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Cancer and screening - A presentation by Cancer Rose

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Cancer and screening - A presentation by Cancer Rose

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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.

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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Cancer and screening - A presentation by Cancer Rose

  1. 1. www.cancer-rose.fr CANCER AND SCREENING
  2. 2. www.cancer-rose.fr Cancer and cancer • In the public mind, cancer and cancer cells are the same thing. • Well, it's not. We produce hundreds of cancer cells every day, and fortunately our immunity eliminates them. • Sometimes our defenses are overwhelmed, and then a cancer may develop.
  3. 3. www.cancer-rose.fr From cell to nodule ■ Sometimes these cells accumulate into small cancerous nodules (small balls). ■ They can remain latent during the person's lifetime, and even disappear. ■ In rarer situations, these cells get out of control, will multiply, invade the body and lead to the death of the patient.
  4. 4. www.cancer-rose.fr Cells, in everyone! ■ In the case of the prostate, cancerous cells in men, this is very common. ■ Half of all men over 60, and almost all men over 90 have cancer cells in their prostate. ■ 80% of men over 80 years old have silent cancer. ■In the case of breast cancer, a study on autopsies of women who have died of other causes shows that 37% of women are carriers of unexpressed cancers between the ages of 40 and 54, 39% between the ages of 40 and 49. ■ Out of 686 autopsied women who died from causes other than cancer, the rate of tumors found in the breasts is 4X that of the living population, at the same time of the study. These tumors remained "silent".
  5. 5. www.cancer-rose.fr ■ Prostate cancer accounts for only 3% of deaths in men. The average age of death is 80 years old and only 0.1% of men die from it before the age of 70. ■ It is detected by a blood test, the PSA level, and a blood test.(Prostate specific antigen<4ng/ml) ■ PSA is a protein that circulates in the blood and is secreted exclusively by the prostate gland. ■ If the level is elevated, the diagnosis must be confirmed by prostate biopsies. ■ Even a simple benign hypertrophy of the prostate gland, or inflammation, can cause the blood level to rise. ■ Out of 100 deaths of women, there are 4 cases of breast cancer, 20 by other causes of cancer, 30 by cardiovascular disease. (Ref : C.Hill,2014, IGR) ■ It is detected by a mammogram and confirmed by a breast biopsy. Prostate Breast
  6. 6. www.cancer-rose.fr ■ Searching for cancer cells when we know they are so common is exposing a person to detection of a disease that is not, and will not become one. ■ 7 out of 10 men with high PSA do not have cancer. ■ Example of the cervix ■ In this case it is a useful screening, because this cancer evolves pejoratively and kills Mortality from cervix cancer in Nordic countries Start of screening in Norway and Denmark Start of screening in Finland and Switzerland
  7. 7. www.cancer-rose.fr The prostate is a gland located under the bladder. It is important for reproduction by providing the necessary nutrients for sperm, and by producing a liquid that makes it fluid. It also produces a protective envelope for sperm. Prostate Testicles Bladder
  8. 8. www.cancer-rose.fr ■ The most aggressive cancers release their metastases at the onset of the disease. ■ In this case the treatment will not protect against death. ■ Treatments for this cancer have negative effects that can be significant (urine leakage, impotence). ■ Beyond the age of 75, there is no reason to look for this cancer because its evolution is very slow. ■ We will alter the patient's life more than we will "save" it. ■ Elderly patients are likely to die before, from something other than their cancer. Prostate
  9. 9. www.cancer-rose.fr Problem for men between 50 and 75 years old, encouraged by urologists to be screened. ■ There is no evidence that screening for this cancer would save people. (HAS High Health Authority in France) ■ The WHO (World Health Organization) also does not recommend this screening. ■ But if one is screened, does it increase his chance of survival and better health? ■ Canadian Study on 46,000 men, half screened (PSA and rectal exam), half not screened); followed over 11 years. ■ Ref: http://onlinelibrary.wiley.com/doi/ 10.1002/pros.20017/abstract; ■ Labrie, Quebec, 2004
  10. 10. www.cancer-rose.fr Results of the Canadian study ■ More mortality in the screened group. ■ Why ? Because the risks of screening, the collateral effects, outweigh the benefit, which is minimal. ■And after surgery on a man who has been screened? ■In an 8-year follow-up study, the overall mortality from all causes was almost the same for men who had undergone surgery as for those who had not. ■Fewer metastases in the operated group. ■But more mortality from other causes. ■More collateral effects of biopsies and treatments in the screened group.
  11. 11. www.cancer-rose.fr
  12. 12. www.cancer-rose.fr The choice? On one side : ■ A medical and especially surgical treatment with a very modest effect on the disease, and which does not save lives. On the other side : ■ A screening that consists in considering as sick men who were screened who were not suffering from anything! ■ No difference in terms of survival ■ But important side effects, impacting daily life. Reduced life due to heavy treatments.
  13. 13. www.cancer-rose.fr
  14. 14. www.cancer-rose.fr In summary, for every 1,000 men aged 55-69 participating in prostate cancer screening over an average period of 9 years : ■ 150 will have abnormally high PSAs. ■ 30 out of 125 men who will accept the biopsy, without symptoms will discover that they have cancer. ■ Of the 30 cancer carriers who will be treated, 20 will be permanently impotent, 15 will suffer from urinary disorders, and 2 will be totally incontinent. ■ Only one man out of the 30 cancer patients, will escape death, whereas he would have died in the absence of screening.
  15. 15. www.cancer-rose.fr Screening "creates" a ill person who didn't complain about anything, and risks making him ill because treatments. ■ Although not recommended by any health authority for asymptomatic men, it is still prescribed. ■ It is clearly established that overdiagnosis is massive without any reduction in mortality. To the point that the discoverer of the PSA test himself had come to regret his own discovery . « I never dreamed that my discovery 4 decades ago would lead to such a profit- driven public health disaster» Richard Ablin, discoverer of PSA
  16. 16. www.cancer-rose.fr But who to believe? ■ Urologists, prescribers of the screening test, are influenced by what they experience during their consultations, they see patients suffering. ■ But the "experience" in the office does not reflect the health of the population. ■ The urologist is a surgeon, when he finds a tumor, he can no longer do otherwise than remove it. ■ This is the job of the urologist. ■ And the patient will not tolerate being told that he has cancer and not doing anything about it. The decision TO NOT prescribe PSA must be done BEFORE.
  17. 17. www.cancer-rose.fr Beware of media campaigns making promotion of prostate cancer or breast cancer screening. Advertising campaigns shift the debate in the affective field, and promoters have many means of persuasion. Doctor's dilemma: if a patient becomes ill with a prostate cancer, he will reproach his doctor for not having done the screening that might have done it "saved" (infinitesimal probability). But the doctor, by not prescribing this screening, has really saved men who don't know it. It's your choice to get tested or not. It's the same thing for breast cancer.
  18. 18. www.cancer-rose.fr In France
  19. 19. www.cancer-rose.fr ■ Mammography: an imperfect tool ■ Screening is done without completely informing women about its risks, and there are such risks. ■ The Pink October campaigns are commercial. …and not sure it will save your life It’s pink, it’s ugly, and it doesn't fit with anything But it can save your life It’s yellow, it’s ugly, and it doesn't fit with anything
  20. 20. www.cancer-rose.fr ■ The radiologist must detect in this difficult texture the image that reflects a TRUE lesion. ■ But the smaller the lesion, the less typical it is. ■ And the less typical it is, the more we examine it. The more we examine it, the more we doubt. ■ The more you doubt, the more you tend to classify the examination as "suspicious", as a precaution. ■ This attitude, human of the radiologist, nevertheless leads to the woman having to undergo many other examinations, including biopsies, at the cost of significant stress. Why mammography is an imperfect tool for systematic screening? ■ Breast texture is a structure that changes from one woman to another, from one cycle to another, from one year to the other; ■ Changing also according to hormonal treatments, physiological changes throughout a woman's life, ■ Depending on weight variations. ■ Depending on hormonal treatment.
  21. 21. www.cancer-rose.fr ■ THE FALSE ALARM: ■ You think you're dealing with cancer. This leads to additional tests, sometimes heavy, and to biopsies, the number of which has greatly increased since screening. ■ The woman has to wait several weeks before confirmation of the absence of disease. For every 1000 women over 50 participating in screening for 20 years, there are about 1000 false alarms leading to 150 to 200 unnecessary biopsies in France. ■ (Prescrire magazine, February 2015/Tome 35 N°376) The risks of screening ■ OVER-DIAGNOSIS ■ It is a diagnosis of cancer that would never have affected the woman's health during her lifetime if it had remained unknown. ■ There is an artificial increase in breast cancer diagnoses through routine screening, resulting in unnecessary treatment and stress for women. ■ Not every cancer cell seen under the microscope is a cell that will develop into a real cancer, ■ But once it's "seen", there's no turning back, and you're forced to treat, because you can't distinguish between real cancers and those that will remain silent.
  22. 22. www.cancer-rose.fr What does that mean, a cancer that would never have affected a woman's life? ■ It was thought that all cancers develop in the same linear and mechanical way. ■ It was believed to be this pattern: ■ 1.Cancer cells ■ 2. Pre-cancer ■ 3. Small local tumor ■ 4. Regional Tumor ■ 5. Metastases and deaths ■ But all cancers do not grow at the same rate. ■ Small does not mean early, or precocious (a small cancer can stay small for a lifetime, without growing). ■ Large does not mean late (a large tumor can develop in months, weeks, or even days).
  23. 23. www.cancer-rose.fr rapid progressing cancer slow cancer very slow cancer stagnant cancer cancer that disappears Different models for tumors grows Years Tumor size Tumor size Years These last three forms of cancer do not cause -palpable tumor -pain -metastasis Do not cause death
  24. 24. www.cancer-rose.fr Evidence of over-diagnosis ■ Two groups of women of the same age, one group screened every two years, the other group screened only once after six years. ■ Result: 22% more cancers in screened women. ■ If all the tumours had developed into real cancers, we should have seen the same number of cancers in both groups of women. ■ If there are more cancers in the group screened every two years, it means that there was an over- diagnosis. ■ Ref (Zahl, Maehlen, Welch, Oslo, 2008)
  25. 25. www.cancer-rose.fr Tumor size Years Slow-growing cancer is "caught up" by screening, but would have been manifested by a symptom. The patient would have consulted in time Rapid cancer is " missed " by the screening There, the screening is useless. Screening Death from other cause Symptoms
  26. 26. www.cancer-rose.fr On a population of 1000 women
  27. 27. www.cancer-rose.fr According to the Cochrane Collaboration study
  28. 28. www.cancer-rose.fr Consequences of over-diagnosis
  29. 29. www.cancer-rose.fr The more you search … …the more you find
  30. 30. www.cancer-rose.fr For a mortality by breast cancer which does not decrease. Mastectomy (breast ablations) Progression of number of total mastectomies Progression of number of total or partial mastectomies
  31. 31. www.cancer-rose.fr Survival is not an indicator of the effectiveness of screening. We are diagnosing tumors that would not have killed their host anyway.
  32. 32. www.cancer-rose.fr It's your choice to say yes or not to screening mammography. On the other hand, in case of symptoms (lump, retraction of the nipple, deformation of the curvature of the breast in hollow or bump, unexplained redness, swelling, lymph nodes in the armpit): you MUST consult, mammography will then have all its usefulness!
  33. 33. www.cancer-rose.fr Some clinical cases, films by courtesy of Dr. B. Duperray Small but not early, a stable image during 18 yeas, DCIS
  34. 34. www.cancer-rose.fr 7 months difference between two images
  35. 35. www.cancer-rose.fr
  36. 36. www.cancer-rose.fr Small and of poor prognosis Diffuse bones metastases
  37. 37. www.cancer-rose.fr Big and of good prognosis
  38. 38. www.cancer-rose.fr Nothing on the mammogram, but presence of bones metastases
  39. 39. www.cancer-rose.fr ▪But pink marketing does nothing to inform women. ▪We haven't solved the basic problems: ▪Breast cancer mortality has not decreased (11,000 to 12,000 deaths/year in France). ▪The severe forms have not been reduced. The pink races give the illusion "to act". Pink October Pink October
  40. 40. 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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