LAUSR

In October 2016, the French Minister of Health released the report of an independent inquiry into mammography screening. The report presented 2 options: (1) end the national breast screening program, or (2) end the current program and put in place a radically reformed program.1 In 2004, after years of ad hoc screening, a national program was introduced. Every 2 years, women between the ages of 50 to 74 years are mailed invitations for mammography screening, for which they are not charged. Over time, however, doubts emerged about the program’s reach,accessibility,effectiveness,andpossibleharmsfrom overdiagnosis and overtreatment. In September 2015, the Minister of Health announced what is known in France as a “civil and scientific inquiry,” and appointed an independent steering committee to oversee it. This committee brought together leading health professionals(oncology,generalmedicine,epidemiology,public health) and social sciences professionals (anthropology, law, economics, history of science, bioethics), all free of financial and academic ties to breast screening. As well as requesting evidence reviews on specific questions (undertaken by a technical support committee of the French National Cancer Institute), the committee oversaw a “civil dialogue,” a concept inherited from the French Revolution of 1789. A website provided information about the inquiry and invited public submissions. Two substantial consultations were established: (1) a civil consultation with a group of 27 women from different regions of France and diverse socio-economicgroups,and(2)aparallelconsultationwith a group of 19 health professionals with relevant professional experience but no ties to breast screening. Each of these consultations took place over 5 days of information presentations, interviews of experts, questions, and discussions. Each consultation group addressed 4 questions (Box), developing a collective response to each. A closing public meeting was held to present the recommendations and respond to questions. The steering committee found an unexpectedly intensescientificcontroversy,centeredonuncertaintyabout the benefits of screening, and concerns about overdiagnosisandovertreatment.Thenationalprogramhadnotacknowledged this controversy, despite the extensive discussion in the scientific literature. The committee found thattheevidenceontheoutcomesofbreastscreeningwas limited,comingfromoldertrialsandstudies,noneofwhich had been conducted in France. They highlighted that knowledge of the natural history of breast cancer remains incomplete, and therefore, breast screening contravenes a fundamental principle of screening,2 namely that the natural history, including development from latent stage to declared disease, should be adequately understood. In addition, they were critical of the information promoted during “Pink October” or Breast Cancer Awareness Month, which they considered as exaggerating the benefit of screening. The citizen consultation concluded that they did not wish to keep the program as currently defined and implemented. They commented on the difficulty of making recommendations without regular evaluations of the program and on the importance of measuring the program’s impact on quality of life (not just on mortality). They noted the need for economic accountability in a publicly funded program. The health professionals consultation recommended continuing the program but with major reforms, including improvements in the quality of information, accessibility, and evaluation. The steering committee recommended ending the program or making radical reforms. If the program were to be continued, their key recommendations included: • Provision of neutral, complete information for women, the public and doctors. • Acknowledgment of the scientific controversy in information for women and doctors. • Training for doctors to better assist women in making informed decisions about breast cancer screening. • A research program into the natural history of breast cancer(s) and the effectiveness of new treatment approaches. • An improved evaluation program to monitor the impact of screening on quality of life, mortality, and costs. • An end to screening of women age 50 years or younger who are at average risk. • Consideration of screening based on risk, so women at low risk might be screened less or not at all, while those at higher risk might be screened more intensively. The Health Minister asked the French National Cancer Institute to develop a plan for reform. In April 2017, the Ministry of Health released a plan of broad ranging reforms to be implemented over several years.3 Immediate steps focus on information for women to make their own decisions with support from their own doctors: a new medical consultation for each 50-year-old woman to discuss cancer screening options and cancer prevention (including primary prevention through lifestyle changes to reduce cancer risk); complete information, provided as a booklet accompanying the invitations to screening and via an online decision support resource; and additional tools and training to help doctors discuss the pros, risks, and limitations of screening. Other provisions are to improve access to the program, provide more support to women during the screening proVIEWPOINT