France: how to end breast cancer screening
The French national breast screening program is to be "radically revised".
In view of controversies surrounding the effectiveness and consequences of breast screening, the French Minister for Health asked the French National Cancer Institute (INCa) to organize a broad public and scientific consultation on breast cancer screening. During one year, all stakeholders on breast screening ranging from citizens, patient’s organisations and charities to health professionals, screening experts, and governmental institutions had an opportunity to express their opinion on the benefits and on the harms of breast screening as well as on the way this screening is organised in France. The consultation report was publicly available on September 30th, 2016 (1).
The consultation report concludes that there is no scientific consensus about the benefits and risks of mammographic screening. It regrets the absence of sound epidemiological studies on the impact of breast screening in France. It expresses deep concerns about the “malfunctions” and “anomalies in the current organization of screening and the consequences it engenders: unequal access; lack of understanding of key concepts underpinning screening by most stakeholders; confusion between primary prevention, screening and early diagnosis; lack of information [of women] on risks and uncertainties of screening (…); lack of involvement of general practitioners (…); misleading and outrageous pink October marketing (…); doubts on the efficiency of some therapeutic strategies, etc.”
The report recommends that the information to women and the information and training of health professionals include a complete, clear and neutral information on the benefit and harm balance of participation to screening, with a depiction of reasons underlying the on-going scientific controversy.
It recommends discontinuing the reimbursement of mammographic screening in women less than 50 years of age at average risk of breast cancer. For healthy women over 50 years of age, the report recommends to take steps towards stratification of screening according to personal risk factors. Screening should be individualised, with the implication that women with low risk profile should not be offered mammographic screening. It also recommends that GPs should be integral part of the screening approach.
The options being considered for the future of screening are as follows:
"Scenario 1: the end of organized screening, with the relevance of mammograms being evaluated in the context of an individual doctor patient relationship.
Scenario 2: the end of organized screening as now practiced, and the establishment of a new, radically altered form of organized screening." [i.e., much reduced]
The report is confident that “the implementation of these recommendations should significantly improve the current situation, which currently does not meet the minimum requirements in terms of scientific validity and of information allowing women at average risk of breast cancer to take decisions””
The consultation report implicitly raises the question of whether the INCa would be the best placed for implementing recommendations and bring the radical changes in the breast screening programme. As a matter of fact, the INCa efforts have largely concentrated on maximizing participation to screening, the consequence of which has been the broadcasting of oversimplified messages insisting on the health benefits of screening while downplaying the undesirable effects like the overdiagnosis. In this regard, the INCa has backed the policy of financial incentives to GPs linked to their ability to convince women to participate to screening. Our opinion is that a neutral body should shape the breast screening programme, determine its main working procedures, and formulate the information to women and to health professionals. The members of this neutral body should have no academic or financial conflict of interest in relation to breast screening, and should not be involved in its implementation. We believe that such a move would be respectful of the consultation report conclusions and contribute to empowering women to decide on their participation to breast screening.
On behalf of The Cancer-rose group*
* The Cancer-rose group (“rose” is the French for “pink”). Is a citizen’s initiative that aims at providing unbiased information on breast cancer screening, in contrast to “pink October” promotional campaigns. See http://cancer-rose.fr/actions.html
1- Cazes C et coll. "Concertation citoyenne et scientifique. Rapport du comité d’orientation" Sept. 2016, available on http://www.concertation-depistage.fr/
2- Ifrah N. "Lettre à Madame le Ministre des Affaires sociales et de la Santé" 16 septembre 2016.
Jean Doubovetzky, GP, senior writer for the French publication Prescrire – no conflict of interest
Centre médical de Cantepau, 14 boulevard du Maréchal Lannes, 81000 Albi
Emilie Franzin, GP, teacher for the Toulouse University Medical School – no conflict of interest
Marc Gourmelon, GP, – no conflict of interest
Philippe Nicot, GP, expert for the Haute autorité de santé, ex-vice-president of the FORMINDEP association, teacher for the Limoges University Medical School – no conflict of interest
Competing interests: No competing interests