Risk based screening against cancer: a miracle or a mirage?
The pledge for risk based approach with informed choice as “the most appropriate way to discuss cancer screening with individuals” which focused on colorectal cancer (CRC), is most welcome. Autier deserves commendations for this crusade as his 2017 presentation at the meeting of the French Society of Senology received "exclamations and whistles".(http://www.bmj.com/content/359/bmj.j5224/rr-6) However, scrutiny is needed when considering barriers and the state of affairs.
First of all, the burden of CRC must be communicated without hype (e.g. in the US risk of developing cancer is 4.2% in life time, the number of deaths is 1.45/10,000 per year, falling steadily from 2.45 in 1990,far before screening has been implemented);(https://seer.cancer.gov/statfacts/html/colorect.html)
Second, drawbacks of a risk based approach at the population level cannot be overlooked. Indeed, according to Rose’s paradox an intervention benefiting a large number of people at moderate risk is of greater overall value than one benefiting just a few people at high risk.(2) Moreover, risk-based screening tends to include older people with comorbidities, who have reduced life-expectancy and reduced life-gained from screening.(3)
Third, targeting specific populations remains an unachieved goal for public health programmes yet: a) uptake of screening programs is enduringly and unacceptably low among people with low socioeconomic status despite they are the most at risk due to smoking, obesity …;(4) b) screening programs fail to account for major and obvious risk factors, e.g. age-specific prevalence for advanced colorectal neoplasms is more than twice higher in men than in women but no national programs has been concerned by this issue yet;(5) c) screening remained common among people who can hardly benefit, as those at very high risk of dying, even withing 5 years.(6)
Fourth, the term “invitation”(1) is not appropriate as almost forced marketing seems the new motto. E.g. editors just rejected my correspondences questioning the ethic of a “mass media campaign“ for the Australian program (Journal of Medical Screening) and, the delivery of Faecal Immunochemical Test to individuals coming “in community pharmacies of Switzerland” (International Journal of Clinical Pharmacy). In France, no national agencies (Haute Autorité de Santé, the Heatlhcare watchdog; National Cancer Institute,; Public Heath France) has been accepting to provide adequate leaflets for informed consents despite enduring calls, even from NGOs.(7) Common-sense pictographs using absolute numbers (with a consistent denominator, such as /1000 screened), time frames and visuals employing the same scale for information on gains and losses of the options, change and improve decision-making.(7) The small kingdom of Belgium implemented them as soon as 2013. Presently, it is Pink October and in my university hospital, as in many other places in France, there are posters everywhere proposing mammography without appointment. How many healthy women will benefit of the 4 steps method before a mammography? a) Trigger, indicating that all options are acceptable; b) Administer the information (as above); c) Promote active participation of the patient by the expression of his or her values; and d) Analyze if the patient is comfortable with the decision by rephrasing.(8)
The main agents causing cancer are clinically obvious (tobacco, alcohol, processed foods promoting obesity) and do not need screening for adequate care. The host-reservoir is the industry. The vector for transmission is a brilliant, but devastating, social marketing which has almost a free ride. Risk based screening may be only window dressing when facing “Commercially Communicable Diseases”, the epidemics of the modern times.
1 Autier P. Personalised and risk based cancer screening. A radical shift that prioritises informed choice over maximising uptake. BMJ 2019;367:l5558.
2 Rose G. The strategy of preventive medicine. Oxford: Oxford University, 1992.
3 Katki HA, Cheung LC, Landy R. Basing eligibility for lung cancer screening on individualized risk calculators should save more lives, but life-expectancy matters. J Natl Cancer Inst 2019. Online Sep 30. doi: 10.1093/jnci/djz165.
4 Kelly DM, Estaquio C, Léon C, Arwidson P, Nabi H. Temporal trend in socioeconomic inequalities in the uptake of cancer screening programmes in France between 2005 and 2010: results from the Cancer Barometer surveys. BMJ Open 2017;7:e016941.
5 Brenner H, Altenhofen L, Hoffmeister M. Sex, age, and birth cohort effects in colorectal neoplasms: a cohort analysis. Ann Intern Med 2010;152:697-703.
6 Rochman S. Cancer screening in older adults: risks and benefits. J Natl Cancer Inst 2014;106:dju414.
7 Braillon A, Nicot P, Bour C. Principles for screening: Too few concerns for informed consent and shared decision-making? CMAJ 2018;190:E1115.
8 Braillon A, Bewley S. Shared decision making for cancer screening: visual tools plus a 4 steps method. JAMA Intern Med 2015;175:1862.
Competing interests: No competing interests