[Access to early breast cancer diagnosis in the Brazilian Unified National Health System: an analysis of data from the Health Information System]

Factors associated with time-to-treatment initiation of breast cancer

The present retrospective study investigated factors associated with time-to-treatment initiation of breast cancer of a cohort of 12,100 cases of health facilities qualified for high complexity in oncology within the scope of the Brazilian Public Health System (SUS) of Rio de Janeiro between 2013 and 2019. Multivariate logistic regression was used to estimate odds ratios and 95% confidence intervals. Of all cases, 82.1% were submitted to the first treatment >60 days. Patients without previous diagnosis history, higher education and in stages III and IV were less likely to have their first treatment >60 days, while treatment at a health facility outside the capital showed a higher probability. Patients with a previous diagnosis history, aged ≥50, non-white race/skin color and in stage I were more likely to be submitted to their first treatment >60 days, while subjects with higher education, treated in a health facility outside the capital and in stage IV showed a lower probability. To summarize, sociodemographic, clinical and health facility-related factors are associated with time-to-treatment initiation of breast cancer.

[Risk of false-positive result in mammography screening in Brazil]

False-positive results on mammography screening are common, putting a burden on both women and the health care system. This study aimed to estimate the risk of false-positive results in Brazilian mammography screening based on data from the Brazilian Unified National Health System (SUS) information systems. A retrospective cohort study was conducted with women aged 40-69 years, who underwent mammography screening and breast histopathological examination at SUS from 2017 to 2019. The rate of false-positive results was estimated based on the prevalence of altered BI-RADS results on mammography screening and the proportion of benign results on breast histopathological examination. Of the 10,671 women with histopathological examination at SUS, 46.2% had a benign result, and this proportion was significantly higher in women aged 40-49 years compared to women aged 50-69 years. The estimate of false-positive results was 8.18 cases per 100 women aged 40-49 years and 6.06 per 100 women aged 50-69 years. This information is useful for public managers in evaluating mammography screening programs, as well as for health care providers to guide women on the implications of mammography screening.

Breast cancer survival and the health system in Brazil: an analysis of public and private healthcare

Background

The incidence of breast cancer is increasing globally; however, survival outcomes vary and are lower in developing countries.

Methods

We analyzed the 5- and 10-year survival rates for breast cancer according to the type of healthcare insurance (public vs. private) in a referral center for cancer care in the Brazilian southeast region. This hospital-based cohort study included 517 women diagnosed with invasive breast cancer between 2003 and 2005. The Kaplan-Meier method was used to estimate the probability of survival, and the Cox proportional hazards regression model was used to assess prognostic factors.

Results

The 5- and 10-year breast cancer survival rates were as follows: private healthcare service survival rate of 80.6% (95% CI 75.0-85.0) and 71.5% (95% CI 65.4-77.1), respectively, and public healthcare service survival rate of 68.5% (95% CI 62.5-73.8) and 58.5% (95% CI 52.1-64.4), respectively. The main factors associated with the worst prognosis were lymph node involvement in both healthcare services and tumor size >2 cm only in public health services. The use of hormone therapy (private) and radiotherapy (public) was associated with the best survival rates.

Conclusions

The survival discrepancies found between health services can be explained mainly by the difference in the stage of the disease at the time of diagnosis, indicating inequalities in access to the early detection of breast cancer.

Potential Role of Fourier Transform Infrared Spectroscopy as a Screening Approach for Breast Cancer

Breast cancer is a heterogeneous disease, and its spread involves a succession of clinical and pathological stages. Screening is predominantly based on mammography, which has critical limitations related to the effectiveness and production of false-positive or false-negative results, generating discomfort and low adherence. In this context, infrared with attenuated total reflection Fourier transform infrared (ATR FT-IR) spectroscopy emerges as a non-destructive sample tool, which is non-invasive, label-free, has a low operating-cost, and requires only a small amount of sample, including liquid plasma samples. We sought to evaluate the clinical applicability of ATR FT-IR in breast cancer screening. ATR FT-IR spectroscopy through its highest potential spectral biomarker could distinguish, by liquid plasma biopsy, breast cancer patients and healthy controls, obtaining a sensitivity of 97%, specificity of 93%, a receiver operating characteristic ROC curve of 97%, and a prediction accuracy of 94%. The main variance between the groups was mainly in the band 1511 cm^-1 of the control group, 1502 and 1515 cm^-1 of the cancer group, which are the peaks of the bands referring to proteins and amide II. ATR FT-IR spectroscopy has demonstrated to be a promising tool for breast cancer screening, given its time efficiency, cost of approach, and its high ability to distinguish between the liquid plasma samples of breast cancer patients and healthy controls.

Evaluation of breast cancer screening indicators in the female population using the National Health System, Brazil, 2018-2019: a descriptive study

OBJETIVE

to analyze breast cancer screening monitoring indicators in the female population using the Brazilian National Health System, from 2018 to 2019.

METHODS

this was a descriptive study based on Cancer Information System (SISCAN) data; screening indicators were calculated following deterministic linkage of the mammography and histopathology databases.

RESULTS

in 2018, 807,430 women aged 50 to 69 years were screened for breast cancer, 91% of whom had a benign result, 1.8% probably benign, 6.7% inconclusive results and 0.5% results suggestive of cancer; the positive mammogram rate was 9.0%; biopsy was estimated to be indicated for 1.6% of the women, 33.9% of whom had a malignant result, and the cancer confirmation rate was 5.4 per 1,000 women.

CONCLUSION

high benign lesion loss to follow-up was identified; the positive mammogram rate was lower than the international parameter, but the cancer detection rate was adequate and the percentage of inconclusive mammograms was acceptable.

Determinants of Lack of Access to Treatment for Women Diagnosed with Breast Cancer in Brazil

Access to timely treatment is essential for the probability of the cure and reduction of severe breast cancer cases. In Brazil, legislation states that cancer treatment must start within 60 days of diagnosis. This study analyzed the factors associated with lack of access to breast cancer treatment in women with a confirmed diagnosis inserted in the health system. We collected secondary data from Brazilian women with a diagnosis and without treatment from January to December 2019 through the Cancer Hospital Registers developed by the National Cancer Institute. Our findings indicate that most women (60.11%) are diagnosed with stage II cancer but are without treatment. Most of them are aged 18–70 years, non-white race/color, have a low educational level and are from the Southeast Brazilian region. In addition, social inequalities are determinant in women’s lack of access to breast cancer treatment.

Mortality due to breast cancer in a region of high socioeconomic vulnerability in Brazil: Analysis of the effect of age-period and cohort

Introduction

Breast cancer is an important public health problem worldwide, with important disparities in incidence, mortality, and survival rates between developed and developing countries due to inequalities regarding access to measures for the prevention and treatment of the disease. In Brazil, there are higher rates of incidence and a downward trend in mortality in regions of greater socioeconomic development.

Objective

To evaluate the effect of age, period, and birth cohort on breast cancer mortality in women aged 20 years and older in the states of the Northeast Region of Brazil, an area of high socioeconomic vulnerability, from 1980 to 2019.

Methods

The death records were extracted from the DATASUS Mortality Information System website (Department of National Health Informatics) from the Ministry of Health of Brazil. Estimable functions were used to estimate the age-period and cohort models (APC) using the Epi library from the R statistical software version 6.4.1.

Results

The average breast cancer mortality rate for the period was 20.45 deaths per 100,000 women. The highest coefficients per 100,000 women were observed in the states of Pernambuco (21.09 deaths) and Ceará (20.85 deaths), and the lowest in Maranhão (13.58 deaths) and Piauí (15.43 deaths). In all of the locations, there was a progressive increase in mortality rates in individuals over 40 years of age, with higher rates in the last five-year period (2015–2019). There was an increase in the risk of death for the five-year period of the 2000s in relation to the reference period (1995–1999) in the Northeast region and in the states of Alagoas, Bahia, Maranhão, Paraíba, and Piauí. In addition, there was an increased risk of death for women born after the 1950s in all locations.

Conclusion

The highest mortality rates in all five-year periods analyzed were observed in states with greater socioeconomic development, with an increase in mortality rates in the 2000s, and a higher risk of death in the younger cohorts.

Breast cancer screening adherence rates and barriers of implementation in ethnic, cultural and religious minorities: A systematic review

Breast cancer is the most common cancer affecting women worldwide. Adherence to breast cancer screening guidelines is frequently lower in racial, ethnic and cultural minority populations and is affected by potential inequities or barriers to screening that these minorities face. Therefore, the aim of the present study was to collect information from different minority groups worldwide, assess adherence to breast cancer screening and evaluate barriers or limitations causing non-adherence, which should facilitate the development of effective interventions. A search was conducted through PubMed and Web of Science. Studies were considered as eligible if they met the following criteria: i) Female patients; ii) breast cancer screening program implemented in the country; iii) minority groups; iv) asymptomatic; v) report written in Portuguese or English; vi) study published from 2015 onwards. The Critical Appraisal Skills Programme checklist was used for qualitative studies and the Strengthening The Reporting of Observational Studies in Epidemiology checklist for cross-sectional studies. From the 348 initial articles, 86 were removed due to duplication and 19 were selected, analyzed and summarized, accordingly. Of the 19 studies included, 5.3% were classified as high quality, 52.6% as moderate to high and 42.1% as moderate. A total of 15 studies were cross-sectional and 4 were qualitative, collectively including 250,733 women. The rate of adherence to mammogram in different minorities was evaluated, obtaining a mean value of 49.7% in the last 2 years, and statistically significant barriers were selected and divided into sociodemographic; personal; ethnic, cultural and religious; and external factors. The characteristics of each population play a major role in the population's breast health practices. If the population, adherence rates, barriers and inequities are carefully studied, screening models may be customized and participation to breast cancer screening can be optimized, thereby reducing the high breast cancer-associated mortality.

Actions for early detection of breast cancer in two municipalities in the Western Amazon

OBJECTIVE

to assess the implementation of actions for early detection of breast cancer in Primary Care and to verify the adequacy of these actions with the Ministry of Health recommendations.

METHOD

a cross-sectional study conducted from September 2017 to March 2018 with 736 women registered in Basic Health Units in two municipalities in Acre. For data collection, a validated questionnaire was used. In statistical analysis, the chi-square test or Fisher's exact test was applied.

RESULTS

the frequency of mammography was 42%. Of the women at standard risk for breast cancer, only 5,8% underwent mammography properly.

CONCLUSION

there was a low compliance of early detection actions to the Ministry of Health recommendations; thus, the need to adopt measures to increase professionals' adherence to government proposals is highlighted, as well as continuous actions assessments.

Fatores associados à realização de mamografia de acordo com dois critérios

Objetivo: objetivou-se comparar as prevalências e os fatores associados à realização de mamografia de acordo com dois critérios em vigência no Brasil.Métodos: estudo transversal, de base populacional, com mulheres entre 40 e 74 anos de Rio Grande, RS, Brasil. A cobertura de mamografia foi avaliada: 1) rastreamento anual para mulheres entre 40 e 74 anos; 2) rastreamento bienal para mulheres entre 50 e 69 anos. Os dados foram analisados por regressão de Poisson.Resultados: participaram do estudo 413 (critério 1) e 246 (critério 2) mulheres. A cobertura de mamografia pelo critério 1 foi de 49,4% (IC95% 43,8 a 55,0), oscilando de um quarto para as que não consultaram um médico no último ano até dois terços para aquelas com maior escolaridade. Segundo o critério 2, a cobertura foi de 65,5% (IC95% 59,2 a 71,7), indo de um terço entre as que não consultaram um médico no último ano a três quartos entre as obesas.Conclusões: a cobertura de mamografia diferiu conforme o critério empregado. Maior nível socioeconômico e ter consultado com médico no último ano foram os fatores mais associados, independentemente do critério.

Health Services, Socioeconomic Indicators, and Primary Care Coverage in Mortality by Lower Genital Tract and Breast Neoplasias in Brazilian Women during Reproductive and Non-Reproductive Periods

Women's health assistance at the low-complexity level is focused on the most common diseases and can be affected by primary health care coverage, particularly in areas far away from large urban centers. Thus, in this work, we aim to analyze the relationship between socioeconomic status, health care indicators, and primary care coverage in mortality from neoplasms of the lower genital tract and breast in Brazilian women during reproductive and non-reproductive periods. We conducted an ecological study at the Gynecology Discipline, Medicine School, University of São Paulo. Secondary data were collected from women according to reproductive periods and mortality data from the Mortality Information System based on International Classification of Disease-10th edition regarding breast and lower genital tract neoplasms in 2017. The health service and socioeconomic indicators were obtained from the Informatics Department of the Unified Health System and Brazilian Institute of Geography and Statistics. Our results showed that primary care coverage and health service indicators were not associated with mortality from breast cancer and the female lower genital tract, both in reproductive and non-reproductive periods. Sociodemographic indicators were found to be associated with mortality from breast cancer and the female lower genital tract, with income being associated with reproductive period (β = -0.4; 95% CI, -0.8 to -0.03) and educational level in the non-reproductive period (β = 9.7; 95% CI, 1.5 to 18.0).

Regional disparities in the flow of access to breast cancer hospitalizations in Brazil in 2004 and 2014

Background

Access to the diagnosis and treatment of breast cancer in Brazil is marked by immense inequalities in the provision of specialized assistance, which leads patients to seek treatment outside the place of residence. To evaluate the variations between 2004 and 2014 in the distribution of flow between place of residence and care, and the average distance traveled for treatment of breast cancer in the administrative regions and federal states of Brazil.

Method

Analysis of secondary data from the years 2004 and 2014, extracted from the Department of Informatics of the Unified Health System through the Hospital Information System. Data from Hospitalization Release Authorizations were collected, and the maps were created with TabWin 3.6 software. Descriptive analysis was performed on Stata® (StataCorp, LC) 11.0.

Results

In the total flow, it was observed that there was a decrease in referrals between 2004 and 2014 in most regions. In 2004 the main direction of flow was in the Midwest and Southeast regions. In 2014, however, the intensity of these admissions was centralized in the Southeast region. In relation to the average distance traveled, the North, Northeast, and Midwest regions had the highest values of displacement. Of the 27 federative units, 17 presented an increase in average distance between these periods.

Conclusion

Despite the improvement in the hospitalization of residents, in most regions and federal units, Brazilians still travel great distances when they require treatment for breast cancer.

Social support in the healthcare of women submitted to breast cancer treatment

This study aimed to verify the prevalence of low social support (LSS) and associated factors in women submitted to breast cancer (BC) treatment. A cross-sectional study was carried out with 101 female residents of the municipality of Natal (Northeast Brazil), diagnosed with BC and submitted to oncological treatment. Data collection took place between July/2015 and May/2016 from medical records and individuals' interviews, and from the Medical Outcome Study-Social Support Survey. Descriptive, bivariate and multivariate statistics were carried out through Poisson's regression with robust variance and significance level 0.05. Prevalence of LSS in women with BC was 22.8% with confidence interval 14.6-39.94. Type of access to public services (p < .03), prevalence ratio (PR) 1.84 and negative self-rated health (p < .001), PR 4.47 were associated with LSS. These results were obtained after adjustments by the variables age and presence of chronic diseases. The associations established herein could have been mostly related to fragilities of the Brazilian health system, and can contribute to the planning of actions directed to the studied population.

Ethnoracial and social trends in breast cancer staging at diagnosis in Brazil, 2001-14: a case only analysis

Background

Policies for early detection of breast cancer, including clinical breast examinations and mammographic screening, were introduced in Brazil in 2004, but their effect on disease stage at diagnosis is unclear. We aimed to assess whether these policies have led to a decrease in the prevalence of late-stage breast cancer at diagnosis.

Methods

In this case only analysis, using an anonymised nationwide hospital based-cancer registry network, we identified women aged 18–89 years who had been diagnosed with an invasive breast cancer in Brazil during 2001–14. We extracted individual patient-level data on patient demographics, tumour variables, and health-care provider variables for the centre where the patient was diagnosed. Our objectives were to estimate the prevalence of late-stage breast cancer (TNM stage III or IV) at diagnosis overall, across age groups, and by ethnoracial and social strata (ie, self-reported ethnoracial group, as white, black, brown, Asian, or Indigenous, and educational level, marital status, and region of residence) across the study period, and compare these estimates with international data from high-income countries (Norway and the USA). We used logistic regression to estimate odds ratios (ORs) for late-stage versus early-stage (TNM stage I or II) breast cancer at diagnosis in relation to relevant exposures, either minimally adjusted (for age, year of diagnosis, and region of residence) or fully adjusted (for all patient, tumour, and health-care provider variables).

Findings

We identified 247 719 women who were diagnosed with invasive breast cancer between Jan 1, 2001, and Dec 31, 2014, with a mean age at diagnosis of 55·4 years (SD 13·3), of whom 36·2% (n=89 550) identified as white, 29·8% (n=73 826) as black or brown, and 0·7% (n=1639) as Asian or Indigenous. Prevalence of late-stage breast cancer at diagnosis remained high throughout 2001–14, at approximately 40%, was inversely associated with educational level (p value for linear trend <0·0001), and was higher for women who identified as black (minimally adjusted OR 1·61, 95% CI 1·53–1·70; fully adjusted OR 1·45, 95% CI 1·38–1·54) and brown (minimally adjusted OR 1·26, 95% CI 1·22–1·30; fully adjusted OR 1·18, 1·14–1·23) than those who identified as white. The predicted prevalence of late-stage cancer at diagnosis was highest for women who were black or brown with little or no formal education (48·8%, 95% CI 48·2–49·5) and lowest for women who were white with university education (29·4%, 28·2–30·6), but both these prevalences were higher than that of all women diagnosed with breast cancer in Norway before the introduction of mammography screening (ie, 16·3%, 95% CI 15·4%–17·2% in 1970–74). Similar ethnoracial and social patterns emerged in analyses restricted to the age group targeted by screening (50–69 years).

Interpretation

The persistently high prevalence of late-stage breast cancer at diagnosis across all ethnoracial and social strata in Brazil, although more substantially among the most disadvantaged populations, implies that early detection policies might have had little effect on breast cancer mortality so far, and highlights the need to focus primarily on timely diagnosis of symptomatic breast cancer rather than on screening for asymptomatic disease.

Funding

Newton Fund, Research Councils UK, and Conselho Nacional das Fundações Estaduais de Amparo à Pesquisa.

Acesso ao cuidado do câncer de mama em um município baiano: perspectiva de usuárias, trabalhadores e gestores

RESUMO Este estudo teve como objetivo avaliar o acesso de mulheres com câncer de mama aos serviços de atenção à saúde em um município de médio porte no interior da Bahia, na perspectiva de usuárias, trabalhadores e gestores. Trata-se de um estudo de caso com abordagem qualitativa, realizado com mulheres com diagnóstico de câncer de mama, tanto da zona urbana quanto da rural. Além disso, participaram trabalhadores da atenção primária em saúde, da média e alta complexidade e gestores municipais. Os resultados foram apresentados em duas categorias: Organização da rede de atenção ao câncer de mama e Acesso à atenção ao câncer de mama na rede de atenção à saúde. Na primeira, destaca-se a inexistência da linha de cuidado ao câncer de mama, financiamento insuficiente da saúde e fragilidade nos mecanismos de integração da rede de atenção. Na segunda, rastreamento mamográfico ineficaz, focalização da atenção ao câncer de mama no Outubro Rosa e dificuldade de acesso aos exames e procedimentos especializados, como consulta com mastologista e punção/biópsia mamária. A pluralidade de perspectivas avaliadas proporcionou observar lacunas importantes na constituição da rede de atenção às mulheres com câncer de mama, em que problemas organizacionais se retroalimentam com aqueles relativos à atenção prestada.

The effect of redistribution of ill-defined causes of death on the mortality rate of breast cancer in Brazil

The relevance of breast cancer for women has driven research about mortality of this disease. However, these studies are affected by problems generated by deaths due to ill-defined causes (IDC). To highlight distortions caused by IDC in studies that evaluate mortality, we calculated the age-standardized mortality rates of breast cancer, with and without adjustment for IDC for the years 1990, 2000, and 2010. Then, panel data regression models were estimated and enabled us to identify that the adjustment for IDC: has elevated breast cancer mortality rate of Brazilian municipalities by 9% in the period considered; has drawn mortality rates of the South, Southeast, Northeast and North regions closer; has reduced the increasing trend of mortality by almost 60%, mainly in the Southeast and South regions; has increased, more sharply, the mortality in cities with less than 5 thousand inhabitants; has curbed the significance of most factors associated with breast cancer; has revealed that the effect of longevity and the public health expenditure may be overestimated. These results highlight the importance of adjustment for IDC in producing reliable mortality indicators.

Acesso ao tratamento da mulher com câncer de mama

RESUMO O objetivo do estudo foi caracterizar o acesso ao tratamento da mulher com diagnóstico de câncer de mama no estado do Piauí, Brasil. Estudo transversal analítico, desenvolvido em duas instituições hospitalares de referência, no período de janeiro a junho de 2018. A população compreendeu mulheres diagnosticadas com câncer de mama que realizaram tratamento no período de 2016 a 2017. A amostra foi de 155 participantes. A amostragem foi estratificada proporcional. Os dados foram processados no IBM® SPSS®, e calculadas estatísticas uni e bivariadas. Constatou-se que o tempo para o tratamento foi de, em média, 112,7 (±93,6) dias, variando de 12 a 550 dias (≡18,3 meses ou 1,5 anos), sendo que 71,6% das mulheres iniciaram o tratamento em um período superior a 60 dias do diagnóstico do câncer de mama. Foram verificadas associações estatisticamente significativas entre o atraso para início do tratamento e o território estadual de residência (p=0,041) e o estágio da doença (p=0,037). Dessa forma, o acesso ao tratamento do câncer de mama não está acontecendo como preconizado. Ressalta-se, portanto, a necessidade de uma maior organização dos serviços de saúde em rede, levando em conta as necessidades da população, por meio do atendimento em tempo oportuno.

Clinical pathways of breast cancer patients treated in the Federal District, Brazil

OBJECTIVE

To identify the clinical pathways of women with breast cancer treated in public hospitals, and to analyze the factors that influence the time interval between the first appointment and the start of therapy.

METHODS

A cross-sectional study was conducted with 600 women with breast cancer treated in nine public hospitals in the Brazilian Federal District. Patients were interviewed between September 2012 and September 2014. Simple and multiple logistic regression models were adjusted to evaluate the variables associated with the time interval studied. The most frequent pathway was the one that started in primary care with following care in the therapy service (28.9%). In the multiple adjustment, factors associated to a longer time interval between the first appointment and therapy were: lower family income (OR = 1.89; 95%CI 1.32-2.68), the first appointment in public services (OR = 1.78; 95%CI 1.20-2.64), care in more than two health services in the clinical pathway (OR = 1.71; 95%CI 1.19-2.44); and obtaining the anatomopathological analysis of the biopsy in public services instead of private health services (OR = 1.87; 95%CI 1.29-2.71). Independently, the implementation of specialist appointment scheduling, with care regulation, was associated with a shorter time interval between first appointment and therapy (OR = 0.33; 95%CI 0.16-0.65).

CONCLUSIONS

We observed that multiple pathways were covered by women with breast cancer treated in public services of the Federal District. Socioeconomic iniquities and several aspectos of the pathways covered were associated with a longer time interval between the first appointment and the start of breast cancer therapy.

Delay in breast cancer diagnosis: a Brazilian cohort study

OBJECTIVES

To evaluate the delay in breast cancer (BC) diagnosis and its risk factors.

STUDY DESIGN

A cohort study of BC patients referred to treatment at oncological reference hospital, Brazil. Delay in BC diagnosis was defined as a time interval ≥90 days between the first contact with a care provider and a BC diagnosis.

METHODS

The association between independent variables and delay was performed by univariate analysis and multiple logistic regression.

RESULTS

Five hundred and twenty-six women were included in the study. Delay was observed in 68.8% and was associated with performing histopathological examination at oncological reference hospital (odds ratio [OR]: 3.96, 95% confidence interval [CI]: 1.91-8.20) or at another public health service (OR: 2.31; 95% CI: 1.50-3.56) and attending gynecological consultations annually (OR: 3.24; 95% CI: 1.97-5.33) or every 2-3 years (OR: 2.86; 95% CI: 1.55-5.28). Patients who presented a lump as the first sign or symptom had a lower chance of delay (OR: 0.43; 95% CI: 0.29-0.65).

CONCLUSIONS

Improvements in the structure and access to health services are needed to reduce the time to diagnosis.

Estudo de análise de rede do fluxo de pacientes de câncer de mama no Brasil entre 2014 e 2016

Resumo: Este estudo busca analisar o fluxo de pacientes oncológicos de mama que são atendidos fora de seu domicílio de residência. Foram considerados as internações hospitalares e os tratamentos por quimioterapia e radioterapia para neoplasias malignas na mama, no âmbito do Sistema Único de Saúde, entre os anos de 2014 e 2016. Foi empregado o método de análise de redes, considerando o município de residência e de tratamento como nós de um grafo, que consiste em um “estudo de redes organizacionais de sistemas de saúde”. Além disso, distância e tempo de deslocamento foram estimados por meio da melhor rota viável, segundo a malha rodoviária do projeto Open Street Maps. Os resultados apontam que 51,34% dos pacientes de câncer de mama no Brasil foram atendidos fora de seu município de residência, seguindo fluxos que são regionalizados e que preservam fronteiras estaduais, em geral, em direção a capitais ou a cidades de grande porte. Por outro lado, os resultados também apontam exceções específicas, visto que alguns municípios detêm um grau de proeminência que supera os limites estaduais. O tempo de deslocamento entre município de residência e município de atendimento apresentou medianas próximas a três horas, e 75% dos deslocamentos se dão em até 324km para tratamento por quimioterapia, 287km para tratamento por radioterapia e 282km para internações. Esses resultados são indicativos das dificuldades de acesso aos serviços de oncologia, o que potencialmente agrava a experiência do adoecimento oncológico em termos de impacto no indivíduo e em sua família.

[Family Health Strategy, private health care, and inequalities in access to mammography in BrazilEstrategia de Salud Familiar, salud suplementaria y desigualdad en el acceso a la mamografía en Brasil]

OBJECTIVE

To evaluate the association between access to mammography and coverage by private health insurance or by the public healthcare system through the Family Health Strategy (FHS).

METHOD

An ecological study was performed with data obtained from the Unified Health System Data Processing Department (DATASUS). Time trends were analyzed using the Prais-Winsten method, having the Brazilian federal units as units of analysis. Multiple linear regression was used to investigate the relationship between the dependent variable - women aged 50 to 69 years who never had a mammogram - and the independent variables (coverage by the FHS or private health care and socioeconomic aspects).

RESULTS

Acre was the only Brazilian state for which an increasing growth trend in private health care was not observed. Roraima, Tocantins, Maranhão, Piauí, Rio Grande do Norte, and Paraíba showed a stable trend for FHS coverage, whereas all other federal units had increasing coverage. A significant association was observed between never having had a mammogram at 50 to 69 years of age and the variables mean per capita income and FHS and private health care coverage (R² = 0.77; P < 0.001).

CONCLUSION

Unequal access to mammography is a reality in Brazil. Both private health care and the FHS have contributed to improve health care accessibility for Brazilian women.

Evaluation of access to mammographies in Brazil and socioeconomic indicators: a space study

OBJECTIVE

To evaluate the correlation between mammography screening coverage in women from 50 to 69 years old and the socioeconomic indicators Human Development Index (HDI) and Gini Index.

METHODS

Epidemiological, retrospective and ecological study carried out in Brazil with secondary data. The sample is made up of 5565 municipalities in Brazil. As a dependent variable: the ratio of screening mammography examinations performed in women aged 50 to 69 years, from 2008 to 2015, and as independent variables: The Human Development Index (HDI) and the Gini Index. Descriptive analysis, univariate and bivariate spatial analysis were performed.

RESULTS

North, Northeast and Center-West are regions that are more propitious for breast cancer, due to the low access for mammograms.

CONCLUSION

The HDI and the Gini index, determinants of inequalities, directly influence the mammography numbers in Brazil, highlighting the importance of evaluating public policies.

Detection of Breast Cancer: Knowledge, Attitude, and Practice of Family Health Strategy Women

In rural area, control of breast cancer is related to health promotion and early diagnosis, which includes knowledge, awareness, and stimulating behavioral change, emphasizing screening for disease. The present study was developed to assess the knowledge, attitude, and practice of rural women about early detection of breast cancer in the Primary Health Care Centre. This is a cross-sectional study in a Primary Health Care Centre with 243 rural women participating in the public health service. Data collection was made by a self-administered questionnaire which included sociodemographic characteristics, questions on breast cancer risk factors, screening, and diagnostic methods. Marks were attributed to each question and calculated for each section. Participants fell in three categories of knowledge, attitude, and practice: appropriate, regular and inappropriate. Knowledge, attitude, and practice of early detection methods were considered especially appropriate for those rural women with education and higher economic level, but inadequate responses to such methods were still significant. It is noted that there is still a significant number of rural women who do not have basic knowledge regarding early detection methods of breast cancer, contributing to the non-realization of these methods, as its advocates.

Overview of female breast cancer in northern Tocantins - Brazil

OBJECTIVE

to evaluate the temporal variation of the percentages of female breast cancer in early and late stages and analyze socio-demographic variables associated with these stages.

METHODS

study of secondary data performed between the years of 2000 and 2015 in the Araguaína Regional Hospital - Araguaína - TO - Brasil.

RESULTS

breast cancer in advanced stages were diagnosed in 51.1% of the cases and at an early stage in 48.9%. There was no difference between the percentages of patients with early and late stages over the years. Women of race/black, illiterate and origin of the southeast of Pará presented a higher percentage of late staging at diagnosis.

CONCLUSIONS

most women was diagnosed with advanced disease; the time evolution of the proportion of cases (advanced/early) did not demonstrate variational changes over the years; association of the disease has been identified in advanced stage in women of race/black, illiterate and from the southeast of Pará state.

Guidelines for early detection of breast cancer in Brazil. III - Challenges for implementation

The objective of the current article is to present the main challenges for the implementation of the new recommendations for early detection of breast cancer in Brazil, and to reflect on the barriers and the strategies to overcome them. The implementation of evidence-based guidelines is a global challenge, and traditional strategies based only on disseminating their recommendations have proven insufficient for changing prevailing clinical practice. A major challenge for adherence to the new guidelines for early detection of breast cancer in Brazil is the current pattern in the use of mammographic screening in the country, which very often includes young women and a short interval between tests. Such practice, harmful to the population's health, is reinforced by the logic of defensive medicine and the dissemination of erroneous information that overestimates the benefits of screening and underestimates or even omits its harms. In addition, there is a lack of policies and measures focused on early diagnosis of symptomatic cases. To overcome these barriers, changes in the regulation of care, financing, and implementation of shared decision-making in primary care are essential. Audit and feedback, academic detailing, and the incorporation of decision aids are some of the strategies that can facilitate implementation of the new recommendations.

[Breast cancer mortality in Brazilian municipalities and associated factorsMortalidad por cáncer de mama en municipios brasileños y factores asociados]

Objetivo.

Analisar o comportamento da mortalidade por câncer de mama nos municípios brasileiros e avaliar a influência de fatores socioeconômicos e demográficos sobre as taxas e mortalidade.

Métodos.

Foram calculadas taxas de mortalidade, padronizadas por faixa etária e corrigidas por causas mal definidas, centradas em 1990, 2000 e 2010. Posteriormente, foram estimados modelos de regressão, com dados em painel, que permitiram verificar o grau de associação entre os fatores de interesse e a taxa de mortalidade pela doença.

Resultados.

Verificou-se uma tendência de crescimento da mortalidade no país. Contudo, os modelos indicaram que a mortalidade poderia ter diminuído (tendência negativa), principalmente no Sudeste e Sul, caso alguns fatores associados à doença (por exemplo, nível de renda, educação, longevidade, taxa de fecundidade, gastos em saúde, infraestrutura, entre outros) tivessem permanecido constantes durante o período considerado. Observou-se que a mortalidade por câncer de mama apresentou associação positiva/significativa com a longevidade e negativa/significativa com o nível de gastos públicos em saúde. A mortalidade foi maior nas regiões Sul e Sudeste, nos municípios com mais de 500 000 habitantes e naqueles onde a população é inferior a 5 000.

Conclusões.

O crescimento da renda per capita, a elevação da expectativa de vida e a diminuição da taxa de fecundidade podem estar associados a elevadas taxas de mortalidade por câncer de mama e a uma tendência de crescimento na mortalidade por esse câncer nos municípios brasileiros.

The role of health policy in the burden of breast cancer in Brazil

Background

Breast cancer affects millions of women worldwide, particularly in Brazil, where public healthcare system is an important model in health organization and the cost of chronic disease has affected the economy in the first decade of the twenty-first century. The aim was to evaluate the role of health policy in the burden of breast cancer in Brazil between 2004 and 2014.

Methods

Secondary analysis was performed in 2017 with Brazilian Health Ministry official data, extracted from the Department of Informatics of the National Health System. Age-standardized mortality and the age-standardized incidence of hospital admission by breast cancer were calculated per 100,000 people. Public healthcare costs were converted to US dollars. Regression analysis was performed to estimate the trend of breast cancer rates and healthcare costs, and principal component analysis was performed to estimate a cost factor. Stata® 11.0 was utilized.

Results

Between 2004 to 2014, the age-standardized rates of breast cancer mortality and the incidence of hospital admission and public healthcare costs increased. There was a positive correlation between breast cancer and healthcare public costs, mainly influenced by governmental strategies.

Conclusions

Governmental strategies are effective against the burden of breast cancer in Brazil.

Delay in Diagnosis and Treatment of Breast Cancer among Women Attending a Reference Service in Brazil

Background: Cancer is a major public health problem. Early diagnosis and treatment are essential for reducing mortality. This study aimed to analyze factors associated with delay in breast cancer diagnosis and treatment among women attending a reference cancer service. Methods: This retrospective, cross-sectional study was performed with data collected from medical records and interviews conducted with women diagnosed with breast cancer and treated from October 2013 to October 2014 at a cancer reference hospital in Paraná, Southern Brazil. Results: A total of 82 participants were enrolled during the study period; their average age was 58.2 ± 11.5 years. The average time taken for final diagnosis of breast cancer was 102.5 ± 165.5 days. Treatment onset was delayed in the majority of cases, and the average time elapsing from diagnostic biopsy to onset of primary treatment was 72.3 ± 54.0 days. The odds of treatment delay were higher among the women with a low educational level. Conclusions: The results underline the need for proposals aimed at early detection, identification of risk factors and timely provision of treatment by health managers that focus on this group.

Análise de sobrevivência de mulheres com câncer de mama: modelos de riscos competitivos

Resumo O objetivo deste estudo foi estimar os efeitos de fatores prognósticos na sobrevida do câncer de mama, como idade, estadiamento e extensão do tumor, utilizando modelos de riscos proporcionais de Cox e de riscos competitivos de Fine-Gray. É um estudo de coorte retrospectiva de base-populacional referente a 524 mulheres diagnosticadas com câncer de mama no período de 1993 a 1995, acompanhadas até 2011, residentes no município de Campinas, São Paulo, Brasil. O ponto de corte (cutoff) da variável idade foi definido utilizando-se modelos simples de Cox. Nos ajustes de modelos simples e múltiplo de Fine-Gray, a idade não foi significativa na presença de riscos competitivos e nem nos modelos de Cox, considerando-se, para ambas as modelagens, óbito por câncer de mama como desfecho de interesse. As curvas de sobrevidas estimadas por Kaplan-Meier evidenciaram diferenças expressivas para óbitos por câncer de mama e por riscos competitivos. As curvas de sobrevida por câncer de mama não apresentaram diferenças significativas quando comparados os grupos de idades, segundo teste de log rank. Os modelos de Cox e de Fine-Gray identificaram os mesmos fatores prognósticos que influenciavam na sobrevida do câncer de mama.

Estimated number of people diagnosed with cancer in Brazil: data from the National Health Survey, 2013

OBJECTIVE

To describe the profile of patients who reported a medical diagnosis of cancer and describe the most prevalent types of cancer, according to selected variables.

METHODS

A descriptive study that used data from the National Survey of Health, 2013, to estimate prevalence and their values of confidence interval (95%CI).

RESULTS

Less than 2% of adults reported a medical diagnosis of cancer, with most reported by women, people over 60, among whites, residents in the village and residents of South Prostate cancer was the most reported among men and breast among women. The lowest average age of first diagnosis was identified for cervical cancer (35.4 years; 95%CI 30.3 - 40.6) and the highest for prostate (65.7 years; 95%CI 64.2 - 67.0).

CONCLUSION

The findings of this study are important for the planning of health services and access, as they show differences mainly regional.

Early detection of breast cancer in Brazil: data from the National Health Survey, 2013

OBJECTIVE

To analyze whether the actions of early detection of breast cancer, initiated with the medical request for mammography, differ between users of the Brazilian Unified Health System (SUS) and those who have private health insurance.

METHODS

From the data collected in the National Health Survey, we estimated the proportions of women who had medical request for mammography according to presence or absence of private health insurance. For assessing the factors related to having mammography medical request, we estimated crude and adjusted odds ratios and respective 95%CI by logistic regression. We also analyzed the main reasons reported for not having performed mammography after medical request, as well as the time between examination and result.

RESULTS

Of the women interviewed, 66.7% had a medical request for mammography (59.4% among SUS users and 83.9% among those with private health insurance). Having private health insurance, higher education level, and being white were positively associated with having the medical request. Only 5.4% (95%CI 4.8-6.0) of women who received medical request failed to perform mammography - 7.6% were SUS users and 1.7% had health insurance. The most reported reasons for not being able to perform the examination were: not thinking it was necessary; having the test scheduled, but not yet performed; and not being able to schedule it. More than 70% of women received the result with less than one month from its execution.

CONCLUSIONS

The barriers to access a medical request for mammographic screening for breast cancer are higher among women who depend exclusively on SUS.

The Rise in Mortality from Breast Cancer in Young Women: Trend Analysis in Brazil

Introduction

Breast cancer is the most common cause of cancer death among women.

Objective

The objective of this study was to analyze time trends in overall mortality from breast cancer in Brazil, Brazilian regions and States.

Methods

This is an exploratory study, of the time series of deaths from breast cancer contained in the Mortality Information System (SIM), of women living in Brazil, Brazilian regions and States, from 1996 to 2013. For the trend analysis, the polynomial regression model was used, and a significant trend was considered when the estimated model obtained a p value <0.05.

Results

There was a tendency of increased mortality from breast cancer in Brazilian women (average increase of 0.18 per year; p <0.001), with regional differences, particularly in the age group 20–49 years (0.07 per year; p <0.001). The age group 50–69 years remained constant but had high average rates (37.14).

Conclusion

More effective planning is needed to focus on the different scenarios of the Brazilian regions. Screening strategies for the incidence and mortality from breast cancer must also be rethought according to age group in the country.

Associated factors with mammographic changes in women undergoing breast cancer screening

Objective:

To evaluate association of sociodemographic, anthropometric, and epidemiological factors with result of mammogram in women undergoing breast cancer screening.

Methods:

This is a cross-sectional study with data obtained through interviews, anthropometric measurements, and mammography of 600 women aged 40 to 69 years at the Preventive Medicine Department of Hospital de Câncer de Barretos, Brazil, in 2014. The results of these examinations in the BI-RADS categories 1 and 2 were grouped and classified in this study as normal mammogram outcome, and those of BI-RADS categories 3, 4A, 4B, 4C, and 5 were grouped and classified as altered mammogram outcome. The statistical analysis included the Student's t-test to compare means, as well as odds ratios (OR), with their corresponding 95% confidence intervals (95%CI), to verify an association by means of the multivariate analysis.

Results:

Of 600 women evaluated, 45% belonged to the age group of 40–49 years-old and 60.2% were classified as BI-RADS category 2. The multivariate analysis showed that women with blood hypertension (OR: 2.64; 95%CI: 1.07–6.49; p<0.05) were more likely to present changes in the mammography, while physical activity was associated with lower chances (OR: 0.30; 95%CI: 0.11–0.81; p<0.05).

Conclusion:

Hypertensive women undergoing screening mammography are more likely to present mammographic changes, whereas women practicing physical activity have lower chances (70%) of presenting changes in the breast compared with sedentary individuals.

Inequalities in socioeconomic status and race and the odds of undergoing a mammogram in Brazil

Background

Access to mammograms, in common with other diagnostic procedures, is strongly conditioned by socioeconomic disparities. Which aspects of inequality affect the odds of undergoing a mammogram, and whether they are the same in different localities, are relevant issues related to the success of health policies.

Methods

This study analyzed data from the 2008 PNAD - Brazilian National Household Sample Survey (11.607 million women 40 years of age or older), on having had at least one mammogram over life for women 40 years of age or older in each of Brazil’s nine Metropolitan Regions (MR), according to socioeconomic position. The effects of income, schooling, health insurance and race in the different regions were investigated using multivariate logistical regression for each region individually, and for all MRs combined. The age-adjusted odds of a woman having had a mammogram according to race and stratified by two income strata (and two schooling strata) were also analyzed.

Results

Having a higher income increases four to seven times a woman’s odds of having had at least one mammogram in all MRs except Curitiba. For schooling, the gradient, though less steep, is favorable to women with more years of study. Having health insurance increases two to three times the odds in all MRs. Multivariate analysis did not show differences due to race (except for the Fortaleza MR), but the stratified analysis by income and schooling shows effects of race in most MRs, with greater differences for women with higher socioeconomic status.

Conclusions

This study confirms that income and schooling, as well as having health insurance, are still important determinants of inequality in health service use in Brazil. Additionally, race also contributes to the odds of having had a mammogram. The point is not to isolate the effect of each factor, but to evaluate how their interrelations may exacerbate differences, generating patterns of cumulative adversity, a theme that is still little explored in Brazil. This is much more important when we consider that race has only recently started be included in analyses of health outcomes in Brazil.

Cobertura de mamografias, alocação e uso de equipamentos nas Regiões de Saúde

RESUMO O rastreamento por intermédio da mamografia é o principal meio de detecção da neoplasia maligna da mama. Considera-se relevante compreender como este tem se dado nas Regiões de Saúde brasileiras, unidade espacial fundamental na atual política de saúde. A análise de indicadores relacionados à cobertura de mamografia das mulheres de 40 a 69 anos, número, distribuição e grau de utilização dos mamógrafos demonstra grandes problemas, que não podem ser simplesmente atribuídos à falta de equipamentos. Destaca-se também a diversidade de situações das Regiões de Saúde e das unidades da federação, caracterizada especialmente pelas melhores condições no Sul e Sudeste e piores nas outras regiões.

Female breast cancer in Central and South America

RATIONALE AND OBJECTIVE

The burden of breast cancer has increased worldwide. Breast cancer mortality has been increasing in Central and South America (CSA) in the last few decades. We describe the current burden of breast cancer in CSA and review the current status of disease control.

METHODS

We obtained regional- and national-level incidence data from 48 population-based cancer registries in 13 countries and cancer deaths from the WHO mortality database for 18 countries. We estimated world population age-standardized incidence and mortality rates per 100,000 person-years for 2003-2007 and the estimated annual percentage change to describe time trends.

RESULTS

In the most recent 5-year period, Argentina, Brazil, and Uruguay had the highest incidence rates (67.7-71.9) and Bolivia and El Salvador had the lowest (7.9-12.7). For most countries, mortality rates were ≤12.3, except in Uruguay, Argentina and Cuba (14.9-20.5). Age-specific rates increased after the age of 40-50 years and reached a maximum after age 65 years (mean age at diagnosis 56-62 years). Most countries have developed national screening guidelines; however, there is limited capacity for screening.

CONCLUSION

The geographic variation of breast cancer rates may be explained by differences in the prevalence of reproductive patterns, lifestyle factors, early detection, and healthcare access. Extending early-detection programs is challenging because of inequalities in healthcare access and coverage, limited funding, and inadequate infrastructure, and thus it may not be feasible. Given the current status of breast cancer in CSA, data generated by population-based cancer registries is urgently needed for effective planning for cancer control.

[Opportunistic screening actions for breast cancer performed by nurses working in primary health care]

OBJECTIVE

To identify opportunistic screening actions for breast cancer performed by nurses working in primary health care units in Ribeirão Preto, São Paulo.

METHOD

Cross-sectional study with 60 nurses from 28 units, who had been working for at least one year in the public municipal health care network. Data were collected between December 2013 and March 2014, by means of a questionnaire, using descriptive analysis and the software IBM SPSS version 20 and Microsoft Excel 2010.

RESULTS

The results showed that 71.7% of the participants questioned their female patients as for risk factors for breast cancer, mainly during nursing consultation; 70.0% oriented users about the age to perform clinical breast exam, whereas 30.0% did not due to lack of knowledge and time; 60.0% explained about the age to perform mammogram; 73.3% did not refer patients with suspicious breast exam results to the referral department, citing scheduling as the main obstacle to referral. Educational activities were not performed by 78.3% of participants.

CONCLUSION

Investment is needed in professional training and management of breast cancer screening.

Análise dos determinantes que influenciam o tempo para o início do tratamento de mulheres com câncer de mama no Brasil

Este estudo teve como objetivo analisar o intervalo de tempo entre o diagnóstico e o início do tratamento do câncer de mama em mulheres e seus determinantes. Foi realizado um estudo de coorte retrospectiva com 137.593 mulheres diagnosticadas em 239 unidades hospitalares do Brasil entre 2000 a 2011. Em 63,1% dos casos, o intervalo entre o diagnóstico e o tratamento foi de até 60 dias. No país, as mulheres mais suscetíveis ao atraso foram não brancas (OR = 1,18; IC95%: 1,13-1,23), sem companheiro (OR = 1,05; IC95%: 1,01-1,09), com menos de oito anos de estudo (OR = 1,13; IC95%: 1,08-1,18), com doença em estadiamento inicial (OR = 1,27; IC95%: 1,22-1,32), tratadas de 2006 a 2011 (OR = 1,54; IC95%: 1,47-1,60) e provenientes do sistema público de saúde (OR = 1,19; IC95%: 1,13-1,25). Na análise estratificada foi observada a variabilidade dos fatores entre as regiões do Brasil. A identificação de fatores associados à demora no início do tratamento poderá possibilitar a elaboração de propostas de intervenções destinadas a grupos populacionais específicos.