Efficiency evaluation ofcancerscreeningis based on:

Age-adjustedincidenceof

advanced cancersshould decrease after

introductionofscreening.

Specific cancer-mortalityshould decrease moreinareaswhere screeningiseffective,than inareaswhere there is noorfew

screening

(ifmanagementofpatientsis similar).

Firstrandom trialsadopted distinctivemethods which led toexagerate theefficiency ofscreening.

Methodologicalflaws inthe

results analysis

Bestresults inthemost

doubtful trials.

(bias)

Cochranewarned aboutbiases inyear2000,beforescreeningwas

putinwidespread use

inFrance

(in2004)

Randomized trialson500000women,failed toshowany mortalitydecrease (risk todie)duetoscreening

Greatdecrease of

Mortality is advanced (-20%) *Decrease oftherateof

mastectomies.

*Decrease ofadvancedforms ofcancer.

Problem is :screeningofbreast cancersis often presented inavery

positiveway.

Serious authors disagree with these assertions:frenchmedical journalPrescrire,CochraneGroup,Swiss Medical Board,recent international

studies.

BUT

BUT

Other claimed

results :

Thekeyelements ofasuccessfulscreeningprogramis adecrease ofmortality and

advanced tumors.

These objectifshavenotbeenreached.

Mortality bybreastcancerdid notdecreasemoreinareaswherewomen havebeeenscreened,since 1980

Decrease is notdifferentinscreened andinnotscreened women.

Strong increase ofthenumber ofsmall

tumors,

with nodecrease ofmortality.

Inreallive,after 30years ofscreening,

key points

incidenceofadvanced

andmetastatic breast

cancerremained

stable.

Onethird toonehalf ofallscreened breastcancerswouldnever havebeensymptomatic(overdiagnosis)

(Gøtzsche PC,Jørgensen KJ.Screeningforbreast cancerwith mammography.CochraneDatabase Syst Rev.2013;6:CD001877.)

Cochranedatabase :

2000pearls inabowl…

...they represent 2000women,40years old andover,screened during 10years.

Screeningis agamble,its consequencesareaquestionofchance…

Onegoldenpearl :1lifeextended byscreening.

10red pearls :10healthy women,with useless diagnosis,subjectedtofutiletreatment.

200whitepearls: : 200women suffer thestressofafalsealarm;they havetoundergo other teststorestorediagnosis;their anxiety may lastforweeks ormonths.

2200women

Screeningdetects alotofsmall tumors whichwould never progress,orwhich would disapear

without treatment.Ifthey had remainedunknown,they would nothaveharm,bother or

kill thepatient.

Another definition ofoverdiagnosisis

discovering tumorsthat would nevercauseany sickness

until thewoman diesforanother reason.

Thatisoverdiagnosis :anunexpecteddiscovery,

caused bymassscreening.

OVERDIAGNOSIS

• Calculation ofoverdiagnosis :excess ofcancersatthewomenscreened /totalnumber ofcancerswhich would havebeendiagnosed withoutscreening(populationwithsame profile,same age).

• Overdiagnosisoccuramong women who takepartinscreening.

• Laststudies (Zahl/Autierandearlier Junod): 50%overdiagnosis=half ofalldetected cancers.

Two errors increase each others :

*radiologic orhistologic images

donotdefine mortal cancerous desease.

*TheHalsted theory,whichdescribeofalinearnaturalhistoryofcancer,quitemechanical,isrefutedbyfacts.

Physicians,patientsandpathologists cannotrecognise who gets overdiagnosed.

Forindividuals,there areonly diagnosis.

Only epidemiologists can detect overdiagnosisbycomparing populationssubmitted toscreenings of

variableintensity.

Studies

• Interval-cancersarenotworse thanbreast cancersdiagnosed intheabsenceofscreening.They donotkillmore,andthey don’t havemoreaggressive clinical andpathologicalfeatures.

• So:ifinterval cancersaresimilar tocancersdiagnosed without screening,andifscreened cancershaveabetterpronosticthan interval cancers,itmeans that some screened cancersarenot-mortal cancers,that would neverhavecaused symptoms.

• Osloexperience,2008,comparison oftwo groupswomen,onescreened,theother onewithoutscreening:22%cancersinexcess =overdiagnosis(only invasivecancerscounted)

• Autopsiesstudies (systematic reviews :40%ofinvasivecancersdetected bysystematic screeningand24%ofalltheinvasivecancerswould beoverdiagnosed.)

• Aplethora ofepidemiological data(Harding,Miller,Bleyer,Zahl,Autier)showsthat,since 1985,progress inthemanagementofbreast cancerpatientshasled tomarked reductions instage-specific breast cancermortality,evenforpatientswith spread desease atdiagnosis.

• Moreover,themoreeffectivethetreatments,theless favourable aretheharm–benefit balanceofscreeningmammography.

• P.Autier :Mammography screening:Amajorissueinmedicine

Anonlinear natural history ofcancer,butaspectrum ofcancers

• theopportunity fordetectionbefore their metastaticdistributionwould be very short.

• These high-staged tumors haveanagressiveandfast evolution,andthey arealready largeatdiagnosis.

• …so these tumors will veryoften be discovered bymammography screening,

• Andthearesmall whendiagnosed because oftheirslowevolution.

• Attheother endofthespectrumarecancerswithgreat metastaticpotential.Theydevelop quickly

• …

• Mostcancersareasymptomatic tumorswhich would remainpainless orwoulddevelop slowly…

Afewofthembecome symptomatic

diseases.

They havealonginfra-clinical period(longresidence timewithout clinical sign in

thebreast)….

...andmetastaseswould be alreadypresent inlymphnodes anddistantorgans when thetumor is detected.Because oftheirshortresidencetimeinbreast…

ld

Two models ofnatural history ofcancerareinconfrontation

Insitucancer

Invasifcancer

Metastatic cancer

death

Some years

Some years

Linear model,

Baseofscreening

Alternativemodel,stemming from facts

Invasivecancer

DeathInsitucancer

Metastase

Cancerdisease

regression Stagnation

Evolutionis notlinear,nor regular,nor systematic

Insitucancers/interval cancers

• Mammography hasahighsensibility forinsitucancers.

• Screeningusually detects atypicepithelial anomaliesorafewagressivetumors,like low stageCIS.

• Buttotreat thesame way insituandinvasivecancersdonotdecreaserecurrences orbreast cancermortality .(StevenNarod,study Toronto2016)

• Taking invasivecancersandCISintoaccount endsinoverdiagnosisaround30oreven 50%.

• Before screening,less than 5%ofallbreast cancerswhere CIS.Whenparticipationinscreeningis significant,15à20%ofalltumors areCIS.

• Incontrast mammography haslowsensibility forsome agressivecancerslike the‘triplenegative’.

• Invasivecancersdetected byscreeningareclinically andhistologically less agressivethaninterval cancers.

• Screened cancerskill less than isinterval cancers.

• So:thefact that abreast cancerwasdetected bymammography screeningis indeed agood-pronosticfactor.

Consequences ofoverdiagnosis

Judicial effect :physician condemned for

"missing"asmall cancerthat would

havehad novitalimpact

Def.:

Nocebo effect occur when anticipationofanunwanted effect makes this

unwanted effect happen.Thesubjectwaits foranegative event defined bysocial,media,professional orpopularmessages,andthis event happens.

Nocebo effect doesn’t affecteverybody.Itvarieswith mentalstate,internal

imaging andrelationwith theexternalworld.

Italso depends onself-analysis capacity,andthesocialcontext.

Suggestionsare:messagesandnegative attitudesfrom medical staff,

autosuggestionsby:

·individual conditioning beliefs,·« doctors whitecoat effect »,

.Collectivesymbolic representations.

Nocebo effect SandersPeirce(american philosoph)Ourconvictionscan be imperative,astheoneaccording to"themoreacanceris taken intime,themorewe havechancetobe cured »:*bytenacity (repetition),even ifpersisting inthebad faith,*byapriori(that mustbe true,even ifit is notdemonstrable)*byargumentofauthority releasingusfromdoubt andfrom reflection,*byscientific method,allowing criticism ofmethod andresults,butintellectually moredemanding.

Chronical stressbecause ofterrorofcancer,maintained bythe

medical profession,relieved bymedia.

Painful,stressful examinations,alarming expectationsofthe

results every 2years,falsealarms,andmedical escalation.

Trans-generationnelnocebo-effect

(convictionoffamilialdisease passed ontodaughters,grand-

daughters.)

Physicalandpsychic impactsof:• Preventive breasts removal,

sometimes demanded bywomen,

• Excessiveradiotherapy andchemotherapies.

• Complicationsofsurgicaloperations.

• Radio-inducted cancersthrough repeatedmammography andradiotherapy.

Atleastastresseffect

Physicians unconsciously noceboeffect byusing certainwords,silences,acts orgestures :

diagnosis becomes aself-fulfillingprophecy,announced bythe

physician intheobsessionofthe« righttoknow »enshrined inlaw.

Anxiety is passed onby:

*roughverbalsuggestionofthephysician ("Ifyou donotfollow my

advice,cancermay kill you ")

*theusual practicejustifying theact(screeninghabit)

*lack ofempathy with patients

*fear felt byphysicians himself

Thewill todowell andto"savelives"may leadto

theopposite

Theterror ofdisease inoursocieties leadstoovermedicalisation.Itmakessick many healthy people(likewomen 50-74years old)

Socialfears,socialrepresentations ofcancerdisease.

Thesocialrepresentations ofcancerdistort theconceptionsofpeople

aboutthis disease,alteritsperception.They influence

therapeutic strategies andpublichealth policies.

Themalignant cell is saw asadisobedient sociopath,anexpansionist enemy who

catchesalltheresources ofthebody.

Malignant cell is considered adelinquent,aninsane,adrug-

addict andamigrant:itcondensesour socialfears

Byrefering tosocialdangers,we leavescientific statement andwe setoutto

judge,sentenceandexclude,andwe castfault andshame tothepatient.

Military vocabulardemand war action

against cancer,butthisanalogy is inadequate.

War supposesthedestructionoftheenemy,butwith theageing ofthepopulation,cancersaregoingtoincrease.

Socialfears,socialrepresentations ofcancerdisease.

Amilitary strategy that aims toeliminate alltumors will increaseovertreatment,with heavy morbid

consequences.

Istheresearcher inoncologyjust anobedient serviceman?

Where is theintellectualadventure which questionsthepreestablished theoreticalmodels?Where is theambitiontodiscover ?

Thepatient is notasoldier takingorders from atopmanagement,heis notacancer-hero,andeven ifheis fighting,there is noreason to

accusehim ofsurrender ifhe fails.

Other cancermodels exist,fundamental research mustquestionthenatural history

ofcancer.

Therearenonmilitary ways tomake diseasefitinthepersonal bibliography ofthepeople,tofacepossiblerecurrences andchronicdisease,which may disrupt onelife.

LesfemmessontPlusvigilantesqu’autrefoissurlesmodificationsdesseins

Fortheamericanphysician andmethodologistD.Sackett,thiskind ofpreventivemedecine is :

A.Assertiveonhealthy individualswithout anysymptom,tellingthem what todotoremain healthy;

B.Presumptuous,claiming that itsinterventionswillgenerally make betterthan worst tothose whosubscribe toit;

C.Tyrannical,doingeverything toexercise itsauthority,through :

• publicfear campaigns• Mediacoverage• Public« education »• Collusionwith pharma

industry.

LesfemmessontPlusvigilantesqu’autrefoissurlesmodificationsdesseins

TodayCurrent treatments aremoreeffectiveagainst

cancer.

Cancerdoes notevolve inalinear,mecanical way.

Letusnotminimize theunwanted effects:*overdiagnosis/overtreatment*falsealerts

*radio-inducted cancer

Itis notethical tousefear ofthecancer,oremotional argumentstocompel women.Neutral,honest,understandable informationenable women tochoose freely.

Screeningmustbeexplained withoutexageration,with thecontroverse,withabsolute risk,andtherealbalancebenefit/risks.

Her bodybelongs

toawoman.

She havearight

tosay yes ornoto

breast cancer

screening,andto

make personal

choice.

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