Cervical cancer control limiting factors and facilitators: a literature review

Lopes, Viviane Aparecida Siqueira; Ribeiro, José Mendes

doi:10.1590/1413-81232018249.32592017

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REVIEW • Ciênc. saúde coletiva 24 (9) • Sept 2019 • https://doi.org/10.1590/1413-81232018249.32592017 copy

Cervical cancer control limiting factors and facilitators: a literature review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This paper reviews the limiting factors and facilitators of access to Brazilian cervical cancer care public health services. This review employed bibliographic database Medline (interface with the Virtual Health Library/BVS and PubMed) and Lilacs / SciELO portals. We sought publications for the period 2011-2016 based on the use of specific terms from the sources consulted, regarding “cervical neoplasms” and “access to health services”. We found 704 papers initially, which were shortlisted to 31 following adopted criteria, which were further reduced to 19 papers to make up the final selection. Access facilitating aspects such as wide coverage of the Pap smear test and coverage of biopsies equivalent to the number of altered prevention tests were mentioned. However, access limiting aspects such as inadequate Pap smear’s periodicity, difficulties in scheduling appointments and exams, high rate of advanced staging and delays in diagnosis and treatment onset were also reported.

Key words
Access to health services; Cervical neoplasms; Unified health system; Brazil Review

Papers selected	Journals	Population and study setting	Study design	Data source and methods used	Care Line Milestones	Object of Study
Silva MR et al. (2016)	Saúde Debate	Women with cervical cancer (CC) in the state of Pernambuco.	Qualitative	Documentary analysis (medical records) + Primary data collection (interviews)	Diagnosis and/or treatment	Integrality / continuity of care
Nascimento MI, Azevedo GS (2015b)	Rev. Saúde Pública	Women with CC referred for radiotherapy at the General Hospital of Nova Iguaçú / RJ.	Quantitative	Documentary analysis (medical records and HBCR) + Database (SIM of SES/RJ)	Diagnosis and/or treatment	Waiting time for treatment
Rangel G et al. (2015)	Saúde Debate	Women with CC at INCA.	Qualitative	Direct observation + Primary data collection: interviews	Diagnosis and/or treatment	Factors related to late diagnosis
Carvalho BG et al. (2015)	Saúde Debate	Women with altered oncology cytology at a UBS in the south of the country.	Qualitative	Documentary analysis (the monitoring report of the PNCCU of the UBSs) + Primary data collection: interviews	Diagnosis and/or treatment	Integrality / continuity of care.
Sadovsky AD et al. (2015)	Cad. Saúde Pública	Women from Brazilian capitals and Federal District	Quantitative	Database (VIGITEL)	Prevention	Access to the Pap smear by segments of the population in situations of poverty and / or vulnerability
Brito-Silva K et al. (2014)	Rev. Saúde Pública	Women from a reference municipality in the northeast of São Paulo	Quantitative-Qualitative	Database (Hygiaweb, regional Siscolo and of the SES/SP) + Primary data collection : interviews	Diagnosis and/or treatment	Integrality / continuity of care
Oliveira MV et al. (2014)	Cienc. & Saúde Colet	Quilombola Women, in Vitória da Conquista (Bahia)	Quantitative	Primary data collection: interviews	Prevention	Access to the Pap smear by segments of the population in situations of poverty and / or vulnerability
Girianelli VR et al. (2014)	Rev. Bras. Ginecol. e Obstet	Women assisted by the ESF, in Duque de Caxias and Nova Iguaçú (RJ)	Quantitative	Primary data collection: interviews	Prevention	Factors related to failure to perform Papanicolau
Thuler LC et al. (2014).	Rev. Bras. Ginecol. e Obstet	Women with CC in Brazil.	Quantitative	Documentary analysis (Hospital-based Cancer Registries)	Diagnosis and treatment	Factors related to late diagnosis
Augusto EF et al. (2013)	Arch. of Gynecol. and Obstet	Women assisted by the Family Doctor Program of Niterói / RJ	Quantitative	Documentary analysis (Papanicolau reports) + Primary data collection: interviews.	Prevention	Factors related to failure to perform Papanicolau
Goes EF, Nascimento ER (2013)	Saúde Debate	White and black women living in Bahia, who had responded to UNDP in 2008.	Quantitative	Prior Research Data: Health Supplement Data from the National Household Sample Survey (UNDP) / 2008.	Prevention	Access to the Pap smear by segments of the population in situations of poverty and / or vulnerability
Correa MS et al. (2012)	Cad. Saúde Pública	Women who had a child in the last two years prior to the survey, living in southern and northeastern Brazilian states, by sampling	Quantitative	Primary data collection: interviews	Prevention	Coverage and adequacy of the Pap smear
Freitas MCM et al. (2012)	Rev. Bras. Ginecol. e Obstet	Elderly women living in the northern area of Juiz de Fora (MG).	Quantitative	Primary data collection: interviews	Prevention	Access to the Pap smear by segments of the population in situations of poverty and / or vulnerability
Gomes CHR et al. (2012)	Rev. Bras. de Cancerologia	Women with invasive CC, in UNACON of Northern Minas Gerais.	Quantitative	Documentary analysis (medical records) + Primary data collection: interviews.	Prevention	Factors related to failure to perform Papanicolau
Borges MF et al. (2012)	Cad. Saúde Pública	Women living in the municipality of Rio Branco (Acre), between 2007 and 2008.	Quantitative	Primary data collection: interviews	Prevention	Pap smear coverage and / or associated factors
Gasperin SI (2011)	Cad. Saúde Pública	Women living in the urban area of Florianópolis, Santa Catarina.	Quantitative	Primary data collection: interviews (use of closed-ended questionnaire)	Prevention	Pap smear coverage and / or associated factors
Bairros FS et al. (2011)	Cad. Saúde Pública	White and black women from two cities in southern Brazil.	Quantitative	Primary data collection: interviews.	Prevention	Access to the Pap smear by segments of the population in situations of poverty and / or vulnerability
Soares MC et al. (2011)	Rev. Gaucha de Enferm.	Women of a certain municipality, identified in SISCOLO	Qualitative	Participatory observation + Primary data collection: interviews.	Diagnosis and treatment	Integrality / continuity of care
Ozawa C, Marcopito LF (2011)	Rev. Bras. Ginecol. e Obstet	Women participating in two household surveys in the city of São Paulo.	Quantitative	Data from household surveys conducted in the city of São Paulo + Database (SIM)	Prevention	Pap smear coverage and / or related factors

Care Line Milestone	Access limiting factors related to public management and / or health professionals.	Access limiting factors, of a subjective-cultural realm.	Facilitators or positive aspects for access
Prevention	. Some females do not perform a Pap smear test. . Women lack of information about adequate Pap smear periodicity. . Socioeconomic and demographic disparities restrains the performance of a Pap smear test. . Difficulties in scheduling exams and consultations, with low flexibility and bureaucratization. . Institutional racism. . Lack of interest, indifference, ill will and lack of patience by professionals scheduling exams and consultations and by doctors. . Shortage of doctors. . Lack of counter-referrals. . Lack of professional secrecy. . Lack of credibility in the collection performed by nurses	. Fear, shame . Women 's lack of time due to work and family care . Belief that Papanicolaou is unnecessary for women over 60	. Pap smear coverage above 80%. . Increased Pap smear coverage versus vulnerable segments. . Extensive knowledge of the Pap smear by women.
Diagnosis	. Low supply of services . Shortage of human resources . Overcrowding . Great proportion of cases with advanced staging . Difficulties in scheduling consultations and/or examinations . Delays in attendance . Delays in the delivery of test results and loss of these results . Payment request by doctors to obtain differential access in the health care network . Delay in medical referrals by postponing appointments for diagnostic investigations . Doctors and/or laboratories issuing wrong diagnoses; . Poor quality of care due to non-identification of the disease by reason of undue consideration of initial complaints . Noncompliance with protocols . Reference wrong . Lack of technical preparation of health professionals . Important disagreements among professionals over the service provided . Evidence of favoritism and disregard for the queue . Lack of reception . Lack of resolve . Poor communication between levels of health care . Flaws in patient data storage . Poor reception and bond		. Adequate coverage of biopsies
Treatment	. Low supply of health services for this purpose . Delayed treatment onset . Difficulty of access to treatment, due to geographical barriers.		. Predominance of treatment through SUS with access to medicines . In most cases, waiting time for radiotherapy did not exceed 60 days . EquiChart access to radiotherapy . Reception and bond . Good infrastructure of treatment facilities . Management of clinical sessions . Users are satisfied with chemotherapy and radiotherapy services

CC care line milestones	Suggestions for improvement	Cross-cutting suggestions for CC care line milestones
Prevention	. Expanding access to primary care . Ensuring timely access . Performing active search to ensure the screening of women at the appropriate ages and intervals . Strengthening preventive actions among the most vulnerable groups . Providing sChart teams, in order not to constantly change their members . Ensuring privacy and respect to female service users . Trainings and qualification of the professional team with a view to understanding the beliefs and emotional limits experienced by service users . Performing educational actions for women and men on CC prevention.	. Evaluate a CC program in addition to aspects such as coverage of exams, including the operation of network services. . Reorganize health services in order to ensure the integrality of care . Encourage / provide the link between users, professionals and services at all times in the line of care. . Creation of care coordination mechanisms, such as protocols, referral and counter-referral system.
Diagnosis	. Decentralization of cancer diagnosis services. . Reduced time to complete the diagnosis of CC, with definition of tumor staging.
Treatment	. Initiate CC treatment in the shortest time possible, not exceeding 60 days provided by law. . Decentralization of reference centers for the treatment of cancer. . Ensuring rapid access to computed tomography and MRI for treatment planning and case follow-up

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[1] Collaborations

JM Ribeiro worked on the conception of the article and the elaboration of its critical review. VAS Lopes worked on the conception of the article, the bibliographical research and the writing of the article.