The debate over breast cancer screening continues, with disagreements about the start age, frequency, mortality effect, overdiagnosis, and overtreatment.
In light of evolving findings of harms and benefits, recommendations about screening have begun to change in both the United States and other nations.
Last year, the French Minister for Health requested that the French National Cancer Institute organize a broad public and scientific consultation on breast cancer screening. While still a work in progress, the subsequent report issued in April 2017 called for multiple reforms and could be the beginning of a more personalized approach to breast cancer screening.
In a Viewpoint article published online October 30 in JAMA Internal Medicine, three experts summarize the reforms and offer some insight on how they differ from efforts in other countries.
Key Elements
One of the steps to be immediately implemented in France is to provide women with information to make their own decisions with support from their doctors, note the trio of Viewpoint essayists: Alexandra Barratt, MBBS, MPH, PhD, from the University of Sydney, Australia; Karsten Juhl Jørgensen, MD, from the Nordic Cochrane Centre, Copenhagen, Denmark; and Philippe Autier, MD, from the International Prevention Research Institute, Lyon, France.
Other immediate steps include a new medical consultation for each 50-year-old woman to discuss cancer screening options and cancer prevention via lifestyle changes and a comprehensive booklet containing screening information. Additionally, tools and training to assist clinicians in their discussion of the benefits, risks, and limitations of screening are called for.
The report also called for improving access to screening programs, providing more support to women during the screening process, improvements in the technical quality of the program, and establishing a research program concurrent with screening efforts.
The plan, explain the authors, does not provide logistic information, such as how these measures will be evaluated.
A Call for Major Changes
A national screening program had been introduced in France in 2004, in which women aged 50 to 74 years were invited to biennial mammography screening. But over time, concerns were increasingly raised about the program itself and the possible harms from overtreatment and overdiagnosis.
An independent steering committee was eventually established to evaluate the breast cancer screening program. This involved not only healthcare professionals and screening experts but also the public.
A civil consultation group of 27 women from different regions of France and diverse socioeconomic groups and a parallel group of 19 health professionals with relevant professional experience but without any financial or academic ties to breast cancer screening were established.
The findings from the steering committee, note Dr Barratt and coauthors, “are different from those of many other recommendations panels, such as those of the US Preventive Services Task Force, the American Cancer Society, and the International Agency for Research on Cancer, which have recently concluded that the benefits of screening for breast cancer with mammography outweigh the harms and continue to recommend it.”
Instead, the French panel found an “unexpectedly intense scientific controversy, centered on uncertainty about the benefits of screening, and concerns about overdiagnosis and overtreatment.”
Despite extensive discussion in the scientific literature, the established French program had not acknowledged this controversy. The committee also pointed out that much of the evidence on screening outcomes was limited and derived from older studies. In addition, no studies had been conducted in France.
Neither the civil nor the healthcare professional consultation groups wished to keep the current program going.
The healthcare professionals recommended continuing the program but making major reforms in its implementation.
Unique Recommendations
The inquiry in France is the third independent review of breast screening in Europe, following reviews that were conducted in the United Kingdom and in Switzerland.
In the United Kingdom, the panel concluded that screening reduces breast cancer mortality but some overdiagnosis occurs, and this information should be made available to women in a transparent and objective manner so that they can make informed decisions.
In Switzerland, however, the Medical Board recommended stopping the introduction of new mammography screening programs and phasing out existing programs. The major idea was to replace systematic screening programs with systematic screening information and individual choices.
The Viewpoint authors hypothesized why the recommendations made in Europe are different than those in the United States. One possible explanation is that some panels may be compromised by the conflicts of interest of members, which is something that was avoided in all three European countries that launched recent reviews.
But the French effort was also unique unto itself, point out the Viewpoint authors. For example, a “broader range of disciplinary perspectives” were represented in the French panel. Also, the public was included in making recommendations, which generally doesn’t occur in this setting.
Experts Weigh In
Two experts in the United States offered their thoughts about the changes in the French national screening program.
As the scrutiny over mammography increases, so do the various arguments, noted Saurabh Jha, MBBS, MRCS, assistant professor of radiology, University of Pennsylvania, Philadelphia.
“The French went to extraordinary efforts to be unbiased, and made that extremely clear, but with all of the inclusion of various stakeholders they still didn’t come up with the goal of abolishing a public screening program,” said Dr Jha. “That tells you more than anything else — after this entire charade about mammograms, it’s still there.”
They still didn’t come up with the goal of abolishing a public screening program.
He emphasized that mammography critics seemed to have missed the point — that screening mammography is a trade-off.
“If you abolish it there will be some deaths that could have been prevented, and the evidence towards that is not controversial,” Dr Jha explained. “But the question is: What is the net benefit?”
Dr Jha also raised the question of tailoring or individualizing treatment, and some of the complexity involved with that. Defining the population most likely to benefit can be difficult. Persons deemed to be at high risk will ultimately have the highest risk of developing cancer, he noted. However, most people are at average risk for cancer by definition, and most cancers occur in persons at average risk.
Much of the screening dispute arises from the fact that the associated benefits are small, he said. Any cancer screening program that does not discuss the trade-offs is inherently dishonest, he added.
“So there is always going to be this debate as to what is the precise rate of survival benefit and what is the precise rate of misdiagnosis, and the reality is that you can’t ever really nail that figure,” he added.
Personalizing Mammography Is the Future
Nancy Keating, MD, a primary care physician at Brigham and Women’s Hospital and professor of health care policy and medicine at Harvard Medical School, Boston, Massachusetts, observed that the French “engaged both patients and clinicians to really think about the benefits and harms and what should the role of mammography be in their government-funded healthcare system.”
The idea that there are associated harms is being increasingly recognized, and it does influence some of the enthusiasm about mammography. “I don’t think anyone is saying that mammography doesn’t have any benefit, but I think they are looking at the best way to improve public health,” she said.
I don’t think anyone is saying that mammography doesn’t have any benefit.
A key part of the French report centers on making individual decisions about mammography. “This is crucial, and we’ve been talking about it in the US, but I don’t think it’s appreciated as much as it should be here,” Dr Keating pointed out.
In a perfect world, clinicians would all be discussing the benefits and harms of mammography screening with patients, their values and preferences, and their individual risk for breast cancer, and then helping them come to the decision that makes sense for them.
“I have been doing this for several years now, with my patients, and by and large it’s a very useful conversation,” said Dr Keating. “We need to make available better tools to help patients understand this complex information — what is the mortality benefit and what is overdiagnosis.”
“We have spent decades telling women that they should get a mammography because it can save their life, and that has led to a real misunderstanding as to what the limitations are. We do need to re-educate both doctors and patients on this,” she noted.
Dr Jørgensen reports that the inquiry report cited his research. Dr Autier reports that the inquiry report cited his research and that the steering committee interviewed him. Dr Jha has served as a speaker or a member of a speakers bureau for Toshiba. D. Keating has disclosed no relevant financial relationships.
JAMA Intern Med. Published online October 30, 2017. Abstract
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