Breast cancer screening in Brazil. Barriers related to the health system

We performed a systematic review in the PubMed and LILACS databases using as keywords "Breast cancer," "system of health" and "Brazil or Brasil." We evaluated the content of the articles using the PRISMA methodology based on PICTOS. The final date was 12/16/2015. We were able to identify 94 publications in PubMed and 43 publications in LILACS. After assessing the title and summary, and excluding 21 repeated publications, we selected 51 publications for full evaluation. At this stage, we excluded 21 articles, with 30 publications remaining for study.

Results:

The population coverage is low, and there are problems related to the quality of mammography. Patients with lower income, nonwhite and less educated are more vulnerable. We observed punctual and initial experiences in breast cancer screening. Diagnosis and treatment flows must be improved. The inequality in mortality reflects the differences related to screening structure and treatment. Better results are observed in well-structured services.

Conclusion:

There are several barriers in the health system leading to advanced stage at diagnosis and limiting the survival outcomes. The establishment of a rapid and effective order for diagnosis and treatment, based on hierarchical flow, are important steps to be improved in the public health context.

Keywords:
breast neoplasms/prevention and control; health systems; screening programs; mammography; Unified Health System

	Proposal	Inclusion
P/ Population	Breast cancer in Brazil	Breast cancer in Brazil; dependence to the SUS
I/ Intervention	Mammography Health management	Mammography; screening Health management
C/ Comparison	Factors related to the Health System	Mammography machine: population-based coverage, availability, quality; management; type of screening
O/ Outcome	Results found	Experience in screening, vulnerable populations, diagnostic flow, clinical stage at diagnosis, treatment and mortality
T/ Time	Any	Any
S/ Study type	Any	Any

PICO	Summary of findings
Goal	Mammography 50-69 years, bi-annually
P/ Population	SUS system population dependent on governmental actions
	Subgroup without MMG: absence of health plan, non-white, low income
	Patients over the age of 40 who never underwent MMG
	Distance from place of residence to treatment greater than 150 km
I/ Intervention	SUS Screening type
	Mammography control done by the SISMAMA
	MMG usually diagnostic
	Opportunistic screening through collective action to meet demand
	Organized screening does not exist
	Organized screening being implemented at a single center in the country
C/ Comparison	Comparison
	Inadequate mammography coverage
	Inadequate biannual recall
	Unsatisfactory quality of mammography in the SUS
O/ Outcome	Result
	Difficulty in patient flow, from diagnosis to treatment
	Diagnosis in symptomatic phase
	Advanced clinical stage of cancer at diagnosis negatively influencing survival
	Mortality: Private < well-structured public < regular public services
	Gradual improvement in the supply of MMG and outcomes related to cancer staging, with no defined indicators
	Increased incidence and increased mortality: Midwest, North and Northeast regions
	Increased incidence and decrease in mortality: South and Southeast

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