Sargassum seaweed health menace in the Caribbean: clinical characteristics of a population exposed to hydrogen sulfide during the 2018 massive stranding.

BACKGROUND: Since 2011, there have been ongoing massive unexplained increases of sargassum seaweed strandings along the coastlines of Caribbean countries. The objective of our study was to describe the clinical characteristics of patients exposed to noxious emissions of decomposing sargassum seaweed. METHODS: This observational study included patients from January 2018 to December 2018 for complaints attributed to decomposing sargassum seaweed. History and geographical characteristics of sargassum seaweed strandings as well as detection of ambient air hydrogen sulfide (H2S) levels were documented during the inclusion period. FINDINGS: A total of 154 patients were included. Mean exposure period was 3 months. Neurological (80%), digestive (77%) and respiratory (69%) disorders were the most frequent reasons for medical visit. Temporal distribution of medical visits was related to history of strandings. Geographical origins of patients were consistent with the most impacted areas of strandings as well as the most elevated ambient air H2S levels. INTERPRETATION: The toxicological syndrome induced by sargassum seaweed exposure is close to the toxidrome associated with acute H2S exposure in the range of 0-10 ppm. Our study suggests that patients living in massive stranding areas may be exposed to H2S > 5 ppm for 50 days per year.

Breast cancer screening: Impact on care pathways.

BACKGROUND: Controversy persists concerning screening programs (SPs), related to a potential risk of overdiagnosis or the impact on survival. One of the main questions to be addressed concerns the aggressiveness of the related treatments. METHODS: Using the "Cancer Cohort," a national-based cohort (medico-administrative database), all women between the ages of 50 and 74 years and treated in 2014 for incident breast cancer were compared, according to whether their diagnosis was made following a mammogram performed within the framework of the SP (SP group) or outside it (NSP group). RESULTS: A total of 23 788 women were identified: 13 530 (57%) in the SP group and 10 258 (43%) in the NSP group. The women in the SP group had a higher rate of in situ or localized invasive breast cancer. They had a higher rate of breast-conserving surgery (82% vs 70%), and a lower rate of chemotherapy (34% vs 53%). These findings were observed irrespective of the stage. They had a higher rate of pathways involving breast-conserving surgery followed by radiotherapy. Among women with metastatic cancer, those in the SP group had a lower proportion of liver, lung, brain, and bone metastases, and a higher proportion of lymph node metastases (other than axillary), irrespective of the time to onset of the metastases. CONCLUSION: The women in whom cancer was diagnosed following a mammogram performed in the context of the SP had less advanced cancer and less aggressive treatments. This observational study helps illustrate the benefit of the SP in France using a different approach.

Cancer care and public health policy evaluations in France: Usefulness of the national cancer cohort.

BACKGROUND: In the context of the national Cancer Plans of France that have changed the healthcare landscape, it has become necessary to better document and assess the related actions, and to promote research and understanding. The national cancer cohort, an exhaustive population-based cohort, was set up on the basis of the National Health Data System (SNDS) by the French National Cancer Institute. OBJECTIVES: The aim is to describe the French national cancer cohort. METHODS: All people living in France (67 million population) with universal insurance coverage and diagnosed, treated or followed up for a cancer, such as survivors, are included and will be followed up for 25 years. It contains all healthcare consumptions and reimbursements (i.e. hospitalization, outpatient care, medication…) since 2010. Every year, around 650 000 new cases are included. RESULTS: From 2010 to 2015, 6.2 million subjects have been included. Most subjects were entered in 2010, in 2015 it concerned 0.6 million. In 2015, the median age was 65 [54-76]; 51% were women. The primary cancer organ could be attributed with certitude to 87% of the people. The most frequent locations were skin (16%), breast (15%), prostate (12%), colon-rectum (11%) and lung (9%). In 2015, 40% of included subjects underwent surgery for cancer, 16% chemotherapy at hospital and 11% at least one session of radiotherapy. CONCLUSION: Based on SNDS, the cancer cohort has been designed to study cancer care use in the short-, medium- and long-term, and evaluate healthcare and public health policies.

Current and Former Smokers: Who Wants To Be Screened?

BACKGROUND: Lung cancer (LC) screening (LCS) with annual low-dose computed tomography scans has been seen to reduce the specific and overall mortality in selected populations. However, participation is key to successful screening programs. The EDIFICE (etude sur le dépistage des cancers et ses facteurs de compliance [survey on cancer screening and compliance factors]) nationwide observational surveys are used to assess behavior related to cancer screening programs in France. MATERIALS AND METHODS: Using comprehensive multivariate stepwise logistic regression analyses of data from current and former cigarette smokers, we sought to identify the explanatory factors associated with the intention to participate in an LCS program. RESULTS: Of the 1463 respondents with no personal history of cancer, 263 (36.4%) of the current cigarette smokers and 170 (26.3%) of the former cigarette smokers stated their willingness to participate in an LCS program. The explanatory factors differed between current cigarette smokers (already screened for LC: odds ratio [OR], 2.81; < 30 pack-years: OR, 2.69; intention to quit smoking: OR, 1.96; no social vulnerability: OR, 2.15) and former cigarette smokers (comorbidities: OR, 0.31). The usual eligibility criteria were not significantly explanatory. CONCLUSION: Our findings highlight the discrepancy that exists between target populations and individuals who actually intend to participate in a screening program for LC, with subsequent potential effects on the participation rates and, thus, on the efficacy of screening.

Beliefs and behavior regarding e-cigarettes in a large cross-sectional survey.

Although e-cigarette use is increasing dramatically, numerous concerns persist regarding toxicity and their role in smoking cessation. We assessed beliefs and behavior regarding e-cigarettes in an adult French population. The 4th French nationwide observational survey, EDIFICE 4, was conducted among representative samples of 1602 laypersons (age, 40-75 years) from 12 June-10 July 2014, using the quota method. Profile, beliefs and behavior were assessed by phone interviews of the participating lay population with no history of cancer (N = 1463). Tobacco use, nicotine dependence (Fagerström test) and e-cigarette use were assessed. E-cigarette users represented 6% of the study lay population. E-cigarette users regarded e-cigarettes as helpful for quitting tobacco smoking and reducing the risk of lung cancer. Current dual users (e-cigarettes + cigarettes) were more likely to attempt to quit than current exclusively cigarette smokers (odds ratio, 3.15 [1.74-5.70]), and to consider themselves at higher risk for lung cancer (OR 3.85 [2.47-5.99]). They also considered e-cigarette vapor to be less toxic than tobacco smoke in terms of both active and passive exposure. Dual users typically consider themselves at higher risk for cancer and intend to quit smoking. Physicians should be made aware of this specific sub-population for whom e-cigarettes may be a useful trigger in the smoking cessation process.

Decline in Cancer Screening in Vulnerable Populations? Results of the EDIFICE Surveys.

BACKGROUND: We studied cancer screening over time and social vulnerability via surveys of representative populations. METHODS: Individuals aged 50-75 years with no personal history of cancer were questioned about lifetime participation in screening tests, compliance (adherence to recommended intervals [colorectal, breast and cervical cancer]) and opportunistic screening (prostate and lung cancer). RESULTS: The proportion of vulnerable/non-vulnerable individuals remained stable between 2011 and 2016. In 2011, social vulnerability had no impact on screening participation, nor on compliance. In 2014, however, vulnerability was correlated with less frequent uptake of colorectal screening (despite an organised programme) and prostate cancer screening (opportunistic), and also with reduced compliance with recommended intervals (breast and cervical cancer screening). In 2016, the trends observed in 2014 were substantiated and even extended to breast, colorectal and cervical cancer screening uptakes. Social vulnerability has an increasingly negative impact on cancer screening attendance. The phenomenon was identified in 2014 and had expanded by 2016. CONCLUSION: Although organised programmes have been shown to ensure equitable access to cancer screening, this remains a precarious achievement requiring regular monitoring. Further studies should focus on attitudes of vulnerable populations and on ways to improve cancer awareness campaigns.

Perception of Lung Cancer Risk: Impact of Smoking Status and Nicotine Dependence.

BACKGROUND: The general population is nowadays well aware that tobacco smoking dramatically increases the risk of developing lung cancer. We hypothesized that a personal history of smoking and the level of nicotine dependence in current smokers may affect the perception of this risk among healthy individuals. METHODS: The fourth French nationwide observational survey, EDIFICE 4, was conducted by telephone among a representative sample of individuals (N = 1602) aged between 40 and 75 years. Interviewees were asked about their smoking habits, perception of the risk of lung cancer, and nicotine dependence (Fagerström test). RESULTS: Regardless of their smoking status or level of nicotine dependence, the majority (96%) of our study population (N = 1463) acknowledged that tobacco smoking is a major risk factor for lung cancer. For 34% of all respondents, smoking ≤ 10 cigarettes per day does not carry any risk of lung cancer. Only half the current smokers considered themselves to be at higher risk of lung cancer than the average-risk population. The majority of current cigarette smokers with a nicotine dependence considered themselves to be at higher risk for lung cancer while only 37% of non-nicotine-dependent individuals had the same perception (P < 0.01). Current smokers were more likely to consider a screening examination than former smokers and never-smokers. However, the intention to undergo screening was not significantly affected by the level of nicotine dependence. CONCLUSIONS: Awareness campaigns may first have to overcome misconceptions about light smoking and, secondly, to target specific populations (heavy smokers, those with a long history, highly dependent smokers).

Fluctuating Behavior of the French Population in Cancer Screening: 5th Edition of the EDIFICE Survey.

BACKGROUND: The EDIFICE surveys have assessed cancer screening behavior in the French population since 2005. METHODS: The 2016 edition was conducted among a representative sample of 1501 individuals (age, 50-75 years). The current analysis focuses on breast, colorectal, prostate, lung, and cervical cancer screening. RESULTS: The rate of women (50 to 74 years) declaring having had at least one breast cancer screening test in their lifetime remained stable and high between 2005 and 2016. Compliance with recommended screening intervals improved between 2005 and 2011 from 75 to 83%, respectively, then decreased significantly to 75% in 2016 (P = 0.02). Uptake of at least one lifetime colorectal cancer screening test procedure declared (individuals aged 50-74 years) increase from 25% in 2005 to 59% in 2011, stabilized at 60% in 2014, then reached 64% in 2016. Opportunistic prostate cancer screening (men aged 50-75 years) rose between 2005 and 2008 from 36 to 49%, plateaued until 2014 then dropped to 42% in 2016. The proportion of women aged 50-65 declaring having undergone one cervical cancer screening test dropped significantly between 2014 and 2016 from 99 to 94% (P < 0.01). Lastly, 11% of our survey population in 2014 and 2016 (55-74 years) declared having already undergone lung cancer screening. CONCLUSION: Cancer screening behavior fluctuates in France, regardless of the context, i.e., organized programs or opportunistic screening. This observation highlights the need for constant analysis of population attitudes to optimize public awareness campaigns.

Awareness and Misconceptions of Breast Cancer Risk Factors Among Laypersons and Physicians.

BACKGROUND: Primary prevention of cancer relies on awareness of and consequent identification of risk factors. We investigated knowledge of breast cancer risk factors not only among laywomen but also among female physicians. METHODS: The EDIFICE 4 nationwide observational survey was conducted by phone interviews of a representative female population (737 laywomen and 105 female physicians) aged 40-75 years, using the quota method. This analysis focuses on spontaneous replies to the question "In your opinion, what are the five main risk factors that increase the risk of breast cancer?". RESULTS: Heredity/Family history of breast cancer was the most widely recognized risk factor in both study populations (98.1% physicians vs. 54.2% laywomen; P ≤ 0.01). Smoking (19.0 and 17.5%) and alcohol consumption (3.8 and 5.5%) were among the lifestyle risk factors that were cited by similar proportions of physicians and laywomen, respectively. Other established risk factors were however very rarely cited by either physicians or laywomen, e.g., Exposure to medical radiation (4.8 vs. 0.4%, respectively; P ≤ 0.05) or not cited at all, i.e., Benign mastopathy and Personal history of breast cancer. CONCLUSION: This survey highlights a number of misconceptions relating to behavioral risk factors for breast cancer, including the relative impact of alcohol and tobacco consumption and the importance of menopausal status. The limited awareness of the risk related to Exposure to medical radiation, Benign mastopathy, or Personal history raises concern regarding compliance with national screening recommendations.

Colon Cancer Screening Programs: Impact of an Organized Screening Strategy Assessed by the EDIFICE Surveys.

BACKGROUND: The aim of EDIFICE surveys is to improve insight into the behavior of the French population with regard to cancer prevention and participation in screening programs. Via the colorectal cancer screening program, all average-risk individuals in the 50-74-year age group are invited every 2 years to do a guaiac-based or, since April 2015, an immunochemical fecal occult blood test. METHODS: The fifth edition of the nationwide observational survey was conducted by phone interviews using the quota method. A representative sample of 1299 individuals with no history of cancer (age, 50-74 years) was interviewed between 22 November and 7 December 2016. The present analysis focuses on minimum lifetime uptake of screening tests, compliance to recommended repeat-screening intervals, and reasons for non-participation. RESULTS: In 2016, 64% survey participants had been screened at least once and 38% had been screened in the previous 2 years, suggesting a trend towards increasing participation rates, particularly in the younger age categories and among men. The 2016 data also suggest that the newly implemented FIT-based screening program has been well perceived by the population. Up to one in four individuals cited "no risk factors" as the reason for not undergoing screening. This reveals ignorance of the fact that the colorectal cancer screening program actually targets all average-risk individuals in a given age group, without individual risk factors. CONCLUSION: We suggest the next step should be dedicated to educational approaches to explain exactly what screening involves and to persuasive messages targeting those who to date have remained unreceptive to information campaigns.

[Cancer screening in France: 10 years of analysis of behaviours by the EDIFICE surveys]. / Dépistage du cancer en France : 10 ans d'analyse des comportements par les enquêtes EDIFICE.

Accessibility to cancer screening in France has been facilitated by the implementation of organised programs (breast cancer and colorectal cancer) and by national recommendations (cervical cancer). Personal motivation may also trigger participation in prostate cancer screening. This paper proposes an overview of attitudes toward cancer screening among the general population over a period of more than 10 years and the perception of this behaviour by general practitioners. It is noteworthy that although certain cancer screening programmes, such as for breast cancer, are widely established throughout the population, uptake of others, such as for colorectal or prostate cancer, is contingent on sociological factors and vulnerability. Monitoring of compliance is thus all the more important since participation may be more acutely affected by the impact of social conditions and vulnerability in the current critical economic climate.

Care organization in oncology / Organisation des soins en cancérologie

Care organization in oncology. The health care organization for cancer patients has been built with the passing and current cancer plans, and the coordination of all the actions against cancer by the French national cancer institute. The authors describe the several phases of a patient pathway during and after cancer treatment, underline the importance of supporting good practice guidelines for health professionals, certification criteria and cancer authorization decrees for health care institutions, as well as coordination structures, and describe the specific organizations for children and elderly patients with cancer and for patients with rare cancers. Constant adaptation of the health care organization for cancer is necessary because of the rapid evolution of the treatments, as the development of ambulatory surgery and of oral chemotherapy in outpatients.

Organisation des soins en cancérologie. L'organisation des soins en cancérologie s'est structurée au fil des Plan cancer successifs et de la coordination par l'Institut national du cancer de toutes les actions de lutte contre le cancer. Sont décrits ici les différents temps du parcours d'un malade atteint de cancer, pendant et au décours de son traitement, l'encadrement des pratiques des professionnels de santé par les référentiels nationaux de bonne pratique, l'encadrement règlementaire des établissements de santé délivrant les traitements des patients, les structures de coordination, les organisations spécifiques pour les enfants, les sujets âgés et les patients ayant des cancers rares. L'évolution rapide des traitements du cancer nécessite une adaptation constante de l'organisation des soins en cancérologie. C'est le cas pour la chirurgie ambulatoire et le développement des traitements médicaux du cancer (chimiothérapie et thérapie ciblée) par voie orale.

Cancer screening in France: third edition of the EDIFICE survey.

The EDIFICE programme began in 2005 and set out to provide a clearer insight over time into the participation of the French population in cancer screening. EDIFICE 3 was conducted in 2011 by phone interviews among a representative sample of 1603 individuals aged between 40 and 75 years using the quota method. The analysis focused on the target populations (50-74 years) of the national screening programmes for breast and colorectal cancer. The same populations were also assessed with respect to prostate cancer screening. In 2005, 93% of the sample population had undergone at least one mammogram in their lifetime; this figure reached 94% in 2008 and 95% in 2011. Compliance with recommended intervals improved between 2005 and 2011, and significantly so for women aged 65-74 years. In 2005, 25% of respondents reported having undergone at least one colorectal cancer screening test; this figure reached 38% in 2008 and 59% in 2011. Recommended intervals were respected by 30 and 51% in 2008 and 2011, respectively. In 2005, 2008 and 2011, a total of 36, 49 and 50% of men reported having undergone at least one prostate cancer screening test. This rate decreased significantly in men aged 50-59 years between 2008 and 2011 (44 vs. 37%, P≤0.05). Attendance rates in national screening programmes are high and stable for breast cancer, and although currently improving for colorectal cancer, the European guideline target has not yet been reached. Despite the absence of recommendations for prostate cancer screening, participation remains constant.

Breast cancer screening controversy: too much or not enough?

The Cochrane analysis exploring the risk/benefit ratio of breast cancer screening resulted in a controversy worldwide spread by the mass media. Our survey sought to assess the impact of this controversy in terms of breast cancer screening awareness and attendance. A nationwide observational study, recorded in the EDIFICE iterative surveys, with a representative sample of 451 women aged 40-75 years, living in France, was carried out in the 3 months after the start of the controversy in January 2013. Of the 405 women with no personal history of cancer, 69 (17%) declared having heard of the controversy (aware group). Women remembering the controversy were more likely to belong to higher socioprofessional categories and to have a higher level of education. The most frequently remembered issues were overdiagnosis (38%), unreliability (16%) and radiation risk (9%). Compared with women who were unaware of the controversy, the aware group knew more about the limits of breast cancer screening (undiagnosed cancers, 20 vs. 7%, P<0.05 and risk of false positives, 20 vs. 2%, P<0.05) and were more likely to change their opinion for the worse over the mass media debate (8.7 vs. 1.2%, P<0.05). Nevertheless, only 1% of the aware-group declared their intention to subsequently undergo screening less frequently. The low impact of the controversy on the behaviour of women with respect to screening suggests that it should not be seen as a threat to screening attendance rates, but more as an opportunity to improve awareness.

Social stratification, risk factor prevalence and cancer screening attendance.

This analysis aimed to assess the extent to which exposure to cancer risk factors and attendance of screening programmes are influenced by social characteristics. The validated Evaluation of deprivation and health inequalities in public health centres (EPICES) index was used to measure social deprivation. A sample of the general population (N=1603) was assessed to search for potential correlations between screening attendance, risk factors and any components of the EPICES score. In 2011, 33% of the population studied was classified as 'vulnerable'. Sex had no significant impact on this rating (32% men, 35% women), whereas occupational status did. Vulnerable individuals were more likely already to have cancer (10 vs. 7%; nonsignificant difference; odds ratio 1.43 [0.98-2.10]). The mean BMI was 26.0 kg/m (SD 4.9) for the vulnerable population versus 24.8 kg/m (SD 3.9) in the nonvulnerable population (P<0.01). The prevalence of current smoking was higher in the vulnerable group (38 vs. 23%, odds ratio 2.03 [1.61-2.56]). In contrast, no statistically significant difference was observed between attendance rates for nationwide organized cancer screening programmes (breast and colorectal; target age group 50-74 years) by the vulnerable and nonvulnerable groups. Social indicators of vulnerable populations are associated with increased rates of risk factors for cancer, but not with screening attendance. Our data support the previously reported marked impact of organized programmes that reduce or even remove inequalities in access to cancer screening. However, although the organized programmes have indeed enabled population-wide, nonselective access to screening, primary prevention as it stands today remains inadequate in the underserved population and further improvements are warranted.

Lung cancer risks, beliefs and healthcare access among the underprivileged.

One of the current goals of the French national cancer plan is to reduce healthcare inequalities. This study investigated the potential links between vulnerable social status, exposure to lung cancer risk factors and access to healthcare to highlight ways to improve lung cancer control in this population. The nationwide observational study EDIFICE 3 was carried out through phone interviews of a representative sample of 1603 individuals (age 40-75 years). The EPICES validated questionnaire was used to assess and classify vulnerable respondents. The vulnerable population identified represented 33% of the sample. Compared with nonvulnerable individuals, they had more risk factors for cancer: a higher BMI (26.0 vs. 24.8, P≤0.01), 38% were active smokers (vs. 23%, P≤0.01) with a heavier and longer-lasting tobacco consumption (16.0 cigarettes/day vs. 10.1, P≤0.01 and 29.4 vs. 26.3 years of smoking, P≤0.01) and they were less likely to undertake any physical activities (42 vs. 77%, P≤0.01). They also presented more comorbidities (on average 2.2 vs. 1.8, P≤0.01). Access to healthcare, however, was not discriminatory: vulnerable individuals declared consulting a general practitioner or an oncologist more often than the nonvulnerable subgroup (5.4 vs. 3.7 and 6.7 vs. 2.5 consultations in the previous 12 months, respectively, P≤0.01). Because access to healthcare and screening attendance show no signs of discrimination against vulnerable populations, efforts to reduce inequities in lung cancer control should focus on prevention.

Future perspectives for cancer screening.

The past 20 years have seen major advances in screening for different cancer types. Screening is however destined to evolve, in terms of target populations, procedures used and the overall positioning of screening in the fight against the different forms of cancer. At the same time, screening is expected progressively to become more closely tailored to the level of risk; the type of tests and the frequency with which they are used will be adjusted in a more personalized approach. A critical issue is also to provide the population at large with more extensive information on the advantages and disadvantages, particularly of screening programmes known for the potentially high rate of overdiagnosis. These issues and their evolution are considered herein, in the context of screening for different forms of cancer (breast, prostate, colorectal, lung, cervical and melanoma).

[Aging and cancer care in France: hospitalization requirement in 2012]. / Sujets âgés atteints de cancer en France : quel recours à l'hospitalisation en 2012 ?

INTRODUCTION: French national cancer plans were rolled out oncogeriatric coordination units in France in particular to enable all elderly people with cancer in each region to benefit from a specific care management. METHODS: The national hospital discharge database was analyzed in order to analyze hospitalizations related to cancer care in ≥75 years patients for year 2012. RESULTS: A total of 358,721 patients with 1,492,935 hospitalizations were recorded, respectively with chemotherapy (32.4%), radiotherapy (23.0%), surgery (10.6%), palliative care (3.9%), or other care (30.9%). Hospital activity was distributed in hospitals (36.3%), clinics (23.4%), academic hospitals (20.9%), cancer centers (11.8%). Their respective share varied according to care. Total activity volume and number of health care facilities involved were highly variable in the different regions. CONCLUSION: These data would permit development of a national oncogeriatric policy through the action of regional oncogeriatric coordination units. These units should prioritize training actions and good practice guidelines dissemination in health care institutions with a high activity volume in this domain.

[Mapping of the key oncology indicators available in France]. / Cartographie des principaux indicateurs disponibles en France dans le domaine du cancer.

BACKGROUND: Available data in the field of oncology in France are scattered due to the large number of available indicators and their sources. In order to facilitate identification and analysis of these indicators, the French National Cancer Institute (INCa) has mapped the main indicators available in oncology. METHODS: Mapping was based on the needs of various categories of potential users. Standardized interviews were conducted face-to-face or by email among representatives to determine their needs and expectations. The underlying data sources were also identified: databases, national surveys, websites. A first selection of indicators was proposed in the report entitled "La situation du cancer en France en 2009" ("The state of cancer in France in 2009") and was expanded. Data collection concerning indicators was performed among INCa correspondents for each theme. RESULTS: Several themes were defined: epidemiology, prevention and risk factors, screening, medical demography, health care offer, living conditions, costs and expenses, research. Data were classified according to: geographical coverage, age, gender, type of cancer, occupational categories. This information was collected for each indicator selected and was made available via the cancer data website (http://lesdonnees.e-cancer.fr). CONCLUSIONS: The available oncology indicators are numerous and scattered. Mapping can be a useful tool to facilitate access to these indicators. It should be regularly updated to reflect the most recent data.