Breast Cancer Screening: What Are the Areas for Improvement?
Seance of wednesday 15 april 2026 (Dépistage des cancers : quelles voies d'amélioration ?)
DOI number : 10.26299/teve-hq13/emem.2026.16.01
Abstract
In France, as in all countries, breast cancer remains a serious disease today, with approximately 62,000 new cases and 12,000 deaths annually. Despite undeniable therapeutic advances, breast cancer treatments remain intensive and lengthy, combining surgery, radiation therapy, chemotherapy, immunotherapy, and targeted therapies in varying combinations.
The prognosis for breast cancer depends on several factors, including the stage of the disease at the time of diagnosis and the biology of the breast tumor. Since it is not possible to alter the biological aggressiveness of cancers, the only ways to reduce the risk of death from breast cancer are primary prevention and detecting the cancer at the earliest possible stage—which is the goal of screening. The expected benefits of this screening include not only reduced mortality but also a reduction in the intensity of treatments—particularly the number of mastectomies, axillary lymph node dissections, and oncological treatments—in favor of less aggressive and shorter-duration treatments.
Following an initial phase of pilot projects launched in several French departments starting in 1989, organized breast cancer screening (OS) was expanded to all French departments in 2004. Women aged 50 to 74 are currently invited every two years to undergo a dual-view mammogram combined with a clinical examination (and, if necessary, a breast ultrasound), with 100% of the cost covered by health insurance without any out-of-pocket expenses. This OS faces competition from so-called individual screening (IS), as it is conducted outside the framework established by public authorities. According to the 2026 report by the Court des Comptes, “IS, which covers patients of all age groups, has shortcomings, such as the absence of a second reading. It is also costly for both patients and the public. The possibility of extra fees under IS creates a risk that women may be incentivized—for example, by manipulating wait times for mammograms—to opt for IS.” Compared to the IS, in addition to equal access for all women and the double reading of images by two radiologists, the OS has other advantages, such as quality control of equipment (and particularly dosimetry) every six months. Furthermore, prospective data collection allows for the precise evaluation of OS programs (which is not possible with IS). It has thus been demonstrated in numerous OS programs that there is a significant reduction in treatment burden and mortality. For example, among women aged 50 to 69, there is a 23% reduction in mortality among invited women and a 40% reduction among participating women. A significant reduction in mortality is also observed among women aged 70 to 74 (B Lauby-Secretan NEJM 2015: 2353-258).
However, despite highly significant results in favor of OS, numerous debates and controversies surrounding this screening—particularly regarding the risks of overdiagnosis and overtreatment, as well as doubts about the actual decline in mortality—continue to be discussed among the general public and the medical community, contributing to a decline in participation rates. These rates stand at approximately 44% in France. However, it has been demonstrated that to reduce mortality rates at the population level, participation rates in this screening must be sufficiently high, exceeding 70%. When analyzing the controversies surrounding screening, it appears that they are often based on older studies with outdated diagnostic and therapeutic approaches. Other publications cited by screening critics pertain to screening programs with modalities very different from the French model, featuring highly variable participation ages (ranging from 35 to 80 years) and a wide variety of technical and organizational protocols (such as the absence of clinical examination or ultrasound). Furthermore, the use of a second reading of mammograms is not systematic across different screening programs, although 7 to 9% of cancers are identified during a second reading. Therefore, it is impossible to extrapolate the results of studies on screening programs that use methods very different from those adopted in French programs. The “real-world” results of recent studies on OS for women over 50 provide strong grounds for unreservedly supporting this screening.
However, modernizing the screening program could likely increase participation rates. In this context, consideration should be given to modifying the age groups involved, personalizing the OS—particularly the intervals between mammograms—and the organization of the second reading (digitization of mammograms), as well as integrating other imaging modalities and modernizing communication methods with healthcare professionals and civil society. Furthermore, digitization would enable the use of artificial intelligence within the screening program, which the Court des Comptes calls for planning and regulating. In this context, the National Academy of Surgery is actively committed to OS and to participating in the essential developments of this screening program.
Prof. Carole Mathelin, MD, PhD
Chief of Surgery. ICANS, 17 rue Albert Calmette, 67200 Strasbourg, France
Past President of the National Academy of Surgery, President of the International Society of Senology
The prognosis for breast cancer depends on several factors, including the stage of the disease at the time of diagnosis and the biology of the breast tumor. Since it is not possible to alter the biological aggressiveness of cancers, the only ways to reduce the risk of death from breast cancer are primary prevention and detecting the cancer at the earliest possible stage—which is the goal of screening. The expected benefits of this screening include not only reduced mortality but also a reduction in the intensity of treatments—particularly the number of mastectomies, axillary lymph node dissections, and oncological treatments—in favor of less aggressive and shorter-duration treatments.
Following an initial phase of pilot projects launched in several French departments starting in 1989, organized breast cancer screening (OS) was expanded to all French departments in 2004. Women aged 50 to 74 are currently invited every two years to undergo a dual-view mammogram combined with a clinical examination (and, if necessary, a breast ultrasound), with 100% of the cost covered by health insurance without any out-of-pocket expenses. This OS faces competition from so-called individual screening (IS), as it is conducted outside the framework established by public authorities. According to the 2026 report by the Court des Comptes, “IS, which covers patients of all age groups, has shortcomings, such as the absence of a second reading. It is also costly for both patients and the public. The possibility of extra fees under IS creates a risk that women may be incentivized—for example, by manipulating wait times for mammograms—to opt for IS.” Compared to the IS, in addition to equal access for all women and the double reading of images by two radiologists, the OS has other advantages, such as quality control of equipment (and particularly dosimetry) every six months. Furthermore, prospective data collection allows for the precise evaluation of OS programs (which is not possible with IS). It has thus been demonstrated in numerous OS programs that there is a significant reduction in treatment burden and mortality. For example, among women aged 50 to 69, there is a 23% reduction in mortality among invited women and a 40% reduction among participating women. A significant reduction in mortality is also observed among women aged 70 to 74 (B Lauby-Secretan NEJM 2015: 2353-258).
However, despite highly significant results in favor of OS, numerous debates and controversies surrounding this screening—particularly regarding the risks of overdiagnosis and overtreatment, as well as doubts about the actual decline in mortality—continue to be discussed among the general public and the medical community, contributing to a decline in participation rates. These rates stand at approximately 44% in France. However, it has been demonstrated that to reduce mortality rates at the population level, participation rates in this screening must be sufficiently high, exceeding 70%. When analyzing the controversies surrounding screening, it appears that they are often based on older studies with outdated diagnostic and therapeutic approaches. Other publications cited by screening critics pertain to screening programs with modalities very different from the French model, featuring highly variable participation ages (ranging from 35 to 80 years) and a wide variety of technical and organizational protocols (such as the absence of clinical examination or ultrasound). Furthermore, the use of a second reading of mammograms is not systematic across different screening programs, although 7 to 9% of cancers are identified during a second reading. Therefore, it is impossible to extrapolate the results of studies on screening programs that use methods very different from those adopted in French programs. The “real-world” results of recent studies on OS for women over 50 provide strong grounds for unreservedly supporting this screening.
However, modernizing the screening program could likely increase participation rates. In this context, consideration should be given to modifying the age groups involved, personalizing the OS—particularly the intervals between mammograms—and the organization of the second reading (digitization of mammograms), as well as integrating other imaging modalities and modernizing communication methods with healthcare professionals and civil society. Furthermore, digitization would enable the use of artificial intelligence within the screening program, which the Court des Comptes calls for planning and regulating. In this context, the National Academy of Surgery is actively committed to OS and to participating in the essential developments of this screening program.
Prof. Carole Mathelin, MD, PhD
Chief of Surgery. ICANS, 17 rue Albert Calmette, 67200 Strasbourg, France
Past President of the National Academy of Surgery, President of the International Society of Senology