Joann G. Elmore, MD, MPH; Suzanne W. Fletcher, MD
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-0505.
Requests for Single Reprints: Joann G. Elmore, MD, MPH, 325 Ninth Avenue, Room 10EH03, Box 359780, Seattle, WA 98104-2499.
Current Author Addresses: Dr. Elmore: 325 Ninth Avenue, Room 10EH03, Box 359780, Seattle, WA 98104-2499.
Dr. Fletcher: 208 Boulder Bluff, Chapel Hill, NC 27516.
Elmore J., Fletcher S.; Overdiagnosis in Breast Cancer Screening: Time to Tackle an Underappreciated Harm. Ann Intern Med. 2012;156:536-537. doi: 10.7326/0003-4819-156-7-201204030-00012
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Published: Ann Intern Med. 2012;156(7):536-537.
The earlier that cancer is found, the better. This underlying tenet of cancer screening has saved many lives. However, studies are beginning to challenge the certainty that finding cancer early is always better. One stark example was the practice of screening infants for neuroblastoma. After the introduction of a simple urine test in Japan led to nationwide screening, the incidence of neuroblastoma approximately doubled, whereas that of mortality and late-stage disease remained unaffected. Widespread urine testing of infants was subsequently abandoned (1). The excess cases of cancer found on screening were examples of overdiagnosis, defined as occurring when “a condition is diagnosed that would otherwise not go on to cause symptoms or death” (2). Overdiagnosis need not imply that a given screening effort is ineffective or ill-advised. Indeed, overdiagnosis has been documented in effective screening programs for several types of cancer, including breast cancer.
Alain, Braillon, Public Health
April 17, 2012
Unbalanced information regarding breast cancer screening: The French touch
Elmore and Fletcher stress that we have an ethical responsibility to alert women and that most education aids do not even mention overdiagnosis during breast cancer screening.(1)
France may ranks first for unbalanced information regarding screening advantages and disadvantages.
First, the mandatory health insurances authority (French Health Insurance Fund National Authority, UNCAM) published a guidance in the official gazette of the French Republic which was ratified by the major unions of general practitioners: "the general practitioner draws the patient's attention to the benefits of (breast cancer) screening... produces positive information about screening... which naturally falls within the scope of mere monitoring...in order to remove the reticences of his patients..." (2)
Second, since 2009, participation rate in breast cancer screening is one of the indicators of the first French pay for performance program for general practitioner. This program is now almost mandatory.
Meanwhile, The French National Cancer Institute (Inca) says it is pursing "the work of conviction" ... to encourage women for participating.(http://www.e-cancer.fr/depistage/depistage-du-cancer-du- sein) Indeed, the use of complex simulation models allowed to overestimate the benefits of screening and to find only a 1.5% rate of overdiagnosis of invasive breast cancer in France.(3,4)
Happily, the Nordic Cochrane Centre provides a leaflet in 13 languages, including French.(5)
1 Elmore JG, Fletcher SW. Overdiagnosis in breast cancer screening: time to tackle an underappreciated harm. Ann Intern Med. 2012;156:536-7
2 UNCAM, CSMF, SML, Alliance, 2007.Arr?t? du 2 mai 2007 portant approbation de l'avenant n? 23 ? la convention nationale des m?decins g?n?ralistes et des m?decins sp?cialistes. Journal Officiel de la R?publique Fran?aise. n? 103 (3 May), 7826. Available at http:// www.legifrance.gouv.fr/WAspad/UnTexteDeJorf?numjo=SANS0752329A Accessed 17 April 2012.
3 Seigneurin A, Francois O, Labarere J, Oudeville P, Monlong J, Colonna M. Overdiagnosis from non-progressive cancer detected by screening mammography: stochastic simulation study with calibration to population based registry data. BMJ. 2011;343:d7017
4 Braillon A, Bewley S. Why use Markov simulation models for estimating the effect of cancer screening policies when randomised controlled trials provide better evidence? Stat Methods Med Res. 2012;21:217-8
5 Nordic Cochrane Centre. Breast cancer screening leaflet. 17 January 2012. Avaliable at http://www.cochrane.dk/screening/index.htm Accessed 17 April 2012.
AB, a tenured senior consultant(Amiens University Hospital) was sacked for whistleblowing by the French Dept of Health against the vote of more than 70% of the members of the National Statutory Committee.(http://blogs.bmj.com/tc/2010/11/08/)
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Hematology/Oncology, Breast Cancer, Cancer Screening/Prevention, Prevention/Screening.
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