness of and overdiagnosis from mammography screening in the Netherlands: population based study. BMJ 2017;359:j5224.

Autier, M. Boniol, R. Middleton, JF Dore, C. Héry, T. Zheng et al. Advanced breast cancer incidence following population-based mammographic screening Ann Oncol, 22 (8) (2011), p. 1726-1735

Bleyer, HG Welch Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence N Engl J Med, 367 (21) (2012), pp. 1998-2005

NA de Glas, AJ de Craen, E. Bastiaannet, EG Op ‘t Land, M. Kiderlen, W. van de Water, et al. Effect of implementation of the mass breast cancer screening programme in older women in the Netherlands: population based study.


Autier, M. Boniol, The incidence of advanced breast cancer in the West Midlands United Kingdom, Eur J Cancer Prev, 21 (3) (2012), pp. 217-221


Nederend, LE Duijm, AC Voogd, JH Groenewoud, FH Jansen, MW Louwman Trends in incidence and detection of advanced breast cancer at biennial screening mammography in The Netherlands: a population based study. Breast Cancer Res, 14 (1) (2012), p. R10


ML Lousdal, IS Kristiansen, B. Moller, H. Stovring, Trends in breast cancer stage distribution before, during and after introduction of a screening programme in Norway Eur J Public Health, 24 (6) (2014), pp. 1017-1022


RH Johnson, FL Chien, A. Bleyer Incidence of breast cancer with distant involvement among women in the United States, 1976 to 2009 JAm Med Assoc, 309 (8) (2013), pp. 800-805


Laura Esserman, Yiwey Shieh, Ian Thompson, Rethinking screening for breast cancer and prostate cancer, Jama, 302 (15) (2009), pp. 1685-1692


Jorgensen, PC Gøtzsche, M. Kalager, P. Zahl Breast Cancer Screening in Denmark
A Cohort Study of Tumor Size and Overdiagnosis, 166 (5) (7 mars 2017), pp. 313-323

HG Welch, DH Gorski, PC Albertsen Trends in Metastatic Breast and Prostate Cancer, N. Engl JMed, 373 (18) (2015), pp. 1685-1687

Di Meglio, RA Freedman, NU Lin, WT Barry, O. Metzger-Filho, NL Keating, et al. Time trends in incidence rates and survival of newly diagnosed stage IV breast cancer by tumor histology: a population-based analysis Breast Cancer Res Treat, 157 (3) (2016), p. 587-596`

[2] « Breast Cancer Screening, Incidence, and Mortality Across US Counties »
Auteurs : Harding C, Pompei F., Burmistrov D., et al. JAMA Intern Med. Published online July 06, 2015. doi:10.1001/jamainternmed.2015.3043

https://jamanetwork.com/article.aspx?articleid=2363025

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.

What is a ductal carcinoma in situ (DCIS) ?

Ductal carcinoma in situ (DCIS) of the breast is defined by the proliferation of cancer cells within a galactophoric duct without these cells protruding beyond the wall of the duct, to spread to the rest of the breast.
It is essentially of mammographic finding, in fact 90% of women diagnosed with DCIS (ductal carcinoma in situ) had microcalcifications at mammography. In their vast majority, these lesions do not threaten women's lives if they are not detected, their prognosis is very good, survival at 10 years, the mostly used measure by the health authorities, is over 95%. There are the ductal form and the lobular form, the latter considered to be rather a risk factor for breast cancer. DCIS largely contribute to overdiagnosis. Tests and studies indicate that the increasing detection of DCIS has not led to the reduction of breast cancer mortality. Before the era of screening, DCIS accounted for less than 5% of all breast cancers, rising to 15-20% in all countries where screening campaigns are taking place. They are not included in the incidence figures (rate of new cases) reported by the National Cancer Institute, as they are considered separately, and not as "real" cancers. In addition, there is a lack of real consensus among pathologists regarding the classification of these lesions when analyzing the biopsies they receive, with a tendency to overclassify them into more unfavorable prognosis categories, due to the fear of underestimating a "disease".

Most DCIS are considered as non-mandatory precursor lesions toward invasive cancer; paradoxically, the spectacular increase in their detection and their subsequent surgical excision has not been followed by a proportional decrease in the incidence of invasive cancers. The major problem is that these particular entities of breast cancer are treated with the same severity as breast cancer.


In November 2016, a study conducted by University of Toronto concluded the following:

  • Their treatment makes no difference to women's survival. - Women with DCIS are heavily treated (sometimes by bilateral mastectomy) and have the same probability of dying from breast cancer as women in the general population.
  • Preventing recurrences by radiotherapy or mastectomy would therefore not reduce the risk of breast cancer mortality.

Similarly, our study of mastectomies in France found a steady increase in surgical procedures, our first hypothesis being the overtreatment of lesions that are not invasive cancers, but rather so-called pre-cancerous lesions and DCIS [1] [2].

The long-term consequences of over-treatment can place women's lives at risk. Radiation therapy for these lesions, for example, appears to be ineffective in reducing the risk of death from breast cancer, but it is associated with a dose-dependent increase (from 10 to 100% over 20 years) in the rate of major coronary events [3].

Moreover, in several countries clinical trials are being conducted to test simple active surveillance, particularly for low-grade CIS, rather than aggressive treatment:

For Philippe Autier [4], of the International Prevention Research Institute (IPRI), the problem is definitely inherent to routine mammography, in particular to digital mammography, which is too efficient in detecting small calcifications; these are the most frequent radiological sign of these forms, and mammography has an excellent sensitivity for the detection of these microcalcifications.

To summarize, in populations screened the incidence of DCIS rises from 1-20% with no corresponding fall in "later stages" nor invasive cancers. Also DCIS is often multifocal demanding a mastectomy yet multifocal invasive cancers are very rare. Read more : https://cancer-rose.fr/en/2021/01/20/carcinoma-in-situ-the-problem-of-its-overdiagnosis-in-screening-mammography/

References :

[1] https://cancer-rose.fr/en/2020/12/17/our-study-does-organized-screening-really-reduce-the-surgical-treatments-of-breast-cancers/
[2] https://cancer-rose.fr/en/2020/12/17/explanation-of-our-study-on-mastectomies-in-france-carried-out-by-cancer-rose/
[3] SC Darby, M. Ewertz, P. McGale, AM Bennet, U. Blom-Goldman, D. Bronnum, et al.
Risk of Ischemic Heart Disease in Women after Radiotherapy for Breast Cancer
N Engl J Med, 368 (11) (2013), p. 987-998
[4] https://cancer-rose.fr/en/2020/12/17/mammography-screening-a-major-issue-in-medicine/

For more information :

A blog : https://dcis411.com/

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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.