RAMB - MAIO 2017

ieira

RAC

472

ssoc

ras

2017; 63(5):466-475

in places where the association between screening and

treatment is effective.

Similarly, as examples of Southern

and Southeastern

Brazil, there are programs in the struc-

turing phase that have presented promising results.

In Sweden, the benefits of mammography screening

are well known.

In Europe, the rules for mammograph-

ic screening are clear and the indicators are acceptable

and desirable,

but understanding the multiple steps

involved in the process is only achieved once the program

is properly structured.

Evaluating screening quality

control, for example, we observed the quality of mam-

mography, the recall rates for complementary exams,

diagnostic rates in incidence and prevalence screening,

rates of invasive tumors, proportion of tumors measur-

ing less than 1.0-1.5 cm, sensitivity of the needle biopsy,

benign/malignant open biopsy ratios, and time between

examinations and surgery.

In Brazil, since organized

screening is not done, there is much to be implemented

in terms of quality. In the experience in the interior of

the state of São Paulo, symptomatic patients are observed

in the initial phase of network structuring,

which is not

ideal in screening programs. However, structuring the

service, acquiring technology, training staff

and par-

ticipating in quality programs, coupled with adherence

strategies,

represent important steps to achieve improve-

ment. Access to mammography refers to: presence of this

technology and ease of access by the general population,

including the quality of the exams and the possibility of

performing complementary tests for biopsy and differ-

ential diagnosis.

Other regional centers need to be set

up, as proposed in Europe.

Lack of knowledge of pro-

cesses makes management-related analyses difficult, and

these are often partially evaluated, based on mammog-

raphy, test results, and cancer mortality. Organized

screening targets asymptomatic patients and should be

associated with a hierarchical and effective network of

examinations until diagnosis, which should be rapid,

comprehensive, and effective. This overrides the alloca-

tion of technological, financial and human resources.

It is estimated that the SUS system is responsible for

75% of health at the national level, with the supplemen-

tary healthcare system being responsible for the rest of

the population. Breast cancer is a population-based disease

and, therefore, the limitations of the SUS affect disease

diagnosis, leading to advanced stages and respective in-

creased mortality curves.

Logistical and technological

limitation leads to delayed examinations and diagnosis,

with low population coverage,

32,43

seen in our study popu-

lation, and is one of the main barriers related to the health

system, as presented in the results section. The SISMAMA

system is an important auxiliary tool for health manage-

ment,

but there is much to be done. There is a need for

evaluation of populations vulnerable to mammogra-

phy,

3,5,17,18

as well as strategies to improve their access.

5,24

Law No. 11.664 authorized on 04/29/2008 access to

mammography for women over 40, but it was superseded

by Directive No. 1253 on 12/11/2013, which limited mam-

mography to the age group of 50-69 years, according to

the public policies related to the age range that should

undergo mammography. Currently, the Ministry of Health

suggests that the examination should target the age range

of 50-69 years,

in keeping with the installed technologi-

cal base and availability to the population. A Brazilian

publication questions the possibility of screening in the

age group of 45-69 years,

as recommended in 2016 by

the American Cancer Society.

The difficulties and results

observed in Brazilian literature

3,5,24,38

limit the proper

analysis of the subject, due to the lack of results related

to the second round screening, where we evaluate breast

cancer detection rate in subsequent-screening examina-

tions and indicators related to the control of quality.

The health systemmust be structured, allowing access

to mammography, complementary examinations, diag-

nosis and effective treatment. There is a migration of

patients within the SUS that reflects its hierarchical sys-

tem, but logistical and structural limitations increase the

time between diagnosis and treatment.

Mammograph-

ic screening is the responsibility of primary health care,

and is associated with procedures of small and medium

complexity. Oncological treatment is the responsibility

of Oncology Centers (CACONs), which perform proce-

dures of medium and high complexity. Directive No. 3535

issue on 09/02/1988, and Health Ministry Directive No.

741 issue on 12/19/2005 regulate the hierarchy of the

oncology system, but because they are treatment services,

the stage at the beginning of treatment is a reflection of

the diagnostic conditions and the structuring of the health

system. Hospital cancer registries show us advanced

stages of diagnosis, which reveals the logistic limitations

prior to treatment, associated with longer periods until

diagnosis,

with many symptomatic patients presenting

advanced disease.

It is interesting that breast cancer pa-

tients in high-demand centers and referral hospitals have

better survival rates,

possibly due to logistical facilities

and use of treatment protocols.

The absence of prospective and randomized studies

on the subject in the literature evaluated is a limitation

of our study, but this has already been reported in other

developing countries.

We report the main results found

in Brazil comparing them with the main results reported