Coverage rate of opportunistic and organised breast cancer screening in France: Department-level estimation

1

Introduction

In France, breast cancer is the leading cancer in women in terms of incidence and mortality, making it a major public health issue [1] . With the aim of reducing breast cancer mortality through early detection and treatment, a national organised breast cancer screening programme (NBCSP) was rolled out in 2004. The objective of the NBCSP is to ensure equal access to screening by encouraging all women aged 50–74, except those identified as being at high risk, to undergo a free biennial screening mammography [2] . The NBCSP includes two mammographic images per breast, a clinical breast examination, an ultrasound scan if high breast density, and an immediate diagnostic check-up if suspicious result. A second reading by an experienced radiologist is performed if the results are considered normal on the first reading. The NBCSP’s national evaluation database tracks the screening process for all invited women, allowing the production of performance indicators of this programme. After increasing to 52.7 % in 2011–2012, coverage rate of the NBCSP is gradually declining and is below 50 % in 2016–2017 [3] . In addition to the NBCSP, the use of opportunistic screening is still permitted and reimbursed by the national health insurance scheme. In theory, opportunistic screening should mainly concern women with a risk factor. In fact, it coexists in France with organized screening as another screening strategy, carried out mainly on prescription from the general practitioner or gynecologist. Actually, women do not always know what type of screening they are undergoing. Drawbacks of opportunistic screening compared to organized screening are as follows: any radiology center can perform a mammography, there is no approved list; no double reading of negative mammography; additional examinations, the interval between two screenings and the number of images per breast are carried out according to the decision of the radiologist; there is an out-of-pocket balance that depends on the woman’s health insurance; there is no monitoring, nor performance and quality requirements.

In France, it has been roughly estimated that 10 % of women in the national programme’s target performed opportunistic screening in 2009 [4] . The coverage of opportunistic screening among women aged 40–50 and women older than 75 is poorly documented. Some studies suggest that its use varies across France and is strongly linked to women’s socio-economic context as well as the availability of care [56] . Although no specific database exists to evaluate this practice, the medico-administrative health data system (SNDS) can be used to identify all reimbursed mammographies. The objective of this article is to estimate both opportunistic use and overall coverage of breast cancer screening in France, using data from the SNDS.