RAMB - MAIO 2017

ieira

RAC

470

ssoc

ras

2017; 63(5):466-475

(state of Rio Grande do Sul), with patients being divided

into symptomatic or asymptomatic, the authors found

nine cases in 7,656 women-years,

with 60% adherence in

one year, suggesting that opportunistic screening in sites

with a high incidence of breast cancer is positive. Regard-

ing lost years of life, an increased risk of death from breast

cancer was observed in the range of 50-59 years, and a

significant increase in the range 40-49 years.

Regarding organized screening, we must consider

the regional experience in the interior of the state of São

Paulo

3,5,24

with a biannual screening proposal in the age

range of 40-69 years. In the first two years of the project,

17,964 women were investigated and 76 cases were diag-

nosed, with an increase in the early stage rate from 14.5%

to 43.2%. Similar to other studies, the authors describe

that 42.1% of this sample had never undergone a previous

mammogram in their lives, especially among women of

low socioeconomic class and low education. The strat-

egy of mobile units and the family health program were

important in identifying these women.

After years of

initiating the project, the authors noted that the rate of

early stage in asymptomatic women was 70.8%, with

only 5.6% reporting difficulty in obtaining a mammog-

raphy examination, and the success of the program was

due to intense community involvement associated with

free mammography, tests performed according to the

norms of the health system, and mammography per-

formed near the patients’ home.

The authors report

the importance of the nurse in the management and

operationalization of the screening action.

As for the issue of health system,

25,26

difficulty in es-

tablishing a diagnosis and treatment flow is observed, which

contributes to increase the time between diagnosis and

beginning of treatment. Thus, in Brazil, 36.9% of the pa-

tients take more than 60 days between the diagnosis and

the start of treatment. The women most susceptible to

delay are not white, do not have a partner, have little formal

education, are at an early stage of the disease and covered

only by the SUS system.

It is true that there are multiple

steps since the initial evaluation, with false-negative results,

follow-up, diagnosis and treatment, which requires a struc-

tured and agile system to optimize time. Failure to give

access for asymptomatic women, fear, low education, age

and false-negative results contribute to the delay.

In terms of the relationship between mortality and

the health system,

27-30

a study carried out in the city of

Juiz de Fora, state of Minas Gerais (n=282), revealed, in

the univariate analysis, that patients treated in public

hospitals presented worse survival. However, in this pop-

ulation, the advanced stage of the disease at the time of

diagnosis was more frequent in public hospitals, possibly

explaining the absence of this relationship in the multi-

variate model.

Another study carried out in Juiz de Fora

(n=437) showed in the multivariate model that public

services and non-white race/color had higher mortality

risk due to breast cancer.

In the state of Rio de Janeiro,

there was an inverse association between the presence of

mammography and mortality.

Another study conduct-

ed in Rio de Janeiro evaluating 15 hospital units (n=310)

showed better survival

in patients treated in services

with private health plans and Oncology Centers (p=0.02),

hospitals with a large number of procedures (p=0.007),

and the time between diagnosis and treatment lower than

6 months (p<0.0001), which emphasizes the importance

of well-structured public services.

For the analysis of trend and mortality curves,

31-34

the period between 1980 and 2002, there was increase

mortality by breast cancer in the southern region of the

country.

In the period from 1991 to 2010, there was an

increase in mortality rates in Brazil, in the North, North-

east and Midwest regions, although they remained stable

in the South region and decreased in the Southeast region.

This is similar to that observed in developed countries

and reinforces the need for appropriate screening and

treatment programs.

This disparity was also observed

in the Brazilian macro-regions in the period from 1980

to 2009, probably due to regional inequalities. There was

decline and stabilization in regions with a higher socio-

economic level and the opposite in regions with low so-

cioeconomic status.

A study comparing mortality in the

USA and in the Brazilian Oncology Hospital showed that,

for the same staging, overall survival was similar. How-

ever, when comparing clinical stages, there was a higher

percentage of patients in advanced clinical stage in Brazil,

which negatively affected the survival of the group. The

conclusion was that, by undergoing the appropriate treat-

ment, the main factor associated with high mortality is

the advanced cancer stage at diagnosis.

iscussion

Screening for breast cancer through mammography is the

best methodology for secondary prevention in the gen-

eral population, promoting early detection in the asymp-

tomatic phase, leading to a substantial reductions in

morbidity and mortality caused by late diagnosis. A

meta-analysis with articles from the Cochrane database

on mammographic screening did not show a reduction in

mortality risk when evaluating studies with adequate ran-

domization. However, the evaluation of studies with sub-

optimal randomization yielded a reduction in mortality