Is Routine Breast Cancer Screening Necessary?


The outreach operation, which begins on Monday, is an opportunity to examine the advantages and disadvantages of systematic health examinations.
   THE WORLD
 | 01.10.2018 at 16:53
 • Updated
01.10.2018 at 17:41
    |

By Anne-Aël Durand
    

                                                                                                                
It is through an illumination of the Eiffel Tower, among other events, that the 25th edition of the information campaign "Pink October" is launched Monday, October 1, to raise awareness about breast cancer. If the interest in talking about a disease that can affect one in eight women during her life is not called into question, the question of the systematic screening for this cancer was raised in 2016 following a report criticizing the current system.
What does breast cancer represent in France?
12,000 deaths a year
Breast cancer is the most prevalent in France. According to the Cancer Institute (INCa), 59,000 new cases are detected each year, or 31% of cancers affecting women. It is also the most deadly female cancer, with nearly 12,000 deaths a year.
In 80% of cases, breast cancer is detected in patients over 50 years of age, and it is estimated that one in eight women will face it during her lifetime. Fortunately, it is also one of the cancers that heal best, with 87% survival rate at five years, according to the Institute of Public Health Surveillance (InVS).

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How was screening organized so far?
In 2004, systematic screening was organized for all women aged 50 to 74, who do not present a particular risk, in the form of a mammogram and a free clinical examination every two years. Those with a history or increased risk complete the exam annually.
But this public health policy has shown its limits: in 2017, one in two women (49.9%) responded to mail inviting them to participate in organized screening, which is well below the European recommendations, which advocate 70% of participation. This proportion has been declining for several years, with significant regional differences. At the same time, 10% of women preferred individualized screening, which leads more to control ultrasounds.
How much does this device cost?
Difficult to have an exact idea. The steering committee report quotes two estimates:
180 million euros in 2008, according to the Haute Autorité de Santé: 79 euros per participating woman; 11,300 euros per declared cancer, and fixed structures costing 35 million euros.300 million euros according to the calculations of the UFC-Que Choisir (ie 130 euros per year and per patient), including premiums of 245 euros per year granted to treating physicians whose patients are well screened. The association of consumers specifies that if mammography is free, the following examinations in case of doubt (ultrasound, biopsy) remain partly the responsibility of the patient. What will change?
The Ministry of Health announced a "modernization of screening" in early 2018. The goal is to individualize the follow-up based on predictable risks, knowing that only 5% of cancers are hereditary.
A prevention consultation will be offered for women aged 25, who will be 100% covered by Medicare, to discuss and evaluate risk factors (tobacco, alcohol, food, etc.). .
From the age of 50, a second screening consultation is organized with personalized follow-up based on risk factors. Ultrasounds prescribed in addition to mammograms will now be reimbursed in full, as desired by consumer associations.
What are the results of screening?
Is screening effective? The difficulty lies in this evaluation. According to the Agence publique publique France, organized screening has detected 37,000 cases between 2013 and 2014, most of the time at an early stage: in 77% of cases, the lymph nodes were not affected, and in 37% the tumor measured less than 1 centimeter.
In total, it is extremely complex to know how many deaths are avoided through screening. Since the 1960s, several clinical trials conducted around the world have concluded a 15% to 25% decrease in mortality. But more recent studies, such as the one published by the British Medical Journal on 90,000 women in Canada, show no significant difference with or without regular mammograms. No study of this magnitude could be carried out in France.
The INCa puts the figure of 150 to 300 deaths averted per 100,000 women screened over seven to ten years, a reduction in mortality from 15% to 21%. But these figures are also controversial, and do not take into account another factor: the risk of overdiagnosis.
What is wrong with screening?
At first sight, one might think that screening can not hurt – even if the mammogram is quite unpleasant – and that the sooner cancer is detected, the easier it is to heal without heavy treatment. But these remarks of common sense are undermined by several risks:
Overdiagnosis: these are cancerous lesions detected when they have not necessarily evolved into a cancer that threatens the life of the person. It is not because a cancer is small that it is recent, or because it is bulky that it will evolve quickly. Several studies lead to figures of the order of 10% to 20% overdiagnosis.The overtreatment: chemotherapy, radiation, even breast removal are sometimes performed unnecessarily; which considerably degrades the life of the patients (anxiety, professional and personal problems, etc.) Interval cancers: conversely, a woman can feel protected after a normal examination and yet develop a tumor very quickly in the following months. Screening is by no means an assurance of not declaring future cancer. Radiation-induced cancers: mammograms expose to very small doses of radiation, which in some cases may increase the probability of future cancer. But this is especially true for young women or women who already have mutations or risk factors. In theory, this is not the target population of organized screening. The psychological consequences, especially the anxiety of women whose mammography is "questionable" and who must wait for the result of many complementary examinations (ultrasound, biopsy, etc.). ) before you rule out a cancer risk.Read also: Breast cancer: do we have too many mammograms Why is the "Pink October" campaign being decried?
The scientific controversy on the "benefit-risk of screening", mentioned by the National Cancer Institute, is not addressed during the many events of "Pink October", a communication operation on breast cancer organized every year in October, with the support of the Cancer League.
This campaign, coming from the United States, was launched in France in 1994 by the cosmetics group Estée Lauder and Marie Claire magazine to promote screening. It enjoys the media and financial support of many commercial brands, sometimes labeled "pinkwashing" – that is to say, to join a cause to improve their image.
A group of independent doctors organized in 2015, under the name of Pink Cancer, to denounce, with the help of brochures and videos, "the official and highly motivating messages" and the commercial campaigns that praise a "not resting" screening. yet no reliable and relevant data ", based on guilt injunctions rather than the objective information of women.

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Should we stop screening and mammography?
Even the most critical physicians are not throwing out the screening as such, but its systematic appearance and imposed on all women who pose no particular risk. They ask that the pros and cons be explained to patients so that they can make an informed choice whether or not to take this test.

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Individual follow-up is not always easier to implement, and can lead to social inequalities in prevention, as noted in Le Monde Suzette Delaloge, oncologist at the Gustave-Roussy Institute, Villejuif (France). de-Marne).

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In addition, screening for breast cancer does not necessarily require mammography. A first step is to make regular palpations of the breasts. This is what is recommended for women under 50, to avoid the harmful effects of excess radiation. In all cases, mammography is considered necessary by physicians as a diagnostic tool, that is to say to verify a previously identified risk.