Breast cancer policy in Latin America: account of achievements and challenges in five countries

Cancer mortality in childhood and adolescence: analysis of trends and spatial distribution in the 133 intermediate Brazilian regions grouped by macroregions

OBJECTIVE

To assess the magnitude, trend, and spatial patterns of childhood and adolescent cancer mortality between 1996 and 2017 in 133 Brazilian intermediate regions by using socioeconomic and healthcare services indicators.

METHODS

This is an ecological study for analyzing the trend of mortality from cancer in childhood and adolescence through time series. Data on deaths were extracted from the Brazilian Mortality Information System. Data on population were extracted from the 1991, 2000, and 2010 demographic censuses of the Brazilian Institute of Geography and Statistics, with interpolation for intercensal years. Time series were delineated for mortality by type of cancer in each intermediate region. Such regions were grouped by macroregions to present the results. The calculation and interpretation of mortality trends use the Prais-Winsten autoregression procedure.

RESULTS

Mortality rates for all neoplasms were higher in the Northern region (7.79 deaths per 100 thousand population), while for leukemias, they were higher in the Southern region (1.61 deaths per 100 thousand population). In both regions, mortality was higher in boys and in the 0-4 age group. The trend was decreasing (annual percent change [APC] - -2.11 [95%CI: -3.14; - 1.30]) for all neoplasms in the Brazilian regions and stationary (APC - -0.43 [95%CI: -1.61; 2.12]) for leukemias in the analyzed period.

CONCLUSION

The mortality rate for all neoplasms showed higher values in regions with smaller numbers of ICU beds in the public healthcare system.

Long-term Mammography Utilization after an Initial Randomized Intervention Period by all Underserved Chilean Women in the Clinics

Chile has one of the highest rates of breast cancer in Latin America. Mammography rates among women, especially those of low socioeconomic status (SES), are thought to contribute to high breast cancer morbidity and mortality. A successful randomized controlled trial among women aged 50 to 70 in a low-SES primary care clinic in Chile led to a significant increase in mammography screening rates in a two-year intervention trial. This study assesses the sustainability of the intervention after ten years and identifies factors that might have been associated with a long-term effect using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. The mammography rates among women aged 50 to 70 in the low-SES intervention clinic were compared to two populations of women aged 50 to 70 from middle-SES clinics and to national data. Qualitative data were used to answer questions of adoption, implementation, and maintenance, while quantitative data assessed the reach and effectiveness. After ten years, low-SES women at the intervention clinic maintained significantly higher mammography screening rates vs. middle-SES women at the comparison clinics (36.2% vs. 30.1% and 19.4% p < 0.0001). Women of a low SES at the intervention clinic also had significantly higher screening rates compared to women of a low SES at a national level (44.2% vs. 34.2% p < 0.0001). RE-AIM factors contributed to understanding the long-term difference in rates. Mailed contact, outreach interventions, and the integration of health promoters as part of the Community Advisory Board were important factors associated with the effects observed. This study provides information on factors that could contribute to reducing the social gap on breast cancer screening.

Public Policies and Programs for the Prevention and Control of Breast Cancer in Latin American Women: Scoping Review

BACKGROUND

Breast cancer has positioned itself worldwide as one of the main public health problems, especially in Latin America. In some countries, several programs for the prevention and control of breast cancer in women have been developed and implemented on a permanent basis, but there are no public reports on the policies that originated such programs.

OBJECTIVE

A scoping review of scientific publications that identify the type, extent, and scope of policies and programs for the prevention and control of breast cancer in Latin American women was performed, and the main results were presented in this paper.

METHODS

This scoping review was carried out according to the method by Arksey and O'Malley based on 3 fundamental questions about breast cancer prevention and control policies in Latin America: their type, extent and scope, and reference framework. The search period was from 2000 to 2019, and the search was carried out in the following databases: MEDLINE (PubMed), MEDLINE (EbscoHost), CINAHL (EbscoHost), Academic Search Complete (EbscoHost), ISI Web of Science (Science Citation Index), and Scopus in English, Spanish, and Portuguese, and Scielo, Cochrane, and MEDES-MEDicina in Spanish and Portuguese. Of the 743 studies found, 20 (2.7%) were selected, which were analyzed using descriptive statistics and qualitative content analysis.

RESULTS

The selected studies identified several Latin American countries that have generated policies and programs to prevent and control breast cancer in women, focusing mainly on risk communication, prevention and timely detection, effective access to health services, improvement of the screening process, and evaluation of screening programs. Evaluation criteria and greater participation of civil society in policy design and program execution are still lacking. This could undoubtedly help eliminate existing barriers to effective action.

CONCLUSIONS

Although several Latin American countries have generated public policies and action programs for the prevention and control of breast cancer, a pending issue is the evaluation of the results to analyze the effectiveness and impact of their implementation given the magnitude of the public health problem it represents and because women and civil society play an important role in its prevention and control.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/12624.

Screen-detected breast cancer is associated with better prognosis and survival compared to self-detected/symptomatic cases in a Chilean cohort of female patients

PURPOSE

The implementation of national breast cancer (BC) screening programs in Latin America has been rather inconsistent. Instead, most countries have opted for "opportunistic" mammogram screenings on the population at risk. Our study assessed and compared epidemiological, clinical factors, and survival rates associated with BC detected by screening (SDBC) or self-detected/symptomatic (non-SDBC) in Chilean female patients.

METHODS

Registry-based cohort study that included non-metastatic BC (stage I/II/III) patients diagnosed between 1993 and 2020, from a public hospital (PH) and a private university cancer center (PC). Epidemiological and clinical data were obtained from medical records.

RESULTS

A total of 4559 patients were included. Most patients (55%; n = 2507) came from PH and were diagnosed by signs/symptoms (non-SDBC; n = 3132, 68.6%); these patients displayed poorer overall (OS) and invasive disease-free survival (iDFS) compared to SDBC. Importantly, the proportion of stage I and "luminal" BC (HR + /HER2 -) were significantly higher in SDBC vs. non-SDBC. Finally, using a stage/subset-stratified age/insurance-adjusted model, we found that non-SDBC cases are at a higher risk of death (HR:1.75; p < 0.001). In contrast, patients with PC health insurance have a lower risk of death (HR: 0.60; p < 0.001).

CONCLUSION

We confirm previous studies that report better prognosis/survival on SDBC patients. This is probably due to a higher proportion of stage I and luminal-A cases versus non-SDBC. In turn, the survival benefit observed in patients with PC health insurance might be attributed to a larger proportion of SDBC. Our data support the implementation of a systematic BC screening program in Chile to improve patient prognosis and survival rates.

[Quality of mammography and breast cancer screening in ArgentinaQualidade da mamografia e prevenção do câncer de mama na Argentina]

Se presentan los resultados del Plan de calidad en mamografía del Programa Nacional del Cáncer de Mama del Instituto Nacional del Cáncer de la República Argentina, enfocado en mejorar la calidad de la mamografía en el sector público de salud e implementar el tamizaje de cáncer de mama por este método diagnóstico. El Plan se comenzó a ejecutar en 2011 con base en la premisa de que una mamografía de mala calidad impide el diagnóstico temprano del cáncer de mama. En ese momento, en Argentina existía poca conciencia sobre la importancia de los controles de calidad, y los continuos cambios en los niveles jerárquicos del sistema de salud tendían a obstaculizar el desarrollo organizado del programa. El Plan consistió en la revisión y el control de calidad de las instalaciones de mamografía, la capacitación de recursos humanos técnicos y médicos y la puesta en marcha de un sistema de acreditación de los servicios de mamografía por parte del Instituto Nacional del Cáncer. La percepción de la importancia de la calidad en el personal involucrado ha mejorado y se obtuvo un panorama general del estado de la mamografía a nivel nacional en cuanto a la calidad, la tecnología, la cantidad de equipos y las posibilidades de implementación del tamizaje. Se capacitó al personal técnico y médico mediante el uso de diferentes metodologías y se impulsó la unificación de la lectura mamográfica en las provincias intervinientes.

Access to innovative cancer medicines in a middle-income country - the case of Mexico

BACKGROUND

Cancer has become the third cause of death in Mexico. Treatment for cancer is often complex and lengthy. New and better medicines enter the market at high prices, which may limit access. Like most Latin American countries, Mexico has an essential cancer medicines list that includes innovative medicines. Their accessibility and use in the public sector remains unknown. Therefore, we describe the use, as a proxy of access, of innovative and essential cancer medicines in the public sector in Mexico, by insurance institution, and by five regions between 2010 to 2016.

METHODS

We used drug utilization research methods to assess the use of eight patented cancer medicines. Through the national transparency platform, we obtained data on the quantities of these medicines used in all public health facilities and social health insurance institutions and recalculated those figures into defined daily dose (DDD) per 1000 population per year.

RESULTS

Overall, the use of all medicines increased over the years, especially for trastuzumab, rituximab and imatinib. The use of innovative medicines was higher per population covered in social health insurance institutions than in governmental facilities. Throughout the study period, the Central region (including Mexico City) has used more medicines per population than the other regions.

CONCLUSIONS

The use and access of some essential innovative cancer medicines has increased over the years, but remains unequal across insurance schemes and regions. Particularly, the Ministry of Health Insurance scheme and Northern and Western regions in the country would benefit from additional efforts to increase access to essential cancer medicines.

Research Priorities and Resource Allocation in the Investigation of New Drugs for Cancer in Least Developed Countries

Cancer incidence has increased significantly in low- and middle-income countries. The priorities of international health research are not always aligned with the global burden of cancer. This study aims to analyze global tendencies in clinical trials in oncology and discuss research priorities and resource allocation in the investigation of new drugs for cancers that significantly affect the least developed countries. This was a retrospective and analytical study that included data collected from the World Health Organization's International Clinical Trials Registry Platform (ICTRP) in 2014. According to our results, there was a tendency for clinical trials involving breast and lung cancer to be conducted in countries with a lower level of economic development. On the other hand, cervical, stomach, and liver cancer, despite the significant burden that these place on middle- and low-income countries, were studied little among the countries selected. In conclusion, the organizations that most fund research to develop new drugs for cancer treatment continue to show little interest in prioritizing resources to fund research for certain types of cancer such as those of the cervix, stomach, and liver, which have a significant impact in low- and middle-income countries.

Quality of life in breast cancer patients: Associations with optimism and social support

Background/Objective: The purpose of this study was to examine quality of life (QoL) in breast cancer patients from Colombia and to explore the relationship between QoL, habitual optimism, and social support. Method: A sample of 95 breast cancer patients treated in a hospital in Bogotá were administered the QoL instrument EORTC QLQ-C30 and the Life Orientation Test LOT-R. Additionally, they were asked to indicate from whom (physicians, friends, nurses, etc.) they wished and received social support. Reference data for the EORTC QLQ-C30 and the LOT-R were taken from a representative sample of the general Colombian population. Results: The breast cancer patients showed detriments to their QoL on most functioning scales and symptom scales of the EORTC QLQ-C30, while their general assessments of health and QoL were not worse than those of the controls. Optimism was positively correlated with QoL. Most patients wanted and received social support from their physicians and friends/family. Conclusions: The results suggest that optimism helps patients better cope with disease. A general assessment of global QoL cannot replace the more specific assessments of the functioning domains and symptoms.

Breast cancer mammographic diagnosis performance in a public health institution: a retrospective cohort study

Objectives

To evaluate the quality assurance of mammography results at a reference institution for the diagnosis and treatment of breast cancer in southern Brazil, based on the BIRADS (Breast Imaging Reporting and Data System) 5th edition recommendations for auditing purposes.

Materials and methods

Retrospective cohort and cross-sectional study with 4502 patients (9668 mammographies)) who underwent at least one or both breast mammographies throughout 2013 at a regional public hospital, linked to a federal public university. The results were followed until 31 December 2014, including true positives (TPs), true negatives (TNs), false positives (FPs), false negatives (FNs), positive predictive values (PPVs), negative predictive value (NPV), sensitivity and specificity, with a confidence interval of 95%.

Results

The study showed high quality assurance, particularly regarding sensitivity (90.22%) and specificity (92.31%). The overall positive predictive value (PPV) was 65.35%, and the negative predictive value (NPV) was 98.32%. The abnormal interpretation rate (recall rate) was 12.26%.

Conclusions

The results are appropriate when compared to the values proposed by the BIRADS 5th edition. Additionally, the study provided self-reflection considering our radiological practice, which is essential for improvements and collaboration regarding breast cancer detection. It may stimulate better radiological practice performance and continuing education, despite possible infrastructure and facility limitations.

Main Messages

• Accurate quality performance rates are possible despite financial and governmental limitations.

• Low-income institutions should develop standardised teamwork to improve radiological practice.

• Regular mammography audits may help to increase the quality of public health systems.