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Breast cancer screening, medical, epidemiologic, social and psychologic aspects

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Breast cancer screening, medical, epidemiologic, social and psychologic aspects

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Presentation «Breast cancer screening, medical, epidemiologic, social and psychologic aspects» by Dr. Cécile Bour, Radiologist and President of Cancer Rose non-profit organization (www.cancer-rose.fr), during 15th International Meeting of Psychiatry, Psychoanalysis and Clinical Psychology & Associated exhibitions, « A couch on the Danube », Budapest, May 8, 2018.
Cancer Rose is a French non-profit organization of health professionals. 
Independent French medical doctors and a doctor in toxicology, have created the site www.cancer-rose.fr to inform you of the most recent and relevant data on breast cancer mass screening.
By decoding and popularizing the most recent research findings published in the most important international medical journals, analyzing the controversy and providing a social and feminine analysis, our objective is to inform women concerned by breast cancer mass screening in order to help them making their choice and to provide independent information resources to interested physicians.
Cancer Rose has no sponsorships, honoraria, monetary support or conflict of interest from any commercial sources.

Presentation «Breast cancer screening, medical, epidemiologic, social and psychologic aspects» by Dr. Cécile Bour, Radiologist and President of Cancer Rose non-profit organization (www.cancer-rose.fr), during 15th International Meeting of Psychiatry, Psychoanalysis and Clinical Psychology & Associated exhibitions, « A couch on the Danube », Budapest, May 8, 2018.
Cancer Rose is a French non-profit organization of health professionals. 
Independent French medical doctors and a doctor in toxicology, have created the site www.cancer-rose.fr to inform you of the most recent and relevant data on breast cancer mass screening.
By decoding and popularizing the most recent research findings published in the most important international medical journals, analyzing the controversy and providing a social and feminine analysis, our objective is to inform women concerned by breast cancer mass screening in order to help them making their choice and to provide independent information resources to interested physicians.
Cancer Rose has no sponsorships, honoraria, monetary support or conflict of interest from any commercial sources.

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Breast cancer screening, medical, epidemiologic, social and psychologic aspects

  1. 1. www.cancer-rose.fr
  2. 2. www.cancer-rose.fr Efficiency evaluation of cancer screening is based on: Age-adjusted incidence of advanced cancers should decrease after introduction of screening. Specific cancer-mortality should decrease more in areas where screening is effective, than in areas where there is no or few screening (if management of patients is similar).
  3. 3. www.cancer-rose.fr First random trials adopted distinctive methods which led to exagerate the efficiency of screening. Methodological flaws in the results analysis Best results in the most doubtful trials. (bias) Cochrane warned about biases in year 2000, before screening was put in widespread use in France (in 2004) Randomized trials on 500 000 women, failed to show any mortality decrease (risk to die) due to screening
  4. 4. www.cancer-rose.fr Great decrease of Mortality is advanced (-20%) *Decrease of the rate of mastectomies. *Decrease of advanced forms of cancer. Problem is : screening of breast cancers is often presented in a very positive way. Serious authors disagree with these assertions : french medical journal Prescrire, Cochrane Group, Swiss Medical Board, recent international studies. BUT BUT Other claimed results :
  5. 5. www.cancer-rose.fr The key elements of a successful screening program is a decrease of mortality and advanced tumors. These objectifs have not been reached. Mortality by breast cancer did not decrease more in areas where women have beeen screened, since 1980 Decrease is not different in screened and in not screened women. Strong increase of the number of small tumors, with no decrease of mortality. In real live, after 30 years of screening, key points incidence of advanced and metastatic breast cancer remained stable. One third to one half of all screened breast cancers would never have been symptomatic (overdiagnosis)
  6. 6. www.cancer-rose.fr (Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database Syst Rev. 2013;6:CD001877.) Cochrane database : >>>>>>>>>>>>>>>>>> 2000 pearls in a bowl… ...they represent 2000 women, 40 years old and over, screened during 10 years. Screening is a gamble, its consequences are a question of chance… One golden pearl : 1 life extended by screening. 10 red pearls : 10 healthy women, with useless diagnosis, subjected to futile treatment. 200 white pearls: : 200 women suffer the stress of a false alarm; they have to undergo other tests to restore diagnosis; their anxiety may last for weeks or months. 2200 women
  7. 7. www.cancer-rose.fr Screening detects a lot of small tumors which would never progress, or which would disapear without treatment. If they had remained unknown, they would not have harm, bother or kill the patient. Another definition of overdiagnosis is discovering tumors that would never cause any sickness until the woman dies for another reason. That is overdiagnosis : an unexpected discovery, caused by mass screening. OVERDIAGNOSIS • Calculation of overdiagnosis : excess of cancers at the women screened / total number of cancers which would have been diagnosed without screening (population with same profile, same age). • Overdiagnosis occur among women who take part in screening. • Last studies (Zahl/Autier and earlier Junod) : 50% overdiagnosis = half of all detected cancers.
  8. 8. www.cancer-rose.fr Two errors increase each others : *radiologic or histologic images do not define mortal cancerous desease. * The Halsted theory, which describe of a linear natural history of cancer, quite mechanical, is refuted by facts. Physicians, patients and pathologists cannot recognise who gets overdiagnosed. For individuals, there are only diagnosis. Only epidemiologists can detect overdiagnosis by comparing populations submitted to screenings of variable intensity.
  9. 9. www.cancer-rose.fr Studies • Interval-cancers are not worse than breast cancers diagnosed in the absence of screening. They do not kill more, and they don’t have more aggressive clinical and pathological features. • So: if interval cancers are similar to cancers diagnosed without screening, and if screened cancers have a better pronostic than interval cancers, it means that some screened cancers are not-mortal cancers, that would never have caused symptoms. • Oslo experience, 2008, comparison of two groups women, one screened, the other one without screening : 22% cancers in excess = overdiagnosis (only invasive cancers counted) • Autopsies studies (systematic reviews : 40 % of invasive cancers detected by systematic screening and 24 % of all the invasive cancers would be overdiagnosed.) • A plethora of epidemiological data (Harding,Miller, Bleyer, Zahl, Autier) shows that, since 1985, progress in the management of breast cancer patients has led to marked reductions in stage- specific breast cancer mortality, even for patients with spread desease at diagnosis. • Moreover, the more effective the treatments, the less favourable are the harm–benefit balance of screening mammography. • P.Autier : Mammography screening: A major issue in medicine
  10. 10. www.cancer-rose.fr A non linear natural history of cancer, but a spectrum of cancers • the opportunity for detection before their metastatic distribution would be very short. • These high-staged tumors have an agressive and fast evolution, and they are already large at diagnosis. • …so these tumors will very often be discovered by mammography screening, • And the are small when diagnosed because of their slow evolution. • At the other end of the spectrum are cancers with great metastatic potential. They develop quickly • … • Most cancers are asymptomatic tumors which would remain painless or would develop slowly… A few of them become symptomatic diseases. They have a long infra-clinical period (long residence time without clinical sign in the breast)…. ...and metastases would be already present in lymph nodes and distant organs when the tumor is detected. Because of their short residence time in breast… ld
  11. 11. www.cancer-rose.fr Two models of natural history of cancer are in confrontation In situ cancer Invasif cancer Metastatic cancer death Some years Some years Linear model, Base of screening Alternative model, stemming from facts Invasive cancer DeathIn situ cancer Cancer disease regression Stagnation Evolution is not linear, nor regular, nor systematic Slow evolution Metastase
  12. 12. www.cancer-rose.fr In situ cancers/interval cancers • Mammography has a high sensibility for in situ cancers. • Screening usually detects atypic epithelial anomalies or a few agressive tumors, like low stage CIS. • But to treat the same way in situ and invasive cancers do not decrease recurrences or breast cancer mortality . (Steven Narod, study Toronto 2016) • Taking invasive cancers and CIS into account ends in overdiagnosis around 30 or even 50%. • Before screening, less than 5% of all breast cancers where CIS. When participation in screening is significant, 15 à 20% of all tumors are CIS. • In contrast mammography has low sensibility for some agressive cancers like the ‘triple negative’. • Invasive cancers detected by screening are clinically and histologically less agressive than interval cancers. • Screened cancers kill less than is interval cancers. • So : the fact that a breast cancer was detected by mammography screening is indeed a good-pronostic factor.
  13. 13. www.cancer-rose.fr Consequences of overdiagnosis Judicial effect : physician condemned for "missing" a small cancer that would have had no vital impact
  14. 14. www.cancer-rose.fr Def. : Nocebo effect occur when anticipation of an unwanted effect makes this unwanted effect happen. The subject waits for a negative event defined by social, media, professional or popular messages, and this event happens. Nocebo effect doesn’t affect everybody. It varies with mental state, internal imaging and relation with the external world. It also depends on self-analysis capacity, and the social context. Suggestions are : messages and negative attitudes from medical staff, autosuggestions by : · individual conditioning beliefs, · « doctors white coat effect », . Collective symbolic representations. Nocebo effect Sanders Peirce (american philosoph) Our convictions can be imperative, as the one according to "the more a cancer is taken in time, the more we have chance to be cured » : * by tenacity (repetition), even if persisting in the bad faith, * by a priori (that must be true, even if it is not demonstrable) * by argument of authority releasing us from doubt and from reflection, * by scientific method, allowing criticism of method and results, but intellectually more demanding.
  15. 15. www.cancer-rose.fr Chronical stress because of terror of cancer, maintained by the medical profession, relieved by media. Painful, stressful examinations, alarming expectations of the results every 2 years, false alarms, and medical escalation. Trans-generationnel nocebo-effect (conviction of familial disease passed on to daughters, grand- daughters.) Physical and psychic impacts of : • Preventive breasts removal, sometimes demanded by women, • Excessive radiotherapy and chemotherapies. • Complications of surgical operations. • Radio-inducted cancers through repeated mammography and radiotherapy. At least a stress effect
  16. 16. www.cancer-rose.fr Physicians unconsciously produce nocebo effect by using certain words, silences, acts or gestures : diagnosis becomes a self-fulfilling prophecy, announced by the physician in the obsession of the « right to know » enshrined in law. Anxiety is passed on by: *rough verbal suggestion of the physician (" If you do not follow my advice, cancer may kill you ") *the usual practice justifying the act (screening habit) *lack of empathy with patients *fear felt by physicians himself The will to do well and to "save lives" may lead to the opposite The terror of disease in our societies leads to overmedicalisation. It makes sick many healthy people (like women 50-74 years old)
  17. 17. www.cancer-rose.fr Social fears, social representations of cancer disease. The social representations of cancer distort the conceptions of people about this disease, alter its perception. They influence therapeutic strategies and public health policies. The malignant cell is saw as a disobedient sociopath, an expansionist enemy who catches all the resources of the body. Malignant cell is considered a delinquent, an insane, a drug- addict and a migrant : it condenses our social fears By refering to social dangers, we leave scientific statement and we set out to judge, sentence and exclude, and we cast fault and shame to the patient. Military vocabular demand war action against cancer, but this analogy is inadequate. War supposes the destruction of the enemy, but with the ageing of the population, cancers are going to increase.
  18. 18. www.cancer-rose.fr Social fears, social representations of cancer disease. A military strategy that aims to eliminate all tumors will increase overtreatment, with heavy morbid consequences. Is the researcher in oncology just an obedient serviceman? Where is the intellectual adventure which questions the preestablished theoretical models? Where is the ambition to discover ? The patient is not a soldier taking orders from a top management, he is not a cancer-hero, and even if he is fighting, there is no reason to accuse him of surrender if he fails. Other cancer models exist, fundamental research must question the natural history of cancer. There are non military ways to make disease fit in the personal bibliography of the people, to face possible recurrences and chronic disease, which may disrupt one life.
  19. 19. www.cancer-rose.fr Les femmes sont Plus vigilantes qu’autrefois sur les modifications des seins For the american physician and methodologist D.Sackett, this kind of preventive medecine is : A. Assertive on healthy individuals without any symptom, telling them what to do to remain healthy; B. Presumptuous, claiming that its interventions will generally make better than worst to those who subscribe to it; C. Tyrannical, doing everything to exercise its authority, through : • public fear campaigns • Media coverage • Public « education » • Collusion with pharma industry.
  20. 20. www.cancer-rose.fr Les femmes sont Plus vigilantes qu’autrefois sur les modifications des seins Today Current treatments are more effective against cancer. Cancer does not evolve in a linear, mecanical way. Let us not minimize the unwanted effects: *overdiagnosis /overtreatment *false alerts *radio-inducted cancer It is not ethical to use fear of the cancer, or emotional arguments to compel women. Neutral, honest, understandable information enable women to choose freely. Screening must be explained without exageration, with the controverse, with absolute risk, and the real balance benefit/risks. Her body belongs to a woman. She have a right to say yes or no to breast cancer screening, and to make personal choice.
  21. 21. www.cancer-rose.fr BIBLIOGRAPHY 1Junod B, Zahl P-H, Kaplan RM, Olsen J, Greenland S. An investigation of the apparent breast cancer epidemic in France: screening and incidence trends in birth cohorts. BMC Cancer. 2011 Sep 21;11(1):401. 2Autier P, Boniol M, Middleton R, Doré J-F, Héry C, Zheng T, et al. Advanced breast cancer incidence following population-based mammographic screening. Ann Oncol. 2011 Aug 1;22(8):1726–35. 3Dépistage des cancers du sein par mammographie Deuxième partie Comparaisons non randomisées : résultats voisins de ceux des essais randomisés. Rev Prescrire. 2014 Nov;34(373):842–6. Dépistage des cancers du sein par mammographie Première partie Essais randomisés : diminution de la mortalité par cancer du sein d’ampleur incertaine, au mieux modeste. Rev Prescrire. 2014 Nov;34(373):837–41. Dépistage des cancers du sein par mammographies Troisième partie Diagnostics par excès : effet indésirable insidieux du dépistage. Rev Prescrire. 35(376):111–8. 4Harding C, Pompei F, Burmistrov D, Welch H, Abebe R, Wilson R. BReast cancer screening, incidence, and mortality across us counties. JAMA Intern Med [Internet]. 2015 juillet [cited 2015 Aug 3]; Available from: http://dx.doi.org/10.1001/jamainternmed.2015.3043 5Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. The BMJ. 2014 Feb 11;348:g366. 6Gøtzsche PC, Hartling OJ, Nielsen M, Brodersen J, Jørgensen KJ. Breast screening: the facts—or maybe not. BMJ. 2009 Jan 28;338:b86. Jørgensen KJ, Gøtzsche PC. Overdiagnosis in publicly organised mammography screening programmes: systematic review of incidence trends. BMJ. 2009 Jul 9;339:b2587. Zahl P-H, Jørgensen KJ, Gøtzsche PC. Overestimated lead times in cancer screening has led to substantial underestimation of overdiagnosis. Br J Cancer. 2013 Oct 1;109(7):2014–9. 7Nielsen M, Jensen J, Andersen J. Precancerous and cancerous breast lesions during lifetime and at autopsy. A study of 83 women. Cancer. 1984 Jan 1;54(4):612–5. 8Zahl 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. 9Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database Syst Rev. 2013;6:CD001877. 10 https://www.cancer-rose.fr/efficacite-et-surdiagnostic-du-depistage-mamographique-aux-pays-bas-etude-populationnelle/ 11 http://www.jle.com/fr/revues/med/e- docs/le_depistage_organise_permet_il_reellement_dalleger_le_traitement_chirurgical_des_cancers_du_sein__310529/article.phtml 12 http://oncology.jamanetwork.com/article.aspx?articleid=2427491 Auteurs : Steven A. Narod, MD, FRCPC1,2; Javaid Iqbal, MD1; Vasily Giannakeas, MPH1,2; Victoria Sopik, MSc1; Ping Sun, PhD1 JAMA Oncol. Published online August 20, 2015. doi:10.1001/jamaoncol.2015.2510
  22. 22. www.cancer-rose.fr
  23. 23. www.cancer-rose.fr Cancer Rose is a French non-profit organization of health care professionals. Cancer Rose has no sponsorships, honoraria, monetary support or conflict of interest from any commercial sources.

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