NOTÍCIAS
19/07/2019
Temporal changes in breast cancer screening coverage provided under the Brazilian National Health Service between 2008 and 2017
Publicação importante do grupo de pesquisadores goianos da Universidade Federal de Goiás.
Danielle
Cristina Netto Rodrigues1, Ruffo Freitas-Junior1, Rosemar
Macedo Sousa Rahal1, Rosangela da Silveira Corrêa1, Pollyana
Alves Gouveia1, João Emílio Peixoto2, Edésio Martins3
and Leonardo Ribeiro Soares1
Abstract Background: In Brazil, 70% of the population depends on the
public healthcare system. Since early detection is considered crucial, this
study aimed to evaluate temporal changes in breast cancer screening coverage
provided under the Brazilian National Health Service (SUS) according to the
different regions of the country between 2008 and 2017. Methods: This ecological study analyzed data on breast cancer
screening within the SUS for women aged 50–69 years. Coverage was calculated
from the ratio between the number of screening tests conducted and the expected
number for the target population. Joinpoint regression analysis was used to
calculate annual percent changes (APC) in coverage. Results: Around 19 million mammograms were performed in 50–69-year
old women within the SUS between 2008 and 2016. The estimated APC indicates
that breast cancer screening coverage increased by 14.5% annually in Brazil between
2008 and 2012 (p < 0.01), with figures stabilizing between 2012 and 2017 as
shown by an APC of ? 0.4% (p = 0.3). In the five geographic regions of the
country, the APC initially increased, then stabilized in the north, northeast
and southeast and decreased in the south and Midwest. Of the 26 states,
coverage increased in seven and remained stable in six. In the other 13, there
was an initial increase followed by stabilization in 11, and a reduction in
coverage in two. In the Federal District, coverage remained stable throughout
the study period. Conclusion: Evaluation of the temporal changes in breast cancer screening
coverage provided under the Brazilian National Health Service revealed an
initial increase, confirming that public policies were effective, although insufficient
to ensure organized screening. There appears to be a lack of uniformity between
the different regions and states and this situation is highlighted in the final
5-year period, with the APC reflecting stabilization of breast cancer screening
coverage. Keywords: Breast cancer, Screening programs, Mammography,
Healthcare coverage, Brazilian National Health Service |
* Correspondence: daniellepsinetto@yahoo.com.br
1Brazilian Breast Cancer Research Network, Advanced Center for Breast Diagnosis
(CORA), School of Medicine, Federal University of Goiás, Primeira Avenida, s/n,
Bloco II, Setor Universitário, Goiânia, Goiás 74605-020, Brazil.
Full list of author information is available at the
end of the article
Background
Several randomized
clinical trials conducted between the 1960s and the 1990s have reported a
reduction in mortality from breast cancer of up to 40% in the female population
of 50–69 years of age submitted to breast cancer screening [1–3]. In
geographical regions with limited financial resources and difficulties in
accessing standard oncological treatment [4–6], this strategy may represent an
opportunity for more conservative treatments and better clinical outcomes [7–9].
Despite the lack of
population-based screening policy in Brazil [10–12], the disparity between
access to screening within the public healthcare system, on which 70% of the
Brazilian population relies, and access to screening within the private
healthcare system is evident. The incidence of tumors diagnosed at advanced
stages reflects this situation, since 36.9% of such cases occur in women
consulting within the public healthcare network, while in the private sector this
rate falls to 16.2% [13–15]. Nevertheless, this scenario has changed over
recent decades, with declining mortality rates in some states of the country,
possibly due to advances in the treatment of the disease [16].
Another factor that
could have contributed to this stabilization was the development of programs
such as the National Mammography Quality Program (PNQM) and the Cancer Database
(SISCAN) [17, 18]. These initiatives aimed to improve the monitoring of the
quality and reporting of test results, and patient follow-up. This represented
an important step forward for public policies in the country [19, 20].
Nevertheless, there
remains a need to improve such public policies. Because early diagnosis
represents an important step in this process, the present study was developed to
evaluate temporal changes in breast cancer screening provided under the
Brazilian National Health Service (SUS) in accordance with the different
regions of the country and the different states including the federal district,
between 2008 and 2017.
Methods
This was an ecological
time-series study in which data referring to mammograms conducted within the
SUS were analyzed, for the country as a whole, each geographic region, the
states and the federal district, for the period between 2008 and 2016. Brazil
consists of 26 states and a federal district, with these areas being grouped
together into five geographic regions: the north, northeast, southeast, south
and Midwest [21].
Target
population
The target population
consisted of women of 50 to 69 years of age, according to the regulations of
the Ministry of Health of Brazil [11]. Data regarding the population of women
between 2008 and 2012 were collected from the System of Demographic and
Socioeconomic Information on Health, Department of Information Technology of
the SUS (DATASUS) [22]. The projected population of Brazil established by the
Brazilian Institute of Geography and Statistics (IBGE) was used for the 2013–2016
period [23].
Estimated
coverage
Breast cancer
screening coverage was estimated based on two-yearly screening aimed at
reaching 100% of the target population. Coverage was expressed as a percentage and
calculated from the ratio between the number of scans performed and the
expected number for the target population [14].
The number of exams
carried out annually between 2008 and 2017 was obtained from the DATASUS
outpatient database [24] according to the codes for the procedure: 0204030030
(mammography) and 0204030188 (bilateral mammography for screening purposes).
The expected number of exams for the target population was calculated from the
total number of women of 50–69 years of age and in accordance with the
recommendations of the National Cancer Institute (INCA) for twoyearly screening
[25].
Statistical
analysis
The annual percent
change (APC) in breast cancer screening coverage was calculated for Brazil as a
whole, its different geographic regions, each state and the federal district.
The relevant 95% confidence intervals (95%CI) were calculated, with p-values
< 0.05 being considered statistically significant. The Poisson regression model
was used for these calculations and the software program used was JoinPoint
Regression, version 4.2.0.2 of June 2015 (National Cancer Institute) [26].
For analysis purposes,
mammography coverage was considered to have increased when the APC increased, and
the minimum value of the confidence interval was above zero. Coverage was
considered to have decreased when the APC decreased, and the maximum value of the
confidence interval was below zero. Coverage was considered to have remained
stable when, irrespective of the rate of coverage, the minimum value of the
confidence interval was below zero and the maximum value was above zero.
Ethical
aspects
The data used are
publicly available [24, 25]. For this type of study, formal consent is not
required. All recommendations of good clinical practice were followed according
to Brazilian law and the Helsinki Convention.
Results
In 2008, the female
population of 50 to 69 years of age in Brazil was estimated at 14,432,692
women. This number increased to 19,584,342 in 2017, representing an increment of
36.0% in this population. Over that timeframe, a total of 1,227,514 and
2,790,937 mammograms, respectively, were approved for payment. This represents
an increase of 127.0% in the number of exams paid for by the SUS, at a total
cost of 968,567,514.42 Brazilian reais.
The estimated extent
of breast cancer screening coverage provided under the SUS in Brazil for the
2008–2017 period ranged from 14.4 to 24.2%. Table 1 shows the estimated coverage
per year for the entire study period according to the different geographic
regions, the states and the federal district.
Table 1 Breast cancer
screening coverage provided under the Brazilian National Health Service, for
the country as a whole, its different geographic regions, states and the
federal district for women of 50-69 years of age between 2008 and 2017
Regression analysis
showed that, for Brazil as a whole, there was a significant increase in breast cancer
screening coverage, with an APC of 14.5% (p < 0.01) for the 2008–2012 period,
while for the 2012–2017 period coverage remained stable (p=0.3) (Fig. 1). The
same was true for the different regions of the country, with the analysis
showing a significant increase in breast cancer screening in the north,
northeast and southeast at the beginning of the study period, with APCs of
11.1, 14.4 and 14.1%, respectively (p<0.01), followed by stabilization (Fig.
2a, b and c).
In the south and
Midwest, however, the increase occurred between 2008 and 2011 and between 2008
and 2013, with APCs of 21.0 and 9.4%, respectively (p < 0.01). Nevertheless,
after this period, there was a reduction in breast cancer screening coverage,
with an APC of ? 2.0% (p<0.01) in the south and ? 9.4% (p < 0.01) in the
Midwest (Fig. 2d and e).
Of the 26 states, a
significant increase in breast cancer screening coverage occurred in 7 (27%),
while in 6 (23%) coverage remained stable throughout the study period. In 13
states (50%), there was significant increase in coverage at the beginning of
the study period; however, after this period coverage remained stable in 11
states and decreased significantly in 2 (Table 2).
In the federal
district, coverage remained stable between 2008 and 2014, with an APC of 17.7%.
The APC for the 2014–2017 period was ? 47.7% (Table 2).
Table 2 Trends in breast cancer screening coverage provided under the Brazilian National Health Service in the different states and the federal district for women of 50-69 years of age between 2008 and 2017
Discussion
The present study
showed that there was an increase in breast cancer screening coverage provided
under the SUS in Brazil between 2008 and 2017. This coverage, however, failed
to reach 25% of the expected number of exams for the Brazilian population of
women of 50–69 years of age. This finding confirms that the number of scans
performed fails to comply with the World Health Organization recommendation
that at least 70% of the target population should have access to breast cancer screening
in order to effectively reduce mortality rates [27, 28].
In the past decade,
the SUS has invested around 969 million reais in breast cancer screening,
representing an increase of 92% in the number of scans performed over the
period. This led to an increase in the percent coverage of the target
population, from 14.4 to 24.2%, suggesting a possible improvement in the
investments and public policies aimed at the early detection of breast cancer
in the country [10, 18, 29].
Nevertheless, analysis
of the APC for breast cancer screening coverage in Brazil showed a significant
annual increase of 14.5% followed by stabilization, with a tendency towards a
decrease, albeit insignificant, of ? 0.4% per year from 2012 onwards. This
performance differed from one geographic region of the country to another, a finding
that is understandable given Brazil’s continental dimensions. Indeed, each
region has different geographic characteristics and there are cultural and
socioeconomic differences as well as factors inherent to income distribution, which
may hamper the population’s access to healthcare services [16, 30, 31].
This poor coverage,
together with the finding that the APC has stabilized, is concerning,
particularly because the study population relies solely on the SUS. In fact, 70%
of the Brazilian population depends exclusively on the National Health Service
for access to healthcare [10, 15]. Another key point is the capacity to deliver
mammography to the target population. Access depends on available appointments for
screening, and geographic distance. A flattening of coverage may reflect
insufficient capacity, long distances to screening facilities and lack of
transportation, or no change in capacity and a large growth in population [7, 32,
33].
Recent studies have
shown that mortality from breast cancer in Brazil is closely related to the
human development index (HDI), with mortality rates being lower in the states with
a higher HDI, while, conversely, in those with a lower HDI, the number of
breast cancer-related deaths was higher [16]. A parallel can be drawn with the
present study in which results show that the states in which breast cancer
screening coverage provided under the SUS is highest were those with the
highest HDI. These states wereMinas Gerais, São Paulo, Paraná and Santa
Catarina.
With respect to the
geographic regions of the country, the northeast merits attention. Although
breast cancer screening was below the internationally recommended level [27],
an annual increase of 14.4% occurred in the first 6 years of breast cancer
screening evaluated in this region. This finding may be explained by the
increase in the number of mammography scanners available to the SUS and by the
investment of government funding, particularly in areas such as health and
education, improving human development indicators in recent years in this region
[34].
On the other hand,
data from the federal district, the seat of the national government, also merit
attention. In the initial years analyzed in the present study, there was an
increase, albeit insignificant, in breast cancer screening coverage, with an
APC of 17.7% per year, which could be explained by local actions such as the
inclusion of a mobile breast cancer screening program. However, problems
related to the maintenance of the equipment, political instability and lack of
investment in public health locally [6, 35] are factors believed to be
responsible for a fall in breast cancer screening coverage, which decreased
from 16% in 2014 to 0.6% in 2016, with a slight increase of 3.2% in 2017,
representing an APC of ? 47.7%. Although a considerable proportion of the population
in the federal district has access to private healthcare, this situation may
lead to an increase in diagnoses at advanced stages of the disease in the near future.
A possible
under-notification of mammograms may constitute a limitation of the present
study; however, this should be negligible, since the exams are only paid for
after they have been included in the DATASUS platform. Nevertheless, this study
illustrates the progress made in breast cancer screening coverage nationwide
and may contribute towards guiding the federal government’s public policies in
the control of breast cancer in Brazil, bearing in mind that the 1988 amendment
to the constitution grants all citizens the right to health and establishes that
the provision of healthcare is a duty of the state [36]. Therefore, all
Brazilian women of 50–69 years of age have the right to a mammogram every 2
years.
Conclusion
Analysis of temporal
changes in breast cancer screening coverage provided under the Brazilian
National Health Service (SUS) showed an initial increase in coverage, confirming
the effectiveness of public policies. However, these were insufficient to
assure an organized screening program. There was a lack of uniformity among the
different regions and states, and this situation is worsening, as highlighted
by the annual percent change showing that breast cancer screening coverage
remained stagnant in the final 5-year period of the study.
Abbreviations
APC: Annual
percent changes; DATASUS: System of Demographic and Socioeconomic Information
on Health, Department of Information Technology of the SUS; HDI: Human
development index; IBGE: Brazilian Institute of Geography and Statistics; INCA:
National Cancer Institute; PNQM: National Mammography Quality Program; SISCAN:
Cancer Database; SUS: Sistema Único de Saúde, Brazilian National Health Service
Acknowledgements
None.
Authors’ contributions
DCNR, RMSR,
RSC, JEP and RFJ designed the study. DCNR, RSC and PAG were responsible for
collecting the data. DCNR, RFJ, RMSR, RSC, PAG, JEP, EM and LRS made
substantial contributions to the data analysis and interpretation. DCNR, RFJ,
RMSR, RSC, PAG, JEP, EM and LRS were responsible for drafting the article and
revising it critically for important intellectual content. All the authors read
and approved the final version of the manuscript.
Funding
This study is
not supported by any funding source.
Availability of data and materials
The public
access to the databases is open.
Links and
references to databases used in the study:
-DATASUS/TABNET: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?ibge/cnv/popuf.def
-IBGE: https://ww2.ibge.gov.br/home/estatistica/populacao/projecao_da_populacao/2013/default.shtm
-SIA/DATASUS: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sia/cnv/qbuf.def
-INCA: http://bvsms.saude.gov.br/bvs/publicacoes/parametros_rastreamento_cancer_mama.pdf.
Ethics approval and consent to participate
Not
applicable.
Consent for publication
Not
applicable.
Competing interests
The authors
declare that they have no competing interests.
Author details
1Brazilian
Breast Cancer Research Network, Advanced Center for Breast Diagnosis (CORA),
School of Medicine, Federal University of Goiás, Primeira Avenida, s/n, Bloco
II, Setor Universitário, Goiânia, Goiás 74605-020, Brazil.
2Brazilian
Breast Cancer Research Network, Division of Quality Control in Ionizing
Radiation, National Cancer Institute (INCA), Rio de Janeiro, RJ, Brazil.
3Brazilian
Breast Cancer Research Network, Faculdade Unida de Campinas, Goiânia, Goiás,
Brazil.
Received: 18 July 2018 Accepted: 3 July 2019
Published online: 18 July 2019
References
1. Tabar L, Vitak B,
Chen TH, et al. Swedish two-county trial: impact of mammographic screening on
breast cancer mortality during 3 decades. Radiology. 2012;260:658–63.
2. Gøtzsche PC,
Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database
Syst Rev. 2013;6:CD001877.
3. Duffy SW, Yen AMF,
Chen THH, et al. Long-term benefits of breast screening. Breast Cancer Manag.
2012;1:31–8.
4. Barrios CH, Reinert
T, Werutsky G. Access to high-cost drugs for advanced breast cancer in Latin
America, particularly trastuzumab. Ecancermedicalscience. 2019;13:898. https://doi.org/10.3332/ecancer.2019.
898.
5. Alves Soares Ferreira N, Melo Figueiredo de
Carvalho S, Engrácia Valenti V, et al. Treatment delays among
women with breast cancer in a low socioeconomic status region in Brazil. BMC
Womens Health. 2017;17:13. https:// doi.org/10.1186/s12905-016-0359-6.
6. Dos Santos Figueiredo
FW, Adami F. Effects of the high-inequality of income on the breast cancer
mortality in Brazil. Sci Rep. 2019;9:4173. https://doi.org/10.1038/s41598-019-41012-8.
7. Greenwald ZR,
Fregnani JH, Longatto-Filho A, et al. The performance of mobile screening units
in a breast cancer screening program in Brazil. Cancer Causes Control.
2018;29:233–41. https://doi.org/10.1007/s10552-017-0995-7.
8. Soares LR,
Freitas-Junior R. The impact of mammography screening on the surgical treatment
of breast cancer. Breast J. 2018;24:1138. https://doi.org/10.1111/tbj.13093.
9. Júnior FR, Nunes RD, Martins E, et al. Prognostic
factors and overall survival of breast cancer in the city of Goiania, Brazil: a
population-based study. Rev Col Bras Cir. 2017;44:435–43. https://doi.org/10.1590/0100-69912017005003.
10. Lee BL, Liedke PER,
Barrios CH, et al. Breast cancer in Brazil: present status and future goals.
Lancet Oncol. 2012;13:e95–e102. https://doi.org/10.1016/S1470-2045(11)70323-0.
11. Migowski A, Silva
GAE, Dias MBK, Diz MDPE, Sant'Ana DR, Nadanovsky P. Guidelines for early
detection of breast cancer in Brazil. II - new national recommendations, main
evidence, and controversies. Cad Saude Publica. 2018;34:e00074817. https://doi.org/10.1590/0102-311X00074817.
12. Rodrigues DCN,
Freitas-Junior R, Corrêa RS, et al. Performance of diagnostic centers in the
classification of opportunistic screening mammograms from the Brazilian public
health system (SUS). Radiol Bras. 2013;46:149–55.
13. Simon SD, Bines J,
Werutsky G, et al. Characteristics and prognosis of stage I-III breast cancer
subtypes in Brazil: the AMAZONA retrospective cohort study. Breast. 2019;44:113–9.
https://doi.org/10.1016/j.breast.2019.01.008.
14. Corrêa RS, Freitas-Junior R, Peixoto JE, et
al. Estimativas da cobertura mamográfica no Estado de Goiás, Brasil. Cad Saúde
Pública. 2011;27:1757– 67. https://doi.org/10.1590/S0102-311X2011000900009.
15. Brasil. Ministério da Saúde. Agência Nacional
de Saúde Suplementar. Caderno de informação da saúde suplementar:
beneficiários, operadoras e planos. Rio de Janeiro, RJ. Ano 11, n.2, p.1–64.
Ministério da Saúde; 2017.
16. Gonzaga CMR, Freitas-Junior R, Curado MP, et
al. Temporal trends in female breast cancer mortality in Brazil and correlations
with social inequalities: ecological time-series study. BMC Public Health. 2015;15:96.
17. Brasil. Ministério da Saúde. Gabinete do
Ministro. Portaria N° 531 de 26 de março de 2012. Institui o Programa Nacional
de Qualidade em Mamografia – PNQM. Brasília, DF: Diário Oficial da União, N°
60, Página 91. Seção 1, de 27 de março de 2012.
18. Brasil. Ministério da Saúde. Gabinete do
Ministro. Portaria N° 3.394 de 30 de dezembro de 2013. Institui o Sistema
Nacional de Informação do Câncer – SISCAN, no âmbito do Sistema Único de Saúde.
Brasília, DF: Diário Oficial da União, N° 253, Página 57. Seção 1, de 31 de
dezembro de 2013.
19. Corrêa RS, Freitas-Junior R, Peixoto JE, et
al. Effectiveness of a quality control program in mammography for the Brazilian
National Health System. Rev Saude Publica. 2012;46:769–76.
20. Passman LJ, Farias
AMRO, Tomazelli JG, et al. SISMAMA – implementation of an information system
for breast cancer early detection programs in Brazil. Breast. 2011;20(Suppl 2):S35–9.
21. Instituto Brasileiro de Geografia e
Estatística (IBGE). Sinopse do Censo Demográfico 2010 – Cidades, Goiás.
Brasília, DF, 2010. http://www.ibge.gov.br/cidadesat/topwindow.htm?1. Accessed
20 June 2016.
22. Brasil. Ministério da Saúde. Departamento de
Informática do SUS – DATASUS. Informações de Saúde (TABNET). Demográficas e Socioeconômicas.
Brasília, DF, 201e6. http://tabnet.datasus.gov.br/cgi/deftohtm.exe?ibge/cnv/popuf.def.
Accessed 20 June 2016.
23. Brasil. Instituto Brasileiro de Geografia e
Estatística. Diretoria de Pesquisas. Coordenação de População e Indicadores
Sociais. Gerência de Estudos e Análises da Dinâmica Demográfica. Projeção da
população do Brasil e Unidades da Federação por sexo e idade para o período
2000–2030. https://ww2.ibge.gov.br/home/estatistica/populacao/projecao_da_populacao/2013/default.shtm.
Accessed 9 June 2018.
24. Brasil. Ministério da Saúde. Departamento de
Informática do SUS – DATASUS. Sistema de Informações Ambulatoriais do SUS
(SIA/SUS). Brasília, DF, 2016. http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sia/cnv/qbuf.def.
Accessed 9 June 2018.
25. Brasil. Ministério da Saúde. Parâmetros
técnicos para o rastreamento do câncer de mama: recomendações para gestores
estaduais e municipais. Rio de Janeiro: INCA, 2009. http://bvsms.saude.gov.br/bvs/publicacoes/parametros_rastreamento_cancer_mama.pdf.
Accessed 30 Apr 2019.
26. United States of
America. National Cancer Institute. Joinpoint Regression Program. Version
4.0.4. Bethesda; 2015. http://surveillance.cancer.gov/joinpoint/. Accessed 31
August 2015.
27. World Health
Organization. Cancer control: knowledge into action. WHO guide for effective
programmes: early detection. Geneva:
WHO; 2007.
28. Freitas-Junior R, Rodrigues DCN, Corrêa RS,
et al. Contribution of the unified health care system to mammography screening
in Brazil, 2013. Radiol Bras.
2016;49:305–10.
29. Brasil. Ministério da Saúde. Instituto
Nacional de Câncer José Alencar Gomes da Silva. Controle do câncer de mama:
documento de consenso. http://www.inca.gov. br/publicacoes/Consensointegra.pdf.
Accessed 9 June 2018.
30. Silva TB, Mauad EC, Carvalho AL, et al. Difficulties
in implementing an organized screening program for breast cancer in Brazil with
emphasis on diagnostic methods. Rural Remote Health. 2013;13:2321.
31. Tomazelli JG, Silva
GAE. Breast cancer screening in Brazil: an assessment of supply and use of
Brazilian National Health System health care network for the period 2010-2012.
Epidemiol Serv Saude. 2017;26:713–24.
https://doi.org/10.5123/S1679-49742017000400004.
32. Vieira RADC, Formenton A, Bertolini SR. Breast cancer
screening in Brazil. Barriers related to the health system. Rev Assoc Med Bras
(1992). 2017;63: 466–74. https://doi.org/10.1590/1806-9282.63.05.466.
33. Buranello MC, Meirelles MCCC, Walsh IAP,
Pereira GA, Castro SS. Breast cancer screening practice and
associated factors: Women's health survey in Uberaba MG Brazil, 2014. Cien Saude Colet. 2018;23:2661–70. https://doi.org/10.1590/1413-81232018238.14762016.
34. Duggan C, Cruz TA, Porto MRT, et al. Improving
breast health Care in the State of Sergipe, Brazil: a commentary. J Glob Oncol. 2018;4:1–3. https://doi.org/10.1200/JGO.18.00114.
35. Barros ÂF, Araújo JM,
Murta-Nascimento C, Dias A. Clinical pathways of breast cancer patients treated
in the Federal District, Brazil. Rev Saude Publica. 2019;53:14. https://doi.org/10.11606/S1518-8787.2019053000406.
36. Brasil. Ministério da Saúde. Constituição da
República Federativa do Brasil, de 5 de outubro de 1988. http://www.planalto.gov.br/ccivil_03/Constituicao/Constituicao.htm.
Accessed 9 April 2017.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.