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Objectives: To determine the procreational intention rates among cancer survivors whose fertility was unimpaired and to identify the factors associated with their procreational intentions. Methods: Six thousand nine hundred and fifty-seven adult cancer patients treated between September and October 2002 were randomly selected from the French National Health Insurance Fund's Chronic Disease File. Of the 6957, 4270 responded to a cross-sectional questionnaire 2 years after diagnosis, of whom 959 reported being fertile and responded to a question about their procreational intentions. Results: Among the 257 male and female survivors aged 20-44, 86 (33.5%) had procreational intentions. After adjusting for age, gender, and already having children, only a high educational level (adjusted odds ratio: 3.1, 95% confidence interval 1.3-7.8) and stable or increasing financial resources (2.4, 1.0-5.7) were independently associated with the respondents' procreational intentions. Neither cancer stage at diagnosis nor the present stage significantly affected their plans in this respect. Conclusions: Two years after cancer diagnosis, the reasons why some survivors who are still fertile have no parenthood projects were similar to those earlier given by members of the general population. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

French national guidelines for the management of HIV non-occupational post-exposure (nPEP) were issued in 1998 and updated in 2003. NPEP is available and free of charge in all emergency or AIDS care units of French hospitals. A regional survey was carried out to study physicians' adherence to national guidelines, and determinants of adherence to nPEP follow-up in individuals sexually exposed to HIV. The survey was based on retrospective data collection of all consultations for nPEP made in the three AIDS information centers in South-Eastern France (January 2001-December 2002). Information included personal data, type of exposure, and treatment at the first visit after exposure and during follow-up. Exposures were classified into high risk (treatment highly recommended), moderate risk (treatment possibly recommended) and negligible risk (treatment never recommended) categories, according to the level of HIV risk of sexual transmission as indicated by the French national nPEP guidelines. Among the 910 sexual exposures, 56%, 37%, and 4% were classified as cases with high, moderate, and no risk respectively. NPEP was prescribed to 85% of cases. HIV risk of sexual exposure was significantly associated with nPEP receipt though more than half of the cases with negligible risk received nPEP. Independent characteristics associated with non-adherence to nPEP follow-up were younger age, being referred to hospital by a physician, sexual exposure with a casual partner or sexual assault, and “moderate risk” exposure. Better information should be provided to physicians prescribing nPEP to limit over-prescription while new strategies should be implemented to improve follow-up of individuals receiving nPEP, especially those who are younger or survivors of sexual assault. [ABSTRACT FROM AUTHOR]

Background: Past studies on smokers' risk perception have produced mixed results. We endorsed a new approach to assess smokers' perceptions of risk by asking them to estimate threshold values for the cancer risk associated with daily consumption of tobacco and number of smoking years. We expected that many smokers would endorse a "risk denial" attitude, with threshold estimates higher than their own smoking consumption and duration. Methodology: A French national telephone survey (n=3820; 979 current smokers) included several questions about smoking behaviours and related beliefs. Results: Among current smokers, 44% considered that smoking can cause cancer only for a daily consumption higher than their own consumption, and an additional 20% considered that the cancer risk becomes high only for a smoking duration higher than their own. Most smokers also agreed with other "risk denial" statements ("smoking is not more dangerous than air pollution," "some people smoke their whole life but never get sick"). Those who considered they smoked too few cigarettes to be at risk were less likely to report personal fear of smoking related cancer. Conclusion: Risk denial is quite widespread among smokers and does not simply reflect a lack of information about health risks related to tobacco. Fully informing smokers about their risks may necessitate changing the way they process information to produce beliefs and limiting their capacity to generate self exempting beliefs. [ABSTRACT FROM AUTHOR]

This article aims to investigate the effect of French mass media national prevention campaigns on attitudes and behaviours of people living with HIV/AIDS (PLWHAs), with a special emphasis on HIV-related sexual risk behaviours. In 2001, a face-to-face survey was conducted in 32 hospital departments delivering HIV care randomly selected in two French regions (Paris metropolitan area and South-Eastern France). Eligible respondents were HIV-infected outpatients aged 18 or older, and diagnosed for at least 1 year. Overall, 1386 patients were asked to participate and 900 agreed to answer the questionnaire (response rate: 64.9%). Most respondents supported national AIDS information media campaigns; some have found support from these campaigns to talk to relatives or friends about AIDS (19.7%), or to manage their sexual life (24.5%). In multivariate analysis, PLWHAs who declared that these media campaigns have helped them to manage their sexual life were more likely to report condom use in the prior 6 months (“sometimes” vs. “never”: OR?=?2.77 [95% CI?=?1.15?–?6.71]; “always” vs. “never”: 2.46 [1.14?–?5.29]). So mass media general information campaigns can play an efficient role for secondary prevention among PLWHAs and may need to be redesigned to include this goal more explicitly. [ABSTRACT FROM AUTHOR]

To evaluate the impact of injection drug users (IDUs) adherence on effectiveness of highly active antiretroviral therapy (HAART), repeated measures of plasma viral load and CD4+ counts before HAART initiation and at last visit in the cohort were studied. Data were collected by means of patient's face-to-face and self-administered questionnaires about adherence to HAART during the week prior to the last visit. Of a total of 119 patients treated with HAART, undetectable viral load was obtained for 55 patients (46.2%) (G3); 34 patients (28.6%) (G2) had a viral load decline > 0.5 log copies/ml but still detectable viral load at last visit in the cohort, while 30 patients (25.2%) (G1) had no decline or decline

Aims. To evaluate the extent to which the introduction (February 1996) of ambulatory prescriptions of buprenorphine for drug maintenance treatment (DMT) has been associated with its intravenous illicit use by French injecting drug users (IDUs). Design. Cross-sectional survey (September 1997), using self-administered questionnaires, in a sample of IDUs recruited at 32 pharmacies, four needle exchange programmes and three syringe vending machines. Setting. Thirty-nine sites where IDUs have access to sterile syringes in the city of Marseille (South-Eastern France). Participants. Sample of IDUs attending community pharmacies, vending machines and needle exchange programs to obtain equipment. Measurement. To compare characteristics of IDUs who declared that they only injected buprenorphine in the prior 6 months versus the rest of the sample. Findings. Among the 343 respondents (response rate = 70.7%), 33.8% were polydrug users who occasionally injected buprenorphine in parallel to heroin and/or cocaine, while 23.9% only injected buprenorphine in the previous 6 months. IDUs in this latter group were younger, injected more frequently, and were more frequently on buprenorphine DMT, but they were less likely to be HIV-infected and to declare HIV-related injecting risky behaviours. Conclusions. Substantial risk of injecting misuse is associated with large-scale diffusion of buprenorphine DMT. A more stringent regulation for medical dispensation of buprenorphine than the current French general freedom of prescription for all physicians, including general practicioners in ambulatory care, may be necessary in other countries which are considering the diffusion of buprenorphine DMT. [ABSTRACT FROM AUTHOR]

Investigates the French nuclear energy policy. Comparison of the French policy with that of the United States; Factors that influenced the country's nuclear energy policy; Reasons behind the public resistance against the nuclear energy policy.

The French contribution to global public health over the past two centuries has been marked by a fundamental tension between two approaches: State-provided universal free health care and what we propose to call State humanitarian verticalism. Both approaches have historical roots in French colonialism and have led to successes and failures that continue until the present day. In this paper, the second in The Lancet's Series on France, we look at how this tension has evolved. During the French colonial period (1890s to 1950s), the Indigenous Medical Assistance structure was supposed to bring metropolitan France's model of universal and free public health care to the colonies, and French State imperial humanitarianism crystallised in vertical programmes inspired by Louis Pasteur, while vying with early private humanitarian activism in health represented by Albert Schweitzer. From decolonisation to the end of the Cold War (1960-99), French assistance to newly independent states was affected by sans frontièrisme, Health for All, and the AIDS pandemic. Since 2000, France has had an active role in development of global health initiatives and favoured multilateral action for health assistance. Today, with adoption of the 2030 Sustainable Development Goals and the challenges of non-communicable diseases, economic inequality, and climate change, French international health assistance needs new direction. In the context of current debate over global health as a universal goal, understanding and acknowledging France's history could help strengthen advocacy in favour of universal health coverage and contribute to advancing global equity through income redistribution, from healthy populations to people who are sick and from wealthy individuals to those who are poor. [ABSTRACT FROM AUTHOR]

Objective: To describe patients who reported treatment-induced infertility 2 years after cancer diagnosis and to highlight what factors are related to the patients'' lack of information on this topic before starting therapy. Design: Cross-sectional study by telephone interview. Setting: Representative French national sample of survivors 2 years after cancer diagnosis. Patient(s): 282 women (<45 years) and 1137 men (<71 years). Intervention(s): None. Main Outcome Measure(s): Self-reported treatment-induced infertility, and what information was provided on this issue before starting treatment, including information on systematic sperm cryopreservation. Result(s): Among the participants, 104 women (37%) and 346 men (30%) reported having treatment-induced infertility. Among them, 31 women (30%) and 45 men (13%) reported that they had not been informed about the risk of infertility before they started treatment. Logistic regressions showed that a lack of information was associated with older age and treatment without hormone therapy among women and older age, cancers other than prostate, and a lack of participation in treatment decision-making among men. Conclusion(s): Information about infertility risks and preservation methods should be provided more systematically to all treated patients, irrespective of their age. [Copyright &y& Elsevier]

Objectives: This study aimed to determine whether cancer patients report different information-seeking behaviors (ISBs), investigate why they searched for information, and determine the relationship between their ISBs and their socioeconomic and behavioral characteristics. The authors also explored the relationship between ISB and participation in the medical decision-making process as well as the patients' health state., Methods: A sample of 4270 French cancer survivors aged 18 or older was interviewed at 2 years following diagnosis. Rather than deciding a priori who should be considered an information seeker, the authors chose to statistically define the different ISBs using cluster analysis., Results: The authors identified 4 distinct profiles: Stereotypical high-information seekers and acquainted seekers are generally highly educated. They search for information due to their own motivation or because they are close to the medical profession. Constrained information seekers are characterized by a low socioeconomic status. They perceive themselves as "dropouts" of the health care system. Finally, the general information seekers did not systematically resort to any specific ISB. The authors show that after adjustment, belonging to a specific ISB was associated with the likelihood of participating in the medical decision-making process and, more surprisingly, with health state., Conclusions: A key finding of this study is that social disparities are significantly associated with the different ISBs. If these relationships are found in other samples, it would further support the need for medical teams to pay more attention to patients with lower levels of education, particularly in health care systems that have acknowledged equality as a founding principle. The clusters determined in this study offer a potential theoretical framework that can be used in future studies.

Background: In July, 2009, French health authorities, like those in many other countries, decided to embark on a mass vaccination campaign against the pandemic A(H1N1) influenza. Private general practitioners (GPs) were not involved in this campaign. We studied GPs' pandemic vaccine (pvaccine) uptake, quantified the relative contribution of its potential explanatory factors and studied whether their own vaccination choice was correlated with their recommendations to patients about pvaccination., Methodology/principal Findings: In this cross-sectional telephone survey, professional investigators interviewed an existing panel of randomly selected private GPs (N = 1431; response rate at inclusion in the panel: 36.8%; participation rate in the survey: 100%). The main outcome variable was GPs' own pvaccine uptake. We used an averaging multi-model approach to quantify the relative contribution of factors associated with their vaccination. The pvaccine uptake rate was 61% (95%CI = 58.3-63.3). Four independent factors contributed the most to this rate (partial Nagelkerke's R(2)): history of previous vaccination against seasonal influenza (14.5%), perception of risks and efficacy of the pvaccine (10.8%), opinions regarding the organization of the vaccination campaign (7.1%), and perception of the pandemic's severity (5.2%). Overall, 71.3% (95%CI = 69.0-73.6) of the participants recommended pvaccination to young adults at risk and 40.1% (95%CI = 37.6-42.7) to other young adults. GPs' own pvaccination was strongly predictive of their recommendation to both young adults at risk (OR = 9.6; 95%CI = 7.2-12.6) and those not at risk (OR = 8.5; 95%CI = 6.4-11.4)., Conclusions/significance: These results suggest that around 60% of French private GPs followed French authorities' recommendations about vaccination of health care professionals against the A(H1N1) influenza. They pinpoint priority levers for improving preparedness for future influenza pandemics. Besides encouraging GPs' own uptake of regular vaccination against seasonal influenza, providing GPs with clear information about the risks and efficacy of any new pvaccine and involving them in the organization of any future vaccine campaign may improve their pvaccine uptake.

Advancing age is often associated with co-morbidities. Patients' chronological and physiological ages do not always correspond. Elderly patients are often excluded from clinical trials and given sub-optimum treatment. In this context, the question of equity in access to health care arises. A specially designed questionnaire was mailed to French oncologists to determine what factors influenced them and to elicit their medical practice using four clinical cases. Significant differences in treatment choice depending only on patient's age were observed. The likelihood of an elderly breast cancer patient undergoing chemotherapy was found to depend on physician specialty and gender, kind of care structure, physician's perception of the age at which patients become elderly, and their knowledge about geriatric assessments. Some physicians did not always prescribe potentially beneficial treatments when dealing with elderly patients. Given the multidimensional nature of the care process, patients' preferences should be taken into account in medical decision-making., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

Background: In July 2009, French public health authorities embarked in a mass vaccination campaign against A/H1N1 2009 pandemic-influenza. We explored the attitudes and behaviors of the general population toward pandemic vaccination., Methodology/principal Findings: We conducted a cross-sectional online survey among 2,253 French representative adults aged 18 to 64 from November 17 to 25, 2009 (completion rate: 93.8%). The main outcome was the acceptability of A/H1N1 vaccination as defined by previous receipt or intention to get vaccinated ("Yes, certainly", "Yes, probably"). Overall 17.0% (CI 95%, 15.5% to 18.7%) of respondents accepted A/H1N1 vaccination. Independent factors associated with acceptability included: male sex (p = .0001); older age (p = .002); highest or lowest level of education (p = .016); non-clerical occupation (p = .011); having only one child (p = .008); and having received seasonal flu vaccination in prior 3 years (p<.0001). Acceptability was also significantly higher among pregnant women (37.9%) and other at risk groups with chronic diseases (34.8%) (p = .002). Only 35.5% of respondents perceived A/H1N1 influenza illness as a severe disease and 12.7% had experienced A/H1N1 cases in their close relationships with higher acceptability (p<.0001 and p = .006, respectively). In comparison to 26.0% respondents who did not consult their primary care physician, acceptability was significantly higher among 8.0% respondents who were formally advised to get vaccinated, and lower among 63.7% respondents who were not advised to get vaccinated (respectively: 15.8%, 59.5% and 11.7%- p<.0001). Among respondents who refused vaccination, 71.2% expressed concerns about vaccine safety., Conclusions/significance: Our survey occurred one week before the peak of the pandemic in France. We found that alarming public health messages aiming at increasing the perception of risk severity were counteracted by daily personal experience which did not confirm the threat, while vaccine safety was a major issue. This dissonance may have been amplified by having not involved primary care physicians in the mass vaccination campaign.

Objective: In women with Human Epidermal growth Receptor 2 (HER2)-positive metastatic breast cancer (MBC), Trastuzumab has become the standard of care but previous studies have raised doubts about its economic acceptability. We carried out the first cost-effectiveness study for Trastuzumab in MBC patients, in France, that is based on observed resource use and outcomes in clinical practice., Methods: We retrospectively analyzed 47 HER2-positive MBC patients in a before-and-after design study. Nineteen patients did not receive Trastuzumab ("before" Trastuzumab introduction in clinical practice) and 28 patients received Trastuzumab (the "after" population). Direct medical costs were estimated on the basis of the physical quantities reported in the patient medical records, for the period from first metastatic progression until death or date of patient last news. Monetary values (2002 French francs) were attributed to these quantities on the basis of unit costs and incremental cost-effectiveness ratios were calculated., Results: In the Trastuzumab group, median overall survival was significantly higher (37 months vs. 19 months in the non-Ttrastuzumab group, P = 0.001) but total treatment costs were 3 times higher (€ 39,608 vs. € 12,795). The cost per additional life-year saved by Trastuzumab treatment was estimated to be € 27,492 (95% confidence interval: € 20,964-€ 34,020/year of life [bootstrapped estimation])., Conclusions: Our data suggest that despite its high unit price, Trastuzumab should be considered cost-effective in MBC patients to the extent that its incremental cost per life-year saved remains lower than gross domestic product per capita in countries like France.

Background: Nurses play a crucial role in end-of-life care, especially for outpatients. It is important to assess their knowledge and attitudes regarding pain management during the end-of-life period., Methods: A random national sample of 602 French nurses providing home care responded to a telephone survey. The questionnaire included a scale of knowledge about pain and a short clinical case related to severe pain management, requiring WHO level 3 analgesia, for a dying patient., Results: The pain knowledge score depended on nurses' training and was higher for those living with another health professional. For the clinical case, only 60% of nurses favored the prescription of the analgesia recommended by international guidelines. This support depended on objective skills in pain management, but was less frequent for elderly or women patients., Discussion: Attitudes toward pain management at the end of life do not depend only on book learning. They are also influenced by more subjective factors that may cause inequality in care for women and the elderly. Nurse training programs should take such factors into account.

Background: Many people living with HIV/AIDS (PLWHA) suffer from stigma and discrimination. There is an ongoing debate, however, about whether stigma, fear and discrimination actually fuel the persisting spread of HIV, or slow it down by reducing contacts between the whole population and high-risk minorities. To contribute to this debate, we analysed the relationship between perceived discrimination and unsafe sex in a large sample of French PLWHAs., Methodology/principal Findings: In 2003, we conducted a national cross-sectional survey among a random sample of HIV-infected patients. The analysis was restricted to sexually active respondents (N = 2,136). Unsafe sex was defined as sexual intercourse without a condom with a seronegative/unknown serostatus partner during the prior 12 months. Separate analyses were performed for each transmission group (injecting drug use (IDU), homosexual contact, heterosexual contact). Overall, 24% of respondents reported experiences of discrimination in their close social environment (relatives, friends and colleagues) and 18% reported unsafe sex during the previous 12 months. Both prevalences were higher in the IDU group (32% for perceived discrimination, 23% for unsafe sex). In multivariate analyses, experience of discrimination in the close social environment was associated with an increase in unsafe sex for both PLWHAs infected through IDU and heterosexual contact (OR = 1.65 and 1.80 respectively)., Conclusions: Our study clearly confirms a relationship between discrimination and unsafe sex among PLWHAs infected through either IDU or heterosexual contact. This relationship was especially strong in the heterosexual group that has become the main vector of HIV transmission in France, and who is the more likely of sexual mixing with the general population. These results seriously question the hypothesis that HIV-stigma has no effect or could even reduce the infection spread of HIV.

Objective: This study aimed to investigate factors that might lead French homecare nurses to consider the prescription of high-dose morphine to terminally ill patients to be euthanasia., Methods: The researchers conducted an anonymous telephone survey among a random sample of 602 French homecare nurses (response rate = 75 percent) in 2005., Results: Overall, 27 percent of responding home nurses considered prescribing high-dose morphine to terminally ill patients to be euthanasia. Such an opinion was more frequently held by older nurses, those who had not followed terminally ill patients during the previous three years, and those with less knowledge about pain management involving opioid analgesics., Conclusion: There is an urgent need to strengthen pain management education among French homecare nurses--especially regarding the use of morphine--in order to both improve their technical skills and correct some misconceptions about opioid analgesics.

This paper argues that the sociology of deviance can be used to improve our understanding of some difficulties and unintended effects of health-promotion interventions designed to change risk behaviours, especially drug-taking. Firstly, many people engaged in 'risk behaviours' tend to deny the 'risky' label just as delinquents neutralise the 'deviant' label, and preventive information itself may be used by individuals in shaping risk denial. Secondly, deliberate risk-taking may be an 'innovative deviance',which is related to difficulties of conforming to the dominant 'risk culture'. Health promotion is likely to be quite ineffective if it remains wedded to the dominant risk culture and de facto contributes to the spread of it.

Criteria for initiation of highly active antiretroviral treatments (HAART) in HIV-infected patients remain a matter of debate world-wide because short-term benefits have to be balanced with costs of these therapies, and restrictions placed on future treatment options if resistant viral strains develop. On the other hand, postponing the introduction of HAART may involve a therapeutic opportunity cost if a patient's health is allowed to deteriorate to such an extent of becoming unable to benefit from new treatments currently under development when they become available. We introduce a two period model where period one treatment adoption is an irreversible act with future, but uncertain, consequences. New information, both endogenous and exogenous, arises over time and shapes the conditions surrounding the second period therapeutic decision. A surprising result is that, under conditions that appear close to those surrounding the HAART debate, the magnitude of the feared resistance effect has no effect on leaves the optimal treatment decision as far as it is high enough.

From a general review of the literature on breast cancer screening, authors appointed by the parliament office for healthcare policy assessment (Office Parlementaire d'Evaluation des Politiques de Santé, OPEPS) demonstrate that, despite recent controversies, screening is both medically and economically effective. The organisation and specifications of screening are considered. The French situation is examined in the light of European recommendations and compared to other systems in place. After analysing the outcome of screening, particularly the results of the 2003 Cancer Plan, the authors considered the risks of screening, and the type of information given to women.

One example of the recent advances of scientific research on the human genome is the identification of two susceptibility genes to breast/ovarian cancer, BRCA1 and BRCA2, making possible the introduction in medical practices of genetic testing to detect patients with an increased risk of developing such cancers. In this context of diffusion, two surveys were carried out to appraise the activity profiles in 1998 and in 2001 of all the different participants in those new medical practices in France, physicians in charge of genetic counselling, medical centres where consultations take place and laboratories. Results show that over the period 1998-2001, few changes occurred, mainly the reduction of the average waiting time to get the result of a genetic test, the increase in the annual number of BRCA2 families identified to a level similar to the one of BRCA1 and the automation of the biological analyses without noting a considerable increase in the annual output of laboratories till 2001 however. This surprising moderate evolution must be connected to the existence of some particular external factors making the framework of the development of these new medical and biological practices and their future really uncertain. The diffusion of BRCA1/2 genetic testing has been carried out facing the traditional difficulties of any innovating activities, but also the uncertainties related to intellectual property rights on genes and the reimbursement of genetic counselling and biological testing. These uncertainties have certainly restrained the pace of change as many actors in this field have opted for a wait and see strategy bearing in mind the possible future constraints imposed to their future activity, especially if European patents on the BRCA1/2 genes are finally granted by the European patent office (EPO).

Despite the acceptance that health gain is the most important attribute of health care, other aspects of health care may affect utility. The aim of this paper is to report an experiment to test the impact of providing different levels of information in the context of the EuroWill study, a joint contingent valuation (CV) of multiple health programmes. Three hundred and three respondents were simultaneously asked for their willingness-to-pay (WTP) for three health care programmes: more heart operations, a new breast cancer treatment and a helicopter ambulance service. To test for the impact of variation in information, three versions of one of the programmes (heart) were provided. Results show that WTP for all three programmes tended to be significantly higher for respondents who were provided additional positive information about the heart programme. Our results show that CV of health care programmes, which only take into account medical outcomes, may lead to the value of such programmes not being adequately estimated, and that the impact of information may even be more decisive in the context of joint evaluation of multiple, rather than single, programmes.

In this paper, after differentiating evaluation from classical research, three issues are addressed: How to deal with the tyranny of randomised controlled trials? How to ascribe behavioural effects to prevention or to treatment? How to disentangle the short and long term effects of interventions? It is argued that addressing these three issues would help to understand why France, as compared to other Anglo-Saxon countries for instance, has been less concerned by the issues of evaluation and effectiveness, and where it could go if it wanted to get more involved around these matters.

In 1999, the French Parliament established a "right to palliative care", which reactivated public debate about euthanasia. In order to investigate jointly physicians' attitude toward palliative care and euthanasia, we conducted a cross-sectional survey of a national sample of French GPs, oncologists, and neurologists. Overall, 917 physicians participated in the survey. Significant proportions of respondents, especially among GPs and neurologists, considered that palliative sedation and withdrawing life-sustaining treatments (WLST) were euthanasia. Multivariate analysis showed that the physicians who had special medical training in palliative care, and those who distinguish palliative sedation and WLST from euthanasia were more likely to oppose legalisation of euthanasia. Thus, French physicians' attitude to the legalisation of euthanasia is strongly influenced by whether or not they distinguish palliative care from euthanasia. Improved palliative care requires better training of the entire medical profession, and clearer guidelines about which end-of-life care practices are legally and ethically acceptable.

To answer patients, caregivers and professionals needs, the "Plan Cancer" has been presented by the French President on the 24 March 2003. This plan's measures form the concrete elements of a modern health care policy against cancer. It's likely that a plan cancer succeeding to improve patients' survival and quality of life would not be associated with a decrease in health care expenses. However, the plan cancer should target to improve our health care system productivity, i.e. to ensure that the gain in years of life (and in welfare) for each Euro invested would increase. To reach this objective, the plan cancer should consider four problems that health economics may highlight. The impact of biomedical innovations in terms of returns; the question about the rational threshold for allocating resources; the influence of the heterogeneity of the medical practice; the role of patients' preferences. We expect that emphasising these difficulties would allow for health economics to be better considered in the research against cancer and to be clearly distinguished from opinion surveys. It's the best way for social surveys based on direct interview of representative samples of patients' and their relatives to give a useful tool for democratic reflection.

Objectives: To access the cost-effectiveness of French recommendations for hepatitis C virus (HCV) screening and the extent to which earlier identification of carriers may or not improve the cost-effectiveness of therapeutic strategies., Methods: Cost-effectiveness analysis were performed using decision-tree analysis and a Markov model. Four alternative strategies were compared: no screening and no treatment; initiation of HCV treatment after the diagnosis of cirrhosis; and two alternative strategies refer to the current French policies of HCV testing, i.e., two enzyme immunoblot assay (EIA) tests in series, or a polymerase chain reaction (PCR) analysis after the first positive EIA test. Costs were computed from the viewpoint of the health care system. The analysis has been applied to populations particularly at risk of infection, as well as the general population., Results: The "wait and treat cirrhosis" strategy was more cost-effective in the general population and in transfusion recipients. The incremental cost-effectiveness ratio of this strategy compared with baseline strategy was 3,476 of euros and Euro15,300 in respective cohorts. Considering the HCV screening strategy, the additional cost would be of Euro4,933 and Euro240,250 per additional year of life saved, respectively. In the intravenous drug user (IDU) population, the "two ElA" screening strategy was the more cost-effective alternative, with an additional cost of Euro3,825 per additional year of life saved., Conclusions: HCV screening would be discarded for transfusion recipients but should be encouraged for IDUs and also for the general population, in which the additional cost of screening is an order of magnitude more acceptable.

Background: In 1994/95, two genes, BRCA1/2, associated with a predisposition to breast or ovarian cancer were identified. Genetic testing of deleterious BRCA1/2 mutations consequently can be proposed to individuals with a family history of breast or ovarian cancer to identify who is at risk. The granting of U.S. patents on BRCA1/2 to a privately owned company has led to the monopoly use of a unique technique (Direct Sequencing of the gene, DS) for BRCA1/2 testing in this country. Alternative strategies using prescreening techniques, however, have been experienced worldwide., Methods: On the basis of data collected at three laboratories of French public hospitals, we carried out a cost-effectiveness study comparing DS to 19 alternative strategies with the number of deleterious BRCA1 mutations detected as the outcome., Results: Results show that the DS strategy presents the highest average cost per mutation detected (9,882.5 Euro) and that there exist strategies using prescreening techniques that can reach similar effectiveness while reducing total costs. Moreover, other strategies can obtain a four- to sevenfold reduction in the average cost per mutation detected as soon as some rates of false negatives (2% to 13%) are deemed to be acceptable., Conclusions: Results suggest that gene patents with a very broad scope, covering all potential medical applications, may prevent health care systems from identifying and adopting the most efficient genetic testing strategies due to the monopoly granted for the exploitation of the gene. Policy implications for regulatory authorities, in the current context of the extension of BRCA1/2 patents in other countries, are discussed.

Purpose: The objective was to evaluate the impact of an intervention for improving adherence to antiretroviral therapies (HAART) in HIV-infected patients., Method: We designed a prospective, controlled, randomized trial to assess the impact of an educational and counseling intervention in addition to standard of care. At M0, the study enrolled 244 HAART-treated patients who attended a medical consultation between September and December 1999 who were not included in another protocol. Patients in the intervention group (IG) were offered three individual sessions by trained nurses. The proportions of adherent patients at 6 months followup (M6) and the change in HIV RNA between M0 and M6 were measured., Results: Between M0 and M6, HIV RNA significantly decreased in the 123 patients of the IG (mean difference = -0.22 log [+/-0.86], p =.013), while it increased (+0.12 log [+/-0.90], p =.14) in the 121 patients of the control group. However, the proportion of patients with HIV RNA <40 copies/mL remained similar in both groups. In an intent-to-treat analysis, the only significant predictor of 100% adherence at M6 was the intervention group (p =.05) after adjustment for baseline adherence (p =.001). Among the 202 patients with available data on adherence, the proportion of adherent patients was similar in both groups at M0 (58% vs. 63%, p =.59) but became higher in the IG at M6 (75% vs. 61%, p =.04)., Conclusion: The educational and counseling intervention was efficient for increasing adherence to HAART and could be implemented in most clinical settings.

The usual implementation of contingent valuation (CV), in the context of priorities setting for allocation of public funds in health care, is to develop as many surveys as there are programmes, i.e. to perform separate evaluations (SE). In the EuroWill project, three health programmes (for heart disease, breast cancer and a service of helicopter ambulance) were however simultaneously evaluated, i.e. a joint evaluation (JE) was performed. The paper examines the issue of the econometric techniques that should be used to estimate WTP values obtained in the context of JE by comparing the application of independent OLS regressions for each programme versus simultaneous estimations using seemingly unrelated regressions (SUR) on data of the French EuroWill survey. It shows that separate estimations may lead to misspecifications because they cannot take into account that JE exogenously provides a reference structure to the respondent which affects the estimates of WTP for each programme. Therefore, the potential advantage of JE versus SE as an elicitation technique in CV studies applied to health care (to better control the referents used by respondents for evaluating different programmes) only holds if simultaneous rather than independent techniques are used in the estimation of WTPs., (Copyright 2002 John Wiley & Sons, Ltd.)

Objective: To evaluate the potential cost savings of using sequential high dose chemotherapy (HDC), with granulocyte colony-stimulating factor (filgrastim) and stem cell support, rather than single course administration of HDC with bone marrow transplantation (BMT) or peripheral blood stem cell transplantation (PBSCT)., Perspective: French public hospital perspective., Methods: Direct medical costs of sequential treatment, estimated on the basis of physical quantities of resources consumed by 95 patients with inflammatory breast cancer (IBC) included in a French pilot multicentric trial (PEGASE 02), were compared with those of historical control groups of patients treated with single course HDC, either with BMT (n = 27) or PBSCT (n = 14). Costs were evaluated in 1998 French francs (1 Euro = 6.55957 French francs)., Results: The total cost of sequential HDC was significantly lower than that for single course HDC both with BMT (-29%; 22,755 Euros vs 32,284 Euros; p < 0.001) or PBSCT (-16%; 22,755 Euros vs 27,209 Euros; p = 0.026). This was mainly due to a reduction in the length of hospitalisation in transplantation units., Conclusion: According to our results, economic arguments cannot be used against the widespread use of sequential HDC for patients with IBC. However, further economic evaluations based on overall and disease-free survivals alongside a randomised clinical trial are still needed to definitively establish the cost effectiveness of sequential administration of HDC.

Objective: We investigated the impact of the first year of highly active antiretroviral therapy (HAART) on health-related quality of life (HRQL)., Methods: Medical data for patients in the French APROCO cohort were collected at enrollment (M0) and month 12 (M12). A self-administered questionnaire gathered information about HRQL (Medical Outcome Study 36-Item Short Form Health Survey) and toxicity-related symptoms. Using the twenty-fifth percentile of HRQL scales in the French population as a threshold, patients with normal values in at least three mental and three physical scales were considered to have a "normal HRQL." RESULTS. Of the 1053 patients followed through M12, HRQL data at M0 and M12 were available for 654. Among the 233 patients with a normal baseline HRQL, 63 (27.0%) experienced a deterioration of HRQL at M12. Among the 421 patients with a low baseline HRQL, 121 achieved a normal HRQL at M12. Logistic regression showed that factors independently associated with a normal HRQL at M12 were normal baseline HRQL, baseline CD4 count <500 cells/mm, time since HIV diagnosis <8 years, undetectable HIV-RNA at M12, and lower number of self-reported symptoms at M12., Conclusion: An assessment of HRQL should be integrated to efficacy outcomes to evaluate and compare long-term strategies properly and to optimize the durability of response to antiretroviral therapy.

Objective: To evaluate the appropriateness of indications and the diagnostic efficiency of colonoscopy taking into account available guidelines., Methods: This was a retrospective study conducted by the Union Régionale des Caisses d'Assurance Maladie de Provence-Alpes-Côte d'Azur (URCAM-Paca) aimed at assessing the appropriateness of the indications and diagnostic efficiency of colonoscopy. Anonymous data concerning near totality of the colonoscopies carried out during one week in all the establishments (public and private) of the area, were collected by consulting the medical records., Results: The indications for colonoscopy were first analyzed with regard to the guidelines for good clinical practices (références médicales opposables and consensus conference) according to two scales of reading (literal interpretation and broad interpretation). We noted that the available guidelines do not cover the totality of the colonoscopies performed, that their formulation does not make them all controllable, and that the colonoscopies, which respect them, range from 27.5% (strict reading) to 74.1% (broad reading). When taking into account not only the quality of the preparation, but also the result of the examination after re-classification into benign, pathological or normal examinations, the differences in efficiency appear only when one retains the broad interpretation of the reference guidelines. The efficiency analysis makes it possible to highlight a defect of predictability of the recommendations with regard to the pathologies considered as serious. It also appears that approximately 10% of the colonoscopies are, at the same time, out of the reference and have a normal result, and thus can be considered as absolutely not justified., Conclusion: Better compliance of the practitioners to colonoscopy recommendations would initially be generated by improvement in the predictability and the legibility of the current reference guidelines.

Unlabelled: Despite the high prevalence of hepatitis C in France ( approximately 1.2%), a large proportion of people infected with hepatitis C virus (HCV) are not known aware of their status. The objective of this study was to investigate the factors related to screening in general medicine., Material and Methods: Three hundred and one general practitioners were interviewed by phone in South-Eastern France about their HCV screening practices, knowledge of the epidemic, of the natural course of the disease, and opinions about health care for people infected with HCV., Results: While general practitioners often offered HCV screening to intravenous drug users, screening for people who had received blood transfusion, and identification of risk factors among patients were not satisfactory. Multivariate analysis showed that certain characteristics in general practitioners were negatively and independently related to the frequency of HCV screening, especially: general practitioners older than 40 (odds-ratio: 3.12), general practitioners who did not care for intravenous drug users (odds-ratio: 2.24) and did not prescribe human immunodeficiency virus tests (odds-ratio: 5.55). Other characteristics such as awareness of the course of hepatitis C and health care were also associated with HCV screening. Conversely knowledge of the size of the epidemic was not related to better HCV screening practices., Conclusion: Our study shows that knowledge about the size of the epidemic and the natural history of hepatitis C, HCV screening practices and investigation of risk factors among patients are not satisfactory among South-eastern French general practitioners. Although HCV screening and health care must be improved among intravenous drug users, hepatitis C should not be considered as a disease of injecting drug users only by general practitioners and the population. Efforts should be made so that hepatitis C is recognized as a global public health issue, and training of general practitioners should be improved to investigate risk factors and offer HCV screening instead of merely dramatizing the situation.