Organized, Population-based Cervical Cancer Screening Program: It Would Be a Good Time for Brazil Now.

Abstract

Estimates indicate that around 16,000 new cases of cervical cancer were diagnosed in 2014 in Brazil. This cancer is the third most frequent in Brazil, the first in the North region, and the fifth in the South region of the country.1 The Unified Health System (SUS), the public health care system of Brazil, has implemented several actions for qualifying cervical cancer screening, but there are challenges to be overcome, such as the large national territory and heterogeneous resources from every site.2 Despite the efforts made by SUS, the current cervical cancer screening has shown many weaknesses. There is no doubt that regular screening of appropriate women for cervical cancer with the cytopathology test reduces mortality from cervical cancer.3 However, appropriate policy and program organization remain essential to achieve a good balance between benefit and harm of any screening program. The knowledge of the potential of population-based cervical screening to reduce the burden of cervical cancer in the population is doubtless. However, as pointed out by Dillner et al,4 this knowledge has not always been translated into effective national programs. To be effective, cervical cancer screening should be performed in an organized, population-based screening program with comprehensive quality assurance covering all steps in the screening process. An organized program should include quality assurance in monitoring cervical cancer screening performance. The European guidelines define such a performance through achieving: (1) an invitation coverage of at least 95% of the target women; (2) an examination coverage of at least 70% (85% is desirable); and (3) a participation rate of at least 70% (85% is desirable).5 The current recommendations for the SUS establish the cytology-based cervical cancer screening, conducted with a three-year interval after two consecutive annual negative exams. The target population for cervical cancer screening comprised women aged 25 to 64 years, which represents around 55 million Brazilian women.6 Although SUS is universal, 25% of all Brazilians have private health; therefore, 41millionwomen are dependent on the SUS as their health care provider. In the last decade, SUS conducted 9 to 11 million cytological exams per year.7 If it maintains the recommended age group and three-year interval preconized, the SUS would be able to include 27 to 33 million women in the screening program, reaching almost 70–85% women as preconized for an organized population-based program for cervical cancer screening.4 In their Historical Analysis of the Brazilian Cervical Cancer Screening Program from 2006 to 2013, Costa et al8 observed that the Pap test coverage rate in Brazil is below 70%. Data from theMinistry of Health from2012 and 2013 showed that around 50% of the cytological tests in Brazil were conducted on an annual basis and only 10%within a three-year interval. Also, around 20% of the tests were conducted onwomen less than 25 years of age.9 Regarding data from 2013, out of total 8,951,266 cytological tests, only 78.7% were conducted in women aged 25–64 years old. Around 16% of these testswere conducted in young women, aged less than 25 years or even younger than 20 years: it is well known that treatment procedures related to cervical lesion could be associated with a higher frequency of obstetric and neonatal morbidity. Also, for 46.9% of women, the interval since the last test was one year or less, and only 9.4% followed the frequency recommended in the Brazilian Cervical Cancer Screening Guidelines.10 These data about Brazil present some regional variability, but the general pattern tends to be homogeneous. An evaluation of the cervical of the cancer screening program in Editorial