Breast Cancer and Access to Healthcare

When people in a country without a national healthcare system talk about "access to healthcare" they are usually talking about making sure people have the monetary means to get medical care.  It's a debate about money - affordability, access to medical insurance, and how the care is to be paid for (through private insurance or through a government program).

In a country like France that has a national healthcare system (one of, if not THE, best in the world) "access to healthcare" means something different.  The care is there, the system to pay for it is in place but the problem is more one of how to get the people to the healthcare (or to bring the healthcare to the people).

While I was waiting around in the hospital I was very startled to read in a magazine that around 40% of French women between the ages of 50 and 74 do not get regular mammograms to screen for breast cancer.  This high rate is in spite of campaigns that have been held yearly since 2004 to get the word out and encourage women to come in for testing.  Breast cancer is one of the top causes of female mortality in France and mammograms are essential for women in this age range. And, yet, in 2011 only 52.7% of the women in the target population had one.  This low number may be higher once private consultations are taken into account but that still only brings the number up to an estimated (they don't know for sure) 65% for France as a whole.

Breaking down the participation rates by region the numbers are even more interesting.  The Institut National du Cancer says:

La participation au dépistage organisé reste inégale sur le territoire. Ainsi, certaines régions présentent des taux de participation supérieurs à 60 % sur la période 2010-2011 (Pays de la Loire, Limousin, Bretagne, Centre) tandis que d'autres ont des taux inférieurs à 45 % (Guyane, Corse, Île-de-France). Au niveau départemental, les chiffres de participation indiquent, là encore, des différences notables, avec des taux s’échelonnant entre 27,4 % et 67,2 % sur la période 2010-2011.
Participation in testing remains unequal in the [French] territory.  Some regions had participation rates of over 60% in the period 2010-2011 (Pays de la Loire, Limousin, Bretagne, Centre) while others had rates of under 45% (Guyane, Corse, Île-de-France).  At the departmental level the participation numbers indicate important differences with rates that range between 27.4% and 67.2% in the period 2010-2011.

To be very clear, access to these prevention programs is not a question of money (direct payment).  These "Dépistages organisés du cancer du sein" (breast cancer testing campaigns) led by the healthcare system and partners offer a complete mammogram to be read by two radiologists and a breast exam, all covered 100% by the national healthcare system with no co-payments or money up front.  With a deal like that, one might assume that the participation rates would be much much higher (80-90%).  But they aren't.  Why?

Because "access" means much more than simply having care available and the means to pay the medical fees.  The article I was reading cited several factors for the low breast cancer screening participation rates of which economic inequality was one (and here is where money does come into play).  Like women all around the world, women in France have family and work responsibilities and the lower the socio-economic status the harder it is to manage them and to get an employer to give time off work.  In more rural areas there is also the problem of getting to the nearest clinic or hospital which may mean a long drive or ride on the public transportation.   As this article from late 2011 points out, a troubled economy makes it all so much worse: "À Paris, comme ailleurs, les inégalités sociales face à la maladie sont croissantes : de plus en plus de femmes repoussent les soins pour des raisons financières." (In Paris as elsewhere social inequalities in the face of illness are rising:  more and more women are putting off care due to financial reasons.)

France is a country, however, where social solidarity means something.   The annual campaigns to convince women to come in for screening are well-organized, well-funded and you don't hear anyone quibbling over the price tag.  The French healthcare community is well aware of the low participation rates and is working on creative solutions to fix it:  television, Facebook and even organizing teams to go out to neighborhoods and public places to talk to women directly.  Another problem not much discussed in France is illiteracy which means that printed texts like pamphlets, posters and banners don't necessarily do much good in some places.  (And if this sounds strange you, I can assure you that I have indeed met French women who are functionally illiterate and who would most assuredly NOT be able to pass a basic French reading/writing exam if they had to take one.)

There is also the very ambitious Plan Cancer which was started under President Jacques Chirac and was renewed for the period 2009-2013.   Fascinating reading.  The latest plan is organized around 6 measures "phares":  

1. Renforcer les moyens de la recherche pluridisciplinaire (More funding for multi-discipline research.)
2. Caractériser les risques environnementaux et comportementaux. (Determine the environmental and behavioral risks.)
3. Produire et communiquer des informations sur le cancer et sur la cancérologie. (Produce and communicate information about cancer and oncology - I have a wonderful book the hospital gave me about chemotherapy that was part of this effort.)
4. Lutter contre les inégalités d'accès et de recours aux dépistages. (Fight the inequalities that limit access and participation in screening - see measure 14 here for the actions the state is taking to achieve this)
5. Personnaliser la prise en charge des malades et renforcer le rôle du médecin traitant. (Personalize patient treatment and reinforce the role of GP's.)
6. Développer une prise en charge sociale personnalisée et accompagner l'après cancer. (Develop a social support structure for cancer patients and for the life after cancer.) 

It's a work in progress but you can actually see the results of this work in the hospitals and clinics here. At the end of the plan's period there will be a test - a national report card that rates how well these objectives were achieved and outlines areas for future progress.

I suspect that they will do very well indeed.  The French may work less than people in other countries but, damn, they do know how to get things done and their ability to organize projects at a national level is almost frighteningly efficient.  I could not be in better hands and I am deeply grateful to be here and not elsewhere.

Vive la France!