RAMB - MAIO 2017

reast

cancer

screening

razil

. B

arriers

the

health

system

ssoc

ras

2017; 63(5):466-475

471

risk of approximately 25%, and about 19% after all these

studies were grouped.

The reduction in breast cancer

mortality in several developed countries was probably due

to the association of screening programs and improve-

ments in adjuvant therapy.

We draw attention to an

American study that compared historical data from the

Surveillance, Epidemiology, and End Results (SEER), as-

sessing clinical stage, and found a reduction in advanced

stages of cancer close to 8%.

However, this study was

much questioned for evaluating global data, with part of

the population not being screened and population cover-

age below the satisfactory value.

Changes in mortality occur mainly after the age of

50 years, with the age limit being 69 to 74 years. Therefore,

to achieve a reduction in breast cancer mortality, mam-

mography should be performed on a large scale at the

general population level. The Brazilian Society of Mastol-

ogy suggests that the initial age should be 40 years,

which was the guideline established by the American

Cancer Society until 2015, updated in 2016 to 45 years.

Eusoma,

the US Task Force and the Brazilian Ministry

of Health,

suggest that this exam should be performed

from the age of 50 years.

In developing countries, the majority of the popula-

tion has low incomes, being dependent on government

actions and public health infrastructure, with multiple

diseases competing for limited resources. Public health

practices are linked to national guidelines, available meth-

odologies and capacity to absorb demand in the public

network. In this context, the BHGI argues that organized

population-based mammography screening should be

conducted only in developed countries.

There is now a lot of literature against and in favor of

mammographic screening. Pro-mammography factors

include: decreasing the size of diagnostic lesions, with

implications for diagnosis and treatment; studies demon-

strating a decrease in mortality due to breast cancer; years

of life saved; an acceptable rate of hyperdiagnosis (1 to

10%); the frequency of subtypes; and the progression of

carcinoma in situ. It is worth mentioning that, in order to

achieve this goal, it is necessary to have population cover-

age, good quality exams, associated with a fast and efficient

diagnostic flowchart.

35,37,40

Cons include partial evaluation

of systematic reviews;

discussions about the actual de-

cline of advanced tumors in the US;

hyperdiagnosis

(31%);

and studies that show that there are lives saved by

mammography screening, but their numbers are limited.

Usually, those who deal with the patient are in favor of

screening,

37,39

while epidemiologists are more cautious,

presenting a somewhat more negative view.

Thus, many

studies suggest that the patient should know all the points

involved inmammographic screening, and should be aware

of the pros and cons associated with the potential gain

related to screening,

which is possible from a theoretical

point of view, but very difficult in medical practice.

The truth is that organizing a mammographic screen-

ing requires technology, money, training, education,

proper staffing and patient adherence. Every program

must have a beginning, a middle and an end,

that is,

measures from planning to the appropriate destination

of suspected and positive cases, and community inter-

vention.

5,24

Associated with this, the team should be

trained to evaluate mammographic screening, and not

only mammographic diagnoses, respecting quality and

logistics standards, as is the case in Europe.

Barriers

related to the health system are the main limiting factors

for not performing mammography in developing coun-

tries. This fact is influenced by accessibility to the ser-

vices of health, unsatisfactory medical adhesions, cost

of the exams and difficulties related to complementary

exams and follow-up. The evaluation of factors related

to the health system and adherence to mammography

is complex, since there is no specific indicator. We noted

in our review, problems related to information manage-

ment, distribution of mammography machines in the

public network, quality of mammography, and other

issues associated with the operationalization of organized

screening and effective treatment.

In developing countries, these issues are more evident,

as health resources are limited. And while there are con-

troversies in the literature, the negative points of breast

screening are considered, as health resources are used

preferentially in more effective programs such as cervical

cancer. In these countries, BHGI suggests self-examination

in conjunction with diagnostic mammography and ul-

trasonography.

The IARC encourages self-examination

education and clinical breast examination as a screening

methodology in low-income countries, with sufficient

evidence for mammographic screening in the 50-69 age

group in developed countries.

In Brazil, there is eco-

nomic and structural diversity. The Brazilian census

(PNAD survey) revealed that mammography examinations

are less frequent in the North region, compared to the

higher examination rate in the Southeast,

which proves

the uneven mammographic coverage in the country.

Another reflex of the association of screening and treat-

ment are the trend curves related to mortality, with a rise

in the North, Northeast and Midwest, stabilization in the

South, and a decrease in the Southeast region.

It should

be noted that the decrease in mortality is only observed