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

Introduction

Cervical cancer is a global public health problem, with approximately 570,000 cases and 311,000 deaths from the disease occurring worldwide in 2018¹1 Arby M, We-iderpass E, Sanjosé S, Bruni L, Saraiya M, Ferlay J, Bray F. Estimates of incidence and mortality of cervical cancer in 2018: a worldwideanalysis. Lancet Glob Health 2020; 8: e191-e203. Published Online, 2019.. Between 87 and 90% of the deaths caused by the disease occurred in low and middle-income countries, illustrating the social inequality issues associated with this type of cancer²2 Hull R, Mbele M, Makhafola T, Hicks C, Wang SM, Reis RM, Mehrotra R, Mkhize Kwitshana Z, Kibiki G, Bates DO, Dlamini Z. Cervical cancer in low and middle income countries (Review). OncolLetters 2020; 20:2058-2074.. However, international experiences show that it is possible to reduce the number of deaths by 80%³3 Goss PE, Lee BL, Badovinac-Crnjevic T, Strasser-Weippl K, Chavarri-Guerra Y, St Louis J, Villarreal-Garza C, Unger-Saldaña K, Ferreyra M, Debiasi M, Liedke PE, Touya D, Werutsky G, Higgins M, Fan L, Vasconcelos C, Cazap E, Vallejos C, Mohar A, Knaul F, Arreola H, Batura R, Luciani S, Sullivan R, Finkelstein D, Simon S, Barrios C, Kightlinger R, Gelrud A, Bychkovsky V, Lopes G, Stefani S, Blaya M, Souza FH, Santos FS, Kaemmerer A, Azambuja E, Zorilla AF, Murillo R, Jeronimo J, Tsu V, Carvalho A, Gil CF, Sternberg C, Dueñas-Gonzalez A, Sgroi D, Cuello M, Fresco R, Reis RM, Masera G, Gabús R, Ribeiro R, Knust R, Ismael G, Rosenblatt E, Roth B, Villa L, Solares AL, Leon MX, Torres-Vigil I, Covarrubias-Gomez A, Hernández A, Bertolino M, Schwartsmann G, Santillana S, Esteva F, Fein L, Mano M, Gomez H, Hurlbert M, Durstine A, Azenha G. Planning cancer control in Latin America and the Caribbean. Lancet Oncol 2013; 14(5):391-436..

To this end, the Pan American Health Organization (PAHO) proposed the creation of national cervical cancer prevention and control programs encompassing primary prevention actions and services, early detection and treatment, and palliative care⁴4 Luciani S, Andrus JK. A Pan American Health Organization strategy for cervical cancer prevention and control in Latin America and the Caribbean - Reprod. Health Matters 2008; 59:59-66.. Most Latin American countries have been implementing these programs since 1980, without achieving the same success achieved by high-income countries³3 Goss PE, Lee BL, Badovinac-Crnjevic T, Strasser-Weippl K, Chavarri-Guerra Y, St Louis J, Villarreal-Garza C, Unger-Saldaña K, Ferreyra M, Debiasi M, Liedke PE, Touya D, Werutsky G, Higgins M, Fan L, Vasconcelos C, Cazap E, Vallejos C, Mohar A, Knaul F, Arreola H, Batura R, Luciani S, Sullivan R, Finkelstein D, Simon S, Barrios C, Kightlinger R, Gelrud A, Bychkovsky V, Lopes G, Stefani S, Blaya M, Souza FH, Santos FS, Kaemmerer A, Azambuja E, Zorilla AF, Murillo R, Jeronimo J, Tsu V, Carvalho A, Gil CF, Sternberg C, Dueñas-Gonzalez A, Sgroi D, Cuello M, Fresco R, Reis RM, Masera G, Gabús R, Ribeiro R, Knust R, Ismael G, Rosenblatt E, Roth B, Villa L, Solares AL, Leon MX, Torres-Vigil I, Covarrubias-Gomez A, Hernández A, Bertolino M, Schwartsmann G, Santillana S, Esteva F, Fein L, Mano M, Gomez H, Hurlbert M, Durstine A, Azenha G. Planning cancer control in Latin America and the Caribbean. Lancet Oncol 2013; 14(5):391-436.^,55 Raúl M, Robles C. Research needs for implementing cancer prevention and early detection in developing countries: from scientists to implementers perspectives. BioMed Res Intern 2019; (n. esp):9607803.. Factors related to access to quality care and the socioeconomic status of women have been highlighted as barriers to the control of cancer in the region⁶6 Organización Panamericana de La Salud (OPAS). Situación de los Programas para la Prevención y el Control del Cáncer Cervicouterino: evaluación rápida mediante encuesta en 12 países de América Latina. Washington, D.C.: OPS; 2010..

This article aims to analyze Brazil and Chile’s cervical cancer prevention and control programs, focusing on national guidelines, prevention strategies and screening. The aim of cervical cancer screening is to reduce mortality and disease incidence through the systematic testing of asymptomatic populations to identify, confirm and treat precursor lesions⁷7 Brawley OW. Cancer screening: a general perspective In Cancer prevention and screening - Concepts, principles and controversies. Edited by Rosalind A. Eeles, Christine D. Berg, Jeffrey S. Tobias. John Wiley & Sons: Oxford; 2019.^,88 World Health Organization (WHO). Cancer Control: knowledge into action: WHO guide for effective programmes, Module 2. Prevention. Geneva: WHO; 2007.. Countries that have implemented organized screening programs have managed to reduce incidence to less than 10 cases per 100,000 women/year⁹9 Zeferino LC. O desafio de reduzir a mortalidade por câncer do colo do útero. Rev Bras Ginecol Obstet 2008; 30(5):213-215.. In contrast, incidence rates in countries without screening programs can exceed 70 cases per 100,000 women/year¹1 Arby M, We-iderpass E, Sanjosé S, Bruni L, Saraiya M, Ferlay J, Bray F. Estimates of incidence and mortality of cervical cancer in 2018: a worldwideanalysis. Lancet Glob Health 2020; 8: e191-e203. Published Online, 2019.^,1010 Capote Negrin LG. "Epidemiologyof Cervical Cancer in LatinAmerica." Ecancer medical science 2015; 9: 577. PMC.. It is important to highlight that prevention and screening interventions are strongly conditioned by social inequalities¹¹11 Lemp JM, De Neve JW, Bussmann H, Chen S, Manne-Goehler J, Theilmann M, Marcus ME, Ebert C, Probst C, Tsabedze-Sibanyoni L, Sturua L, Kibachio JM, Moghaddam SS, Martins JS, Houinato D, Houehanou C, Gurung MS, Gathecha G, Farzadfar F, Dryden-Peterson S, Davies JI, Atun R, Vollmer S, Bärnighausen T, Geldsetzer P. Lifetime Prevalence of Cervical Cancer Screening in 55 Low- and Middle-Income Countries. JAMA 2020; 20; 324(15):1532-1542. and require well-structured and organized health systems in order to ensure adequate access to health services⁵5 Raúl M, Robles C. Research needs for implementing cancer prevention and early detection in developing countries: from scientists to implementers perspectives. BioMed Res Intern 2019; (n. esp):9607803..

Chile and Brazil began to implement national cervical cancer prevention and control programs in 1987 and 1998, respectively. Despite similarities between the programs, they have been developed in specific contexts conditioned by the different of configurations of the countries’ respective health systems¹²12 Chile. Ministerio de Salud. Guía Clínica AUGE. Cáncer Cervicouterino (CaCu). Santiago: Minsal; 2015.^,1313 Brasil. Ministério da Saúde. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Diretrizes Brasileiras para o Rastreamento do Câncer do Colo do Útero. Coordenação de Prevenção e Vigilância. 2ª ed. Rio de Janeiro: INCA; 2016.. This article therefore analyzes Chile and Brazil’s cervical cancer prevention and screening guidelines and strategies, discussing challenges and the results of the actions implemented by each country.

Besides the magnitude of the cervical cancer problem in Latin America, this study is justified by the need to promote critical reflection in order to improve actions and design effective strategies for the timely diagnosis and treatment of precursor lesions, thus reducing preventable deaths, especially among socially disadvantaged women.

Method

We conducted an exploratory multiple case study using the comparative method to analyze Brazil and Chile’s cervical cancer prevention and screening guidelines and strategies¹⁴14 Marmor T, Freeman R, Okma K. Comparative Perspectives and Policy Learning in the World of Health Care. J Comp Policy Analysis: Res Practice 2005; 7(4): 331-348.^,1515 Rose R. Learning from comparative public policy. New York, NY: Routledge; 2005., seeking to identify similarities and differences in the actions developed by the two countries. We also sought to highlight the effects of contextual features and the configuration of the countries’ respective health systems¹⁶16 Conill EM, Fausto MCR, Giovanella L. Contribuições da análise comparada para um marco abrangente na avaliação de sistemas orientados pela atenção primária na América Latina. Rev Brasil Saude Materno Infantil 2010; 10(Supl.1):S151-S27. on the occurrence of common specific problems and results of the actions implemented in each country.

Brazil and Chile were chosen because they have the lowest cervical cancer incidence and mortality rates in South America, are pioneers in the development of national cervical cancer prevention and control programs, Papanicolaou (Pap) testing, clinical guidelines, and nationwide actions, and are members of the Network of National Cancer Institutes of Latin America’s Cervical Cancer Operating Group.

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. Official documents (normative instruments) on national cervical cancer prevention and control programs were obtained from searches of official government sites. We also used socioeconomic and health indicators made available by the International Agency for Research on Cancer (IARC) (https://gco.iarc.fr/), United Nations Economic Commission for Latin America and the Caribbean (CEPAL in Portuguese) (https://www.cepal.org/pt-br), Organization for Economic Cooperation and Development (OCDE) (http://www.oecd.org/), World Health Organization (WHO) (https://www.who.int/es), and World Bank (https://www.worldbank.org/), and from Brazil and Chile’s health information systems (http://datasus1.saude.gov.br/ and https://www.minsal.cl/, respectively). In both countries, the consultations with experts, ministry of health officials responsible for the coordination of national actions and professionals responsible for program coordination at the regional and local level were held in 2019.

Searches were also performed of the following databases: MEDLINE® (Medical Literature Analysis and Retrieval Sistema Online); LILACS® (Latin American & Caribbean Health Sciences Literature); Scopus®; and the Theses and Dissertations Catalog of the Coordination of Improvement of Higher Education Personnel (CAPES).

The study protocol was approved by the research ethics committee.

Results

National cervical cancer prevention and control program guidelines

Brazil and Chile established national guidelines for the prevention and control of cervical cancer, defining the target age group, screening intervals, and clinical procedures for the treatment and follow-up of women with abnormal test results. The guidelines aim to reduce cervical cancer incidence, morbidity and mortality, improve the quality of life of women with cervical cancer, and provide a sound and up-to-date scientific basis for health teams on aspects related to prevention, early diagnosis and treatment¹²12 Chile. Ministerio de Salud. Guía Clínica AUGE. Cáncer Cervicouterino (CaCu). Santiago: Minsal; 2015.^,1313 Brasil. Ministério da Saúde. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Diretrizes Brasileiras para o Rastreamento do Câncer do Colo do Útero. Coordenação de Prevenção e Vigilância. 2ª ed. Rio de Janeiro: INCA; 2016..

The first organized cervical cancer prevention strategies in Brazil date back to 1984, within the scope of the Comprehensive Women’s Health Care Program (PAISM, acronym in Portuguese), with the promotion of routine collection of material for the cytopathology test at gynecological consultations¹³13 Brasil. Ministério da Saúde. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Diretrizes Brasileiras para o Rastreamento do Câncer do Colo do Útero. Coordenação de Prevenção e Vigilância. 2ª ed. Rio de Janeiro: INCA; 2016.. In 1986, the Ministry of Health initiated the Expansion of the Prevention and Control of Cervical Cancer project, enabling the expansion of the material collection network, increasing the capacity of cytopathology laboratories across the country, and establishing screening frequency and the target age group¹³13 Brasil. Ministério da Saúde. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Diretrizes Brasileiras para o Rastreamento do Câncer do Colo do Útero. Coordenação de Prevenção e Vigilância. 2ª ed. Rio de Janeiro: INCA; 2016.. In 1998, after the evaluation of the Expansion project, the Ministry of Health created the National Program for Combating Cervical Cancer (PNCCCU, acronym in Portuguese), coordinated by the National Cancer Institute (NCI), better known as the Programa Viva Mulher¹⁷17 Teixeira LA, Fonseca CMO, coordenadores. De Doença desconhecida a problema de saúde pública: o INCA e o controle do Câncer no Brasil. Rio de Janeiro: Ministério da Saúde; 2007.. This term gradually went out of usage, being replaced by the National Cervical and Breast Cancer Control Program and, further down the line, by cervical cancer and breast control actions¹⁸18 Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Viva Mulher 20 anos: história e memória do controle do câncer do colo do útero e de mama no Brasil: catálogo de documentos. Rio de Janeiro: INCA; 2018., developed within the realm of primary health care, mainly through the expansion and strengthening of the Family Health Program.

In Chile, efforts to promote the early detection of cervical cancer began in 1966, under an agreement with the University of Chile School of Medicine with support from the PAHO. The agreement enabled the progressive expansion of cytology laboratories and training of human resources at the three levels of care. After an evaluation of the results in 1987, the program was reformulated following PAHO recommendations, giving rise to the National Cancer Research and Control Program. The Pap testing interval was set at once every three years and the target age group was defined as women aged between 25 and 64 years. Strategies were tested through a pilot project implemented in the Metropolitan Region between 1988 and 1994, which was expanded after an evaluation to the rest of the country¹⁹19 Lanza SS, Sepúlveda CV, Olate MB, Espejo CC. Aplicación de metodología de marco lógico para el análisis del Programa Nacional de Pesquisa y Control del Cáncer Cervicouterino en Chile. Rev Chil Obstet Ginecol 2010; 75(5):294-299..

Chart 1 shows the main milestones in the control of cervical cancer in Brazil and Chile.

Precursor lesion prevention, diagnosis and treatment strategies

Prevention strategies in Brazil and Chile include vaccination against the human papillomavirus (HPV). Vaccination was incorporated into the countries’ national immunization schedules in 2014, is free of charge and has been available to both boys and girls since 2019. Vaccination is mandatory in Chile and performed in schools, following international recommendations for adolescents. In Brazil, vaccination is performed in primary care facilities. In 2019, second dose vaccination coverage for girls in Chile and Brazil was 79.6% and 47.4%, respectively. In both countries, factors such as lack of public knowledge about the vaccine, inadequate medical prescription, and misinformation about the safety of the vaccine contribute to vaccine refusal²⁰20 Cordeiro GV, Pérez SC, Iñarrea AF, Simón DV, Reboredo CR, Couceiro EN, Ramón y Cajal C. ¿Por qué no se vacunan nuestras pacientes?: Motivos por los que las pacientes fuera de los programas de vacunación sistemática, con infección por el virus del Papiloma Humano, deciden decir no a la vacuna. Rev Chil Obstet Ginecol 2014; 79(5):390-395.^,2121 Zanini NV, Prado BS, Hendges RC, Santos CA, Callegari FVR, Bernuci MP. Motivos para recusa da vacina contra o Papilomavírus Humano entre adolescentes de 11 a 14 anos no município de Maringá-PR. Rev Brasil Med Fam Comum 2017; 12(39):1-13..

The screening method used in Brazil since 1998 is conventional cytology (Pap test), which should be performed once every three years¹³13 Brasil. Ministério da Saúde. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Diretrizes Brasileiras para o Rastreamento do Câncer do Colo do Útero. Coordenação de Prevenção e Vigilância. 2ª ed. Rio de Janeiro: INCA; 2016.. In Chile, since 2015, there are two guidelines for specific population groups: 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 year¹²12 Chile. Ministerio de Salud. Guía Clínica AUGE. Cáncer Cervicouterino (CaCu). Santiago: Minsal; 2015.. Unlike countries with active recruitment strategies, screening in Brazil and Chile is generally opportunistic or spontaneous, with services being provided to women who request it or who are already in a health facility for other services.

In Brazil, since 2001, laboratories outsourced by the country’s national health service (the Unified Health System or Sistema Único de Saúde - SUS) must undergo an external quality assessment. However, in 2019, only 10 of the country’s 27 states provided information on external quality monitoring (EQM) to the SUS’s Outpatient Information System (http://datasus1.saude.gov.br/). In Chile, EQM is coordinated by Chile’s Public Health Institute (PHI), which has been implementing an external quality assessment program encompassing the countries public and private laboratories since 1993, thus assuring the quality and reliability of public system test results.

Created in 2013, Brazil’s nominal cancer information system (SISCAN) enables the monitoring and follow-up of women who take the Pap test. The system also records, archives and synthesizes test information and selects samples for external monitoring, facilitating the creation of a quality management program. However, the system has yet to be fully implemented across the country. Chile uses two information systems for program monitoring: “Cito-Expert”, which records test data on an online platform, where authorized professionals are able to check whether the service user has been screened according to the intervals established in the national guidelines; and SIGGES, designed to monitor performance against the goals set by the Ministry of Health.

Brazil faces persistent challenges related to information on follow-up of women with abnormal test results. In 2010, only 23% of women diagnosed in the previous year had a follow-up recorded in the information system. In Chile, the mandatory registration of patients in primary care facilities and establishment of deadlines for testing and complementary treatment facilitates follow-up. In addition, program management is highly centralized in Chile, facilitating coordination, unlike in Brazil, where management is decentralized, with actions being implemented by municipal and state governments.

The main features of the two countries’ cervical cancer prevention and screening strategies are summarized in Chart 2.

Discussion

Brazil and Chile are characterized by stark social and economic inequalities, and social policies and actions are more limited in scope than in the majority of middle and high-income countries. This is reflected in poorer indicators in areas such as education, security, employment, housing and access to health services²²22 Organização para a Cooperação e Desenvolvimento Económico (OCDE). Relatórios Econômicos OCDE: Brasil. Paris: OECD; 2018.^,2323 Organización de Cooperación y Desarrollo Económicos (OCDE). Estudios económicos de la OCDE: Chile. Paris: OCDE; 2018.. Social inequalities have a direct impact on the magnitude the problem, meaning that cervical cancer continues to be a major public health concern in both countries²⁴24 Parikh S, Brennan P, Boffetta P. Meta-analysis of social inequality and the risk of cervical cancer. Int J Cancer 2003; 105:687-691.^,2525 Nuche-Berenguer B, Sakellariou D. Socioeconomic determinants of cancer screening utilisation in Latin America: A systematic review. PloS ONE 2019; 14(11): e0225667., resulting in disparities in incidence, epidemiological profile, survival rates and quality of life after diagnosis²⁶26 Wunsch Filho V, Antunes JLF, Boing AF, Lorenzi RL. Perspectivas da investigação sobre determinantes sociais em câncer. Physis 2008; 18(3):427-450.. Chart 3 shows some selected socioeconomic and health funding indicators in the two countries.

In Brazil, public health services are provided by the SUS, the country’s universal health care system. In Chile, to access the country’s public health system (Fondo Nacional de Salud - FONASA), workers and pensioners must make a mandatory contribution of 7% of their taxable income²⁷27 Chile. Ministerio de Salud (MS); Subsecretaría de Salud Pública. Decreto com Fuerza de Ley 1. Santiago: MS; 2005.. Strategies to promote timely access to cervical cancer screening in Chile are restricted to the health guarantees included in the AUGE Scheme, which defines priority health problems treated on the public health system. In other care schemes, patient flows differ, resulting in generally longer appointment wait times. Nevertheless, the AUGE Scheme, created during Chile’s health system reform in 2005, has led to an increase in access and established active monitoring of goals²⁷27 Chile. Ministerio de Salud (MS); Subsecretaría de Salud Pública. Decreto com Fuerza de Ley 1. Santiago: MS; 2005.^,2828 Chile. Ministerio de Salud (MS). Subsecretaría de Salud. Pública. AUGE 85. Garantías de Oportunidad. Santiago: MS; 2019..

In both countries, regional inequalities are barriers to accessing health care. In Brazil, populations living in remote rural areas, especially in the country’s North and Northeast regions, face greater difficulties accessing health services, particularly specialist services²⁹29 Instituto Nacional de Câncer (INCA). Plano de ação para redução da incidência e mortalidade por câncer do colo do útero: sumário executivo. Rio de Janeiro: INCA; 2010.. In addition to regional disparities and the centralization of care in metropolitan areas, barriers to access in Chile include mandatory financial contributions and spending on medications, doctor’s appointments and examinations in the form of copayments³⁰30 Urrutia MT. Cáncer Cervico uterino en Chile: análisis de um nuevo paradigma preventivo. Temas de la agenda pública 2015; 10(78). In both countries, areas isolated from large urban centers have the highest incidence and mortality rates.

Despite an increase in screening coverage and access to treatment of precursor lesions, incidence and mortality rates have not decreased at the same rate as high-income countries¹1 Arby M, We-iderpass E, Sanjosé S, Bruni L, Saraiya M, Ferlay J, Bray F. Estimates of incidence and mortality of cervical cancer in 2018: a worldwideanalysis. Lancet Glob Health 2020; 8: e191-e203. Published Online, 2019.. In 2018, the estimated incidence of cervical cancer in both countries was 12.2 per 100,000 women, making cervical cancer the fourth and sixth most common cancer among women in Brazil and Chile, respectively¹1 Arby M, We-iderpass E, Sanjosé S, Bruni L, Saraiya M, Ferlay J, Bray F. Estimates of incidence and mortality of cervical cancer in 2018: a worldwideanalysis. Lancet Glob Health 2020; 8: e191-e203. Published Online, 2019.. Figure 1 depicts trends in cervical cancer mortality rates in Brazil and Chile, showing that differences narrowed considerably between 1980 and 2010. In 1980, Chile’s mortality rate was almost three times greater than that of Brazil (14.85 per 100,000 women versus 5.20 per 100,000 women). The considerable reduction in cervical cancer mortality in Chile (more than 50%), was partially a result of significant changes in prevention and treatment policies. Other important factors include a decrease in the percentage of the population living below the poverty line (from 38.4% in 1990 to 14.4% in 2011) and an increase in Gross Domestic Product (GDP) in recent decades³¹31 Vidal C, Hoffmeister L, Biagini L. Tendencia de la mortalidad por cáncer de cuello uterino en Chile: aplicación de modelos de regresión joinpoint. Rev Panam Salud Publica 2013; 33(6):407-413..

Both countries set a national target of 80% coverage of the target population, considered to be the necessary coverage to ensure a significant reduction in incidence and mortality. In Chile, coverage is calculated based on data from the nominal information system and has remained stable at around 70%. In Brazil, coverage is estimated at 80%, based on self-reported information from national surveys, since the country’s information system has yet to be fully implemented. The two programs face difficulties in meeting the coverage target and reaching women from the target population who have never done the test or have done it outside the recommended interval. Both countries have yet to implement an organized population-based screening program that provides for direct contact with women through letters or telephone messaging.

Nominal information systems are the sine qua non of organized screening³²32 International Agency for Research on Cancer (IARC). Handbooks of Cancer Prevention. Vol. 10. Cervix Cancer Screening. Lyon: IARCPress; 2005.^,3333 Organização Pan-Americana da Saúde (OPAS). Controle integral do câncer do colo do útero. Guia de práticas essenciais. Washington, DC: OPAS; 2016.. In Brazil, the effective implementation of the SISCAN is vital to structuring an organized program that enables follow-up of women with abnormal test results and monitoring of coverage indicators. A marked difference between Chile and Brazil is that the former has a fully implemented nominal information system, thus facilitating follow-up. Furthermore, the existence of preset goals and strong ministerial control over the procedures performed under the Explicit Health Guarantees makes it mandatory for health services to promote active tracking of women with abnormal test results in order to meet deadlines and ensure the provision of appropriate treatment. In Brazil, opportunistic screening, combined with quality issues related to information system records and low adherence to national protocols, hamper monitoring and evaluation and the effective organization of cervical cancer actions³⁴34 Ribeiro, CM, Azevedo e Silva, G. Avaliação da produção de procedimentos da linha de cuidado do câncer do colo do útero no Sistema Único de Saúde do Brasil em 2015. Epidemiol Serv Saude 2018; 27(1):e20172124.. Furthermore, inconsistencies between test results and the clinical procedures set out in the national guidelines and poor coordination of care services lead to treatment interruptions and delays³⁵35 Farias ACB, Barbieri AR. Seguimento do câncer de colo de útero: Estudo da continuidade da assistência à paciente em uma região de saúde. Esc Anna Nery 2016; 20(4)..

Assuring Pap test quality is another critical issue in cervical cancer screening³⁶36 Araujo JR MLC, Santana DA, Almeida LB, Quintana SBS, Silva GRF, Fonseca RCSP. Quality in cytopathology: ananalysis of the internal quality monitoring indicators of the Instituto Nacional de Câncer. J Bras Patol Med Lab 2015; 51(2):102-107.^,3737 Instituto Nacional de Câncer (INCA). Coordenação de Prevenção e Vigilância. Divisão de Detecção Precoce e Apoio à Organização de Rede. Manual de gestão da qualidade para laboratório de citopatologia. 2ª ed. rev. ampl. Rio de Janeiro: INCA; 2016.. Studies show that most Brazilian laboratories do not meet the quality criteria established by the Ministry of Health³⁷37 Instituto Nacional de Câncer (INCA). Coordenação de Prevenção e Vigilância. Divisão de Detecção Precoce e Apoio à Organização de Rede. Manual de gestão da qualidade para laboratório de citopatologia. 2ª ed. rev. ampl. Rio de Janeiro: INCA; 2016.. In Chile, monitoring seems to be reflected in the positivity rate, a benchmark that shows the sensitivity of testing in detecting lesions. In 2018, the positivity rate in Chile was 3.62%, compared to 2.76% in Brazil, which is below the national parameter of equal to or greater than 3%³⁷37 Instituto Nacional de Câncer (INCA). Coordenação de Prevenção e Vigilância. Divisão de Detecção Precoce e Apoio à Organização de Rede. Manual de gestão da qualidade para laboratório de citopatologia. 2ª ed. rev. ampl. Rio de Janeiro: INCA; 2016.. In Chile, the centralized coordination of EQM facilitates organization and helps ensure the quality of planning of a set of integrated activities in association with University of Chile, whose laboratory is accredited by the College of American Pathologists, one of the world’s most stringent international assessment systems.

Brazil’s Family Health Program is the cornerstone of primary care and the country’s health system, playing a pivotal role in the organization of cervical cancer prevention through the promotion of health education, vaccination and screening¹³13 Brasil. Ministério da Saúde. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Diretrizes Brasileiras para o Rastreamento do Câncer do Colo do Útero. Coordenação de Prevenção e Vigilância. 2ª ed. Rio de Janeiro: INCA; 2016.. However, a census of the country’s primary care centers revealed that only half had appropriate facilities to carry out preventive screening and only 30% of teams showed adequate screening practices, indicating a lack of equipment and supplies, thus restricting the scope of actions and signaling barriers to access to good-quality screening³⁸38 Tomasi E, Oliveira TF, Fernandes PAA, Thumé, E, Silveira DS, Siqueira FV, Duro SMS, Saes MO, Nunes BP, Fassa, AG, Facchini LA. Estrutura e processo de trabalho na prevenção do câncer de colo de útero na Atenção Básica à Saúde no Brasil: Programa de Melhoria do Acesso e da Qualidade - PMAQ. Rev Bras Saude Matern Infant 2015; 15(2):171-180.. Lack of coordination between levels of care is another problem constantly mentioned by studies of Brazil’s health system, resulting in shortcomings in follow-up³⁹39 Fernandes NFS, Galvão JR, Assis MMA, Almeida PF, Santos AM. Acesso ao exame citológico do colo do útero em região de saúde: mulheres invisíveis e corpos vulneráveis. Cad Saude Publica 2019; 35(10).. Chile on the other hand stands out from Brazil for the effective institutionalization of instruments designed to strengthen the coordination of care and development of protocols by the Ministry of Health⁴⁰40 Almeida PF, Oliveira SC, Giovanella L. Integração de rede e coordenação do cuidado: o caso do sistema de saúde do Chile. Cien Saude Colet 2018; 23(7).. Despite having one of the region’s most unequal health systems⁴¹41 Gallardo K, Varas L, Gallardo M. Inequality of opportunity in health: evidence from Chile. Rev Saude Publica 2017; 4(51):110.^,4242 Chile. Ministerio de Salud (MS). Subsecretaría de Salud. Pública Decreto N. 42.449. Aprueba garantías explícitas em salud del régimen general de Garantías em Salud. Santiago: MS; 2019., the situation of cervical cancer and the other priority health problems listed in the AUGE Scheme are exceptions in the Chilean context.

In Brazil, since the creation of the program to the present day, the responsibility for coordinating the program has shifted between the NCI and departments of the Ministry of Health in Brasília, generating instability. These changes and the lack of definition of coordinating roles at the federal level compromise follow-up and monitoring and evaluation. This situation is aggravated by difficulties in structuring and retaining program management health teams in both tate and municipal government health departments. Program management has posed “an ongoing challenge to the sustainability of actions, affecting planning and agreement processes, staff training and development policy and the continuity of care (p.9)²⁸28 Chile. Ministerio de Salud (MS). Subsecretaría de Salud. Pública. AUGE 85. Garantías de Oportunidad. Santiago: MS; 2019.. Finally, the findings show that lack of coordination and wide-scale systematic monitoring of actions and results across different levels of management has been an ongoing problem in the Brazilian context.

When comparing the two countries, certain key factors responsible for program shortcomings 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 results⁴³43 Wiesner-Ceballos C, Murillo Moreno RH, Piñeros Petersen M, Tovar-Murillo SL, Cendales Duarte R, Gutiérrez MC. Control del câncer cervicouterino en Colombia: la perspectiva de los actores del Sistema de salud. Rev Panam Salud Publica 2009; 25(1):1-8.. In addition, the partial implementation of the SISCAN, precluding the monitoring of screening received by the target population, the lack of a nationwide quality control system, and shortcomings in the follow-up of women with abnormal test results aggravate the situation in Brazil.

Chart 4 synthesize some of the main features of public health policy and cervical cancer control strategies and guidelines in Brazil and Chile.

Final considerations

This analysis of actions to promote the early detection of cervical cancer in Brazil and Chile highlights the importance of ensuring the quality of Pap testing and effective follow-up, including timely confirmation of diagnosis and treatment. Program organization, including well-defined coordination and consolidated, nationwide evaluation and monitoring mechanisms also warrant highlighting.

The main features of the Chilean program include centralized management, continuity of staff, standardization of protocols, and continuous nationwide monitoring of goals and performance indicators. The Chilean program stands out from the Brazilian program in terms of coordination and synthesis of clinical procedures. Unlike Chile, Brazil lacks clear lines of coordination for results-based monitoring and evaluation and a clear definition of the responsibilities of federal entities, particularly state governments, which weakens the national program.

In both countries, incidence and mortality rates are highest among vulnerable groups, demonstrating that higher risk of cervical cancer is indicative of poor access to health services. Although cancer prevention and control programs can reduce barriers arising from social inequalities, they do not eliminate them. It is therefore important to promote strategies designed to increase coverage, including interventions targeting vulnerable groups. In this regard, both Brazil and Chile need bolder actions to reach women in the target age group on the margins of screening.

In countries with organized screening programs and universal health services and actions, socioeconomic inequalities have less impact on the results of screening strategies⁴⁴44 Sarfati D. Why social inequalities matter in the cancer continuum In Reducing social inequalities in cancer: evidence and priorities for research / edited by S. Vaccarella, J. Lortet-Tieulent, R. Saracci, D.I. Conway, K Straif, CP Wild. IARC Library Cataloguing in Publication Data. Geneva: World Health Organization; 2019.^,4545 Menvielle G, Kulhánová I, Mackenbach JP. Assessing the impact of a public health intervention to reduce social inequalities in cancer In: Reducing social inequalities in cancer: evidence and priorities for research /edited. Vaccarella S, Lortet-Tieulent J, Saracci R, Conway DI, Straif K, Wild CP. IARC Library Cataloguing in Publication Data, World Health Organization; 2019.. Although Brazil has a universal health system in which early detection should be promoted across the country by health teams under the Family Health Program, screening is predominantly opportunistic. Prevention and control measures do not include active tracking and recruitment of women in the target age group, health education and follow-up⁴⁶46 Galvão JR, Almeida PF, Santos AM, Bousquat A. Percursos e obstáculos na Rede de Atenção à Saúde: trajetórias assistenciais de mulheres em região de saúde do Nordeste brasileiro. Cad Saude Publica 2019; 35(12):e00004119., repeating a pattern that results in greater screening coverage among educated women. In turn, in addition to not having a universal health system, Chile has still not managed to implement an organized program, insofar as there is no system for recruiting women in the target age group within the recommend screening interval.

Unlike countries where screening actions have yet to be implemented due to lack of funding, infrastructure, human resources, equipment and supplies, and monitoring and surveillance, Brazil and Chile have cervical cancer prevention and control programs and a complex network of services. However, to achieve more significant reductions in cervical cancer incidence and mortality, both countries need to develop the capacity to address the problems and limitations identified above. Brazil needs to step up efforts to ensure testing quality and timely confirmation of diagnosis and treatment, as our findings show that Chile outperforms the country in terms of laboratory quality, scope of the information system and organization of referral networks. In both countries, cervical cancer remains a major public health problem and the strategies employed to address this issue point to the structuring of organized screening with the aim of increasing coverage among the target age group and guaranteeing follow-up of women with abnormal test results.

Acknowledgements

LD Lima and PF Almeida received research scholarships from the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). LD Lima received support from the Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ) for research on health policy in Brazil and the state of Rio de Janeiro.

References

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