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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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).

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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

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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 :

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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)

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(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

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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.

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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.

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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

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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

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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

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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.

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Consequences of overdiagnosis
Judicial effect : physician condemned for
"missing" a small cancer that would
have had no vital impact

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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.

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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

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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)

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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.

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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.

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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.

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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.

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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

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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.