[MUSIC] In this presentation, I will give you a brief overview of the main types of controversies we can encounter in the general framework of screening. A different type of controversy with very different natures. The four main ones are, first, the concept of screening itself, which is challenged by people. It’s a followed precept in healthcare throughout the world, that we should not risk causing more harm than good. « first do not harm ». And this precept is to some extent challenged by screening. The second cause of controversy is scientific dissent, very different estimates of benefit and harms measured by different scientists in the world. How could there be such differences sometimes based on the same data or the same health care context? The third area is communications. What communication should be provided? Is it intended to encourage attendance, or to allure people to make informed choice? And then what information, how, and by who should it be conveyed? And fourth area of controversies are the potential conflict of interest, not only financial, maybe political or intellectual. So let's look at the first concept of screening itself. Screening fundamentally differs from the clinical practice. In practice, you treat sick people. They could be harmed from your treatment, but But at least they’ll have a chance of benefiting from it. This is quite different from screening because some of the people who had suffered the side effect from screening do not have the disease, which is intended to be screened, so they would not be able to benefit from the interventions. So there should be a general acceptance that screening isn't always the right thing. It harms as well as benefits, and then the benefits should outweigh the harms and all that at an affordable cost. So in terms of controversy, it can be summarized by some simple questions. Is it, for instance, acceptable to cause death of a healthy person in order to benefit many others? Is it also acceptable to spend limited healthcare resources for an intervention targeting only a subgroup of the population? These are the kind of recurrent questions and controversies about screening in general. The second area of controversy, the scientific dissent, it has to be recognized that screening evaluations is an area of expertise as is nursing, public health, It is an area of itself, and unraveling the methodological aspect, statistical methods Metrics of screening is not an easy task to perform, to understand, and to explain. So explaining then from the same data different scientists have arrived At different reasons. Based generally on different methods, is quite challenging to explain to the lay public, general populations, or the journalists. It is challenging because, first, you need to have some statistical knowledge to explain, to understand that, and also, because the topic is not something which is perceived as very interesting by the journalist or the public. It is much easier for a journalist to conclude the different result for the different people argue to a quarrel of experts. But often it is not the case, it is due to submission issue which are not easy to explain. And it does create confusions about benefit and harms of screening and can give these wrong impressions of a quarrel among experts. What contributes to that also is the lack of clear metrics about how to balance the benefits and harms of screaming. For instance, I've looked at breast cancer screening because it has been in 2013 in the panel review with the UK. One of the conclusions was for any life saved by screening, there was three cases of a woman being over diagnose. So we see case of a diagnosis for one death avoided. Is it a very good, is it a moderate Is it a sufficient balance of benefit and harm? There are no really clear metrics to answer these questions. This issue goes beyond scientific evidence and our values, and how much are authorities are willing to pay to save a life. Even when scientists agree on the magnitude of the benefits and harm for screening, they can be disagreement on how to communicate scientific reasons to the population. We know that how to frame the information and framing is a jargon, saying how to present the information to the public or to the medical professionals can affect the judgement and the behaviors. Let's take an example. Without a screening intervention, we may have 4 deaths 1,000 operations. And 4 in 1,000 with a screening intervention. So you can't frame it as saying there is 20% reduction in deaths due to screening. 5 in 1,000 versus 4 in 1,000 is 20%. But you may look at the absolute reductions which is 1 5 minus 4 in 1000 which sounds far less impressive and people did tend to be impress by larger numbers. But actually talking about why they're saving 1,000 is much easier in terms of numbers to understand and to grasp the populations and the relative scales. You can play with these numbers and say, for instance, what is my chance of not dying from the disease? So you'll be asking yourself before deciding whether or not you may want to be screened. And in this present situation, without screening, you may have 995 chance out of 1,000 not dying of a disease. And we spending 996 out of 1,000. So you risk all qualified person or 1 chance in 1,000 less of dying from screening, from the disease if you get screened. In other words you need to screen 1,000 people to save one life, Which is a way that maybe public health authorities are interested in seeing that. You can see for the same figures, the way it is presented, that it will have an impact on people's decisions and behavior. Who produces information? It is generally people interested in screening, either the general practitioners, screening programs themselves or the health authorities. Though we may ensure that sufficient enforcement that information provided is balanced. There's mounting evidence that providing natural frequencies is easier to understand by most people. But the controversy is already to who provides the informations, screening leaders, program managers, health authorities or GPs, are generally interest in screening, and if they can get rewards, when some uptake targets are met, then they be inclined to provide some unbalanced information. Because easiest way to increase your uptake is to provide and balance information and to gloss over some of the harms of screening. But there are ethical question there. For instance, for some harder to reach sub groups of the population, will it be acceptable to Gloss over some of the risk of screening in order to reach people who are harder to reach to be screened? Which maybe a populations who could benefit the most of screening. What is the role of media in communications? Well, media tends to report stories which are the best selling stories. They'd be more interested in picking up a controversial study result, showing informations or which are at variance which are you know results, your study is showing and screening is a very beneficial or has no benefit or that some groups of the population are not eligible to be screened, rather than reporting a study which confirmed what has been showed previously that some benefits, which from a media point of view is no new information so not something which is very interesting. Also, journalists are not objective persons. They have their personal belief or opinion and Know someone who has already suffered, or died from a cancer and in promoting maybe some cancer screening. So they are all these issues about communications and controversies. The last area of controversial conflict of interest, which are very various, we can mention the interest from providers of screening animation who may have a direct financial benefit. Board members, and institutions in screening committees, Who may help favoring the implementation of screening. How the political good will, screening needs political support? Depends on the agenda of politician, politician are interested if screening for instance could lead to new employment, help the economy, it could be aspects in favor of the implementation of screening whether or not it is really justified. In terms of scientist that all go more invisible type of conflict of interest for some, the publications, or defending may depend on screening or the old cover for screening whether it is a positive or a negative all come over screening, there are some clear interest here, and looking sometimes at a literature, looking at the names of a published papers, you could see it is most oriented in favor or in disfavor of screening. The medical jurors although have some conflict of interests, a report which is controversial is more likely to be highly cited, it would improve the impact factor, which is important for journals. And then the criticism of high-profile medical journals, who have favoured sensationalism rather than scientific information. So in conclusion, screening entails several types of controversies. Some are specific to screenings, others are common to other fields. These controversies may vary across settings, may vary according to the disease being screened and social values Most of these controversies are unlikely to disappear in the near future, except maybe the balance of information on which most populations and healthcare providers agree that we should move towards more balance healthcare information. [MUSIC]
