Inequality in breast cancer care in a Brazilian capital city: a comparative analysis of narratives

Molecular subtypes as a prognostic breast cancer factor in women users of the São Paulo public health system, Brazil

OBJECTIVE

This study aimed to analyze the prognosis of women with breast cancer by molecular subtypes, sociodemographic variables, and clinical and treatment characteristics.

METHODS

This hospital-based retrospective cohort study analyzed 1,654 women over 18 years of age diagnosed with invasive breast cancer from 2000 to 2018. Data were extracted from Brazil's Oncocenter Foundation of São Paulo. The variables analyzed were age, histology, molecular subtypes, clinical staging, treatment type, and diagnosis-to-treatment time. Cox regression analysis was applied to estimate death risk.

RESULTS

Women with HER-2-positive (nonluminal) and triple-negative molecular subtypes were more than twice more likely to be at risk of death, with adjusted hazard ratio - HRadj=2.30 (95% confidence interval - 95%CI 1.34-3.94) and HRadj=2.51 (95%CI 1.61-3.92), respectively. A delayed treatment associated with an advanced clinical stage at diagnosis increased fourfold the risk of death (HRadj=4.20 (95%CI 2.36-7.49).

CONCLUSION

In summary, besides that interaction between advanced clinical stage and longer time between diagnosis and treatment, HER-2-positive (nonluminal) and triple-negative phenotypes were associated with a worse prognosis. Therefore, actions to reduce barriers in diagnosis and treatment can provide better outcome, even in aggressive phenotypes.

Leveling Up the Access to Radiation Therapy in Latin America: Economic Analysis of Investment, Equity, and Inclusion Opportunities Up to 2030

PURPOSE

Latin America faces a shortage in radiation therapy (RT) units and qualified personnel for timely and high-quality treatment of patients with cancer. Investing in equitable and inclusive access to RT over the next decade would prevent thousands of deaths. Measuring the investment gap and payoff is necessary for stakeholder discussions and capacity planning efforts.

METHODS AND MATERIALS

Data were collected from the International Atomic Energy Agency's Directory of Radiotherapy Centers, industry stakeholders, and individual surveys sent to national scientific societies. Nationwide data on available devices and personnel were compiled. The 10 most common cancers in 2020 with RT indication and their respective incidence rates were considered for gap calculations. The gross 2-year financial return on investment was calculated based on an average monthly salary across Latin America. A 10-year cost projection was calculated according to the estimated population dynamics for the period until 2030.

RESULTS

Eleven countries were included in the study, accounting for 557,213,447 people in 2020 and 561 RT facilities. Approximately 1,065,684 new cancer cases were diagnosed, and a mean density of 768,469 (standard deviation ±392,778) people per available unit was found. By projecting the currently available treatment fractions to determine those required in 2030, it was found that 62.3% and 130.8% increases in external beam RT and brachytherapy units are needed from the baseline, respectively. An overall regional investment of approximately United States (US) $349,650,480 in 2020 would have covered the existing demand. An investment of US $872,889,949 will be necessary by 2030, with the expectation of a 2-year posttreatment gross return on investment of more than US $2.1 billion from patients treated in 2030 only.

CONCLUSIONS

Investment in RT services is lagging in Latin America in terms of the population's needs. An accelerated outlay could save additional lives during the next decade, create a self-sustaining system, and reduce region-wide inequities in cancer care access. Cash flow analyses are warranted to tailor precise national-level intervention strategies.

Intercultural Competence Predicts Intercultural Effectiveness: Test of an Integrative Framework

Why does someone thrive in intercultural situations; while others seem to struggle? In 2014, Leung and colleagues summarized the literature on intercultural competence and intercultural effectiveness into a theoretical framework. This integrative framework hypothesizes that the interrelations between intercultural traits, intercultural attitudes and worldviews, and intercultural capabilities predict the effectiveness with which individuals respond to intercultural situations. An empirically verified framework can contribute to understanding intercultural competence and effectiveness in health care workers, thus contributing to more equity in health care. The present study sets out to test this integrative framework in a specific health care context. Future health care practitioners (N = 842) in Flanders (Belgium) were questioned on all multidimensional components of the framework. Structural equation modeling showed that our data were adequate to even a good fit with the theoretical framework, while providing at least partial evidence for all hypothesized relations. Results further showed that intercultural capabilities remain the major gateway toward more effective intercultural behavior. Especially the motivation and cognition dimensions of cultural intelligence seem to be key factors, making these dimensions an excellent target for training, practical interventions, and identifying best practices, ultimately supporting greater intercultural effectiveness and more equity in health care.

Challenge of Incorporating New Drugs for Breast Cancer in Brazil: A Proposed Framework for Improving Access to Innovative Therapies

PURPOSE

The objective of this review is to address the barriers limiting access to treatment of advanced metastatic breast cancer (mBC) in Brazil, specifically for patients in the public health care system, arguably those with the least access to innovation.

MATERIALS AND METHODS

A selected panel of Brazilian experts in BC were provided with a series of relevant questions to address in a multiday conference. During the conference, responses were discussed and edited by the entire group through numerous drafts and rounds of discussion until a consensus was achieved.

RESULTS

The authors propose specific and realistic recommendations for implementing access to new drugs in cancer care in Brazil. Moreover, in creating these recommendations and framework, the authors strive to address the most important barriers and impediments for technology incorporation. A feasible and specific multidisciplinary process is proposed, which is based on the collective participation of all involved stakeholders.

CONCLUSION

Given the current benefits and likely future developments, there is a great need to expand treatments for mBC not only in Brazil but also in most other countries in the world where access issues remain an unresolved demand. Adapting the current framework is essential for accomplishing this goal. The recommendations in this review can serve as a framework for adoption of new technologies in countries with limited resources.

A multilevel assessment of the social determinants associated with the late stage diagnosis of breast cancer

The advanced-stage diagnosis of breast cancer reveals the inequalities associated with socioeconomic conditions and the offer of health services. This study analyzes the prevalence of advanced breast cancer and its relationship with individual and contextual socioeconomic indicators and offer of health service. A cross-sectional study is presented herein, on the assessment of malignant breast neoplasms in women diagnosed between 2006 and 2015 (n = 195,201). Data were collected from the Hospital Cancer Registry (HCR), Atlas of Human Development in Brazil, and from the National Registry of Health Institutions (NRHI). A multilevel Poisson Regression was carried out with random intercept. The prevalence of advanced breast cancer diagnosis was 40.0%. Advanced staging was associated with younger age groups (PR 1.41), race/nonwhite (PR 1.13), lower education levels (PR 1.38), and public access to health services (PR 1.25). There was also an association with a low density of mammographic equipment (PR 1.08), and with low indices of local social inequality (PR 1.33) and human development (PR 0.80). This study maps and highlights the causes related to inequalities in the diagnosis of advanced breast cancer in Brazil, and presents essential data to reorient public policies and health-related actions to strengthen the control of breast cancer in Brazil.

Realizing the right to health in Latin America, equitably

This special issue “Realizing the Right to Health in Latin America and the Caribbean” provides an overview of one of the most challenging objectives of health systems: equity and the realization of the right to health. In particular, it concentrates on the issues associated with such a challenge in countries suffering of deep inequity. The experience in Latin America and the Caribbean demonstrates that the efforts of health systems to achieve Universal Health Coverage are necessary but not sufficient to achieve an equitable realization of the right to health for all. The inequitable realization of all other human rights also determines the realization of the right to health.