Breast cancer in Brazil: strategies for prevention and control
Gulnar Azevedo e Silva
Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brasil. firstname.lastname@example.org
The important increase in breast cancer incidence in the late 1980s and throughout the 90s in Western countries resulted from childbearing and lifestyle changes imposed by the industrialized world. However, in high-income countries, breast cancer mortality has actually decreased in recent decades due to early detection, allowing women with the diagnosis to benefit from the significant advances in treatment. Unfortunately, recent global estimates indicate that breast cancer has also become the most common type of cancer in developing countries, where resources to deal with the problem are scarce or nonexistent. Secondary prevention measures are thus urgently needed to avoid evolution of the illness to death.
Considering that primary prevention measures for breast cancer, focused on modifiable risk factors, do not differ from the strategies proposed for other chronic non-communicable diseases, the priority for specific measures to control the disease should be organized screening within the recommended age brackets.
Attention should focus on the recent debate in the scientific literature on the results of randomized screening trials with mammography. After publication of controlled studies conducted in developed countries which showed at least a 30% decrease in deaths in the group of women that underwent mammogram screening, recent evaluations have shown that the protective effect against mortality appears to be less than expected. In trials where randomization of women was adequately followed for more than ten years, the reduction in mortality was only 15%. Nevertheless, the countries where these studies were performed have the capacity to supply health services to all women, which minimizes the differences between women recruited into the intervention group versus those assigned to the control group.
The Brazilian data confirm breast cancer as the leading cancer in women, and that over the last 30 years the specific mortality trend is increasing in the country as a whole. However, stratifying the data between State capitals versus other counties, although the rates are always higher in capitals, different trends are observed beginning in the late 1990s, especially in the Southeast, South, and Central-West: there is a downward in the State capitals and a statistically significant upward trend in the smaller counties. Among the population living outside the State capitals, there appears to be a real increase in risk, probably associated with the industrialized lifestyle that has spread rapidly to the counties in the interior, in addition to greater inequality in access to screening, diagnosis, and treatment.
Implementation of an effective policy for breast cancer control in the Brazilian Unified National Health System (SUS) should be capable, in the short term, of expanding and upgrading the supply of screening measures with guaranteed follow-up of all detected cases, thereby reducing mortality and the enormous regional inequalities.