Reform of the National Screening Mammography Program in France

Abstract

the French Minister of Health released the report of an independent inquiry into mammography screening. The report presented 2 options: (1) end the national breast screening program, or (2) end the current program and put in place a radically reformed program. 1 In 2004, after years of ad hoc screening, a national program was introduced. Every 2 years, women between the ages of 50 to 74 years are mailed invitations for mammography screening, for which they are not charged. Over time, however, doubts emerged about the program's reach, accessibility, effectiveness, and possible harms from overdiagnosis and overtreatment. In September 2015, the Minister of Health announced what is known in France as a "civil and scientific inquiry," and appointed an independent steering committee to oversee it.This committee brought together leading health professionals (oncology, general medicine, epidemiology, public health) and social sciences professionals (anthropology, law, economics, history of science, bioethics), all free of financial and academic ties to breast screening. As well as requesting evidence reviews on specific questions (undertaken by a technical support committee of the French National Cancer Institute), the committee oversaw a "civil dialogue," a concept inherited from the French Revolution of 1789. A website provided information about the inquiry and invited public submissions. Two substantial consultations were established: (1) a civil consultation with a group of 27 women from different regions of France and diverse socio-economic groups, and (2) a parallel consultation with a group of 19 health professionals with relevant professional experience but no ties to breast screening. Each of these consultations took place over 5 days of information presentations, interviews of experts, questions, and discussions. Each consultation group addressed 4 questions (Box), developing a collective response to each. A closing public meeting was held to present the recommendations and respond to questions.The steering committee found an unexpectedly intense scientific controversy, centered on uncertainty about the benefits of screening, and concerns about overdiagnosis and overtreatment. The national program had not acknowledged this controversy, despite the extensive discussion in the scientific literature. The committee found that the evidence on the outcomes of breast screening was limited, coming from older trials and studies, none of which had been conducted in France. They highlighted that knowledge of the natural VIEWPOINT

Behavior within a Clinical Trial and Implications for Mammography Guidelines

“…(Biller-Andorno and Jüni, 2014), and in 2016 the French Minister of health released results of an independent review that recommended an end to screening or radical reforms (Barratt et al, 2018).…”

Overutilization of Breast Cancer Screening in the US: Awareness of a Growing Problem

“…For example, France is completely reforming their approach to breast cancer screening to emphasize individualized risk and informed decision making. 11 Ideally, here in the US, as we aim to improve the quality and value of care, we will design a system that allows women the opportunity to make an informed decision about whether to be screened, regardless of age. To do so will likely require that quality metrics shift from focusing on receipt of breast cancer screening to receipt of individualized and understandable information on the benefits and harms of breast cancer screening.…”

Applying the precautionary principle to breast cancer screening: implications to public health

“…The former should have a wider socialization process about their recommendations to improve informed decision to policymakers. The broad public and scientific consultation process on breast cancer screening in France stands out as an example of such initiative 17 . Additionally, rigorously quality-assured and evidencebased screening programmes should inform their target population about the potential harms and benefits of screening.…”