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.

Feasibility of radiation therapy in patients 90years of age and older: a French multicentre analysis.

BACKGROUND: There are only scarce data on the management of patients aged 90years or older with cancer, and more particularly on the place of radiation therapy (RT). We report the first large study on patients (pts) aged 90years or older receiving RT. METHODS AND MATERIALS: Records from RT departments from five institutions were reviewed to identify pts 90years of age and older who underwent RT for various malignant tumours treated between 2003 and 2012. Tumours' characteristics were examined, as well as treatment specificities and treatment intent. RESULTS: 308 pts receiving 318 RT courses were identified, mean age was 93.2years (standard deviation 2.8). Treatment was given with curative and palliative intent in 44% and 56%, respectively. Factors associated with a curative treatment were performance status (PS), place of life, previous surgery and tumour stage. Median total prescribed dose was 36Gy (4-76Gy). Hypofractionation and split course were used in 88% and 7.3%, respectively. Most toxicities were mild to moderate. RT could not be completed in 23 pts (7.5%). No long-term toxicity was reported. Median overall survival was 22.9months (95CI: 15.5-42.7months). Cancer was the cause of death in 8.7% and 46% of pts treated with curative and palliative intent, respectively. CONCLUSION: This study shows that RT is feasible for patients aged 90years or more. PS, place of life and tumour stage were factors of the therapeutic decision. There is no reason to withdraw pts with good general health condition from potentially curative RT, provided that careful attention is paid to factors of toxicity and to geriatric vulnerabilities.

Mammography utilization in women aged 40-49 years: the French EDIFICE survey.

In France, mammography screening is offered to women aged between 50 and 74 years. EDIFICE, the iterative nationwide survey, collected data on a national level about consumers utilization of available cancer screening procedures. This analysis compared data from a subset of 241 women aged between 40 and 50 years with that of 488 women aged between 50 and 74 years. Multivariate analysis showed the following significant factors to be linked with screening attendance for women younger than 50 years: age, with a threshold value at 44 years; awareness of the recommended screening period (2 years); consultation within the last 12 months with a general practitioner or a gynaecologist; and long standing local programme for colon cancer screening. Notwithstanding the debate on risk/benefit of breast cancer screening for women in their 40s, we observed more differences with regard to attendance between women aged 40-45 years versus that of 46-74 years than between women aged 40-49 years versus that of 50-74 years. The issue that is unanswered as yet is, do women make a kind of heuristic for starting breast cancer screening, leading them to a threshold choice of 45 years or alternatively to a collective answer of standard age minus 5 years!

Uptake of breast cancer screening in women aged over 75 years: a controversy to come?

In France, the age range for organized screening for breast cancer is 50-74 years. From a layperson's perspective, the public health message focusing on a specific target population may be difficult to understand. The aim of this study is to assess how women aged over 75 years deal with this absence of screening recommendations for their age group. The population-based survey, EDIFICE, was carried out by telephone in 2008. Women were interviewed with regard to their behaviour, and in particular relating to breast cancer screening. For 136 breast cancer-free women, aged 75 and above and who had undergone at least one mammography in their lifetime, the test had been done within the last 2 years for only 62 (51%) of them. In a multiregression analysis, only one item (i.e. already having undergone at least five mammographies) was statistically associated with a higher rate of attendance (odds ratio=3.3, 95% confidence interval=1.03-11.1). According to our data, for women aged 75 and above, an estimated 17,000,000 Euros are spent each year on breast cancer screening in France, the net benefit of which is still unknown.

Organized colorectal cancer screening programmes: how to optimize efficiency in the general population.

In France, free faecal occult blood testing is offered to individuals aged between 50 and 74 years every 2 years as a method of screening for colorectal cancer (CRC). To assess how a proposed organized programme of CRC screening would be perceived among a representative sample of individuals living in France, aged between 40 and 75 years, and by a representative sample of general practitioners, two nationwide observational telephone surveys were carried out in 2005 (EDIFICE 1; 1601 individuals) and 2008 (EDIFICE 2; 1801 individuals). In 2008, 38% of individuals aged between 50 and 74 years reported undergoing screening for CRC; this corresponded to a statistically significant 13% increase in CRC screening rate compared with 2005 (P=0.01). When asked whether it was possible to screen for CRC, 94% of individuals who had undergone screening (N=350) responded positively compared with 87% of individuals who had not been screened. The main reason for individuals not to undergo screening was a lack of awareness (35% of men and 37% of women, P=not significant); the second reason was lack of advice and referral from their general practitioner (21% of women versus 15% of men, P=0.03). The French population is aware of the potential benefit of CRC screening; however, many do not undergo regular screening. It is therefore important to identify the hurdles associated with CRC screening.

Screening for prostate cancer: growth without control.

In France, no official recommendations for or against systematic screening for prostate cancer have been issued yet. Therefore, individuals' choices with regard to screening or non-screening, and general practitioners' (GPs) recommendations for or against systematic screening should reflect personal preferences. Four nationwide observational studies (surveys) were conducted in France, two in 2005 and two in 2008, on a representative sample of participants aged between 40 and 75 years and a representative sample of GPs. In 2005, 36% of the male population interviewed, and aged between 50 and 75 years declared having undergone a screening test, compared with 49% in 2008 [odds ratio (OR)=1.63; 95% confidence interval (CI)=1.25-2.12]. In 2008, the number of men interviewed who reported having undergone screening less than 1 year earlier increased from 51% in 2005 to 74% (OR=2.18; 95% CI=1.40-3.40). The screening rate for young men (45-49 years) was only 7% in 2008 (data not available in 2005). In 2005, 58% of GPs systematically recommended prostate cancer screening for their patients aged 50-74 years, whereas in 2008, the figure was 65% (OR=1.32; 95% CI=1.04-1.66). The sex or age of the GPs had no significant impact on this rate. In France, we have observed a highly significant increase in prostate cancer screening: more men are screened, more often, at a younger age and more frequently using a prostate-specific antigen blood test. In our surveys, the observed threshold age for onset of prostate cancer screening is 50 years, almost the same as that for approved organized breast and colorectal screening programmes.

Impact of awareness of cancer among acquaintances on cancer screening attendance.

Two nationwide observational surveys were carried out in France in 2005 and 2008 with the aim of assessing the impact on attitudes towards cancer screening of a positive history of cancer among a person's close circle of acquaintances (relatives, friends or colleagues). In 2005, 67% (993/1482) of people interviewed reported having someone in their close circle of acquaintances affected by cancer and in 2008, the rate was 80% (1158/1454). In 2008, having someone within a person's close circle of acquaintances affected by cancer did not increase the rate of screening for breast cancer (already high at >80%). However, it did increase the rate of screening for colorectal cancer [odds ratio (OR)=2.3; 95% confidence interval (CI)=1.6-3.3] and prostate cancer (OR=2.2; 95% CI=1.4-3.5). Knowing someone affected by cancer within the close circle of acquaintances clearly increases awareness, and thus could be an incentive for undergoing cancer screening. With regard to cancer types, such as prostate cancer, for which there is no national programme or media communication, this awareness might be the main source of information and motivation. The impact of awareness on screening behaviour seems to be greatest for the same cancer location as that in the affected acquaintance, as opposed to cancers at other sites. Increased awareness as observed in our survey, which may be attributable to less social stigma associated with a diagnosis of cancer, might increase the rate of screening attendance in the general population.

Impact of general practitioners' sex and age on systematic recommendation for cancer screening.

Characteristics of primary-care providers have been associated with their patients' participation in breast cancer screening. A nationwide observational survey, 'EDIFICE', was conducted by telephone from December 2007 to January 2008 on a representative sample of 600 general practitioners (GPs) working in France, to investigate how a GP's characteristics may influence patient participation in screening for breast, colorectal and prostate cancer. For breast cancer screening, systematic recommendation was associated with female physicians [odds ratio (OR) =1.9; 95% confidence interval (CI) 1.2-3.1]. This systematic recommendation was also correlated with systematic referral for colorectal cancer (OR=1.5; 95% CI=1.0-2.5) and prostate cancer screening (OR=2.7; 95% CI=1.8-4.1). For colorectal cancer screening, the sex of the GP had no significant impact. However, systematic recommendation for both breast and prostate cancer screening was shown to be associated with systematic recommendation for colorectal cancer screening (OR=2.7; 95% CI=1.6-4.7 and OR=1.8; 95% CI=1.1-3.0, respectively). For prostate cancer screening, there was no significant sex specificity. However, systematic recommendation for both breast and colorectal cancer screening was associated with an advice on prostate cancer screening (OR=2.9; 95% CI=2.0-4.4 and OR=2.0; 95% CI=1.3-3.2, respectively). The age of the GP was not associated with a higher rate of systematic recommendation for screening for the three types of cancer. Male GPs were more likely than female GPs to perform digital rectal examinations on male patients (69 vs. 54%; OR=1.86; 95% CI=1.31-2.63). There is a global pattern of physicians being screening-prone (as suggested by the cross impact of recommendations from one cancer type to another). Although the frequency of systematic recommendation for breast cancer screening is higher with female GPs, systematic recommendation for prostate cancer is not higher among male GPs. The factors associated with systematic recommendation for screening are both a matter of concern and a target for action, to improve adherence of individuals through GP commitment.

Breast cancer screening in women aged 50-74 years: is there room for improvement?

Regular mammography screening has been available in France, free of charge, for all women aged 50-74 years since 2005. Two nationwide surveys [EDIFICE 1 (507 women interviewed; age 50-74 years) and EDIFICE 2 (488 women)] recently collected data on individuals' access to cancer screening procedures. Two further surveys interviewed 600 general practitioners (GPs) each to determine their attitudes towards screening in general and screening for breast cancer in particular. The method of quotas ensured the populations surveyed were representative. In 2005, 93%, and in 2008, 94% of women reported having undergone a screening mammography. Anage-related effect was apparent in the 70-74 year subgroup in 2005, whereas in 2008, over 90% of women aged 50-74 years had had a mammography in their lifetime. In 2008, 66% of women had undergone a mammography as a part of an organized screening programme, versus 45% in 2005. In 2005, 15% of women reported having received no recommendation from their GP, whereas this figure fell to 4% in 2008. In both EDIFICE surveys, two thirds of GPs systematically recommended breast cancer screening to female patients aged 50-74 years; however, female GPs were more likely to systematically recommend this screening. In 2008, 77% of the GPs questioned were aware of the recommended frequency for breast cancer screening, compared with 71% in 2005. Results of studies such as EDIFICE may help increase the proportion of women who undergo breast cancer screening. Successful implementation of organized screening relies heavily on treating physicians. The impact of mammography in breast cancer screening may be further improved by systematic organized screening, by encouraging regular examination and by targeting women who give up screening.

Staged laparoscopic adjuvant intraperitoneal chemohyperthermia after complete resection for locally advanced colorectal or gastric cancer: a preliminary experience.

BACKGROUND: Cytoreductive surgery followed by intraperitoneal chemohyperthermia (IPCH) is a promising treatment for patients with peritoneal carcinomatosis, a disease with dismal prognosis. METHODS: We describe our preliminary experience with staged adjuvant laparoscopic IPCH after complete resection in patients with locally or regionally advanced colorectal or gastric cancer. RESULTS: Twenty-one patients underwent resection for colorectal (N = 16) or gastric cancer (N = 5) followed by staged laparoscopic IPCH. No conversion to laparotomy was required. No major operative incident occurred. Mean duration of hospital stay was 12 days (range 9-23 days). No mortality occurred in the 30-day postoperative period. Four patients developed major complications (19%). One patient (5%) was reoperated. Mean follow-up period was 15.5 months (range 9-29 months). Three patients died, including two of cancer-related causes. No patient developed peritoneal carcinomatosis during the follow-up period. CONCLUSION: Staged laparoscopic adjuvant IPCH after open or laparoscopic resection in selected patients with colorectal or gastric cancer is feasible and reasonably safe. However, additional data are required to determine the effect on long-term survival.

Impact of organised programs on colorectal cancer screening.

PURPOSE: Colorectal cancer (CRC) screening has been shown to decrease CRC mortality. Organised mass screening programs are being implemented in France. Its perception in the general population and by general practitioners is not well known. METHODS: Two nationwide observational telephone surveys were conducted in early 2005. First among a representative sample of subjects living in France and aged between 50 and 74 years that covered both geographical departments with and without implemented screening services. Second among General Practionners (Gps). Descriptive and multiple logistic regression was carried out. RESULTS: Twenty-five percent of the persons(N = 1509) reported having undergone at least one CRC screening, 18% of the 600 interviewed GPs reported recommending a screening test for CRC systematically to their patients aged 50-74 years. The odds ratio (OR) of having undergone a screening test using FOBT was 3.91 (95% CI: 2.49-6.16) for those living in organised departments (referent group living in departments without organised screening), almost twice as high as impact educational level (OR = 2.03; 95% CI: 1.19-3.47). CONCLUSION: CRC screening is improved in geographical departments where it is organised by health authorities. In France, an organised screening programs decrease inequalities for CRC screening.

Cancer screening in France: subjects' and physicians' attitudes.

OBJECTIVE: Since screening for cancer has been advocated, funded, and promoted in France, it is important to evaluate the attitudes of subjects in the general population and general practitioners (GPs) toward cancer screening strategies. METHODS: EDIFICE is a nationwide opinion poll that was carried out by telephone among a representative sample of 1,504 subjects living in France and aged between 40 and 75 years and among a representative sample of 600 GPs. The questionnaire administered to subjects queried about previous screening for cancer. RESULTS: Ninety-three percent of women stated that they had undergone at least one mammography. Although rated "A" recommendation-strongly recommended-by the US Preventive Services Task Force, screening for colorectal cancer received less attention than prostate cancer screening which is rated "I"-insufficient evidence-(reported screening rates of 25% and 36%, respectively). Six percent of subjects stated that they had undergone lung cancer screening. GPs' attitudes toward cancer screening showed similar inconsistencies. CONCLUSIONS: It thus appears that understanding of cancer screening practices in the French general population does not match scientific evidence. To a lesser extent, this also holds for GPs.

Multicenter randomized phase II study of two schedules of docetaxel, estramustine, and prednisone versus mitoxantrone plus prednisone in patients with metastatic hormone-refractory prostate cancer.

PURPOSE: Mitoxantrone-corticosteroid is currently the standard palliative treatment in hormone-refractory prostate cancer (HRPC) patients. Recent clinical trials documented the high activity of the docetaxel-estramustine combination. We conducted a randomized phase II study to evaluate prostate-specific antigen (PSA) response (primary end point) and safety of two docetaxel-estramustine-prednisone (DEP) regimens and mitoxantrone-prednisone (MP). PATIENTS AND METHODS: One hundred thirty metastatic HRPC patients were randomly assigned to receive docetaxel (70 mg/m2 on day 2 or 35 mg/m2 on days 2 and 9 of each 21-day cycle) and estramustine (280 mg p.o. tid on days 1 through 5 and 8 through 12) or mitoxantrone 12 mg/m2 every 3 weeks; all patients received prednisone (10 mg daily). RESULTS: One hundred twenty-seven patients were assessable for PSA response and safety. A > or = 50% PSA decline was found in a greater percentage of patients in the docetaxel arms (67% and 63%) compared with MP (18%; P = .0001). Median time to PSA progression was five times longer with DEP than with MP (8.8 and 9.3 v 1.7 months, respectively; P = .000001). Overall survival was better in the docetaxel arms (18.6 and 18.4 months) compared with the MP arm (13.4 months), but not significantly so (P = .3). Crossover rates differed significantly among treatment arms (16%, 10%, and 48% in arms A, B, and C, respectively; P = .00001). Treatment-related toxicities were mild and mainly hematologic. CONCLUSION: The results of this randomized phase II study showed significantly higher PSA decline < or = 50% and longer times to progression in HRPC patients receiving DEP-based chemotherapy than MP, and that DEP could be proposed in this setting.