PurposeIn diseases where there is no real consensus regarding treatment modalities, promoting shared decision-making can contribute to improving safety and quality of care. This is the case in low- or intermediate-risk localized prostate cancer (PC) treatment. The aim of this study was to investigate the preferences guiding men's decisions regarding the characteristics of the treatment strategies for PC to help physicians adopt a more patient-centered approach.MethodsThis prospective multicenter study used a discrete choice experiment (DCE). The attributes and the modalities were identified from a qualitative study and a literature review. Relative preferences were estimated using a logistic regression model. Interaction terms (demographic, clinical and socio-economic characteristics) were added to the model to assess heterogeneity in preferences.Results652 men were enrolled in the study and completed a questionnaire with 12 pairs of hypothetical therapeutic alternatives between which they had to choose. Men's choices were significantly negatively influenced by the risk of impotence and urinary incontinence, death, and the length and frequency of care. They preferred treatments with a rescue possibility in case of deterioration or recurrence and the use of innovative technology. Surprisingly, the possibility of undergoing prostate ablation negatively influenced their choice. The results also highlighted differences in trade-offs according to socio-economic level.ConclusionThis study confirmed the importance of considering patients' preferences in the decision-making process. It appears essential to better understand these preferences to allow physicians to improve communication and promote case-by-case decision-making.

BACKGROUND:Because of the benefit-risk ratio, the French health authorities recommend that patients make an informed choice concerning prostate cancer screening. The aim of this study was to investigate men's decision process. The process was explored by assessing information-seeking behavior, knowledge on prostate cancer, and men's involvement in screening decisions.METHODS:Nineteen men aged 50 to 75 years old were included in the study in 2018. Semi structured face-to-face interviews were performed. Interviews were audio-recorded and then transcribed verbatim. A thematic analysis was performed.RESULTS:In some cases, men's knowledge about prostate anatomy, prostate physiology, and prostate cancer screening modalities (procedure and risks) was poor. Moreover, despite international recommendations about shared decision-making, several GPs (General Practitioner) prescribed prostate cancer screening without discussing the matter with their patients.CONCLUSION:French men should receive better information so that they can make an informed choice about prostate cancer screening and share the decision with their GP.

Background: Because of the benefit-risk ratio, the French health authorities recommend that patients make an informed choice concerning prostate cancer screening. The aim of this study was to investigate men's decision process. The process was explored by assessing information-seeking behavior, knowledge on prostate cancer, and men's involvement in screening decisions. Methods: Nineteen men aged 50 to 75 years old were included in the study in 2018. Semi structured face-to-face interviews were performed. Interviews were audio-recorded and then transcribed verbatim. A thematic analysis was performed. Results: In some cases, men's knowledge about prostate anatomy, prostate physiology, and prostate cancer screening modalities (procedure and risks) was poor. Moreover, despite international recommendations about shared decision-making, several GPs (General Practitioner) prescribed prostate cancer screening without discussing the matter with their patients. Conclusion: French men should receive better information so that they can make an informed choice about prostate cancer screening and share the decision with their GP.

Background: Prostate cancer screening is controversial because of uncertainty about its benefits and risks. The aim of this survey was to reveal preferences of men concerning prostate cancer screening and to test the effect of an informative video on these preferences. Methods: A stated preferences questionnaire was sent by e-mail to men aged 50-75 with no history of prostate cancer. Half of them were randomly assigned to view an informative video. A discrete choice model was established to reveal men’s preferences for six prostate cancer screening characteristics: mortality by prostate cancer, number of false positive and false negative results, number of overdiagnosis, out-of-pocket costs and recommended frequency. Results: 1024 men representative of the French general population filled in the entire questionnaire. Each attribute gave the expected sign except for overdiagnosis. The video seemed to increase the intention to abstain from prostate cancer screening. Conclusions: The participants attached greater importance to a decrease in the number of false negatives and a reduction in prostate cancer mortality than to other risks such as the number of false positives and overdiagnosis. Further research is needed to help men make an informed choice regarding screening.

Abstract Background Cervical cancer screening is effective in reducing mortality due to uterine cervical cancer (UCC). However, inequalities in participation in UCC screening exist, especially according to age and social status. Considering the current situation in France regarding the ongoing organized UCC screening campaign, we aimed to assess general practitioners’ (GPs) and gynaecologists’ preferences for actions designed to reduce screening inequalities. Methods French physicians’ preferences to UCC screening modalities was assessed using a discrete choice experiment. A national cross-sectional questionnaire was sent between September and October 2014 to 500 randomly selected physicians, and numerically to all targeted physicians working in the French region Midi-Pyrénées. Practitioners were offered 11 binary choices of organized screening scenarios in order to reduce inequalities in UCC screening participation. Each scenario was based on five attributes corresponding to five ways to enhance participation in UCC screening while reducing screening inequalities. Results Among the 123 respondents included, practitioners voted for additional interventions targeting non-screened women overall (p < 0.05), including centralized invitations sent from a central authority and involving the mentioned attending physician, or providing attending physicians with the lists of unscreened women among their patients. However, they rejected the specific targeting of women over 50 years old (p < 0.01) or living in deprived areas (p < 0.05). Only GPs were in favour of allowing nurses to perform Pap smears, but both GPs and gynaecologists rejected self-collected oncogenic papillomavirus testing. Conclusions French practitioners tended to value the traditional principle of universalism. As well as rejecting self-collected oncogenic papillomavirus testing, their reluctance to support the principle of proportionate universalism relying on additional interventions addressing differences in socioeconomic status needs further evaluation. As these two concepts have already been recommended as secondary development leads for the French national organized screening campaign currently being implemented, the adherence of practitioners and the adaptation of these concepts are necessary conditions for reducing inequalities in health care.

Le cancer de la prostate et le cancer colorectal sont, avec celui du poumon, les cancers les plus fréquents et les plus meurtriers chez l’homme en France. Malgré les preuves de l’efficacité du dépistage du cancer colorectal, les taux de participation de la population aux programmes de dépistage organisé restent faibles. À l’inverse, les hommes sont nombreux à pratiquer un dosage sanguin de PSA pour détecter un éventuel cancer de la prostate, alors que cette technique n’est pas recommandée par les autorités sanitaires françaises. Objectif : L’objectif de ce travail était d’identifier, parmi les caractéristiques des programmes de dépistage du cancer de la prostate et du cancer colorectal, celles qui constituaient des freins ou, au contraire, des moteurs à la participation des hommes, afin de tenter d’expliquer les différences de participation entre ces dépistages. Méthode : Dans cette perspective, 1 008 hommes âgés de 50 à 74 ans ont été interrogés par questionnaire sur leurs préférences en matière de participation aux dépistages des cancers selon la méthode des choix discrets. Les réponses ont été analysées au moyen de modèles de régression qualitatifs. Résultats : Les résultats n’ont pas montré de différences majeures entre les processus de participation à ces deux dépistages. Ils ont confirmé le rôle central de l’information délivrée par le médecin dans la prise de décision. Ils ont également révélé une attitude surprenante des hommes à l’égard du risque de surdiagnostic qui invite à réfléchir à la compréhension et à la perception par la population de cette notion de « surdiagnostic » dans le dépistage des cancers.

Prostate and bowel cancers are with lung cancer the most frequent and most deadly cancers in men in France. Despite evidence of the effectiveness of screening for bowel cancer, the rates of population participation in organized screening programs remain low. Conversely, many men have a PSA blood test to detect prostate cancer, although this technique is not recommended by French health authorities. OBJECTIVE The aim of this work was to identify among the characteristics of screening programs for prostate and bowel cancers those which constituted brakes or, on the contrary, engines to the participation of men in order to try to explain the differences participation between these screenings. METHOD 1,008 men aged 50-74 were questioned on their preferences for participating in cancers screening using a discrete choice experiment. Responses were analyzed using qualitative regression models with random effects. RESULTS The results did not show any major differences between the participation processes in these two screenings. They confirmed the central role of information provided by the physician in decision-making. They also revealed a surprising attitude of men with regard to the risk of overdiagnosis which invites to think about the understanding and the perception by the population of this notion of overdiagnosis in the cancer screening.

Face au constat d'inégalités d'accès à la mammographie de dépistage, des initiatives locales ce sont développées sur le territoire français mais l'absence d'évaluation limite souvent la transférabilité des interventions. Afin de dépister les femmes sur leurs lieux de vie, le département de l'Orne qui est un département rural, s'est doté dès 1992 d'un mammographe mobile : le mammobile, intégré au dépistage organisé du cancer du sein depuis 2004. Nous avons entrepris de réaliser une étude rétrospective afin d'évaluer l'effet du mammobile sur l'augmentation de la participation et la réduction des inégalités sociales et territoriales. Les résultats de cette analyse montraient que dans l'Orne, les inégalités sociales et géographiques de participation au dépistage organisé du cancer du sein étaient diminuées par l'ajout au dispositif actuel d'une unité mobile de radiographie. Les limites de cette étude sont celles inhérentes à son caractère rétrospectif et observationnel et nous réfléchissons actuellement à un essai d'intervention sur le territoire normand. Dans sa construction, notre projet, qui inclue des objectifs de réduction des inégalités socio-territoriales tente d'intégrer le principe de l'universalisme proportionné et la proposition d'actions multiniveaux en ciblant à la fois des déterminants proximaux et des déterminants distaux du comportement en santé. Enfin, Cette recherche interventionnelle, intègre des acteurs de terrain et les institutions concernées. La prise en compte des enjeux politiques et économiques enrichit le projet mais le contraigne également. La mise en œuvre de cette recherche interventionnelle nécessite la bonne coordination entre des acteurs de terrain d'origines différentes, des acteurs politiques et des financeurs dans un contexte de recherche de l'efficience. La détermination de la population à inviter, des zones de stationnement du mammobile et des modalités pratiques de réalisation de la mammographie dans le mammobile sont autant d'éléments de conflits potentiels qui illustrent bien la nécessité de la négociation entre les enjeux individuels de chacun des acteurs et les enjeux collectifs.

Le constat des inégalités sociales dans le domaine du cancer est établi depuis maintenant de nombreuses années. Ces inégalités se construisent tout au long de l'histoire médicale de la maladie dès la phase de découverte du cancer. En France, le dépistage du cancer colorectal est organisé au niveau national depuis 2009. La participation à ce dépistage reste insuffisante et reconnaît un gradient social décroissant entre les populations les plus aisées et les plus défavorisées. L'implémentation d'intervention ciblant ces déterminants sociaux pour réduire les inégalités sociale face au cancer est devenue une priorité de santé publique. Notre hypothèse était qu'en adaptant le concept américain de « Patient Navigator », aux modalités actuelles de l'organisation du dépistage du cancer colorectal en France, la participation pouvait être augmentée et les inégalités réduites. Afin d'évaluer l'efficacité d'une telle intervention, un essai randomisé en cluster a été construit. L'intervention consistait pour un travailleur social d'entreprendre en complément du dépistage organisé, l'ensemble des actions possibles permettant d'identifier puis de lever les barrières limitant l'accès au dépistage pour des sujets ne participant pas au dépistage. L'action était basée sur une lettre d'information suivie d'appels téléphonique. L'intervention a été conduite durant deux ans dans trois départements français. Le design était un essai randomisé en cluster (IRIS). L'évaluation était basée sur la comparaison de la participation dans les clusters d'intervention et des clusters témoins comparables. Cette comparaison a été réalisée dans l'ensemble de la population incluse dans l'étude qui représentait la population cible du dépistage, et dans la sous population des sujets joignables par l'accompagnateur. Pour les deux populations, l'efficacité de l'intervention a été évaluée à la fois au niveau agrégé et individuel. Quelle que soit la population ou le niveau d'analyse, l'intervention était toujours plus efficace chez les sujets des zones favorisées et en milieu rural. La modélisation des résultats a montré que si l'application d'une telle intervention suivant le principe d'universalisme augmentait les inégalités sociales de participation, son application suivant le principe d'universalisme proportionné (intervention ciblant les sujet non participants et défavorisés) avait la potentialité d'effacer le gradient social de participation au dépistage du cancer colorectal. Au-delà des résultats quantitatifs portant sur les résultats de l'intervention, l'analyse du processus de cette étude permet d'engager une réflexion sur la définition de l'accompagnateur, sa formation, ces missions et les modalités optimales d'action qui pourrait être intégrées au dépistage organisé du cancer colorectal.

Background: Breast cancer is the leading cancer in terms of incidence and mortality among women in France. Effective organized screening does exist, however, the participation rate is low, and negatively associated with a low socioeconomic status and remoteness. Objectives: To determine the cost-effectiveness of a mobile mammography (MM) program to increase participation in breast cancer screening and reduce geographic and social inequalities. Methods: A cost-effectiveness analysis from retrospective data was conducted from the payer perspective, comparing an invitation to a mobile mammography unit (MMU) or to a radiologist's office (MM or RO group) with an invitation to a radiologist's office only (RO group) (n = 37461). Medical and nonmedical direct costs were estimated. Outcome was screening participation. The mean incremental cost and effect, the incremental cost-effectiveness ratio, and the cost-effectiveness acceptability curve were estimated. Results: The mean incremental cost for invitation to MM or RO was estimated to be (sic)023.21 (95% CI, 22.64-23.78) compared with RO only, and with a point of participation gain of 3.8% (95% CI, 2.8-4.8), resulting in an incremental cost per additional screen of (sic)610.69 (95% CI, 492.11-821.01). The gain of participation was more important in women living in deprived areas and for distances exceeding 15 km from an RO. Conclusion: Screening involving a MMU can increase participation in breast cancer screening and reduce geographic and social inequalities while being more cost-effective in remote areas and in deprived areas. Because of the retrospective design, further research is needed to provide more evidence of the effectiveness and cost-effectiveness of using a MMU for organized breast cancer screening and to determine the optimal conditions for implementing it.

Objective: French health authorities put general practitioners at the heart of the colorectal cancer screening. This position raises organisational issues and poses medico-legal problems for the professionals and institutions involved in these campaigns, related to the key concepts of medical decisions and suitability of standards. The objective of our study is to reveal the preferences of general practitioners related to colorectal cancer screening organisation with regard to the medico-legal risk Methods: A discrete choice questionnaire presenting hypothetical screening scenarios was mailed to 2114 physicians from 20 French different areas. The preferences of 358 general practitioners were analysed using logistic regression models. Results: The factors that have significant impact on the preferences of general practitioners are the capacity of the primary care professional in the procedure, the manner in which pre-screening information is given to patients, the manner in which screening results are given to patients, the number of reminders sent to patients who test positive and who do not undergo a colonoscopy and the remuneration of the attending physician. Conclusions: Our results reveals that current colorectal cancer screening organisation is not adapted to general practitioners preferences. This work offers the public authorities avenues for reflection on possible developments in order to optimize the involvement of general practitioners in the promotion of cancer screening programme. (C) 2017 Elsevier B.V. All rights reserved.

Despite free colorectal cancer screening in France, participation remains low and low socioeconomic status is associated with a low participation. Our aim was to assess the effect of a screening navigation program on participation and the reduction in social inequalities in a national-level organized mass screening program for colorectal cancer by fecal-occult blood test (FOBT). A multicenter (3 French departments) cluster randomized controlled trial was conducted over two years. The cluster was a small geographical unit stratified according to a deprivation index and the place of residence. A total of 14,556 subjects (72 clusters) were included in the control arm where the FOBT program involved the usual postal reminders, and 14,373 subjects (66 clusters) were included in the intervention arm. Intervention concerned only non-attended subjects with a phone number available defined as the navigable population. A screening navigator was added to the usual screening organization to identify and eliminate barriers to CRC screening with personalized contact. The participation rate by strata increased in the intervention arm. The increase was greater in affluent strata than in deprived ones. Multivariate analyses demonstrated that the intervention mainly with phone navigation increased individual participation (OR = 1.19 [1.10, 1.29]) in the navigable population. For such interventions to reduce social inequalities in a country with a national level organized mass screening program, they should first be administered to deprived populations, in accordance with the principle of proportionate universalism. ClinicalTrials.gov Identifier: NCT01555450

Background: Patient navigation programs to increase colorectal cancer (CRC) screening adherence have become widespread in recent years, especially among deprived populations. Objectives: To evaluate the cost-effectiveness of the first patient navigation program in France. Methods: A total of 16,250 participants were randomized to either the usual screening group (n = 8145) or the navigation group (n = 8105). Navigation consisted of personalized support provided by social workers. A cost-effectiveness analysis of navigation versus usual screening was conducted from the payer perspective in the Picardy region of northern France. We considered nonmedical direct costs in the analysis. Results: Navigation was associated with a significant increase of 3.3% (24.4% vs. 21.1%; P = 0.003) in participation. The increase in participation was higher among affluent participants (+4.1%; P = 0.01) than among deprived ones (+2.6%; P = 0.07). The cost per additional individual screened by navigation compared with usual screening (incremental cost-effectiveness ratio) was 1212 globally and (sic)1527 among deprived participants. Results were sensitive to navigator wages and to the intervention effectiveness whose variations had the greatest impact on the incremental cost-effectiveness ratio. Conclusions: Patient navigation aiming at increasing CRC screening participation is more efficient among affluent individuals. Nevertheless, when the intervention is implemented for the entire population, social inequalities in CRC screening adherence increase. To reduce social inequalities, patient navigation should therefore be restricted to deprived populations, despite not being the most cost-effective strategy, and accepted to bear a higher extra cost per additional individual screened.

OBJECTIVES:In the European context of falling reimbursement rates for some osteoarthritis (OA) treatments, we performed a study to determine whether the cost covered by patients influenced the decisions of their physicians' prescriptions for medication.METHODS:The study involved 106 general practitioners (GPs) and 82 rheumatologists. Preferences were elicited using a discrete choice experiment. Scenarios were generated including seven treatment attributes with associated different levels: pain relief, improvement in function, retardation of joint degradation, risk of moderate side effects, risk of serious side effects, cost borne by the patient and degree of patient acceptance of the treatment.KEY FINDINGS:OA treatment choices were significantly influenced by pain relief (β = 1.1533, P < 0.0001 for GPs and β = 0.5043, P = 0.0024 for rheumatologists), improvement in function (β = 1.2140 for GPs and β = 0.7192 for rheumatologists, P < 0.0001), annual cost to the patient (β = -0.0054 for GPs and β = -0.0038 for rheumatologists, P < 0.0001) and serious side effects (β = -0.5524 for GPs and β = -0.4268 for rheumatologists, P < 0.0001). The risk of moderate side effects only had an impact on GP decision making (β = 0.0282, P = 0.0028). All physicians were willing to make patients bear an extra annual cost of: (1) €225 among GPs and €189 among rheumatologists so that they could benefit from one unit improvement in function; and (2) €214 among GPs and €133 among rheumatologists so that they could benefit from a one unit improvement in pain relief.CONCLUSION:When making decisions about which treatment to prescribe, physicians take into account the cost to patients. Changes in reimbursement rates for some OA treatments may lead to changes in prescribing practices.

The aim of the study was to test whether a screening navigation program leads to more favorable health beliefs and decreases social inequalities in them. The selected 261 noncompliant participants in a screening navigation versus a usual screening program arm had to respond to health belief measures inspired by the Protection Motivation Theory. Regression analyses showed that social inequalities in perceived efficacy of screening, favorable attitude, and perceived facility were reduced in the screening navigation compared to the usual screening program. These results highlight the importance of health beliefs to understand the mechanism of screening navigation programs in reducing social inequalities.

UNLABELLED Prostate cancer remains a public health concern in France for men between 50 and 70 years old. Low-risk or intermediate-risk localised prostate cancer can be treated by a number of therapeutic options. OBJECTIVE Identify, in patients' discourse, the mechanisms and the logic involved in therapeutic decision-making. METHOD Qualitative study involving 15 men aged between 53 and 70 years, treated for early-stage prostate cancer, via interviews examining diagnosis pathway, how patients perceive and cope with the illness, and how they choose a treatment. RESULTS The men made their choices using their own initiative during a multiple-stage process. The determining factors were: quality of relationship with physicians, wish to benefit from the available technological advances in medical care, and minimum impairment to their sexual and reproductive identity. Chances of survival did not appear to be their primary concern. CONCLUSION This qualitative study reveals that men make their own decisions in terms of choice of therapy, whether encouraged by their physicians to participate or not.

OBJECTIVE:To study the relevance of liver function test (LFT) results for early detection of liver metastasis of uveal melanoma. DESIGN:Evaluation of diagnostic test. PARTICIPANTS:Eighty-eight patients were included in whom metastasis developed while undergoing semiannual follow-up with LFTs, including aspartate-aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyltransferase (γGT), lactate dehydrogenase (LDH), and phosphatase alkaline (PA). As controls, 174 patients with uveal melanoma without metastasis were included. METHODS:The diagnostic attributes of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for each test were estimated from cross-tabulation tables of test results according to the diagnosis of metastasis. The proportions of false-positive results between groups of patients with and without metastasis were compared in log-binomial regression models. MAIN OUTCOME MEASURES:Sensitivity, specificity, PPV, NPV, and cost evaluation. RESULTS:Metastases were detected after LFT abnormality (at least 1 abnormal test result) in 40 (45%) patients. The overall sensitivity of LFTs ranged from 12.5% to 58.0%, and the PPV ranged from 9.4% to 38.6%. The overall specificity and NPV were 90% or greater. The proportions of false-positive results between groups of patients with and without metastasis did not differ significantly (all P≥0.38). Using a cost evaluation, semi-annual screening by LFTs was calculated to cost $35.5/year per patient, including liver imaging induced by true and false-positive results. CONCLUSIONS:Isolated or combined LFTs for AST, ALT, γGT, LDH, and PA are not helpful for detection of early metastasis. However, the high NPVs suggest that LFT screening can allow clinicians to reassure the patient when the LFT results are negative.

The impact of social factors on healthcare inequality is well-recognized in many industrialized countries and involves a wide range of pathological conditions (cardiovascular disease, cancer, etc.). In general, the poorest indicators of health are observed in socially disadvantaged populations. Beyond this observation is the question of actions taken to prevent the formation of social inequality in healthcare. The purpose of this work was to evaluate the potential contribution of an intervention tool called the “patient navigator”, used in English-speaking countries and to determine its feasibility in France.

The impact of social factors on healthcare inequality is well-recognized in many industrialized countries and involves a wide range of pathological conditions (cardiovascular disease, cancer, etc.). In general, the poorest indicators of health are observed in socially disadvantaged populations. Beyond this observation is the question of actions taken to prevent the formation of social inequality in healthcare. The purpose of this work was to evaluate the potential contribution of an intervention tool called the "patient navigator", used in English-speaking countries and to determine its feasibility in France. (C) 2010 Elsevier Masson SAS. All rights reserved.

Purpose The liver is the main target for screening for uveal melanoma metastasis, which could be achieved by liver function tests (LFTs). The aim of our study is to analyze the relevance of LFTs for detection of metastatic disease in term of prognostic value and cost evaluation Methods Patients (n=88, who developed metastasis while undergoing semi-annual follow-up with LFTs including aspartate-aminotransferase (AST), alanine-aminotransferase (ALT), gammagutamylransferase (γGT), lactodeshydrogenase (LDH), and phosphatase alkaline (PA) were included. For assessing the level of LFTs for metastasis only the one preceding screening LFTs before the diagnostic by imaging was recorded. Consecutive patients (n=174) with uveal melanoma were chosen as control from patients who did not develop metastasis Results We were able to detect metastasis after LFTs abnormality in 40 (45%) patients. However, at the time of the one preceding screening LFTs before the metastasis diagnosis, 51(58%) patients had at least one abnormal LFT. The metastasis diagnosis was missed in 11 patients (13%). The overall sensitivity of LFTs ranged from 12.5 to 58.0% and the predictive positive value ranged from 9.4 to 38.6%. Interestingly we observed false positives in 20.3% with the variable “at least one abnormal LFT”. Using financial approach, we calculated the semi-annual screening by LFTs. Conclusion Using the most important retrospective series analyzing semi-annually all LFTs, we demonstrate that LFTs screening (AST, ALT, γGT, LDH and PA) is not relevant for detection of early metastasis even if the over cost induced by imaging requested for false positive is low