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Brazilian specialists in the fields of mastology, oncology, genetics, pathology, radiology and radio-oncology published a review article in Brazilian Journal of Oncology after a multidisciplinary discussion of the current scenario of the breast cancer patient’s journey (pre-pandemic) both in SUS and in supplementary health, listing bottlenecks, access problems, but also suggesting changes to reduce the difficulties in the treatment of Breast Cancer ( CM) in Brazil, notably in SUS.
This theme is important because the mortality rate due to CM in Brazil is increasing, while in other countries the drop is significant (40%) and since the end of the last century. The multidisciplinary discussion focused on the scenario of the diagnosis and treatment of early CM but also on the metastatic, in the different phases of this journey: What specialty should be involved? What are the benefits of the multidisciplinary team working together? What are the consequences of not having this integrationto? What recommendations to adopt and what to implement in a context of scarce resources?
Read too: Does starting screening at 40 with mammography reduce breast cancer mortality?
Current situation and future estimates for breast cancer in Brazil
As we know, INCA estimated for the period 2020-2022 about 66,280 new cases per year, with an incidence of 61.61 per 100 thousand inhabitants. With or without pandemic, vaccine for Covid-19 or not, 200 thousand new cases in these next 3 years.
Despite the Ministry of Health (MS) recommending biannual mammography between 50-69 years of age, we know that (before the pandemic) only 20-30% of the target audience of this campaign had performed at least one exam between 2017-2018. Now the MS itself admits a 47% drop in the number of mammograms performed between Jan-July 2020, when compared to last year. I emphasize that this coverage was already well below the WHO recommendations of (70% coverage). It worsened what was already very bad.
Whereas the average age at diagnosis of CM in Brazil is 53 years old (AMAZONA study) and 40% of cases are under 50 years old, a significant number of women are outside the recommendation of the MoH. Add to that delay in scheduling appointments, delays in scheduling exams, delay in obtaining results, delay in making and obtaining biopsy reports and it is not feasible to make an early diagnosis in our country.
With all this, the average time for diagnosis is up to 31 days in supplementary healthbut in SUS the average is 93 days, which in some cases can reach 180. You don’t need to be a specialist to understand how this impacts the outcome of patients with late diagnoses of advanced cases, leading to more aggressive, mutilating and more expensive treatments, with irreparable individual damage but also for society as a whole. It is no wonder that 40-60% of CM cases in the country are diagnosed at a more advanced stage. As we are in a continental country, these differences between SUS and the private sector may be greater or lesser depending on the region.
One of the bottlenecks identified is in pathology, especially in the north and northeast of the country, so effective action in the direction of expanding services is essential to mitigate the problem, as we know that the identification of the molecular subtype (luminal, triple negative or HER2 positive) is essential to define the best treatment to be started if surgery or preoperative chemotherapy.
It is not acceptable to wait 30-60 days for an immunohistochemistry result. Multidisciplinary decisions are fundamental in breast oncology in these times, but without agile and quality pathology the evaluation is compromised.
In Brazil, the gynecologist is the first professional who raises the suspicion of CM, therefore it is recommended a continuous training of these top professionals in the correct indication of diagnostic and follow-up exams and referral of cases to treatment services.
In the field of outpatient pathology, pre-analytical artifacts must be minimized and improvement in the fixation of materials (with TAMPONADO formaldehyde), adequate transport and storage are essential. If these initial stages are not respected, all subsequent stages will be compromised. In hospitals, the scenario is no different, since most hospitals do not have their own pathology service.
Know more: Breast cancer in men
What can be done?
Flows should be reviewed and, as already occurs in SP, it is suggested that hospitals have cryostat, microscope and pathologist close to the operating room for these analyzes. Some processes can be automated with the possibility of cost reduction.
Experts recommended that before new imaging centers with digital mammography devices are made available, it is essential to expand access and functionality to existing mammography devices, often defective and unbalanced, even if conventional.
The creation of regional and multidisciplinary centers to assist the CM is essential, but in the absence of these centers, videoconferences or telemedicine may help professionals in regions where these centers are not yet available.
In radiotherapy the scenario in some parts of the country is bleak. The WHO recommends a linear accelerator for every 300 thousand inhabitants, in some regions of the country we have 1 for 1 million. With current needs, we have only 50% of the machines needed for SUS. We have a deficiency of technicians, physicists and radio-oncologists, but considering this current precarious park there is no deficit.
Perhaps one of the biggest shortcomings of our system is public or private is the lack of communication between specialists. Often, the consequence of this is inadequate therapy. A multidisciplinary team that meets periodically can improve the diagnosis, treatment and consequently the prognosis of patients with CM. It is not a luxury, even hospitals that are members of the SUS or affiliated to the SUS can organize their multidisciplinary groups, discuss protocols and procedures and help patients, not just difficult or rare cases. And with today’s technology still interacting with experts outside the center.
The English Department of Health defines these groups as “a group of people from different specialties who meet regularly – no matter if physically or virtually – to discuss clinical cases, so that each professional can contribute independently to the treatment decisions of that person. patient”.
Several centers that have already adopted the practice have demonstrated cost-effectiveness for the system, improving outcomes, reducing morbidity and mortality. It is essential to have a system that can make the patient get appointments and exams, biopsy with immunohistochemistry, surgery, chemotherapy and radiotherapy within the appropriate timeframes, without getting lost in a labyrinth of barriers in “Deregulation systems” and endless virtual queues. We have good examples of agile services in the country, even serving through SUS. Increasing funding is important, but it is not everything.
The navigation of patients with nurses and social workers can help to lower these barriers of time, and time is LIFE! We have good navigation projects already underway in the country, and these examples must be replicated.
You can do more, better and faster with the same meager resources, just seriousness, will, leadership, management.
Brazilians (and Brazilians) in this pandemic year realized how important health is, and how fragile it is. This is priceless. SUS, in its recently celebrated 30 years, can do more, and health plan operators too.
* Conflict of interest: The author of the text is one of the authors of the publication.
Graduated in 1992 at UFRJ • Medical Residency in Clinical Medicine at HUCFF – UFRJ • Residency in Clinical Oncology at INCA • Oncologist at INCA from 01/1998 to 04/2008 – Head of the HCIII Service from 11/1999 to 05/2001 and from 12/2003 to 12/2005 • Full member of SBOC since 1996 • Full member of “ASCO” since 2001 and “ESMO since 2016 • Honorary member of the Brazilian Society of Mastology since 2009 • Oncologist and National Coordinator of Mammary Oncology of“ Oncology D’Or ”, since 05/2011 • Volunteer member of the Scientific Committee of FEMAMA, INSTITUTO ONCOGUIA and Fundação Renda Rosa
- Buzaid, AC, Achatz MI, Amorim GLS, Barrios CH, Carvalho FM, Cavalcante FP, Conceição KGM, Gobbi H, Klock C, Millen EC, Oliveira VM, Rosa AA, Simon SD. Challenges in the Journey of Breast Cancer Patients in Brazil. doi: 105935/2526-8732.20200021.