Cervical cancer guidelines, prevention and screening strategies: experiences from Brazil and Chile

Claro, Itamar Bento; Lima, Luciana Dias de; Almeida, Patty Fidelis de

doi:10.1590/1413-812320212610.11352021

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ARTICLE • Ciênc. saúde coletiva 26 (10) • Oct 2021 • https://doi.org/10.1590/1413-812320212610.11352021 copy

Cervical cancer guidelines, prevention and screening strategies: experiences from Brazil and Chile

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This article analyzes cervical cancer control policies and actions in Brazil and Chile, focusing on prevention and screening. We adopted a comparative approach to identify similarities and differences in guidelines and cervical cancer prevention and screening strategies between the two countries. We used the following data collection techniques: analysis of official documents and secondary data, consultations with experts, government officials and program coordinators, and literature review. The findings show that Chile has a well-structured program with centralized decision-making and a system that permits monitoring of actions. Brazil on the other hand faces ongoing issues with lack of coordination and shortcomings in the follow-up of women with abnormal test results. The following challenges to consolidating cervical cancer screening stand out in Brazil: lack of active tracking of the target population; absence of a test quality assurance system; and inadequate follow-up of women with abnormal test results. Both countries need to increase coverage and implement organized screening.

Key words:
Cervical cancer; Screening; Public policy; Health systems

Brazil	Chile
Launch of the Comprehensive Women’s Health Care Program, focusing on the prevention of cervical and breast cancer (1984). Creation of the Oncology Program (Pro-Onco) by the National Cancer Institute/Ministry of Health, focusing on the four most common types of cancer, including cervical cancer (1986). Creation of the SUS by the Federal Constitution (1988). Development of a pilot of the National Cervical Cancer Control Program (1995). Implementation of the pilot project “Viva Mulher” in six locations (Curitiba, Brasília, Recife, Rio de Janeiro, Belém and the state of Sergipe) (1997). Creation of the National Program for Combating Cervical Cancer (1998). Creation of the Cervical Cancer Information System - SISCOLO (1999). Second phase of the intensification of the Programa Viva Mulher (2002). Creation of the National Oncology Care Policy, including the control of cervical breast cancer as a core component (2005). Development of the Control of Cervical and Breast Cancer Action Plan 2005-2007 (2005). Indicators and state and municipal targets included in the Health Pact with the aim of improving the performance of cervical cancer control actions (2006). Creation of a working group to evaluate the National Cervical Cancer Control Program (2010). Launch of a national plan to strengthen the cancer prevention, diagnosis and treatment network by President Dilma Rousseff, prioritizing the control of cervical cancer (2011). Launch of a strategic action plan to tackle non-communicable chronic diseases, 2011-2022 (2011). Publication of an updated version of the Brazilian Guidelines for Cervical Cancer Screening by the NCI (2011). Publication of the Cytopathology Laboratory Quality Management Manual (2012). Creation of the National Cancer Prevention and Control Policy in the Health Care Network for People with Chronic Diseases within the SUS (2013). Launch of the Cancer Information System (SISCAN), a digital platform integrating the cervical and breast cancer information systems (SISCOLO and SISMAMA, respectively) (2013). Publication of the QualiCito policy directive defining quality standards and Pap test quality assessment in the SUS (2013)	Start of national cervical cancer control actions (1966). Reformulation of the National Cervical Cancer Program (1987). Implementation of a pilot project in the Metropolitan Region (1988). Investment in secondary and tertiary care facilities (1993). Publicity campaigns (1993). Creation of the National Cytopathology Referral Laboratory (1993). National expansion of new program strategies (1994). Computerization of cytology laboratories (1996). Radiotherapy provided free-of-charge on the public system (1997). Publication of updated methodological guidelines for the program (1998). National Consensus Conference on the Treatment of Invasive Cancer (1999). Funding of chemotherapy and radiotherapy under the public system (2001). Study on the situation of cervical cancer diagnosis and treatment (2001). Cervical Cancer Resources and Care Study (2002). Publication of Clinical Guidelines on Cervical Cancer (2002). Inclusion of cervical cancer in the Pilot AUGE Program, ensuring compliance with maximum intervals for diagnosis, treatment and follow-up (2003). Update and national unification of nomenclature for cytology reports (2005). Modernization of the cervical cancer care network (2005). Introduction of the Universal Access with Explicit Health Guarantees (AUGE) health scheme (2005). Updated version of clinical guidelines for cervical cancer screening (2006). Publication of the AUGE Clinical Guide- Cervical Cancer (2006) Publication of an updated version of the AUGE Clinical Guide- Cervical Cancer (2010). HPV vaccine included in the annual immunization program for girls aged between 9 and 13 years (2013). Implementation of pilot project under the External Quality Assessment Program (PEEC). All public and private laboratories invited to participate in the certification of the analytical quality of Papanicolaou test diagnosis methodologies (2014). Vaccination against HPV expanded to include girls aged up to 13 years (2015).
Brazil	Chile
Publication of a ministerial order creating the Referral Service for the Diagnosis and Treatment of Cervical Cancer Precursor Lesions (SRC) (2014). HPV vaccination campaign for girls aged between 11 and 13 years under the National Immunization Program (PNI) (2014). Publication of the second edition of the Brazilian Guidelines for Cervical Cancer Screening (2016). Publication of the second edition of the Cytopathology Laboratory Quality Management Manual (2016).	Publication of an updated version of the AUGE Clinical Guide- Cervical Cancer (2015). Authorization of HPV DNA testing for women aged 30 years and over (where available) (2015). Pilot study in the Valdívia Region to test the implementation of DNA HPV screening (2016). Publication of the National Cancer Plan 2018 - 2028 (2018) Introduction of DNA HPV screening in 15 health services across the country; nationwide implementation forecast for 2020 (2020).

Components	Brazil	Chile
Clinical guidelines	Brazilian Guidelines for Cervical Cancer Screening, 2016	Cervical Cancer Clinical Guidelines, 2015
Target population	Women aged between 25 and 64 years	Women aged between 25 and 64 years
Method and Interval	Conventional cytology (Papanicolaou test) once every three years after two negative , annual tests	Pap test for women aged between 25 and 64 years once every three years; primary screening of women aged 30 to 64 years, with HPV detection and Pap test or HPV 16/18 genotyping in five-year intervals (when available)
HPV vaccine	Included in the SUS’ national immunization schedule in 2014. Currently targeted at girls and boys aged between 9 and 14 years	Included since 2014 and provided free of charge by the Ministry of Health to girls aged between 11 and 12 years. Currently provided to girls and boys.
Coverage target	80% of the target population	80% of the target population
Information system	Cancer Information System (SISCAN)	Information System for the Management of Explicit Health Guarantees (SIGGES)

Indicators		Year	Brazil	Chile
Socioeconomic	Population (million)^a	2020	212.559	19.116
	Female population (million)^a	2020	108.124	9.691
	Life expectancy at birth (women)^b	2016	77.80	83.10
	Adult population literacy rate^c	2017	93.08%	96.40%
	Smoking prevalence among women^c	2016	10.1%	34.2%
	Parity (average number of children born per woman)^c	2017	1.73	1.67
	Gross Domestic Product per capita^c	2018	15,820	24,190
	Population coverage (public system)	2019	100%	76.01%^b
	Population coverage (private system)	2019	24.20%	17.97%^e
Funding	Overall expenditure on health as a proportion of GDP^d	2017	9.47%	8.98%
	Public expenditure on health as a proportion of GDP^d	2017	3.96%	4.50%
	Public expenditure on health as a proportion of overall health spendingd	2017	42%	50%
	Public expenditure on health per capita in US$^d	2017	795.66	1,190.55
	Out-of-pocket expenditure as a proportion of overall expenditure on health^d	2017	27.46%	33.55%

Dimension	Brazil	Chile
Context and components of the public health system	Federal Constitution provides that health care is a right for all and the duty of the State. Universal public health system with comprehensive coverage. Around 24% of the population have private health insurance, resulting in dual coverage. No legal barriers to accessing the public system. The government is the main regulator and, as well as defining macro-processes, also establishes mechanisms to direct health care. With regard to funding, 9.47% of Gross Domestic Product (GDP) is allocated to health. The Ministry of Health is responsible for developing regulations and parameters for structuring the SUS and providing financial incentives for the state and municipal spheres. At state level, health planning is regional and based on municipalities’ needs. Municipal governments are responsible for planning, organizing, executing and monitoring local health actions, prioritizing the management of primary care, with technical and financial support from the state and federal government. Regional inequalities are barriers to access to health care. Difficulties retaining specialists and staff shortages in remote areas lead to gaps in health care. Services and actions are delivered through a regionalized, hierarchical network. Three-tiered organization with single command and control governance structure and autonomy of each sphere of government.	National Constitution states that the government is responsible for overseeing the execution of health actions and services. Dual system based on health insurance. Public health system with broad coverage. Public system (FONASA) and private system (ISAPRES) cover around 76% and 14% of the population, respectively. Mandatory contribution of 7% of taxable income to fund the public health system. The government is the main regulator and, as well as defining macro-processes, also establishes mechanisms to direct health care. With regard to funding, 8.98% of Gross Domestic Product (GDP) is allocated to health. The Ministry of Health proposes policies, formulates health programs, defines lines of action and parameters for each activity, and is responsible for resource allocation. Policies are adapted at regional level by regional secretariats. All policies, plans and projects should be in line with the National Health Plan. Municipal governments are autonomous, but services should be managed and delivered in accordance with the policies formulated by the Ministry of Health. The main barriers to access are the mandatory contribution, centralization of medical care in the Metropolitan Region, and spending on medications, doctor’s appointments and examinations in the form of copayments. Public health services are coordinated by the National Health Services System (SNSS). Service networks are decentralized to regional and sub-regional levels.
Cervical cancer control strategies and guidelines	Conventional cytology screening once every three years after two negative annual exams for women aged between 25 and 64 years. Opportunistic screening program without a system for recruiting women from the target age group. Quality assurance program not fully implemented. Population-based information system (SISCAN) not fully implemented. Difficulties implementing organized screening due to the lack of a nationwide population-based information system. Lack of coordination and wide-scale systematic monitoring of actions and results at different levels of management. Some program indicators published by the NCI on a periodic basis through the Early Detection Newsletter, providing information on cytology testing received from states and regions, and an overview of program actions. Screening performed in primary care; confirmation of diagnosis and treatment of precursor lesions performed in secondary care; and treatment of cervical cancer performed in tertiary care. Poor communication between levels of care and shortage of procedures, especially in secondary care, lead to treatment interruption and delay.	Conventional cytology screening once every three years for women aged between 25 and 64 years and DNA HPV testing at five-year intervals (where available) for women aged between 30 and 64 year. Opportunistic screening program without a system for recruiting women from the target age group. Quality assurance program since 1993. Nationwide population-based information system (SIGGES). Transition to organized screening facilitated by the existence of a population-based information system and mandatory registration in primary care facilities in order to access the public health system. Strong ministerial control over preset goals results in active tracking and follow-up of women with abnormal test results. Program results publicized via an annual evaluation report analyzing effectiveness in relation to detection, diagnosis, staging and treatment, and identifying gaps in compliance with explicit health guarantees, thus informing decision-making and resource allocation. Screening performed in primary care; confirmation of diagnosis and treatment of precursor lesions performed in secondary care; and treatment of cervical cancer performed in tertiary care. Monitoring of the health guarantees defined in the AUGE Scheme establishes deadlines for each action.

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[1] Collaborations

IB Claro contributed to study conception and design, data analysis and interpretation, and to writing and critically revising the article and approving the final version to be published. LD Lima contributed to study conception and design, data analysis and interpretation, and to writing and critically revising the article and approving the final version to be published. PF Almeida contributed to writing and critically revising the article and approving the final version to be published.