Search

In 1989 the European Breast Cancer Network (EBCN) was established by the first pilot projects for breast cancer screening, co-funded by the Europe Against Cancer programme. We report early performance indicators for these EBCN projects while taking into account their organizational setting. Out of 17 projects in the network, 10 projects from six European countries contributed aggregated data on number of invitations, screening examinations, and breast cancers detected over the period 1989-2000. Results were summarized separately for projects in centralized versus decentralized health care environments. The European Guidelines for quality assurance in mammography screening provided reference values for the performance indicators. The most prominent finding in this study was the higher participation rate in centralized versus decentralized projects (average participation in 1998: 74 versus 33%; P<0.001), whereas the invitation system and screening policy in these projects were similar. Detection rates and characteristics of cancers detected at initial and subsequent screening examinations showed no significant differences between centralized and decentralized projects. Even though early performance indicators for centralized versus decentralized projects were similar, the impact of breast screening on mortality from this disease at the population level will differ since the decentralized projects reach only part of the target population.

Purpose: To assess difficulties in reading screening mammographies related to hormone replacement therapy (HRT) in the setting of a breast cancer screening program. Disagreement between two readers is used as the assessment criterion., Population and Methods: The study population consisted of all women participating in the ADEMAS breast cancer screening program in Bas-Rhin (France). Agreement between the two radiologists was considered when the same global conclusion (call-back or not of the women for further examination) or the same conclusion for each of the nine possible lesions was observed., Results: HRT is associated with a higher risk of disagreement between the two radiologists on global conclusion and on opacities. Conversely, disagreement risk is lowered for microcalcifications (whether benign or malignant) for HRT users., Conclusion: HRT is associated with a higher risk of disagreement on global conclusion. This has an impact on whether the women should be called-back or not according to reading of breast cancer screening program mammographies.

Since 1989, in the French department of Bas-Rhin, a breast cancer screening program in going on and its results are presented here. This program, concerning women of 50 to 65 years-old, is decentralized, based on private or public radiologists and the motivation of women because there is no invitation. The interval between screening test is 2 years. After 8 years, the results are rather satisfactory: participation rate of the initial cohort is 77% in December 31st 1997, participation at incident screenings is above than 85%, early indicators (recall rate, detection rate, PPV of screening, PPV of biopsy) are improving with time to attain numbers like international studies. The ADEMAS program shows that a decentralized screening program, based on existing medical structures is possible in France. Anyway, it must be organized, evaluated at any time, with a quality assurance system to guarantee the women the best taking charge.

Purpose: This paper presents the cost of two decentralised breast cancer screening programmes in France, in the Bas-Rhin and the Bouches du Rhône districts. Materials and methods. The costs directly related to running the two screening programmes were collected for the time period 1990-1997. Only direct costs of each programme, excluding assessment and treatment costs, are included in the cost analysis. Costs are presented per screening period, per programme attender and per cancer detected by screening., Results: The screening programme costs an average of 397 francs per woman screened and 90,828 francs per cancer detected in the Bas-Rhin, and 379 francs and 76,159 francs, respectively, in the Bouches du Rhône., Conclusions: These costs are high compared to those of existing centralised programmes. Further research is needed to investigate means of ensuring the optimal efficiency of these programmes. The results of this study may help guide future decisions on the further development of breast cancer screening in France.

Breast cancer is the most frequent cancer in women: more than 8 to 9% of women will develop a breast cancer during their life and the incidence rate is regularly increasing. Despite therapeutic improvements, breast cancer mortality still remains important and varying according to regions (five years survival: 62 to 80% for the last years). The risks factors analysis shows that a primary prevention of the major risks factors is not yet possible (genetic or endogenous hormonal risk). The chemoprevention is still is discussion and under investigation. For the moment, secondary prevention using screening is the only way to improve survival. The lead-time induced by the screening allows an earlier detection of breast cancers. The randomized trials have demonstrated a significant benefit on mortality and morbidity from breast cancer in women aged 50 to 69. So many countries started regional, pilot or national breast cancer screening programmes using mammography with a 2-year interval and specialized centers.

Cancer registries are necessary to evaluate the efficacy of cancer screening programmes. They provide early indicators of screening efficacy, needed to correct certain campaign failings without waiting for the mortality data, available only 7 to 10 years after the beginning of the screening. They allow to mesure the screening effect not only on the screened women, but also on the entire target population. They also allow to mesure the negative and deleterious effects of the screening. Finally, they are essential to all cost/efficacy study. The evaluation of the breast cancer screening programme in the French department of Bas-Rhin by the cancer Registry showed very quickly the interest of the mesures concerning the quality assurance programme and to estimate on the first screen results basis, that it will be difficult to reduce the mortality by breast cancer to 25%.

The ultimate effectiveness of any mass screening campaign is directly related to strict compliance with certain rules and technical protocols designed for radiological installations. Concerning radiological screening, the primary technical objective is to ensure reproducibly high quality images at low radiation dose to the patient. This paper describes the methodology followed for the implementation of a quality control (QC) programme of 48 mammography installations used within the context of the breast cancer screening campaign in the Bas-Rhin region of eastern France. In order to demonstrate the efficacy of such a programme, results of QC tests and procedures relating to each element of the radiological imaging chain are presented and compared for four control visits carried out at 6 month intervals over a period of 2 years. A reduction of 50% (from 16 mGy to 7.5 mGy) of breast entrance doses (normalized to a breast thickness of 4.5 cm) and a significant improvement of detectability of high contrast details are discussed. The importance of encouraging an extension of a similar process to the other screening experiments currently underway in France is emphasized.

A questionnaire survey of 200 doctors who were a sample of the general practitioners of the Bas-Rhin department was carried out. This was in order to ascertain what they knew about cancer of the breast and how they practised medically in this area, what were their doubts and what motivated them to screen for this kind of cancer? The questionnaire was found on the whole to acceptable. The enquiry showed that undoubtedly doctors were in favour of screening for cancer of the breast but were less enthusiastic carrying it out routinely. They also were unaware of ways in which such screening could be carried out (mammography being considered and examination which shows where the cancer was and not as a screening method). Furthermore, there was some confusion between screening and means of diagnosis. Results of this study show that it should be possible to outline the content and means of informing general practitioners about how to screen in order to enable them to participate in the Alsatian pilot campaign for screening for breast cancer.

A mammographic breast cancer screening began in May 1989 in the Bas-Rhin. It has been selected by "Europe against Cancer" for France. Its aim is not to prove the efficiency of mammography screening by one view every two years, as many studies has proven it. Its purpose is to find the best methodological model for a national campaign. Its principles are to change attitudes and to obtain the active participation of the physicians without creating new structures. This campaign is offered to women aged 50 to 65, living in Bas-Rhin (74,200 women) without individual convocations. Their participation is obtained by a continuous information and motivation. The mammographic examinations are taken in charge by the Health Insurance and performed by the radiologists who have signed a convention. The homogeneity of the results is assured by a double and triple reading under the responsibility of the ADEMAS. In May 1990, after one year, 17,228 women had presented to the screening test. The positive test rate is 7.6% and 7.6% of the women had a diagnostic procedure which indicated a biopsy for 188 women. Among the first 176 histological results, 76 cancers have been diagnosed, 100 women had a benign lesion. The ratio cancer/benign lesion is 0.76.

The results of different programmes for screening carried out at present in foreign countries give sufficient proof of the value of screening for cancer of the breast in asymptomatic women of over 50 years of age. There is a significant reduction in mortality between 30 and 70%, according to different studies. Women who were screened had their cancers diagnosed at an earlier stage of the illness than those who were not screened whatever the ages of the women were. These results give a basis for planning screening in France. However, controlled pilot studies should still be carried out to widen screening in a country. These studies should in particular look at technical methods, evaluate the quality of the information that is obtained and the acceptability by women, as well as the training of radiologists and the qualities of the methods used. Finally, each programme should be controlled by the Public Authorities who will be paying for it.