Breast cancer: in France, a screening program for women between 50 and 74 years of age

Although breast cancer can occur at any age, it is more common in post-menopausal women. This is why all women between the ages of 50 and 74 are offered screening in metropolitan France and the overseas territories. Every two years, they receive a letter from the public insurance body inviting them to make an appointment for screening, which is fully covered by public health insurance.

This screening includes two examinations.

• Manual breast exam, to detect any anomalies.
• A mammogram, which is an X-ray of the breast tissue. As part of the screening program, the mammogram results are read twice by two radiologists for increased safety.

Of course, it is possible to obtain mammograms outside of the screening program. They may be offered to women with risk factors (family history, for example) before the age of 50, or may be performed more frequently, including when the patient also receives screening as part of the screening program. In these cases, patients must contact their ob-gyn.

Following introduction of the screening program, the proportion of ductal breast cancers detected (at a very early stage) has increased from 5% to 20% between 1980 and today. When detected very early, these tumors do not metastasize, and the five-year survival rate is 100%. Their treatment by tumorectomy or mastectomy, followed by radiotherapy, is aggressive in terms of side effects and after effects. This raises the regularly recurring debate on screening, which can lead to over-treatment. “Can we refrain from treating [editor’s note: this type of cancer]?”, wonders Roman Rouzier, medical director of the senology department at Institut Curie. “These questions about over-screening advocate for therapeutic de-escalation for ductal cancer in situ. However, the procedure to be followed (intervention or monitoring) must be assessed scientifically. A very specific study over the course of 10 to 15 years is required, with enough patients and frequent monitoring to limit the risk of letting an in situ cancer develop into an infiltrating cancer.” The LORD (LOw Risk Dcis) study, which pursues this goal, is soon to be launched. It will be coordinated by the European Organization for Research and Treatment of Cancer, and aims to monitor 1,842 patients over the course of 13 years.

Monitoring women at very high risk

Enacted on September 1, 2016, the reimbursement of the costs of breast imaging services for women with high breast cancer risk had been long-awaited. The first national recommendations for monitoring of women carrying an alteration of the BRAC1 or BRAC2 genes date back to 1995.

In 2014, the Haute autorité de santé (HAS) recommended the monitoring of women if they have a high level of risk, namely connected to the presence of a genetic alteration, family history, a history of chest radiation treatments or the presence of a histological risk. 

Monitoring via imaging of women at very high risk (genetic factor, significant family history without genetic explanation, history of radiation treatments, etc.) is somewhat burdensome and leads to anxiety. Usually from the age of 30 onwards, it includes MRIs, mammograms and sonograms once per year.