Presentation « Screening of breast cancer : tribulations of a radiologist in France , autobiographical presentation» by Cécile Bour, MD, Radiologist and president of organization Cancer Rose. Drawings made by Dr. Cécile Bour. Cancer Rose is a French non-profit organization of health professionals.  Independent French medical doctors and a doctor in toxicology, have created the site www.cancer-rose.fr to inform you of the most recent and relevant data on breast cancer mass screening. By decoding and popularizing the most recent research findings published in the most important international medical journals, analyzing the controversy and providing a social and feminine analysis, our objective is to inform women concerned by breast cancer mass screening in order to help them making their choice and to provide independent information resources to interested physicians. Cancer Rose has no sponsorships, honoraria, monetary support or conflict of interest from any commercial sources.

1. www.cancer-rose.fr
Tribulations of a Radiologist in the
« Screening-land »

2. As a radiologist having
participated for twenty
years in organized breast
cancer screening in
Moselle region, France, I
ended up wondering how it
was possible to get entire
crowds to run around with
a pink ribbon on a T-shirt,
under the illusion of a
"cause": the fight against
breast cancer.
How do explain that despite
the hype of pink incentive
marketing, supposed to halt
the progression of breast
cancer, the incidence of this
disease has just exploded
since the beginning of
screening?
Pink October
Pink October

3. www.cancer-rose.fr
Two obligations of medical practice flouted:
inform the patient, and do no harm.
• Delivering "clear, fair, appropriate information" (article 33 of the public
health law in France). The information on the risk-benefit balance of
screening is difficult to find for the patient and even for the professional.
■"primum non nocere", there are adverse effects that our screening
practices may inflict on the woman being screened.
■It appeared to me that these two principles were not guaranteed to the
patient.
« I inform you that is in your
head, the problem »

4. www.cancer-rose.fr
■ From the onset of screening, a technical system was adopted,
namely mammography, which over time proved to be an
imperfect tool, unable to give a binary result. We then had to
adapt this tool to each woman screened, taking into account the
highly subjective and variable nature of the organ that is the
breast.
■ Finally, we now perform individualized screening under the
illusion of performing mass screening without providing women
with the benefit-risk balance of mammography screening.
It’s pink, it’s ugly, and
it doesn't fit with
anything
…and not sure it
will save your life
It’s yellow, it’s
ugly, and it
doesn't fit with
anything
But it can save
your life

5. www.cancer-rose.fr
■ From these observations, in May 2015, I
communicated my doubts in an interview with our
regional newspaper, the Republican Lorrain.

6. www.cancer-rose.fr
■ The virulence of the response from local screening officials,
led me to believe that the controversy was beyond the
medical debate, and that the protest was disturbing other
interests besides those of women's health and well-being.
■"Irresponsible, cruel and prideful to torment women by
sowing confusion in their minds", were reproached to me.
Pride and cruelty lie in depriving women of the information to
which they are entitled, considering them as poor little
infantile beings ...

7. www.cancer-rose.fr
■ The paternalistic vision of the medical profession locks women into these
unhealthy stereotypes, reducing them to "buy-and-run" women for a
"cause" that is thriving.
■ The promoters of this "cause" of which we, radiologists, are taking part,
are the same people who unilaterally inform, in defiance of the notion of
conflict of interest that currently plagues the breast cancer screening
campaign.
« But why are we all running like that? »
« Well, to catch up with cancer ! »

8. www.cancer-rose.fr
■ For all these reasons we have
created, together with a group
of colleagues worried about
the deviations (three general
practitioners, an anatomo-
pathologist and myself, met
within Formindep, French
organization for independent
medical training), an
information site on breast
cancer screening, whose aim
is to provide the most loyal,
objective and complete
information, containing articles
on all aspects of screening, as
well as a downloadable
information brochure, available
at www.cancer-rose.fr.

9. www.cancer-rose.fr
The problem of double mammography reading
Serious scientific studies…
Are always made in double blind…

10. www.cancer-rose.fr

11. www.cancer-rose.fr
■ A mammogram cannot be read, it is an image that has to be
interpreted. Yes, but this is without considering two major
pitfalls:
■ The difficulty of "reading" a mammogram objectively,
■ And the state of mind of the "reader".

12. www.cancer-rose.fr
■ The texture of the breast is
composed of voids, solids,
organizing themselves in a
random way. This thread-
like structure, more or less
dense, compact or airy,
changes from one woman
to another, from one cycle
to another in the same
woman, from one year to
another; according to
hormonal treatments,
physiological modifications,
weight variations.
■It will be a question of detecting
in this capricious texture the
image that reflects a real
lesion. But the smaller a lesion
is, the less characteristic it is.
And the less characteristic it is,
the more we examine it. The
more we examine it, the more
we wonder, the more we doubt,
and the more we tend to "cover
up" by classifying the file as
"suspect", as a precaution.
Why is this an interpretation?

13. www.cancer-rose.fr
Human factor
■ Humans are also capricious, changeable. There are three
kinds of radiologists: the relaxed-serene, the pragmatic-
focused, the anxious-stressed.
■ Depending on the radiologist's experience (suspected but
unconfirmed cancers, "missed" cases, patients needlessly
alarmed), he or she may go from a relaxed-serene attitude to an
anxious-stressed state or the opposite.
■ The performance is therefore uneven depending on the
temperament and state of mind of the reader.

14. www.cancer-rose.fr
In Screening-land the examiner is the law and order
authority and cancer is the offender.
■ Either you are a relaxed and serene person, you are confident and won't call
out to others. Your results in the fight against crime will not be very good.
■ But you will have given a dubious individual the chance to not evolve
pejoratively and to prove his benevolence. According to our analogy, you take
the risk of letting a real cancer go free.

15. www.cancer-rose.fr
Either you are one of the focused pragmatists, you apply
the strict criteria of radiological semiology that you have
been taught, and you miss the atypical but real cancer.

16. www.cancer-rose.fr
■ Or you are an incorrigible anxious and
stressed person, and you are not
discriminating enough. You arrest all
criminals, but also based on
"appearance profiling"! Your crime rate
will tend towards zero, but you will have
eliminated genuine innocents, who
would never have endangered the lives
of others.
■ To continue the comparison, you will
classify too many images in a positive
light, which will result in multiple
biopsies, sometimes useless.
MEDICAL
RESPONSABILITY

17. www.cancer-rose.fr
■ The pressure to discover ever smaller lesions pushes the
screener towards an abusive diagnosis, with the double
reading increasing this phenomenon.
…the more you find
The more you search …

18. www.cancer-rose.fr
■ So those are the hazards of screening that gradually made me
give up on the second reading.
■ Because for each individual woman it means 100% in every situation.
One hundred percent in the case of a false negative or false alarm, or
over-diagnosis, one hundred percent invasion of her breast if a biopsy
is decided upon...

19. www.cancer-rose.fr
■ Nocebo effect: causes the disease by anticipating
the disease in a favorable emotional context
■ Healthy women who are over-diagnosed and treated
■ Chronic stress caused by the terror of cancer
■ Anxiety causing tests and anxious waiting
■ Ohysical and psychological impact of the treatments

20. www.cancer-rose.fr
■ Equality in the
nonsense?
■ Or do we think
together about the
information to be
given, and the
relevance of
screening to the
community?
Men claim the right to their
screening testography !

21. www.cancer-rose.fr
Cancer Rose is a French non-profit organization of health care professionals.
Cancer Rose has no sponsorships, honoraria, monetary support or conflict of
interest from any commercial sources.