Association of Mammography Screening With a Reduction in Breast Cancer Mortality: A Modeling Study Using Population-Based Data From 2 French Departments.

Meta-analyses of randomized controlled trials that started from 1963 to 1991 reported a decrease of breast cancer mortality, associated with mammography screening. However, the effectiveness of population-based screening programs conducted currently might have changed due to the higher effectiveness of treatments for late-stage cancers and the better diagnostic performance of mammography. The main objective of this study was to predict the reduction of breast cancer mortality associated with mammography screening in the current French setting. We compared breast cancer mortality in 2 simulated cohorts of women, which differed from each other solely in a 70% biennial participation in screening from 50 to 74 years old. The microsimulation model used for predictions was calibrated with incidence rates of breast cancer according to stage that were observed in Isère and Loire-Atlantique departments, France, in 2007-2013. The model predicted a decrease of breast cancer mortality associated with mammography screening of 18% (95% CI: 5, 31) and 17% (95% CI: 3, 29) for models calibrated with data from Isère and Loire-Atlantique departments, respectively. Our results highlight the interest in biennial mammography screening from ages 50 to 74 years old to decrease breast cancer mortality in the current setting, despite improvements in treatment effectiveness.

Impact of a health literacy intervention combining general practitioner training and a consumer facing intervention to improve colorectal cancer screening in underserved areas: protocol for a multicentric cluster randomized controlled trial.

BACKGROUND: Colorectal cancer (CRC) is a leading cause of cancer burden worldwide. In France, it is the second most common cause of cancer death after lung cancer. Systematic uptake of CRC screening can improve survival rates. However, people with limited health literacy (HL) and lower socioeconomic position rarely participate. Our aim is to assess the impact of an intervention combining HL and CRC screening training for general practitioners (GPs) with a pictorial brochure and video targeting eligible patients, to increase CRC screening and other secondary outcomes, after 1 year, in several underserved geographic areas in France. METHODS: We will use a two-arm multicentric randomized controlled cluster trial with 32 GPs primarily serving underserved populations across four regions in France with 1024 patients recruited. GPs practicing in underserved areas (identified using the European Deprivation Index) will be block-randomized to: 1) a combined intervention (HL and CRC training + brochure and video for eligible patients), or 2) usual care. Patients will be included if they are between 50 and 74 years old, eligible for CRC screening, and present to recruited GPs. The primary outcome is CRC screening uptake after 1 year. Secondary outcomes include increasing knowledge and patient activation. After trial recruitment, we will conduct semi-structured interviews with up to 24 GPs (up to 8 in each region) and up to 48 patients (6 to 12 per region) based on data saturation. We will explore strategies that promote the intervention's sustained use and rapid implementation using Normalization Process Theory. We will follow a community-based participatory research approach throughout the trial. For the analyses, we will adopt a regression framework for all quantitative data. We will also use exploratory mediation analyses. We will analyze all qualitative data using a framework analysis guided by Normalization Process Theory. DISCUSSION: Limited HL and its impact on the general population is a growing public health and policy challenge worldwide. It has received limited attention in France. A combined HL intervention could reduce disparities in CRC screening, increase screening rates among the most vulnerable populations, and increase knowledge and activation (beneficial in the context of repeated screening). TRIAL REGISTRATION: Registry: ClinicalTrials.gov. TRIAL REGISTRATION NUMBER: 2020-A01687-32 . Date of registration: 17th November 2020.

Prediction of the severity of colorectal lesion by fecal hemoglobin concentration observed during previous test in the French screening program.

BACKGROUND: The rate of positive tests using fecal immunochemical test (FIT) does not decrease with subsequent campaigns, but the positive predictive value of advanced neoplasia significantly decreases in subsequent campaign after a first negative test. A relationship between the fecal hemoglobin concentration (Fhb) and the opportunity to detect a colorectal cancer in subsequent campaign has been shown. AIM: To predict the severity of colorectal lesions based on Fhb measured during previous colorectal cancer screening campaign. METHODS: This etiological study included 293750 patients aged 50-74, living in Auvergne-Rhône-Alpes (France). These patients completed at least two FIT [test(-1) and test(0)] between June 2015 and December 2019. Delay between test(-1) and test(0) was > 1 year and test(-1) result was negative (< 150 ngHb/mL). The severity of colorectal lesions diagnosed at test(0) was described according to Fhb measured at test(-1) [Fhb(-1)]. The relationship between the severity classified in seven ordinal categories and the predictive factors was analyzed in an ordered multivariate polytomous regression model. RESULTS: The test(0) positive rate was 4.0%, and the colonoscopy completion rate was 97.1% in 11594 patients who showed a positive test(0). The colonoscopy detection rate was 77.7% in those 11254 patients who underwent a colonoscopy. A total of 8748 colorectal lesions were detected (including 2182 low-risk-polyps, 2400 high-risk-polyp, and 502 colorectal cancer). The colonoscopy detection rate varied significantly with Fhb(-1) [0 ngHb/mL: 75.6%, (0-50 ngHb/mL): 77.3%, (50-100 ngHb/mL): 88.7%, (100-150 ngHb/mL): 90.3%; P = 0.001]. People with a Fhb(-1) within (100-150 ngHb/mL) (P = 0.001) were 2.6 (2.2; 3.0) times more likely to have a high severity level compared to those having a Fhb(-1) value of zero. This risk was reduced by 20% in patients aged 55-59 compared to those aged < 55 [adjusted odds ratio: 0.8 (0.6; 1.0)]. CONCLUSION: The study showed that higher Fhb(-1) is correlated to an increased risk of severity of colorectal lesions. This risk of severity increased among first-time participants (age < 55) and the elderly (≥ 70). To avoid the loss of chance in these age groups, the FIT positivity threshold should be reduced to 100 ngHb/mL. The other alternative would be to reduce the time between the two tests in these age groups from the current 2 years to 1 year.

A twelve-year study of the prevalence, risk factors and characteristics of interval colorectal cancers after negative colonoscopy.

INTRODUCTION: The objective of our study was to describe and analyse the Post-Colonoscopy Colorectal Cancers (PCCRCs) and endoscopist performance-related risk factors in the Isère regional screening programme. METHOD: This was a population-based retrospective cohort study between 2002-2013, where Post-Colonoscopy Colorectal Cancers (PCCRCs) were defined as colorectal adenocarcinoma diagnosed between six and sixty months post-colonoscopy following a positive gFOBT. We analysed the endoscopist performance-related risk factors of the 62 gastroenterologists who had carried out at least 30 colonoscopies during this period. RESULTS: During the period reviewed, there were 10,557 negative colonoscopies performed. Fifteen post-colonoscopy colorectal cancers were diagnosed from 2002-2013 with an average patient age of 67.1 years. Men comprised 73% of the cases and 53% of all the cases were found in the distal colon. These 15 cases comprised 1.1% of all Colorectal Cancers (CRCs) diagnosed in the screening programme, with an incidence rate of 0.42 (0.21-0.77) per 1,000 person-years. The aetiological breakdown was as follows: 47% related to missed cancers, 27% were new cancers, 20% were failed biopsy detection, and 6% related to incomplete removal. The Adenoma Detection Rate (ADR) among gastroenterologists was an average of 30%, but large heterogeneity was present within this number, ranging from 11% to 49%. CONCLUSION: The post-colonoscopy colorectal cancer prevalence and incident rate were low relative to the literature. However, significant heterogeneity was present in the adenoma detection rate. Decreasing this heterogeneity by establishing a national benchmark, regular performance feedback and training modules should homogenise adenoma detection rates and decrease the number of interval cancers in the region.

Evaluation of a combined screening programme for breast, cervical and colorectal cancers in France.

A combined breast, cervical and colorectal cancer screening programme was set up in 1990 in Isère, for women aged 50-69 years (target population 100,000) comprising an initial medical visit. The programme was evaluated in 1997. The evaluation covered uptake results, sensitivity, specificity, two opinion surveys among 1025 physicians and 400 women to measure the impact, and three surveys regarding radiologists', gastroenterologists' and pathologists' attitudes. Sensitivity and specificity rates were 74 and 87% for breast, 83 and 99% for cervical and 43 and 97% for colorectal screening. The number of cervical smears completed by women aged 60-69 years doubled with the programme. Acceptability of the faecal occult blood test was 88%. Eighty percent of physicians were in favour of the programme but 67% said that they often prescribed outside the programme. Overall, 71% of the interviewed women said they had had a breast screen, 69% a Pap smear and 53% a faecal occult blood test when only 25-35% of the target population was actually recorded in the programme. This programme increased the uptake of women not previously screened both within and outside the programme. It showed discrepancies between beliefs and practices of physicians. Protocol changes were implemented after this evaluation.

Overdiagnosis and overtreatment associated with breast cancer mammography screening: A simulation study with calibration to population-based data.

OBJECTIVES: The magnitude of overdiagnosis of breast cancer associated with mammography screening remains controversial because of methodological issues. The objective of this study was to quantify overdiagnosis and overtreatment associated with a population-based screening programme, taking into account lead time and uncertainty concerning baseline incidence of breast cancers. MATERIAL AND METHODS: A simulation model was developed to replicate incidence and detection rates of breast cancer observed in the Isère Département, France. The parameters of the model were estimated using an approximate Bayesian computation method. RESULTS: For women aged 50-74 years during the 2007-2010 period, overdiagnosis of non-progressive breast cancers accounted for 17.0% (95% credibility interval (CI): 2.5%-35.5%) of all in situ cancers diagnosed, 5.5% (95% CI: 0.8%-9.8%) of all invasive cancers diagnosed, and 20.3% (95% CI: 3.0%-38.9%) of in situ and 13.0% (95% CI: 2.2%-23.3%) of invasive screen detected breast cancers. The estimates of overdiagnosis due to competitive causes of death were 1.0% (95% CI: 0.2%-%1.7) and 1.1% (95% CI: 0.6%-1.7%) for all in situ and invasive cancers diagnosed, respectively, and 1.3% (95% CI: 0.2%-2.0%) and 2.6% (95% CI: 1.4%-4.0%) of all in situ and invasive screen detected breast cancers, respectively. Among 1000 screen-detected cancers in 2010, 155 (95% CI: 27-284), 134 (95% CI: 10-242) and 140 (95% CI: 25-254) women underwent breast conserving surgery, lymph node dissection and radiation therapy for overdiagnosed cancers, respectively. CONCLUSION: Our estimates of overdiagnosis should be balanced against the reduction of breast cancer mortality to assess the value of breast cancer screening programme.

[Breast cancer screening in thirteen French departments]. / Dépistage du cancer du sein dans treize départements français.

BACKGROUND: In France, breast cancer screening programme, free of charge for women aged 50-74 years old, coexists with an opportunistic screening and leads to reduction in attendance in the programme. Here, we reported participation in organized and/or opportunistic screening in thirteen French departments. POPULATION AND METHODS: We analyzed screening data (organized and/or opportunistic) of 622,382 women aged 51-74 years old invited to perform an organized mammography screening session from 2010 to 2011 in the thirteen French departments. The type of mammography screening performed has been reported according to women age, their health insurance scheme, the rurality and the socioeconomic level of their area or residence. We also represented the tertiles of deprivation and participation in mammography screening for each department. RESULTS: A total of 390,831 (62.8%) women performed a mammography screening (organized and/or opportunistic) after the invitation. These women were mainly aged from 55-69 years old, insured by the general insurance scheme and lived in urban, semi-urban or affluent areas. CONCLUSION: The participation in mammography screening (organized and opportunistic) in France remains below the target rate of 70% expected by health authorities to reduce breast cancer mortality through screening.

Moisture content of Hemoccult slides influences test sensitivity.

BACKGROUND: Mass screening programmes in Europe and in the USA have shown that a 15-18% decrease in mortality rate from colo-rectal cancer can be achieved with biannual testing. In a 10 year screening programme in the Isère region (France), we have noticed that the positivity percentage of Hemoccult II changes significantly with seasons: it varies from 1.61% in summer to 2.80% in winter, while intermediate values occur in spring (1.69%) and autumn (2.50%). During transport in the mail, Hemoccult slides are stored in unheated rooms, without air-conditioning, and are thus being exposed to outdoor conditions of temperature and humidity. In this paper, we show that the moisture content of Hemoccult slides influences test sensitivity. METHODS: In an in-vitro experiment, we smeared slides from the same batch all with the same blood-spiked stool sample. Positivity rate varies from 58%, when slides contain 0.46% moisture, to 84% when they contain 10.90% moisture (P = 0.0066). Positivity rates are not different in rehydrated and in saturated Hemoccult slides. RESULTS: Data collected from the Grenoble meteorological centre were compared to positivity percentages. Regression studies show that moisture deficit in the air is strongly correlated (r = 0.794, P < 0.01) to positivity percentage and explains most of its seasonal variations. CONCLUSIONS: These results would suggest that Hemoccult slides should be allowed to equilibrate for 24 h at the same level of moisture in all seasons at least in regions where large temperature variations are observed between winter and summer, and between day and night. Indeed, positivity percentages are probably too high in winter, and too low in summer.

[Yield of colonoscopy by indication and consequences for colorectal polyp and cancer screening: a prospective survey in Isère, France]. / Résultats des coloscopies selon leurs indications et conséquences pour le dépistage des polypes et des cancers colorectaux.

AIM: The aim of this study was to determine yields of colonoscopy by indication, especially after a positive Hemoccult test, in the Isère area in southeastern France where a mass screening campaign for colorectal cancer using the Hemoccult test was conducted in women aged 50 to 69 years. METHOD: This prospective survey was conducted with the participation of all gastroenterologists in the Isère department. Information about indications of all colonoscopies performed and their results were collected. RESULTS: The study involved 1,779 colonoscopies performed for: digestive symptoms (40%), surveillance of colon disease (22%), hematochezia (18%), a family history of colon cancer (10%), anemia, poor general condition or metastasis (4%), and a positive test for blood in the stool (3%). The presence of a pathological colonic condition was significantly related to age (11% of cancers or large polyps after 50 years compared to 3% before), sex (10% of the women with lesions and 15% of the men) and the reason for prescription: after the age 50 a cancer or a large polyp was found in 27% of the cases if the colonoscopy was performed for anemia, metastasis or poor general condition, 21% for hematochezia, 20% for a positive test, 8% for digestive symptoms, and 2% because of a family history. CONCLUSION: Positive Hemoccult tests represent only a small part of the indications for colonoscopies performed in the Isère department. However, the screening program should be extended to develop its use given its yield which is equivalent to that of hematochezia and much higher than that of digestive symptoms or family history.

Sensitivity of a colorectal cancer screening program based on a guaiac test: a population-based study.

BACKGROUND: The main objective of this study was to estimate the sensitivity of a colorectal cancer-screening program based on a guaiac fecal occult blood (FOB) test. The secondary objective was to determine whether the sensitivity varied by sex and if the difference between males and females could be explained by differences in age group at the time of the test, round of screening, how the test was provided to the participant, tumor location, and the presence of theoretical screening program exclusion criteria. METHODS: For the 2002-2006 period, we retrospectively analyzed data from the organized colorectal screening program in Isère, France, which was designed for asymptomatic individuals aged 50-74. Sensitivity was assessed considering the number of interval cancers diagnosed in the 2 years following the test. A logistical regression analysis was done to evaluate the factors associated with the sensitivity of the screening program. RESULTS: A total of 506 participants were included in the analysis. The overall sensitivity of the screening program was 48.4%, being 58.3% for males and 32.5% for females. In multivariate analysis, sensitivity for males was still higher than for females (OR=2.1 [95% CI, 1.4-3.4]) after adjusting for age group, presence of exclusion criteria, the way the test was given, the round of participation, and the tumor location. A total of 183 (36.2%) study subjects presented with at least one exclusion criterion for the screening program. CONCLUSION: The sensitivity of the colorectal cancer-screening program based on a guaiac test was insufficient, being higher for males than for females. This difference in sensitivity was not entirely explained by differences in age, characteristics of screening participation, and tumor location.

The mean number of adenomas per procedure should become the gold standard to measure the neoplasia yield of colonoscopy: a population-based cohort study.

BACKGROUND: Measuring adenoma detection is a priority in the quality improvement process for colonoscopy. Our aim was (1) to determine the most appropriate quality indicators to assess the neoplasia yield of colonoscopy and (2) to establish benchmark rates for the French colorectal cancer screening programme. METHODS: Retrospective study of all colonoscopies performed in average-risk asymptomatic people aged 50-74 years after a positive guaiac faecal occult blood test in eight administrative areas of the French population-based programme. RESULTS: We analysed 42,817 colonoscopies performed by 316 gastroenterologists. Endoscopists who had an adenoma detection rate around the benchmark of 35% had a mean number of adenomas per colonoscopy varying between 0.36 and 0.98. 13.9% of endoscopists had a mean number of adenomas above the benchmark of 0.6 and an adenoma detection rate below the benchmark of 35%, or inversely. Correlation was excellent between mean numbers of adenomas and polyps per colonoscopy (Pearson coefficient r=0.90, p<0.0001), better than correlation between mean number of adenomas and adenoma detection rate (r=0.84, p=0.01). CONCLUSION: The mean number of adenomas per procedure should become the gold standard to measure the neoplasia yield of colonoscopy. Benchmark could be established at 0.6 in the French programme.

Determinants of participation in organized colorectal cancer screening in Isère (France).

BACKGROUND AND AIMS: In France, participation in organized colorectal cancer screening remains low. The objective of this study was to identify the determinants of participation in colorectal cancer screening in Isère, a French administrative entity. METHODS: This study examined the target population invited for screening between 2007 and 2008 in Isère. The statistical analysis method was based on a two-level logistic regression model: the first was the individual level relative to the individuals invited for screening and the second was an aggregate level corresponding to the socioeconomic level of an invited person's residence area (IRIS: "Ilot regroupé pour l'Information Statistique"; Regrouped statistical information block). The evaluation of the socioeconomic level was based on the Townsend deprivation. RESULTS: Participation varied depending on sex, age, and health insurance plan. The people residing in the least deprived IRISes participated more than individuals residing in the most deprived IRISes. The multilevel analysis showed a 24% difference in participation between the least and the most deprived IRISes. CONCLUSIONS: The use of socioeconomic data on the IRIS geographical unit has identified, socially and geographically, the populations that participate the least, although this reflects "mean" behaviors. These results could be used to set up targeted actions to encourage participation in these populations.

Determinants of quality of life of bladder cancer survivors five years after treatment in France.

OBJECTIVES: The aim of the population-based study presented here was to evaluate quality of life (QOL) among bladder cancer survivors at least five years after diagnosis, ascertain the long term effects of treatments, and investigate important pathological and sociodemographic factors influencing the QOL of such survivors. METHODS: A Functional Assessment of Cancer Therapy (FACT) questionnaire with a bladder-specific option (FACT-Bl), was sent by mail to patients randomly selected from the database of the Isère and Tarn cancer registries in France. Ninety-five valid completed questionnaires were returned by 78 males and 17 females, with a median age of 72 years (range, 33-90). The pathological information contained in the completed questionnaires was examined. RESULTS: Of the 95 patients (76 with a superficial tumor, 17 with an invasive tumor), 20 had undergone total cystectomy. Total cystectomy clearly deteriorates the autonomy of survivors (ECOG-PSR), as well as their scores on the bladder cancer-specific sub-scale in sexuality-related questions. Survivors claimed impotency and loss of sexual interest after the cystectomy. In contrast, neither the type of treatment nor the time from the most recent major treatment were score-modifying factors. Negative psychological effects of treatments in the long-term were not observed. Rather, patients' QOL was affected by their autonomy in daily life and by old age. In addition, familial situation had a critical impact on emotional and Familial/Social Well-being. CONCLUSION: The present study showed the long-term negative effect of total cystectomy on survivors. Survivor autonomy and other sociodemographic backgrounds were also determinants of their QOL. The maintenance of good health, sexual function and active family relationships should be promoted so that patients can lead full lives after treatment.

Incidence and mortality trends for prostate cancer in 5 French areas from 1982 to 1996.

After an increase in the 1980s, incidence and mortality for prostate cancer in North America or England and Wales started to decrease in the early 1990s. The reasons for this evolution are widely debated, notably the importance of early detection. This study describes trends of prostate cancer incidence and mortality in 5 areas in France, where practices of early detection for this cancer are widely used. The 5 French administrative areas, covered by a population-based registry, have a total population of approximately 1,700,000 men. Incidence data from these registries were studied for the period 1982-1995, and mortality data were provided by the Institut National de la Santé et de la Recherche Médicale (INSERM) for the period 1982-1996. Age-Period-Cohort models by Poisson regression were created to characterize these trends. Between 1982 and 1995, 14,699 cases of prostate cancer were registered by the 5 registries under consideration. After a little intensification of the increase in 1987, undoubtedly due to early detection (notably using Prostate-Specific Antigen), the trend of the incidence seems to reverse from 1993. Mortality increased monotonically from 1982-1990 by an average of 1.8% per year, before decreasing annually by an average of 3.3% until 1996. Poisson regressions indicated a period effect on both incidence and mortality data; a small, but significant, cohort effect exists for incidence evolution, showing that elements such as etiologic factors may have an influence. Until results of randomized studies on mass screening are available, the question of individual screening remains; improved knowledge of risk factors could be interesting.