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In France, in March 1999, a synthesis document was produced by the French Agency for Accreditation and Health Evaluation (ANAES) in order to answer very basic questions about breast cancer screening:

1. At what age does breast cancer screening bring a genuine scientifically proven improvement in the survival of breast cancer patients?

2. What is the optimal interval before repeating a screening mammography?

3. How many radiological examinations should be carried out in order to optimise screening?

4. Are there women who should be excluded from screening programs?

The recommendations of this report are listed below:

Systematic screening is recommended between 50 and 69 years.

In the general population, the benefit of a breast cancer screening policy has clearly been demonstrated from the age of 50 to 69. Thus, in this age bracket, systematic screening should be set up.

In the 70 - 74 year age bracket, the incidence of breast cancer is high, but data concerning the value of mass screening is scarce. Taking into account the organisational difficulties involved in large scale campaigns, the extension of screening to this age bracket appears to be currently premature in France. On the other hand, it appears logical to continue screening between 70 and 74 years for women already included in the systematic screening program from the age of 50 to 69.

For the 40-49 year age bracket, the benefit of systematic screening is low and is only proven for studies with at least ten years follow-up with regular mammographies carried out in optimal conditions. Screening risks are not insignificant, particularly the risk of false positives which are followed by numerous other examinations (up to biopsies), bringing a lot of unnecessary anxiety and psychological traumatism.

A mammography every two years

The interval between two screening mammographies must be lower than three years. When the interval is 3 years, there is an important number of interval cancers during the third year.

Two views for each mammography

If some trials or programs in optimal situations have shown the efficiency of screening with only one mammographic view (mediolateral oblique), it has been clearly demonstrated that two views (mediolateral oblique and craniocaudal) are most cost-effective and reduce the risk of false negatives. Examination conditions should always be optimal

Women to be excluded from screening programs

Systematic screening programs are not recommended for women having had breast carcinoma, who should be followed-up according to other protocols. It is also not recommended for women with familial predisposition to breast cancer for whom more strict surveillance should be established.

Quality control of screening programs

Screening campaigns are a very costly investment (around 50 € per screened woman) and directly financed by the State or local authorities. Therefore, resources and results are essential.

The European reference for participation level after three years should be at least 60% (in France, it is around 65% if we include the mammographies carried out outside campaigns for benign breast pathologies).

The recall level (suspect images needing further exploration) should not be higher than 7%: a higher level would mean a great quantity of false positives and a much lower rate would suggest a high number of false negatives (poor radiological interpretation).

The biopsy rate (i.e. to verify dubious radiological images) should be lower than 1.5%, otherwise mammography interpretation should be improved by radiologist training. In France this rate is approximately 1%.

Taking into account epidemiological data in Europe, the detection rate (cancer / women tested) should be around 5% . In France the mean rate is 5.9%.

The percentage of invasive cancers without node involvement (i.e. small cancers of good prognosis) should be higher than 60% (in France, it is around 69%). At least 30% of the discovered cancers should have a diameter of less than 1 cm (in France: 36%).

Therefore, similarly to many other countries, breast screening in France is a question of political commitment: the recent French 'plan cancer' has established the goal that every woman in our country should have access, in the next two years, to efficient breast cancer screening. We should see a genuine decrease in the mortality of breast cancer in the next few years.