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Vieira RAC et al.
466 Rev Assoc Med Bras 2017; 63(5):466-475
REVIEW ARTICLE
Breast cancer screening in Brazil. Barriers related to
the health system
René Aloisio da Costa Vieira1,2*, Alessandro Formenton1,3, Silvia Regina Bertolini1,3
1Graduate Program (Lato Sensu) in Health Care Management, Universidade Federal de São Paulo, São Paulo, SP, Brazil
2Hospital de Câncer de Barretos, Fundação Pio XII, Barretos, SP, Brazil
3Universidade Federal de São Paulo, Hospital São Paulo, São Paulo, SP, Brazil
Summary
Study conducted at Universidade Federal
de São Paulo, Hospital São Paulo, with
the Department of Health Economics,
São Paulo, SP, Brazil
Article received: 9/15/2016
Accepted for publication: 11/7/2016
*Correspondence:
Address: Rua Antenor Duarte
Villela, 1.331
Barretos, SP – Brazil
Postal code: 14784-400
Objective: Identify factors related to the health system that lead to a late diagnosis
of breast cancer in Brazil.
Method: We performed a systematic review in the PubMed and LILACS databases
using as keywords “Breast cancer,” “system of health” and “Brazil or Brasil.” We
evaluated the content of the articles using the PRISMA methodology based on
PICTOS. The final date was 12/16/2015. We were able to identify 94 publications
in PubMed and 43 publications in LILACS. After assessing the title and summary,
and excluding 21 repeated publications, we selected 51 publications for full
evaluation. At this stage, we excluded 21 articles, with 30 publications remaining
for study.
Results: The population coverage is low, and there are problems related to the
quality of mammography. Patients with lower income, nonwhite and less educated
are more vulnerable. We observed punctual and initial experiences in breast
cancer screening. Diagnosis and treatment flows must be improved. The inequality
in mortality reflects the differences related to screening structure and treatment.
Better results are observed in well-structured services.
Conclusion: There are several barriers in the health system leading to advanced
stage at diagnosis and limiting the survival outcomes. The establishment of a
rapid and effective order for diagnosis and treatment, based on hierarchical flow,
are important steps to be improved in the public health context.
Keywords: breast neoplasms/prevention and control, health systems, screening
programs, mammography, Unified Health System.
Introduction
Breast cancer is a worldwide problem, with 1.7 million
new cases a year. Half of the cases are in developed countries,
but 62% of deaths occur in developing nations. Mortality
in the United States is declining, a fact attributed to early
diagnosis by mammography and to improvements in
treatment. In South America, however, incidence and
mortality are increasing.1 Breast cancer is diagnosed in
advanced stages in countries with limited resources due
to a deficit in the ability to promote early detection, diag-
nosis and treatment. To assess the complexity of the health
system in relation to breast cancer, the Breast Health
Global Initiative (BHGI)2 sought to categorize the orga-
nization levels of different countries in relation to breast
cancer, so that the basic level encourages breast self-exam,
the limited level refers to the availability of diagnostic
ultrasound and mammography, the increased level includes
diagnostic mammography with opportunistic breast
screening, and the maximum level refers to organized
population mammary screening.2 In the United States, the
rate of mammography screening is high, but in countries
with budget limits there are no effective screening programs,
and in some cases access to treatment is limited.1
Survival in developed countries is around 73%, and
57% in developing countries. In developing countries, the
incidence of breast cancer is lower, while the incidence/
mortality ratio is higher than in developing countries.1
Due to the economic and logistical limitations in Brazil,
mammographic screening is not a widespread reality, a
fact that is reflected in the high number of patients diag-