The French breast cancer screening programme. Epidemiological and economic results of the first round of screening

Transcription

1 EUROPEAN JOURNAL OF PUBLIC HEALTH 1996; 6: The French breast cancer screening programme Epidemiological and economic results of the first round of screening SUZANNE H. WAIT, HUBERT M. ALLEMAND * This paper presents the epidemiological and economic results pertaining to the first round of breast cancer screening programmes in France. Breast cancer screening is based within existing radiologic facilities in the private and public sector and on-going competition exists between organized and spontaneous screening. The mean screening attendance rate was 36.7%, the mean recall rate was 10.4%, the positive predictive value (PPV) for the screening test 5.8% and the biopsy rate 1.2%. There were 5.1 carcinomas detected per 1,000 women screened. Of these, 30.7% were smaller than 10 mm in diameter and 69.0% had no nodal involvement. A retrospective resource-based cost analysis revealed a mean cost of US$63 per woman screened. This cost includes all direct programme costs excluding diagnostic testing and treatment costs. Organizational as opposed to technical aspects of screening accounted for 38% of this cost in the first round. These results reveal discrepancies in the quality, cost and estimated efficacy between the district programmes during the first screening round. Overall, epidemiological indicators reach European target values, with the exception of a low PPV for both the screening test and biopsy. In addition to the strict adherence to quality control and interpretation protocols, the shift of French women away from individual screening practices towards organized screening behaviour will be necessary to enable the French breast cancer screening programmes to reach their optimal efficacy. Key words: breast cancer, screening programme, mammography, cost Clinical trials conducted over the past 30 years suggest that breast cancer screening by mammography, if performed in conditions of optimal quality, can reduce breast cancer mortality by 20-40% in women aged years.1-3 However, very few countries have adopted a national breast cancer screening policy and most countries remain hesitant about extending current pilot projects or regional programmes. In France, the Prevention Department of the main national Sickness Insurance Fund (Caisse Nationale d'assurance Maladie des Travailleurs Salaries, CNAMTS) launched its first pilot screening programmes in Six administrative districts (departements) were chosen to initiate screening programmes, and 4 more followed in The purpose of these pilot programmes was to test the applicability of an organized breast cancer screening programme within a decentralized private-sector radiology market and to observe whether such a system could reproduce the target quality indicators achieved in European clinical trials. The projects were set up on an experimental basis and digressions from the proposed protocol were allowed. In early 1994, a decision was made by the French Ministry of Health to extend screening programmes gradually to cover the remaining 85 French S.H. Wait', H.M. Allemand ' 1 CREDES (Centre de Recherche, d'etude et de Documentation en Economie de la Sante), Paris, France 2 Prevention Department, Echelon National du Service Medical CNAMTS (Caisse Nationale d' Assurance Maladie des Travailleurs Salaries), Paris, and Department of Public Health Medicine, University of Besan on, France Correspondence: S.H. Wait, 8 rue Fondary, Paris, France, tel , fax districts over a 2-5 year period. The inclusion of new districts into the national programme is contingent upon their demonstration of adequate training and organization as well as strict adherence to the national protocol. The 10 existing district programmes cover a target population of 938,000 women aged years. The programmes address a target population of women used to receiving mammograms as part of premenopausal surveillance and had been well exposed to screening before entering the programme. In a country lacking a strong prevention tradition, this programme represents a bold attempt to incorporate organized screening behaviour into the existing health care network, to improve the overall quality of mammography practice and to divert women away from individual clinical practices and towards an organized preventive cultural framework. This paper presents the results of an epidemiologic assessment of the 6 first pilot projects (target population, 645,209 women aged years and a cost analysis of 5 of these programmes. All results pertain to the first round of screening only. METHODS The French breast cancer screening model The supply of mammographic facilities in France greatly outweighs demand and need. The number of mammographic facilities in use numbered 2,101 in 1993, an increase of 931 facilities since 1989 (table 1). In order to avoid further inflation of supply, the French screening programme was based within existing radiologic facilities in both the private and public sector. At least 95% of m Downloaded from

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