In 20 years, cervical cancer could become a residual disease in Brazil, if the country follows a new plan to combat the disease, which foresees advances in screening, treatment and, mainly, vaccination against HPV. Today, this is the third most prevalent type of tumor among Brazilian women and the fourth leading cause of death, with around 17 thousand new cases per year, and approximately 7 thousand deaths. Almost 100% of cases are due to infection with the Human Papillomavirus, or HPV, a virus with more than 200 types, of which only two – 16 and 18 – are responsible for 70% of cases.
Almost 65% of patients only discover the disease at an advanced stage. Therefore, one of the main novelties of the new National Plan for the Elimination of Cervical Cancer is the intention to implement in the Unified Health System a new type of test, of the molecular type, for the diagnosis of HPV, replacing the cytopathological examination. currently done, popularly known as preventative or pap smear. “It’s a test that allows you to know whether or not the virus persists. People become infected with HPV very frequently, at an early age, probably 90% of the population. Normally, this virus disappears, but when it persists, there is a greater possibility of developing associated diseases, leading to precursor lesions and cervical cancer itself”, explains the general director of the National Cancer Institute (Inca), Roberto Gil.
According to Gil, currently, the available tests are being validated to choose the best option. But results from model tests carried out by the World Health Organization (WHO) show that they can reduce cancer cases by 46% and mortality from the disease by 51%, rates higher than those of cytopathological examination. The target audience is made up of all women, or people with a uterus, aged 25 to 64, especially those who have never had a preventive exam.
Associated with the new diagnosis, public services must also implement a self-collection system, in which the patient herself can extract the material for analysis, without the need for a gynecological consultation. “One bottleneck we have when carrying out screening is that many women do not go to the clinic or feel intimidated, especially if it is a man taking the test. As this molecular test is simpler to collect, we also started working with self-collection”, adds the general director of Inca. The method is already being tested in cities in Pernambuco and São Paulo and, from the beginning of next year, it should be adopted in a staggered manner, in selected places, mainly in the North and Northeast regions, which have the highest mortality rates from the disease. illness.
In addition to late screening, patients suffer from the delay in starting treatment. Although Brazilian law determines that it must begin within 60 days, around half of them only receive any treatment after this period in the Southeast, Northeast and Central-West regions. The South is the only region where the most common situation is for people diagnosed to begin treatment within 30 days, which occurs with 44% of patients. In the North, in 65% of cases, treatment only begins after two months. This delay also impacts the proportion of deaths, which exceeds 15% in the region, well above the Brazilian average, which is 6%.
The World Health Organization’s goal is to screen at least 70% of women, with high-performance tests. Therefore, 90% of HPV-positive cases must be treated quickly. The director of Inca explains the ideal route, starting from the diagnosis: “If you took the test and detected the virus, the ideal is to have a colposcopy exam, to assess whether you have any lesions and perform a biopsy when necessary. If If a precursor lesion is identified, excision should be carried out and if the disease is diagnosed, with an adenocarcinoma already present, the patient must be referred to a highly complex service to treat colon cancer.” To reach the WHO target, Brazil needs to increase the number of colposcopies by at least 56% and the number of biopsies by more than 600%.
Vaccination
The elimination of cervical cancer, however, will only be possible if new HPV infections stop occurring, which depends on vaccination. The goal is to reach 90% of the target audience, currently made up of girls and boys aged 9 to 14. Vaccination through the Unified Health System (SUS) is also available for immunocompromised people, victims of sexual violence and users of Prep, HIV Pre-Exposure Prophylaxis, up to 45 years of age. Furthermore, the Ministry of Health launched a strategy to rescue young people up to 19 years of age who have not been vaccinated at the appropriate age.
The director of the National Immunization Program, Eder Gatti, explains why this is the scheme adopted by the SUS: “This is the public that has not yet entered into sexual life, that is, has not yet been exposed to the virus. It is the public that has the greater risk and, at the same time, the best opportunity to protect themselves. For the sake of targeting efforts, considering that the PNI is a programmatic and preventive action, we chose this target group of 9 to 14 years old. of the person, greater the risk of having already experienced exposure to HPV, which is a very common virus. So, in terms of results, it ends up being better to target teenagers.”
Vaccination against HPV in Brazil turns ten years old in 2014 and has included a larger target audience since then. The most up-to-date figures show that until last year, Brazil achieved an average vaccination coverage among girls of 81.1%, which rose from 96% in Paraná, but did not reach 43% in Acre. The vaccination of boys is more worrying, with an average coverage of 56.9% in Brazil and just 25% in the state of the Northern Region.
This Friday (6), the PNI should launch a new tool for monitoring the application of the vaccine, with coverage rates divided by each age of the target audience. It shows that coverage among 9-year-old children was below 69% last year, but among 13-year-old teenagers, it had already reached 100%.
Since April, the PNI has adopted a vaccination schedule of just one dose, replacing the two that were previously necessary. The change is recommended by the WHO, as it prevents the teenager from having to return to the health center to take the booster dose and only then be completely immunized. This year, more than 6 million doses of the vaccine were distributed to states and municipalities. According to the director of the National Immunization Program Eder Gatti, the priority for next year is to increase reach in municipalities that still have low coverage, especially among boys.
