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reast
cancer
screening
in
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razil
. B
arriers
related
to
the
health
system
R
ev
A
ssoc
M
ed
B
ras
2017; 63(5):466-475
469
problem overview (3), management-related articles (4),
mammogram and population coverage (3), assessment
of factors related to non-adherence to mammography (4),
the experience of oportunistic (4) and organized screening
(2), difficulties in establishing a diagnostic flow (2), and
mortality (8). Table 1 summarizes the findings.
Three articles were selected based on an overall assess-
ment of the problem.
8-10
The Ministry of Health held a
workshop where mammographic screening was discussed.
Observing positive experiences, but considering the Euro-
pean position and recommendations of the BHGI, the
Ministry restricted the orientation of mammographic
screening to the age group of 50-69 years, a guideline that
should be followed by health managers.
9
A 2012 thesis
discussed mammography screening and public health
conditions in Brazil, and is a good roadmap for health
managers.
10
Evaluating the problem in a global way, there
is a difference in terms of the distribution of mammogra-
phy machines, with a higher proportion of unused devices
in the North/Northeast of Brazil. 30-35% of women un-
dergo proper mammography, mainly in the private sector,
and 80% do not have referral from a doctor. The mean time
between presentation of symptoms and diagnosis is 72-185
days, which leads to high rates of advanced stage diagnosis,
with 37.0% in stage III and IV, different from that observed
in the private sector, where this rate is 16.2%.
8
Regarding health management
11,12
and information
systems for the support of health management,
13,14
four
articles were selected. Assessing the origin-destination flow
of outpatient visits and hospitalizations related to breast
cancer, we observed that the treatment is generally per-
formed in large cities and in reference centers, and patients
travel distances greater than 150 km from their city source.
11
Despite the existance of different information systems on
breast cancer, they are little explored.
12
The SISMAMA
system showed promising results with 50% of the examina-
tions performed in the age group 50-69 years and about
66% of mammography reports were performed in a period
inferior to 30 days.
13
National coverage is low, including
32% of women in the 50-59 age group and 25% in the 60-69
age group, though this actually depends on the age group
of the macro-region. In general, the coverage of women in
the 50-59 age group is higher in the Southern and South-
eastern states, and lower in the North and Northeast.
14
Evaluating the mammograms, we must observe the
population-based coverage, the differences in quality of
the exam, the differences related to form of the diagnosis
(symptomatic or asymptomatic), and factors related to
the failure to undergo mammography. Despite regional
differences in population coverage in Brazil,
14
a study
carried out in the state of Goiás
15
evaluated coverage based
on the number of mammography machines, the number
of devices in operation for the SUS, where the state cover-
age was 61%, divided into 13% coverage by the SUS and
48% by non-SUS.
15
Also in the state of Goiás, the study
assessed the quality of the machines
16
using performance
tests. The authors found initial conformity of 64.1%, and
77.1% of unacceptable rates (< 70%), which is a percentage
considered high, since low quality mammography predis-
poses to incorrect diagnoses.
16
There are studies that attempt to evaluate the factors
related to non-mammography.
17-20
Considering biannual
mammograms, the authors evaluated a population sample
of women over the age of 40 (n=290) from the state of São
Paulo and found that non-white elderly women (> 70 years)
with low income (≤ 5 minimum salaries) were more likely
to fail to undergo mammography. However, in this study,
the SUS was responsible only for 28.8% of the population
undergoing mammography.
17
A study carried out in the
capital of the state of Piauí (n=433), evaluating women
aged 40-69 years, revealed that 24.7% of the sample had
never undergone mammography, and among those who
had undergone the examination, 17.5% had mammograms
more than two years earlier, and 66.6% in the previous year.
In this population, 56.3% of the exams were funded by the
SUS system. Factors related to failure to undergo mam-
mography included non-white ethnicity, low educational
index, low income and absence of health plan, highlighting
the importance of the social and racial context for not
undergoing mammography.
18
This fact is more serious
when the regular repetition of the exams is assessed. A study
conducted in the city of Taubaté (state of São Paulo) showed
that correct adherence to biannual repetition occurred in
only 30% of the population, and differential access to pub-
lic or private health services contributed to such a reduced
rate.
19
Another factor that must be carefully evaluated is
the result of mammography, both diagnostic and screening.
The detection rate was 8.8 cases/1,000 mammograms in
asymptomatic patients (screening) and 61.7/1,000 mam-
mograms in symptomatic patients, reflecting a large num-
ber of advanced stage at diagnosis in symptomatic women.
20
There is no organized screening in Brazil, but collective
mobilization/actions to provide mammography and or-
ganized screening models are described.
4,21-23
A collective
action to provide mammography performed in the city of
Marília (state of São Paulo) yielded 0.84 diagnosed cas-
es/1,000 mammograms. The cost of the mobilization per
case diagnosed was considered high, suggesting the supe-
riority of implementing screening services.
22
Investigating
a population of 4,037 women in the city of Porto Alegre