A Brémond

University of Lyon, Lyons, Rhône-Alpes, France

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Publications (149)331.24 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: (1) To explore empirically the extent to which early stage breast cancer patients in France, wish to be informed about their disease and treatments and (2) in view of the statutory duty of physicians to inform patients, to explore, from the patients' point of view, the type of information given by physicians and whether it meets their information needs. A retrospective, cross-sectional survey questionnaire using standardized questions was administered by mail to newly diagnosed breast cancer patients and evaluated their relationships with the different physicians involved in their treatment at different points in time. Focus was placed on the relationship between surgeons and patients. Two hundred and thirty-eight patients completed the questionnaire on their relationship with their surgeon. Patients' reported information needs are considerable, though significantly different depending on the item. Patients report that surgeons do not fully respond to their needs. Even though physicians are legally required to provide information to their patients, in routine practice they seem to favour providing information about disease and treatment side effects over treatment consequences, even though patients express a need for information on these latter items. More research is needed on the development, use and outcomes of the various strategies and interventions designed to facilitate and improve information transfer in the physician-patient encounter in France.
    Health Policy 02/2009; 91(2):162-73. · 1.73 Impact Factor
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    ABSTRACT: This paper deals with the physician-patient encounter. In France, the current legal framework allows patients to be informed (patients' rights to health information) and to participate to decisions regarding their own health. In such a context, this paper aims to give the reader the broad key components of the so-called 'patient treatment preferences elicitation process' in breast cancer, our research area. We first present the general context, with a definition of the different physician-patient models. We then present decision aids, tools that aim to provide high-quality information to patients in the decision-making process. Finally, based on our previous studies and on examples drawn from the international literature, we present the empirical process of patients' preferences elicitation, which not only increases patients' knowledge of and satisfaction with the decision made, but also allows patients to be part of their disease management. Far from being a phenomenon in the air supported by a legal system, this method developed in the 90s allows patients and more generally healthcare users to be autonomous without constraining them to a choice.
    Revue d Épidémiologie et de Santé Publique 07/2008; 56 Suppl 3:S231-8. · 0.66 Impact Factor
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    ABSTRACT: Background This paper deals with the physician-patient encounter. In France, the current legal framework allows patients to be informed (patients’ rights to health information) and to participate to decisions regarding their own health. In such a context, this paper aims to give the reader the broad key components of the so-called ‘patient treatment preferences elicitation process’ in breast cancer, our research area.
    Revue d Épidémiologie et de Santé Publique 07/2008; 56(4). · 0.66 Impact Factor
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    ABSTRACT: Central breast cancer has long been an indication for mastectomy. Plastic surgical techniques adapted to cancer (oncoplastic surgery) have made it possible to offer breast cancer patients conservative surgery with resection of the nipple-areolar complex (NAC). We evaluated carcinologic results and cosmetic outcomes as a function of the oncoplastic technique used. We performed a retrospective study in 47 patients with central breast cancers undergoing breast-conserving with NAC resection. Carcinologic results were assessed by calculating local and metastatic recurrences rates. Cosmetic results were evaluated on four criteria assessed by the patient then by two surgeons. The mean age of the patients was 59.8 (44-84) years. The mean tumour diameter was 17.4 (6-39)mm. Histological involvement of the nipple is present in 53% of the cases. No local recurrence, neither death was observed at 4.5 years median follow-up. One patient had liver metastatic recurrence at 83 months. Cosmetic results were assessed in 33 patients. Round-block provided better aesthetic results: the shape of the breast was considered very good or satisfactory for 90% of the surgeons with the round-block technique and for 46% with transverse incision (P=0.02). Breast-conserving surgery is feasible in selected patients with T1 or T2 central breast cancers, with no impact on the risk of local recurrence. NAC resection is essential especially when the patients have clinical signs of nipple involvement. It provides satisfactory cosmetic results, especially with the round-block technique, possibly associated with nipple reconstruction using the "cat-design" technique developed by our team.
    Annales de chirurgie plastique et esthetique 05/2008; 53(2):112-23. · 0.33 Impact Factor
  • Annales de Chirurgie Plastique Esthétique 04/2008; 53(2):112-123. · 0.59 Impact Factor
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    ABSTRACT: La Méthode des Choix Discrets (MCD) est utilisée pour analyser les choix des consommateurs. Sous certaines hypothèses de comportement, elle permet d’expliciter les arbitrages des individus entre les attributs d’un bien ou d’un service. Le Traitement Hormonal substitutif de la Ménopause (THM) est caractérisé par des risques et bénéfices de santé et par un coût monétaire. Nous explorons dans cette situation la capacité de la MCD à révéler les préférences individuelles, en commençant par étudier sa validité théorique. Les comportements sont-ils conformes aux hypothèses standard : cohérence interne, transitivité et stabilité des préférences, absence de préférences lexicographiques, absence d’effet de présentation ? Méthode: Onze paires de scénarios ont été construites à partir d’attributs du THM : troubles climatériques, fractures, cancer colorectal, cancer du sein, risque cardiaque, risque thromboembolique, coût. Les variables sociodémographiques et médicales des femmes ont été collectées. Deux versions du questionnaire ont été développées pour tester les effets de présentation des probabilités. La validité théorique a été testée à l’aide de statistiques descriptives. Résultats: 462 femmes de la Région Rhône-Alpes âgées de 45 à 65 ans ont renvoyé leur questionnaire. La cohérence interne, la transitivité, et la stabilité des préférences sont observées dans de larges proportions (95%, 97% et 88% des femmes respectivement.). Seules 12% des femmes expriment des préférences lexicographiques. Aucun effet de présentation sur la qualité des réponses n’est détecté. Conclusion: Compte tenu de la bonne conformité des comportements aux hypothèses, il sera possible d’estimer une fonction d’utilité et de discuter les préférences des femmes pour le THM ainsi que leur disposition à payer.
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    ABSTRACT: This article aims to explore 1) whether after all the research done on shared decision making (SDM) in the medical encounter, a clear definition (or definitions) of SDM exists; 2) whether authors provide a definition of SDM when they use the term; 3) and whether authors are consistent, throughout a given paper, with respect to the research described and the definition they propose or cite. The authors searched different databases (Medline, HealthStar, Cinahl, Cancerlit, Sociological Abstracts, and Econlit) from 1997 to December 2004. The keywords used were informed decision making and shared decision making as these are the keywords more often encountered in the literature. The languages selected were English and French. The 76 reported papers show that 1) several authors clearly define what they mean by SDM or by another closely related phrase, such as informed shared decision making. 2) About a third of the papers reviewed (25/76) cite these authors although 8 of them do not use the term in a manner consistent with the definition cited. 3) Certain authors use the term SDM inconsistently with the definition they propose, and some use the terms informed decision making and SDM as if they were synonymous. 4) Twenty-one papers do not provide or cite any definition, or their use of the term (i.e., SDM) is not consistent with the definition they provide. Although several clear definitions of shared decision making have been proposed, they are cited by only about a third of the papers reviewed. In the other papers, authors refer to the term without specifying or citing a definition or use the term inconsistently with their definition. This is a problem because having a clear definition of the concept and following this definition are essential to guide and focus research. Authors should use the term consistently with the identified definition.
    Medical Decision Making 09/2007; 27(5):539-46. · 2.27 Impact Factor
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    ABSTRACT: To determine the optimal injection path for blue dye and radiocolloid for sentinel lymph node (SLN) biopsy in early breast cancer. A prospective randomized multicentric study was initiated to compare the peritumoral (PT) injection site to the periareolar (PA) site in 449 patients. The detection rate of axillary SLN by lymphoscintigraphy was significantly higher (P = .03) in the PA group (85.2%) than in the PT group (73.2%). Intraoperative detection rate by blue dye and/or gamma probe was similar (99.11%) in both groups. The rate of SLN detection was somewhat higher in the PA group than in the PT group: 95.6% versus 93.8% with blue dye (P = .24) and 98.2% versus 96.0% by probe (P = .16), respectively. The number of SLNs detected by lymphoscintigraphy and by probe was significantly higher in the PA group than in the PT group, 1.5 versus 1.2 (P = .001) and 1.9 versus 1.7 (P = .02). The blue and hot concordance was 95.6% in the PA group and 91.5% in the PT group (P = .08). The mean ex vivo count of the SLN was significantly higher in the PA group than in the PT group (P < .0001). This study strongly validates the PA injection technique given the high detection rate (99.1%) of SLN and the high concordance (95.6%) between blue dye and the radiotracer, as well as higher significant ex and in vivo counts, improving SLN probe detection.
    Journal of Clinical Oncology 09/2007; 25(24):3664-9. · 17.88 Impact Factor
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    ABSTRACT: In France, patients' claim for information and participation to medical decision-making was initiated in the eighties by AIDS associations, then reinforced by the tainted blood scandal and more recently by demands from cancer patients. The right to patient information was recognised on March 4th 2002 by the law pertaining to patients' rights and the quality of the healthcare system. The present article will explore this background by examining the bases, the current status and the development of shared decision-making in the physician-patient encounter in France. We will describe the evolution of the physician-patient relationship on the basis of legal and administrative documents, then show that patients' information, and more generally healthcare users' information, is a central concern for some national health institutions. Finally, we will demonstrate that even if the literature on shared decision-making is little developed in France as compared to other European countries, Northern America and Australia, some studies have nonetheless been conducted. Their results, combined with a legal context and national health institutions encouraging shared decision-making, should prompt otherwise reluctant healthcare professionals to implement this approach in everyday medical practice.
    Zeitschrift für ärztliche Fortbildung und Qualitätssicherung. 02/2007; 101(4):223-8.
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    ABSTRACT: The debate concerning poorer survival for patients with breast cancer (BC) carrying a BRCA1 germline mutation is unresolved, and requires additional data from population-based studies. We followed 232 women with invasive BC under age 46, ascertained prospectively through a French population-based BC registry and tested for BRCA1/2 mutations (median follow-up: 82 months). We compared tumour characteristics and survival rates between 21 BRCA1/2 deleterious mutation carriers and 211 non-carriers. As compared to sporadic tumours, BRCA1/2 tumours showed higher grade (P = 0.02), fewer ductal carcinoma in situ (P = 0.02), more frequent medullary histology (P = 0.02), more frequent negative oestrogen and progesterone receptors (P = 0.001 each). At 5 years, BC-specific survival, metastasis-free survival, ipsilateral recurrence-free survival and contralateral BC-free survival rates for BRCA1/2 mutation carriers were 95.0%, 94.7%, 100% and 90.0% respectively, compared with 89.6%, 78.2%, 88.8% and 94.4% respectively, for non-carriers (not significant). Rates for women carrying only a BRCA1 mutation were 93.3%, 93.3%, 100%, 86.7%, respectively. 76% of BRCA1/2 carriers received chemotherapy. Despite unfavourable tumour features, we found no evidence for poorer short-term survival in BRCA1 mutation carriers compared to non-carriers in this prospective population-based cohort. The high rate of BRCA1 carriers who received chemotherapy for their BC should question the positive impact of this treatment, as suggested by preclinical studies showing increased chemosensitivity of BRCA1-associated tumours.
    Breast Cancer Research and Treatment 02/2007; 101(2):233-45. · 4.20 Impact Factor
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    ABSTRACT: Patients often search for a second opinion (i.e., a search for additional information on the diagnosis and/or treatment options and the potential prognosis, which will help the patient decide what to do or not to do, where, with whom and how). The scope of this phenomenon is not well documented. Also it is not clear if this is warranted or not. This paper aims to explore whether knowing that his clinician follows practice guidelines eliminates the need of a patient's to seek a second opinion. Given that practice guidelines should allow each patient to benefit from the best current clinical evidence, one might wonder if in such a context a second opinion is still necessary, and if so, for what reasons? We review the literature to find the reasons that may prompt a patient to seek a second opinion before the implementation of practice guidelines. We then analyse, from a conceptual point of view, whether for 'informed patient' (i.e., one who knows about and understands practice guidelines) these reasons still hold after the implementation of practice guidelines and if new reasons for seeking a second opinion have emerged. We also discuss practical limitations to searching for a second opinion. We show that even if some reasons, like the search for a second opinion to check whether the treatment prescribed by the first physician is appropriate or not, can be questioned after the implementation of practice guidelines, an 'informed patient' may still wish to seek a second opinion stemming from new reasons which have emerged after the introduction of practice guidelines, e.g., to determine which practice guidelines his physician follows and whether they are appropriate to his case. We conclude that the implementation of practice guidelines will not eliminate the need for a second opinion consultation. On the contrary, the use of guidelines can even stimulate a broader request for second opinions. This conclusion however needs to be validated in an empirical study.
    Health Policy 02/2007; 80(1):43-50. · 1.73 Impact Factor
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    ABSTRACT: Discrete Choice Experiments (DCE) consists in providing individuals with fictive scenarios in which characteristics of the good to be evaluated are varying, and asking them to indicate their preferences. Under some behavioural hypotheses, DCE allows to explain individuals’ trade-offs between those characteristics. Since Hormone Replacement Therapy (HRT) presents risks, benefits and monetary costs we aim at exploring the potentialities of DCE regarding individual preferences elicitation, by an application to HRT. In this paper, we study the theoretical validity of the method by testing standard behavioural hypotheses: internal consistency, transitivity, and stability of the preferences, no lexicographic preferences, no framing effects. Methods: Eleven pairs of scenarios were derived from the following HRT attributes: climacteric troubles, osteoporosis fractures, colorectal cancer, breast cancer, cardiac risk, thromboembolism risk, and monetary cost of the treatment. Women’s demographics and medical background were also collected. Two versions of the questionnaire were developed and randomly administered allowing to test framing effects due to the presentation of probabilities. Theoretical validity was tested by descriptive statistics. Results: 462 women aged 45 to 65 and from Lyon, France, sent back their questionnaires. Internal consistency, transitivity and stability of preferences were observed in large proportions of women (95%, 97% and 88%, respectively). Only 12% expressed lexicographic preferences. No framing effect was detected on data quality. Conclusion: since behavioural hypotheses were verified, it will now be possible to estimate a utility function and to discuss women’s preferences and willingness to pay for HRT.
    Groupe d'Analyse et de Théorie Economique (GATE), Centre national de la recherche scientifique (CNRS), Université Lyon 2, Ecole Normale Supérieure, Working Papers. 01/2007;
  • 12/2006;
  • Nora Moumjid, Alain Brémond
    [Show abstract] [Hide abstract]
    ABSTRACT: This paper deals with the physician-patient encounter. In France, the current legal framework allows patients to be informed (patients'rights to health information) and to participate to decisions regarding their own health. In such a context, this paper aims to give the reader the broad key components of the so-called 'patient treatment preferences elicitation process'in breast cancer, our research area. We first present the general context, with a definition of the different physician-patient models. We then present decision aids, tools that aim to provide high-quality information to patients in the decision-making process. Finally, based on our previous studies and on examples drawn from the international literature, we present the empirical process of patients'preferences elicitation which not only increases patients'knowledge of and satisfaction with the decision made, but also allows patients to be part of their disease management. Far from being a phenomenon in the air supported by a legal system, this method developed in the 90s allows patients and more generally healthcare users to be autonomous without constraining them to a choice.
    Bulletin du cancer 08/2006; 93(7):691-7. · 0.61 Impact Factor
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    ABSTRACT: The prevalence of BRCA1/2 germ-line mutations was assessed in a prospective population-based series of early-onset breast cancer (BC) patients in France, and the usefulness of a clinical assessment of hereditary BC risk, based on multiple criteria including pedigree structure, was evaluated. Through the Rhone region BC registry, 232 women diagnosed with BC before 46 years of age were included. They were tested for BRCA1/2 mutations an average of 10 months after diagnosis. All the women were classified according to their family history of cancer: high risk of hereditary breast cancer (HBC), low risk of HBC, isolated BC, and unknown HBC risk. Deleterious mutations were observed in 21 women (9.1%): 15 (6.5%) BRCA1 and 6 (2.6%) BRCA2. Mutations were more prevalent in women who developed BC before age 41 than in women who developed BC between ages 41 and 45 (12.8% versus 5.2%, respectively, P = 0.04). A high prevalence of BRCA1/2 mutations was found among women in the high-risk category with particular family features (i.e., small family size, predominantly male pedigree, specific cancers; 23.5%) and among women with isolated BC before age 41 and with five or fewer close adult female relatives (16.6%). According to the 10% probability level recommended by the American Society of Clinical Oncology guidelines for genetic testing of cancer, BRCA1/2 mutation screening should be considered for all women diagnosed before age 41, except for those with isolated BC in a large pedigree including multiple unaffected female relatives. The clinical assessment of HBC risk that we have developed should help in the decision to perform genetic testing.
    Genes Chromosomes and Cancer 09/2005; 43(4):404-13. · 3.84 Impact Factor
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    ABSTRACT: The French Adjuvant Study Group 05 (FASG-05) showed that fluorouracil 500 mg/m2, cyclophosphamide 500 mg/m2, and epirubicin 100 mg/m2 (FEC 100) was superior to the same regimen with epirubicin 50 mg/m2 (FEC 50) in terms of disease-free survival (DFS) and overall survival (OS) in adjuvant treatment of early breast cancer. We report 10-year data on efficacy, and long-term side effects for FASG-05. We randomly assigned 565 patients to treatment with FEC 50 or FEC 100 after surgery. Postmenopausal patients also received tamoxifen for 3 years, and almost all patients (96%) also received radiotherapy. Median follow-up was 110 months. The 10-year DFS was 45.3% (95% CI, 41.9% to 48.7%) with FEC 50 and 50.7% (95% CI, 47.3% to 54.1%) with FEC 100 (Wilcoxon P = .036; log-rank P = .08). The 10-year OS was 50.0% (95% CI, 46.7% to 53.3%) with FEC 50 and 54.8% (95% CI, 51.3% to 58.3%) with FEC 100 (Wilcoxon P = .038; log-rank P = .05). Delayed cardiac toxicity (before relapse) occurred in four patients (1.5%) in the FEC 50 arm and three patients (1.1%) in the FEC 100 arm. Cardiac toxicity after relapse occurred in six (4.3%) and five (4.1%) patients treated with FEC 50 and FEC 100, respectively. Treatment with adjuvant FEC 100 demonstrated superior DFS and OS versus FEC 50 at 10 years of follow-up. This survival advantage was not offset by long-term complications such as cardiac toxicity and second malignancy. Given the risk-benefit ratio, FEC 100 is a more optimal regimen for long-term survival in patients with poor prognosis.
    Journal of Clinical Oncology 05/2005; 23(12):2686-93. · 17.88 Impact Factor
  • B Camhi, N Moumjid, A Brémond
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    ABSTRACT: Information is an important part of the patient care in oncology. The role and objectives of patient information were determined by a law passed in March 2002. This study investigates the knowledge of the patients about their rights and their views on what they consider most important. Information about health status and treatments is considered a priority (92.8% of respondents). The majority of patients whish to be given every information about their disease and treatments. On the contrary only 6.7% would rather receive less precise information tailored to what they want to know. Keeping control on the communication of their health information to relatives and other doctors is the option preferred by the majority of patients. Fifty two per cent of the persons are reluctant to be given medical information on the telephone. However opinions differ among social classes since 62% of patients from the upper classes consider it positively. This study demonstrates that the 2002 law is, in its broad outlines, a good response to patient's information needs.
    Bulletin du cancer 01/2005; 91(12):977-84. · 0.61 Impact Factor
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    ABSTRACT: Although dendritic cells (DC) and T cells can infiltrate primary breast carcinoma, it remains unclear whether the immune response influences the clinical outcome. T lymphocytes and DC infiltration within primary tumors was investigated in 152 patients with invasive nonmetastatic breast cancer. CD1a, CD3, CD68, CD123, CD207/Langerin, and CD208/DC-LAMP expression was assessed with semiquantitative immunohistochemical analysis. Expression of chemokines involved in DC migration (MIP-3a/CCL20, MIP-3b/CCL19, and 6Ckine/CCL21) was also examined. The correlation between these markers and the characteristics of the tumors, as well as relapse-free and overall survival was analyzed. Significant prognostic parameters were then tested in a validation series. Infiltration by immature CD207/Langerin+ DC was found in a third of the cancers and did not correlate with clinicopathological data. Presence of mature CD208/DC-LAMP+ DC (56%) and CD3+ T cells (82%) strongly correlated with lymph node involvement and tumor grade. Among the chemokines analyzed, only the presence of MIP-3b/CCL19 in 57% of the tumors correlated with prolonged overall survival. CD123+ plasmacytoid DC (pDC) infiltrated 13% of the primary tumors. Their presence was strongly associated with shorter overall survival (93% versus 58% at 60 months) and relapse-free survival (90% versus 37% at 60 months) and was found to be an independent prognostic factor for overall survival and relapse-free survival and confirmed in an independent validation series of 103 patients. Infiltration by pDC of primary localized breast tumor correlates with an adverse outcome, suggesting their contribution in the progression of breast cancer.
    Clinical Cancer Research 12/2004; 10(22):7466-74. · 8.19 Impact Factor
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    ABSTRACT: The feasibility and accuracy of sentinel lymph node biopsy (SLNB) in the treatment of breast cancer is widely acknowledged today. The aim of our study was to compare the hospital-related costs of this strategy with those of conventional axillary lymph node dissection (ALND). A retrospective study was carried out to determine the total direct medical costs for each of the two medical strategies. Two patient samples (n = 43 for ALND; n = 48 for SLNB) were selected at random among breast cancer patients at the Centre Leon Bérard, a comprehensive cancer treatment center in Lyon, France. Costs related to ALND carried out after SLNB (either immediately or at a later date) were included in SLNB costs (n = 18 of 48 patients). Total direct medical costs were significantly different in the two groups (median 1965.86 Euro versus 1429.93 Euro, p = 0.0076, Mann-Whitney U-test). The total cost for SLNB decreased even further for patients who underwent SLNB alone (median, 1,301Euro). Despite the high cost of anatomic pathology examinations and nuclear medicine (both favorable to ALND), the difference in direct medical costs for the two strategies was primarily due to the length of hospitalization, which differs significantly depending on the technique used (9-day median for ALND versus 3 days for SLNB, p < 0.0001). A lower morbidity rate is favorable to the generalization of SLNB, when the patient's clinical state allows for it. From an economic point of view, SLNB also seems to be preferred, particularly because our results confirm those found in two published studies concerning the cost of SLNB.
    International Journal of Technology Assessment in Health Care 11/2004; 20(4):449-54. · 1.56 Impact Factor
  • Revue d Épidémiologie et de Santé Publique 09/2004; 52:69-69. · 0.66 Impact Factor

Publication Stats

2k Citations
331.24 Total Impact Points


  • 2009
    • University of Lyon
      Lyons, Rhône-Alpes, France
  • 2007
    • Université Lumiere Lyon 2
      Rhône-Alpes, France
    • French National Centre for Scientific Research
      Lutetia Parisorum, Île-de-France, France
  • 1996–2007
    • Centre Léon Bérard
      Lyons, Rhône-Alpes, France
  • 2002
    • The Society of Rheology
      Columbia, South Carolina, United States
  • 2001
    • Institut Bergonié
      Burdeos, Aquitaine, France
  • 2000
    • Claude Bernard University Lyon 1
      Villeurbanne, Rhône-Alpes, France
  • 1998–1999
    • Institut Paoli Calmettes
      Marsiglia, Provence-Alpes-Côte d'Azur, France
  • 1982–1996
    • CHU de Lyon - Groupement Hospitalier Edouard Herriot
      Lyons, Rhône-Alpes, France
  • 1991–1994
    • Institut de Cancérologie Gustave Roussy
      Île-de-France, France