Biomedical subjects
Publications and source records attributed to P Haehnel.
Since 1989, several breast cancer screening mammography programs have been established. The purpose of this chapter is to provide the history and the main results of the previous programs. Furthermore, special attention is given to the new rules established in 2001 with emphasis of the general principles as well as the ethical principles of breast screening.
Mass cancer screening is new in France inasmuch as the country has never up to now carried out such a large-scale and wide-reaching public healthcare operation. The organisation of the screening brings up the question of where healthcare is actually heading. Should the community as a whole should have preference over the individual or, on the other hand, should the individual and his or her private life be defended against a faceless community that is becoming more and more demanding? This question is fundamental to all the difficulties that are met when organising mass screenings. There are, of course, certain technical aspects and indicators of effectiveness that are common to all screening campaigns, but there are also wider considerations that must be respected, such as social justice and liberty of both the individual and the community. Anyone who wishes to take advantage of the screening should be free to do so, but the individual must also be free to refuse. Screening must remain voluntary. It is essential to maintain full data secrecy and to provide appropriate training for the doctors involved. It is also of fundamental importance to carry out an assessment of the campaign from a neutral angle. The training issue is crucial, with the doctor's suitability to carry out the test a key factor. Doctors need to be trained to acquire the necessary skills, especially as it will soon become necessary to monitor doctors' competence in the field. An assessment will have to be made not simply of performance but also of doctors' ability to handle a given situation.
Since 1989, in the French department of Bas-Rhin, a breast cancer screening program in going on and its results are presented here. This program, concerning women of 50 to 65 years-old, is decentralized, based on private or public radiologists and the motivation of women because there is no invitation. The interval between screening test is 2 years. After 8 years, the results are rather satisfactory: participation rate of the initial cohort is 77% in December 31st 1997, participation at incident screenings is above than 85%, early indicators (recall rate, detection rate, PPV of screening, PPV of biopsy) are improving with time to attain numbers like international studies. The ADEMAS program shows that a decentralized screening program, based on existing medical structures is possible in France. Anyway, it must be organized, evaluated at any time, with a quality assurance system to guarantee the women the best taking charge.
Cancer of the breast is so widespread that it has become a genuine problem of public health, with around one woman in twelve developing it in her lifetime. Mass breast-cancer screening campaigns began some 30 years, first in the United States and then in Sweden. Results showed a lowering of the breast-cancer-related death-rate. French doctors experienced considerable difficulties in changing over from an individually-focused organization to the kind of public healthcare service that exists in Nordic and Anglo-saxon countries. However, the first departmental-level breast-cancer screening program, launched in Strasbourg, France, in 1989 proved successful inasmuch as it obtained the involvement of the vast majority of radiologists and general practitioners. Results of the campaign were broadly in line with those obtained elsewhere in Europe. It is only possible to bring this sort of campaign into wider use through intensive groundwork and by providing suitable training for general practitioners, radiologists and gynecologists alike.
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The ultimate effectiveness of any mass screening campaign is directly related to strict compliance with certain rules and technical protocols designed for radiological installations. Concerning radiological screening, the primary technical objective is to ensure reproducibly high quality images at low radiation dose to the patient. This paper describes the methodology followed for the implementation of a quality control (QC) programme of 48 mammography installations used within the context of the breast cancer screening campaign in the Bas-Rhin region of eastern France. In order to demonstrate the efficacy of such a programme, results of QC tests and procedures relating to each element of the radiological imaging chain are presented and compared for four control visits carried out at 6 month intervals over a period of 2 years. A reduction of 50% (from 16 mGy to 7.5 mGy) of breast entrance doses (normalized to a breast thickness of 4.5 cm) and a significant improvement of detectability of high contrast details are discussed. The importance of encouraging an extension of a similar process to the other screening experiments currently underway in France is emphasized.
Sixty-four patients with non metastatic high risk breast cancer were randomized in a double blind trial of adjuvant immunotherapy with sodium dithiocarb (DDC) versus placebo. All patients underwent prior surgery (mammectomy according to Patey) then adjuvant FAC chemotherapy +/- DDC. With a median follow-up of 5 years we observed 6 relapses and 5 deaths in DDC group; 13 relapses and 12 deaths in control group. At 6 years, overall survival is 81% in DDC group versus 55%. Disease free survival (DFS) is 76% in DDC group versus 55%. DDC associated to chemotherapy and locoregional treatment can improve survival and probably DFS in this high risk breast cancer subgroup.
A mammographic breast cancer screening began in May 1989 in the Bas-Rhin. It has been selected by "Europe against Cancer" for France. Its aim is not to prove the efficiency of mammography screening by one view every two years, as many studies has proven it. Its purpose is to find the best methodological model for a national campaign. Its principles are to change attitudes and to obtain the active participation of the physicians without creating new structures. This campaign is offered to women aged 50 to 65, living in Bas-Rhin (74,200 women) without individual convocations. Their participation is obtained by a continuous information and motivation. The mammographic examinations are taken in charge by the Health Insurance and performed by the radiologists who have signed a convention. The homogeneity of the results is assured by a double and triple reading under the responsibility of the ADEMAS. In May 1990, after one year, 17,228 women had presented to the screening test. The positive test rate is 7.6% and 7.6% of the women had a diagnostic procedure which indicated a biopsy for 188 women. Among the first 176 histological results, 76 cancers have been diagnosed, 100 women had a benign lesion. The ratio cancer/benign lesion is 0.76.
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The results of different programmes for screening carried out at present in foreign countries give sufficient proof of the value of screening for cancer of the breast in asymptomatic women of over 50 years of age. There is a significant reduction in mortality between 30 and 70%, according to different studies. Women who were screened had their cancers diagnosed at an earlier stage of the illness than those who were not screened whatever the ages of the women were. These results give a basis for planning screening in France. However, controlled pilot studies should still be carried out to widen screening in a country. These studies should in particular look at technical methods, evaluate the quality of the information that is obtained and the acceptability by women, as well as the training of radiologists and the qualities of the methods used. Finally, each programme should be controlled by the Public Authorities who will be paying for it.
A four-year prospective study was conducted on more than 25,000 women, both asymptomatic (59%) and symptomatic (41%), with a view to investigating the thermal and vascular disorders associated with early stages of breast malignancy. All the patients underwent thermographic, mammographic and physical examinations performed under standard conditions and, when indicated, complementary radiographic (spot/magnified pictures), ultrasound and cytologic tests. Of the 294 in situ, microinvasive and nonpalpable cancers diagnosed in this study, 60-70% generated significant thermal anomalies that, in most cases, consisted of distorted thermovascular patterns. A tentative explanation for these clinical observations was formed from intramammary measurements of temperature and blood flow performed on seven patients and was based on recent experimental data on the origin of vascular reactions associated with cancer growth. This study clearly showed that thermography may contribute to the early detection of breast cancer and to the identification of women at high risk of developing breast cancer. Two hundred four (21.3%) of the 958 patients who, on their first visit, had an abnormal thermogram but no findings at physical examination or mammography developed cancer within the next three years (length of follow-up, 4-41 months).
This paper is a review of the recent technical and clinical advances in the area of breast thermography. Emphasis is placed upon thermal imaging using liquid crystal films, and computer-assisted analysis of breast thermograms. New data are presented concerning the value of thermography for the identification of women at high risk of developing breast cancer, the early detection of mammary carcinomas, and the detection of cancer in fibrocystic breasts.
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Quantitative study of the regression 50 mammary cancers after radiotherapy showed that it took an exponential course. The graphic impression was confirmed by statistical study of the linearity of the regression. A time for half-disappearance can therefore be useful in order to distinguish the regression of mammary cancer after irradiation. Its mean value for 47 of our cases was 17.8 days. The significance of this parameter is certainly complex; it is possible that a prognostic value can be attributed to it.
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The action of ionizing radiation on the metabolic heat production by cancers has been investigated on a group of 24 small breast carcinomas (T1 and T2), all treated exclusively by radiotherapy under equivalent conditions (60Co) and then followed up regularly (mean recall period of five years). Following techniques have been used: intratumoral thermometry and fluvography for computing the specific heat power of the tumour, infrared thermography for analysing the skin thermal pattern quantitatively. Comparison between clinical, radiographical and thermal findings has more especially shown; a) the constant agreement between the final loco-regional results of radiotherapy and the evolution of both the heat production by the tumour and the related hyperthermia on the skin; b) the early appearance of the thermal signs of either a regression or a recurrence of the tumour, compared with the corresponding morphological signs. The fundamental and practical consequences can be summarized as follows: 1 degree distinction between radiosensitive and radioresistant carcinomas accroding as the specific heat power of the tumour is reduced or not after irradiation; 2 degrees definition of three types of thermal evolution by normalization, regression followed by re-increase, and continuance of both tumour heat production and malignant skin hyperthemia, and corresponding to the clinical concepts of sterilization, recurrence and nonsterilization respectively; 3 degrees justification of the systematic use of thermal methods for post-irradiation follow-up, especially to detect a local recurrence earlier and to specify the nature of a doubtful remaining opacity; 4 degrees description of objective thermal criteria allowing to decide a repairing mastectomy within shorter delays.