Socio-Territorial Inequities in the French National Breast Cancer Screening Programme-A Cross-Sectional Multilevel Study.

Abstract

Simple SummaryFrance implemented a national breast cancer screening programme in 2004, which, despite recommendations, still coexists with opportunistic screening practices. We aimed to study socio-territorial inequities in participation in the 2013–2014 screening campaign, using multilevel models. With a representative sample of 42% of the estimated eligible population, we found that the organized programme does not erase social or territorial inequities in participation. Social inequities, at multiple levels, were found in nearly all départements, whereas territorial inequities seemed more context dependent. The impact of the coexistence with opportunistic screening, beyond any control and evaluation, is adding more risks (over-diagnosis, over-treatment) and leads to underestimating the true coverage of the population, mainly in the wealthiest, therefore leading to an underestimation of the true social gradient in participation. The French breast cancer screening programme needs to evolve to be more efficient in coverage, notably through the reduction of the unfair inequities in participation.Background. France implemented in 2004 the French National Breast Cancer Screening Programme (FNBCSP). Despite national recommendations, this programme coexists with non-negligible opportunistic screening practices. Aim. Analyse socio-territorial inequities in the 2013–2014 FNBCSP campaign in a large sample of the eligible population. Method. Analyses were performed using three-level hierarchical generalized linear model. Level one was a 10% random sample of the eligible population in each département (n = 397,598). For each woman, age and travel time to the nearest accredited radiology centre were computed. These observations were nested within 22,250 residential areas called “Îlots Regroupés pour l’Information Statistique” (IRIS), for which the European Deprivation Index (EDI) is defined. IRIS were nested within 41 départements, for which opportunistic screening rates and gross domestic product based on purchasing power parity were available, deprivation and the number of radiology centres for 100,000 eligible women were computed. Results. Organized screening uptake increased with age (OR1SD = 1.05 [1.04–1.06]) and decreased with travel time (OR1SD = 0.94 [0.93–0.95]) and EDI (OR1SD = 0.84 [0.83–0.85]). Between départements, organized screening uptake decreased with opportunistic screening rate (OR1SD = 0.84 [0.79–0.87]) and départements deprivation (OR1SD = 0.91 [0.88–0.96]). Association between EDI and organized screening uptake was weaker as opportunistic screening rates and as département deprivation increased. Heterogeneity in FNBCSP participation decreased between IRIS by 36% and between départements by 82%. Conclusion. FNBCSP does not erase socio-territorial inequities. The population the most at risk of dying from breast cancer is thus the less participating. More efforts are needed to improve equity.