[Using medical imaging for a comprehensive breast cancer screening program]. / Imagerie au service du dépistage : l'exemple du dépistage organisé du cancer du sein.

We described here the national breast cancer-screening program that is used, in France, today. First we depict official rules and regulations along with the organization needed to screen a whole population. Then, a technical assessment is made on the efficacy and limits on mammography analyses leading to tumor classification. Finally, an evaluation of the program is discussed.

[Assessment of the dense breast within the French screening program: the role of ultrasonography]. / Seins denses et dépistage organisé: place de l'échographie.

Mammographic density is associated with an increased risk of breast cancer. It also reduces the reliability of screening mammography. Among the population targeted by the French screening program, about 28% have dense breasts and 3% have very dense breasts. Breast density varies with age, HRT and mammographic technique. Ultrasonography for dense but otherwise clinically and mammographically normal breasts allows detection of cancers not visible on mammograms. The French program protocol allows the evaluation of results from breast US in this context with regards to the number of detected cancers and false positive rate.

[Bilateral ductal carcinoma in situ of the breast: independent events or bilateral disease?]. / Carcinomes canalaires in situ bilatéraux: événements indépendants ou maladie bilatérale?

OBJECTIVES: In a retrospective study of bilateral Ductal Carcinoma In Situ (DCIS), cases were analysed to determine the relationship between the two events. MATERIAL AND METHODS: From 1971 to 2001, among 812 patients with DCIS in Bergonie Institute, 78 suffering from bilateral DCIS and only19 were treated entirely in our institute. It was either synchronous DCIS or asynchronous (before 6 months). We realised a comparative study between, clinical and pathological characteristics of each DCIS. RESULTS: In case of asynchronous DCIS, contra lateral DCIS occurred after a median 75-months period and until 22 years after the first event. We found at least for one histological subtype an agreement in 53% of cases. In 31% of cases, the grade was the same. For low plus intermediary grade versus high grade, the agreement was 53%. There was a subtype and grade agreement of 32% and a subtype or grade agreement in 63% of cases. CONCLUSION: Histological agreement between the two lesions indicated the possible existence of in situ bilateral disease in these women. The local relapse rate was 20% and all of them were invasive. The risk of relapse in controlateral breast is high and patient needs a long follow up even in case of mastectomy.

[Psychological adjustment of stereotactic breast biopsy instrumentation procedures: about 73 cases]. / Le vécu psychologique de la procédure de prélèvements percutanés du sein. Etude quasi prospective à propos de 73 cas.

OBJECTIVE: The aim of the study was to investigate patients' perceptions after stereotactic breast biopsy instrumentation, after both procedure and results. PATIENTS AND METHOD: From 1 March 2002 to 31 March 2003, a questionnaire (Likert response type) on stress was given to 73 patients who had breast biopsies procedures, the first time at the end of the procedure (T1) and then after the histological diagnosis (T2). RESULTS: The questionnaire was validated through analysis of principal component with Varimax rotation. Three factors were identified: procedure, quality of life, information and perception after biopsy. Responses were analysed with Chi-square. Two groups of women were identified, the first group (G1) corresponding to patients with a benign diagnosis (N=32) and the second group (G2) to patients with malignant diagnosis (N=32). Only the "procedure" factor was different at T1 and T2 (P=0.022). Compression was found to be painful: 11% at T1 versus 21% at T2. Women were disturbed by local anesthesia: 26% at T1 versus 21% at T2. Biopsy was painful: 6% at T1 versus 13% at T2. Examination was too long: 24% at T1 versus 35% at T2. The procedure was discomfortable: 52% at T1 versus 54% at T2. Information satisfied patients in 90% cases. There was no statistically significant difference according to procedures and histological disease (P=0.357). DISCUSSION AND CONCLUSION: Information and medical empathy conditioned patients' perceptions. Patients tolerated the procedures well.

[Breast cancer screening: specific features of the French program]. / Le dépistage organisé des cancers du sein: particularités du système français.

The breast cancer screening program developed in France is an original model, adapted to the specific features of the French healthcare system. Both public and private mammographic units are involved with an active participation of practitioners in prescription and management. Two views per breast every two years together with physical examination are performed. An immediate diagnosis process is planned if an abnormality is detected. The French model is also a rigorous public health program involving prior training, strict organisation, quality assurance of all the process, double reading and epidemiologic evaluation. Logical benefits and difficulties of such a system are discussed.

[Psychological adjustment of short interval follow-up mammography: about 50 cases]. / Une étude exploratoire sur le vécu psychologique des femmes lors de la surveillance des anomalies mammographiques probablement bénignes: à propos de 50 cas.

The objective was to investigate women's perceptions and the perceived stress experience when undergoing surveillance mammography for benign lesions (ACR3, BI-RADS). A semi-prospective study was carried out on women with diagnosed "probably benign" breast abnormalities. It was a multicentric study from 1st March to 10th June 2002. The survey was performed at the first follow-up mammography and included questions about perceptions and perceived stress related to the follow-up experience. The response is analysed with chi-square test. Fifty women (35-75 years) answered the questionnaire. All women were satisfied with reception. The mammographies were painful (23 cases). Subsequent time seemed to be too long (seven cases) and they were anxious in 19 cases. Quality of life was spoiled (disturbed) (20 cases). Professional and social perturbations were not frequent (four cases). Speaking to a relative is frequent (39 cases), but patients were not satisfied with it (33 cases). Medical information was estimated (47 cases) but was not satisfactory (36 cases). The median of the stress scale is 4-5. There are two pickaxes, one at 2 (11 cases), the second at 5 (8 cases). "Low-stressed" women could have an avoidance coping. "High-stressed" women could use a helplessness- hopelessness coping strategy. Women reported a good and informative medical support and adequate comprehension of the short follow-up mammography. They were reassured by the medical care, but the evaluation of the stress level shows it to be high, probably due to the uncertainty of diagnosis.

[Breast biopsies: stereotactic vacuum-assisted core biopsy and stereotactic surgical breast biopsy]. / Les prélèvements mammaires en stéréotaxie: macrobiopsies avec aspiration et biopsies chirurgicales stéréotaxiques.

Stereotactically-guided procedures for diagnosis of breast lesions can avoid a lot of surgical biopsies. Stereotactic guidance is used for vacuum-assisted core biopsies and for stereotactic breast biopsies. Technical details of the procedures are described, and the benefits and the limits of these methods are discussed. Indications for breast sampling are proposed according to the Breast Imaging Reporting and Data System (BI-RADS) assessment categories.

["Standards, Options and Recommendations 2001" for radiotherapy in patients with non-metastatic infiltrating breast cancer. Update. National Federation of Cancer Campaign Centers (FNCLCC)]. / Standards, Options et Recommandations 2001 pour la radiothérapie des patientes atteintes d'un cancer du sein infiltrant non métastatique, mise à jour. Fédération nationale des centres de lutte contre le cancer (FNCLCC).

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of french cancer centers (FNCLCC), the 20 french cancer centers, and specialists from french public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. OBJECTIVES: To develop clinical practice guidelines for non metastatic breast cancer patients according to the definitions of the Standards, Options and Recommendations project. METHODS: Data were identified by searching Medline, web sites, and using the personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to 148 independent reviewers. RESULTS: This article presents the chapter radiotherapy resulting from the 2001 update of the version first published in 1996. The modified 2001 version of the standards, options and recommendations takes into account new information published. The main recommendations are: (1) Breast irradiation after conservative surgery significantly decrease the risk of local recurrence (level of evidence A) and the decrease in the risk of local recidive after chest wall irradiation is greater as the number of risk factors for local recurrence increases (level of evidence A). (2) After conservative surgery, a whole breast irradiation should be performed at a minimum dose of 50 Gy in 25 fractions (standard, level of evidence A). (3) A boost in the tumour bed should be performed in women under 50 years, even if the surgical margins are free (standard, level of evidence B). (4) Internal mammary chain irradiation is indicated for internal or central tumours in the absence of axillary lymph node involvement (expert agreement) and in the presence of lymph node involvement (standard, level of evidence B1). (5) Sub- and supra-claviculr lymph node irradiation is indicated in patients with axillary node involvement (standard, level of evidence B1).

Analysis of 676 cases of ductal carcinoma in situ of the breast from 1971 to 1995: diagnosis and treatment--the experience of one institute.

Six hundred seventy-six patients with ductal carcinoma in situ of the breast (DCIS) from 1971 to 1995 were included in the study. Computerized patient files were retrospectively analyzed. Clinical findings were less frequently reported to reveal DCIS after 1989. Positive mammographic findings were obtained in 87% of patients and were mainly represented by microcalcifications (79.4%). Treatment procedures were breast-conserving surgery (BCS) alone (37.5%), BCS followed by radiation (BCSR) (25.5%), or mastectomy (M) (37%). The actuarial local recurrence was 2.6% in the M group (94 months of follow-up), 14.5% in the BCS group (85,7 months of follow-up), and 7.5% in the BCSR group (78.8 months of follow-up). Predictive factors of recurrence in all patients were invaded margin status and age. In the BCS group, grade was also a predictive factor. The analysis per decade shows that the lesions currently diagnosed are less serious than those of the past. All the recurrence in patients with positive margins was in the same quadrant as the original lesion. This further emphasizes the need for clear margins.

[Anthropological studies of the representations of menopause in a population of women invited to a mass screening for breast cancer in Bouches-du-Rhône and Charente]. / Approche anthropologique des représentations de la ménopause dans une population de femmes invitées au dépistage de masse organisé des cancers du sein--Bouches-du-Rhône et Charente.

This is an anthropological study of a target population (breast screening women) in the Bouches-du-Rhône and Charente regions of France. The occurrence of menopause is comparable in these two departments and depends on providing medical care which leads to breast screening. Menopause is natural for these women and is considered as a sign of ageing. Psychosomatic symptoms vary with sociocultural groups. Hormonal replacement therapy furthers breast screening. In the popular imagination, there is a deficit between nature (non-HRT) and culture (HRT). They take estrogen in the form of soy to offset this inadequacy, which creates a new cultural syncretism.

[Contribution to the study of the future of silicon-gel breast implants in mammary reconstruction after cancer: concerning 205 implants]. / Contribution à l'étude du devenir des implants mammaires siliconés en reconstruction mammaire après cancer: à propos de 205 implants.

Long term follow-up of 187 women with mammary reconstruction using 205 silicone-gel implants enables a retrospective analysis of the evolution of both patients and their prosthesis. Most patients have not presented local or general disease related to implant leakages. However, these leakages are not uncommon, being present in nearly one-third of 38 explantations motivated by aesthetic considerations (of which 50% are capsular retractions). All the ruptured or pre-ruptured implants are more than seven years old. Leakage frequency sharply increases after ten years. Authors tried to assess the place of radiologic evaluations (digitized costal profile, ultrasound, MRI...) in order to detect deterioration of the prosthesis. Although suspicions raised by these evaluations have made it possible to adequately target the explantations, pathogenicity of silicone-gel implants appears low enough to confirm the predominance of clinical follow-up.

[ROC analysis comparing screen film mammography and digital mammography]. / Etude comparative par méthodologie ROC: mammographie conventionnelle versus mammographie numérique.

PURPOSE: To compare the diagnosis performances of radiologists on screen film versus digital mammography. MATERIAL: and methods: Two sets of 123 mammograms, screen film mammography and storage phosphor digital mammography, are studied comparatively with ROC analysis. RESULTS: Phantom study show that conventional method give better scores for usual tension but the detectability of smaller microcalcification is equivalent. To obtain with digital technic the same conventional score you have to increase the radiation dose. Roc Curves, simulated "detection" mode showed that radiologists performed with higher accuracy with conventional system but this difference is weekly statistically significant. ROC Curves, simulated "diagnostic" mode showed the same results wit no statistically significant difference but when the decision to go to the biopsy is the gold standard, ROC Curves were essentially equivalent for both film screen and digital mammography system. The readers consistently considered the digital mammograms to be less suspicious for cancer findings. The agreement study as proposed by the FDA indicate that probability of a positive digital mammograms given a positive screen film is 75% (threshold value 90%) and the probability of a negative digital mammograms given a negative analog film is 85% (threshold value 85%). CONCLUSION: Analysis of specific discrepancies indicate that spatial resolution is an essential limiting factor for digital method but high resolution phosphor plate are interesting in imaging treated breast, radioluscent lesion, fatty benign tumor, hamartoma, intramammary lymph node, breast with prosthesis.

[Large core of nonpalpable breast lesions]. / Microbiopsies des lésions mammaires non palpables.

The development of breast cancer screening has radically changed the diagnostic approach to breast lesions. Stereotactic large-core breast biopsy was developed to reduce the number of unnecessary surgical excisional biopsies in the increasing number of patients with doubtful or suspicious mammogram findings. The methods used to evaluate this new technique are discussed, as well as results in terms of efficacy, factors that may influence efficacy, and difficulties in interpreting large-core biopsies. Recommendations regarding the harvesting and interpretation of stereotactic large-core biopsies are made.

The debate over mass mammography: is it beneficial for women?

The authors discuss the controversy about mass screening for breast cancer in order to assess the soundness of a nationwide expansion of such programmes. Mass screening is second best because of the failure of prevention, therapeutic progress or ability to target high risk populations, but its efficacy reducing mortality is not clearly demonstrated and the chances of one woman being saved from participating are very low. Detrimental side-effects such as anxiety, false alarms, unnecessary biopsies, overdiagnosis and overtreatment and deficiency of psychological approach are reported. On the other hand, mass screening may save lives and if no recent study can provide absolute proof of efficacy, inefficacy of systematic mammography cannot be proven either, even concerning 40 49 years old women. Moreover, screening trials have allowed an improvement in medical practice, especially concerning quality and dose in mammography and radiographer's performance. Many questions remain unanswered about mass screening for breast cancer and the best way to achieve it.

[Stereotaxic fine-needle aspirations of clinically latent breast cysts: an efficient and neat procedure]. / Les cytoponctions sous stéréotaxie des kystes mammaires infracliniques: une procédure efficace et élégante.

The purpose was to evaluate the interest of stereotaxic fine-needle aspiration for round opacities when the ultrasound and echoguided punctures are inefficient; especially when women are under menopausal hormonal replacement therapy. Sixty stereotactic guided fine-needle aspirations detected by mammography have been performed between january 1990 and august 1996. The stereotaxic procedure is performed with a DMR unit (GE with Stereotix II). Stereotaxic views are done to verify needle position. After aspiration, cytologic examination is realised. Cystic fluid was always obtained and cytologic examination proved benign cysts in all cases. In 50 cases, cysts completely disappeared. There were 2 relapses that received after a second. This method is reliable for evaluation of non palpable mammographically detected opacities. The use of this technique spares the patient a surgical biopsy. This procedure enables women under menopausal hormone replacement therapy to continue the treatment.