Démocratie participative et évolution d'une politique de santé publique ?

This article provides a dual perspective, both academic and operational, on the 2016 scientific and citizen consultation on breast cancer screening and the public health actions being developed. METHOD: In view of controversies around breast cancer screening, the Ministry of Health asked the French National Cancer Institute to organize this consultation to clarify the benefits and limitations of breast cancer screening, health objectives, organizing and tackling the health inequalities of this program. It has combined the setting up of an independent and multidisciplinary steering committee, a conference of citizens and professionals. It relied on the hearing of experts representing the trends of the controversy, on a technical and prospective report and on the analysis of nearly 500 online contributions. At the end of this process, the policy committee produced a report. RESULTS: In the end, two scenarios were presented, leading to a complete overhaul of the current screening process. As a result of this report, the Ministry announced the action plan for the renovation of organized breast cancer screening in 12 measures in April 2017. DISCUSSION: The discussion focuses on the consultation methodology as a tool for health democracy and on the levels of arbitration that led to the action plan. The objective is to reflect on the possible interactions between consultation and decision-making and to propose benchmarks for the development and improvement of this consultation.

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.

[French national cancer screening programs: What does the future hold?] / Quelle évolution pour les programmes de dépistage des cancers ?

French national cancer screening programs : what does the future hold? Three organized screening programs are in place or being rolled out in France for breast, colorectal and cervical cancers. Short or medium-term developments aim at facilitating the integration of technological or organizational innovations and at meeting the quality and safety requirements of the screening procedure. However, the stakes differ between the different programs. It is for the screening of breast cancer, the oldest program, the integration of technological innovations, such as breast tomosynthesis -3D- and dematerialization of mammograms, and the renovation of the program in order to propose a personalized follow-up, better coordinated and with an increased involvement of general practitioners. For colorectal cancer, given that a highly effective screening program using a fecal immunological test has been rolled out in 2015, the challenge is now to increase participation, which is too low -35%-, in order to improve the impact of the program. The cervical cancer screening program, whose opportunistic practice is already widespread, is currently being deployed ; it aims to reduce inequalities in access to screening by sending invitations to women who have not been tested in the last 3 years; the sampling will be performed in liquid phase which allows to anticipate a future migration to the HPV test.

Quelle évolution pour les programmes de dépistage des cancers ? Trois programmes de dépistage organisé sont en place ou en cours de déploiement en France pour les cancers du sein, colorectal et du col de l'utérus. Les perspectives d'évolution à court ou moyen termes visent à faciliter l'intégration des innovations technologiques ou organisationnelles dans ces programmes et à satisfaire aux exigences de qualité et de sécurité de la procédure de dépistage. Les enjeux diffèrent cependant entre les différents programmes. Il s'agit pour le dépistage des cancers du sein, le programme le plus ancien, de l'intégration d'innovations technologiques, notamment la tomosynthèse et la dématérialisation des mammographies pour la seconde lecture, et de la rénovation du programme de sorte à proposer aux femmes un suivi personnalisé, mieux coordonné et impliquant davantage le médecin traitant. Pour le cancer colorectal, dans la mesure où un programme performant de dépistage par test immunologique est en place, l'enjeu est d'augmenter la participation, par trop insuffisante, ce qui permettra d'améliorer l'impact du programme. Le programme de dépistage du cancer du col de l'utérus, dont la pratique est déjà bien répandue, est quant à lui en phase de déploiement ; il vise à réduire les inégalités d'accès par l'envoi d'invitations en direction des femmes n'ayant pas réalisé de dépistage dans les 3 dernières années ; le prélèvement sera réalisé en phase liquide ce qui permet d'anticiper un passage au test HPV le cas échéant.

[Participatory democracy and development of a public health policy?] / Démocratie participative et évolution d'une politique de santé publique ?

This article provides a dual perspective, both academic and operational, on the 2016 scientific and citizen consultation on breast cancer screening and the public health actions being developed. METHOD: In view of controversies around breast cancer screening, the Ministry of Health asked the French National Cancer Institute to organize this consultation to clarify the benefits and limitations of breast cancer screening, health objectives, organizing and tackling the health inequalities of this program. It has combined the setting up of an independent and multidisciplinary steering committee, a conference of citizens and professionals. It relied on the hearing of experts representing the trends of the controversy, on a technical and prospective report and on the analysis of nearly 500 online contributions. At the end of this process, the policy committee produced a report. RESULTS: In the end, two scenarios were presented, leading to a complete overhaul of the current screening process. As a result of this report, the Ministry announced the action plan for the renovation of organized breast cancer screening in 12 measures in April 2017. DISCUSSION: The discussion focuses on the consultation methodology as a tool for health democracy and on the levels of arbitration that led to the action plan. The objective is to reflect on the possible interactions between consultation and decision-making and to propose benchmarks for the development and improvement of this consultation.

Invitation letter with a standardized form is a reliable tool to exclude increased risk patients from organized fecal immunological testing-based colorectal cancer screening program.

In Europe, screening guidelines for colorectal cancer (CRC) recommend colonoscopy for high-risk patients and fecal immunological testing (FIT) for the standard-risk group. Currently, there is not any validated screening tool to exclude high-risk patients. The aim of the study is to evaluate the validity of exclusion and evaluate the follow-up of patients identified as increased risk for CRC. In this retrospective study using a prospective database, patients at increased risk were identified using the standardized form and then excluded from the FIT screening invitation. A specific questionnaire was sent to all patients at increased risk in order to confirm the reason for the exclusion and evaluate their follow-up. Among 220 695 eligible individuals, 16 693 (7.5%) were excluded after being characterized at increased risk using the standardized form. The questionnaire was sent to these 16.693 excluded patients and completed by 5076 (30.7%) patients. Validity of exclusion was confirmed in 92% of cases. Endoscopic follow-up was in agreement with guideline in 89% of persons at increased risk (inflammatory bowel disease 93%, personal history of CCR 92%, of colonic polyps 82%, family history of CRC 77%). This study suggests that the standardized form is a reliable tool to correctly exclude from the screening program 92% of patients at increased risk for CRC.