[Opportunistic screening versus missed opportunities: non-adherence to Pap smear testing in women attending prenatal care]

Pap smears in the extreme South of Brazil: low coverage and exposure of the most vulnerable pregnant women

OBJECTIVE

To estimate prevalence, assess trends and identify factors associated with non-performance of Pap smears among postpartum women residing in Rio Grande, Southern Brazil.

METHODS

Between 01/01 and 12/31 of 2007, 2010, 2013, 2016 and 2019, previously trained interviewers applied a single standardized questionnaire at the hospital to all postpartum women residing in this municipality. It was investigated from the planning of pregnancy to the immediate postpartum period. The outcome consisted of not performing a Pap smear in the last three years. The chi-square test was used to compare proportions and assess trends, and Poisson regression with robust variance adjustment in the multivariate analysis. The measure of effect was the prevalence ratio (PR).

RESULTS

Although 80% of the 12,415 study participants had performed at least six prenatal consultations, 43.0% (95%CI 42.1-43.9%) had not been screened in the period. This proportion ranged from 64.0% (62.1-65.8%) to 27.9% (26.1-29.6%). The adjusted analysis showed a higher PR for not performing Pap smears among younger puerperal women, living without a partner, with black skin color, lower schooling, and family income, who did not have paid work during pregnancy or planned pregnancy, who attended fewer prenatal consultations. smoked during pregnancy and were not being treated for any illness.

CONCLUSION

Despite the improvement in coverage, the observed rate of non-performance of Pap smears is still high. Women most likely to have cervical cancer were those who had the highest PR for not having this test.

Cervical cytology results among pregnant and non-pregnant women in Brazil

OBJECTIVE

To compare the prevalence of abnormal cervical smear results among pregnant and non-pregnant women with and without representation of the transformation zone (TZ) in a mid-sized city in Brazil.

STUDY DESIGN

This observational analytical and retrospective study analyzed cervical smear results from pregnant and non-pregnant women in a mid-sized city in Brazil. Private data were collected at private clinics over seven years and from public services over 16 years. All results were reported according to Bethesda System. Pregnant women were separated from non-pregnant women, and women were stratified into two age groups (25-29 years and 30-34 years) in general analyses. For TZ representation and cytologic-histologic correlation, there was no age stratification.

RESULTS

Among public services cervical smears, the frequency of atypical squamous cells of undetermined significance (ASC-US) was higher for pregnant women in the entire group (odds ratio [OR] 1.91; confidence interval [CI] 1.07-3.39) and among women from 30 to 40 years old (OR 2.79; CI 1.38-5.66). The same occurred for low-grade squamous intraepithelial lesion (LSIL) in the total group (OR 3.50; CI 1.44-8.53) and among women 30 to 40 years old (OR 4.57; CI 1.45-14.42). The frequency of ASC-US was higher in pregnant women with TZ representation exams than those without (OR 4.62; CI 2.17-9.84). The same occurred for those with atypical squamous cells, which cannot exclude high-grade squamous intraepithelial lesion (OR 9.81; CI 1.63-59.15) and LSIL (OR 10.47; CI 3.39-32.36). Among pregnant women with abnormal cervical smear results, 85.74% were followed up through cytology, and an average of 26.12% of patients underwent biopsy, of which almost all were positive for dysplasia.

CONCLUSION

Pregnant and non-pregnant women did not differ in cervical smears with actual precursor lesions. Nevertheless, considering the opportunistic nature of Brazilian cervical cancer screening, prenatal visits present an opportunity to perform cervical smears in pregnant women. TZ representation correlated with higher rates of abnormal cervical smears, reinforcing the clinical importance of endocervical/metaplastic cell representation, including among pregnant women.

Barriers to Access the Pap Smear Test for Cervical Cancer Screening in Rural Riverside Populations Covered by a Fluvial Primary Healthcare Team in the Amazon

Cervical cancer is a major public health problem, especially in the north region of Brazil. The aim of the study was to identify the factors associated with not undergoing the cervical cancer screening test in rural riverside populations in the Amazon. A cross-sectional home-based survey was carried out in 38 locations covered by a fluvial primary healthcare team, and the administrative records of the screening tests from January 2016 to May 2019 were analyzed. After the descriptive analysis, logistic regression was performed considering the outcome of having undergone cervical cancer screening within the past three years. Of the 221 women assessed, 8.1% had never undergone the test, and 7.7% had undergone it more than three years ago. Multiparity (OR = 0.76 (95%CI = 0.64-0.90)), occupation in domestic activities (OR = 0.31 (95%CI = 0.11-0.89)), and lack of knowledge of the healthcare unit responsible for the service (OR = 0.18 (95%CI = 0.04-0.97)) were associated with not undergoing the cervical cancer screening test. The administrative records revealed that the screening test was performed outside the recommended age range (24%), performed needlessly (9.6%) with undue repetitions (3.2%), and a high percentage of the samples collected were unsatisfactory (23.5%). The findings revealed the existence of barriers for riverside women to access cervical cancer screening tests.

Tratamento ambulatorial do câncer do colo do útero em tempo oportuno: a influência da região de residência de mulheres no Estado de Minas Gerais, Brasil

O objetivo deste estudo é investigar se há associação entre as Regiões Ampliadas de Saúde (RAS) de residência de Minas Gerais, Brasil, e o intervalo entre diagnóstico e início de tratamento de mulheres que realizaram tratamento ambulatorial (quimioterapia ou radioterapia) para câncer do colo do útero pelo Sistema Único de Saúde (SUS), entre 2001 e 2015. Trata-se de um estudo transversal, recorte de uma coorte, com 8.857 mulheres. Para avaliar a associação da RAS de residência e o intervalo entre diagnóstico e início de tratamento (em dias), foram utilizados modelos de regressão binomial negativa, considerando nível de significância de 5%. Os modelos foram construídos usando blocos de covariáveis sociodemográficas, clínicas e relacionadas ao tratamento. Foi determinado que a RAS de residência das mulheres está associada ao intervalo entre o diagnóstico e o início de tratamento. A RAS Norte foi a região do estado onde a média de tempo para iniciar o tratamento foi menor, e não residir nessa RAS aumenta a média de tempo para iniciar o tratamento entre 24% e 93% em comparação com outras RAS do estado. Fica evidente a disparidade no intervalo entre diagnóstico e início de tratamento entre as regiões do Estado de Minas Gerais. A disponibilidade de serviços habilitados para o tratamento do câncer nas RAS não reflete necessariamente em maior agilidade para início de tratamento. Compreender os fluxos das Redes de Atenção Oncológica e suas diferenças regionais é fundamental para aprimorar políticas públicas que garantam o cumprimento de leis vigentes, como a Lei nº 12.732/2012, que preconiza o início do tratamento de pacientes com câncer em até 60 dias após o diagnóstico.

Trends in access to female cancer screening in Brazil, 2007-16

BACKGROUND

This study aims to analyse changes in the prevalence of cervical cancer (CCa) and breast cancer (BCa) screening among women in the Brazilian capitals and Federal District in the last decade (2007-16).

METHODS

Data from the surveillance system of risk and protective factors for chronic diseases through telephone interviews (n = 267 949) were used. Adequate screening consisted of, at least, one Pap test triennially, for women aged between 25 and 64 years, and mammography exam biannually, for women aged between 50 and 69 years. The prevalence of adequate screening was investigated for each type of cancer isolated and combined (women aged between 50 and 64 years). The prevalence of adequate screening was estimated for the total population and according to socioeconomic variables. Linear regression models were used.

RESULTS

The prevalence of adequate screening test for CCa remained stable, around 82%, while the screening test for BCa increased from 71 to 78% between 2007 and 2016. Higher increases were observed among women with low schooling and from less developed regions. The percentage of adequate screening (considering both types), for women aged between 25 and 69 years, remained stable, close to 78%.

CONCLUSIONS

Screening for BCa increased significantly. Smaller coverage rates are verified among women with low schooling and from less developed regions.

[Access to uterine cervical cytology in a health region: invisible women and vulnerable bodies]

This article evaluates access to the Papanicolaou test in the Family Health Strategy (FHS) in municipalities in a health region. Cervical cancer control depends on a well-organized Family Health Strategy, so assessment of access to the Papanicolaou test reflects the quality of care at this level. This is a qualitative study with data produced in 10 focus groups, totaling 70 participants in four municipalities. We analyzed the organizational, symbolic, and technical dimensions of access to the Pap test, with cervical cancer control as the marker. The results indicate that living in rural areas was a barrier to access to the Papanicolaou test and exacerbated the inequalities. Nurses were the principal reference for access to the Pap test. The absence of necessary items for collecting cervical cytopathology specimens was a barrier to access in all the municipalities. There were obstacles to access for women with disabilities and lesbian women, with care that was fragmented and out of sync with individual characteristics. The numerous obstacles to access to the Papanicolaou test exposed the selectiveness of the Family Health Strategy in the health region, since it reproduced the invisibility of women with greater social vulnerability and exacerbated the existing inequalities.

Evaluation of non-attendance for Pap test through the Surveillance System by telephone survey

OBJECTIVE

To estimate the prevalence of the Pap test and analyze the factors associated with its non-attendance by Brazilian women.

METHOD

Cross-sectional, population-based study in which were used Vigitel (Surveillance System for Protective and Risk Factors for Chronic Diseases by Telephone Survey ) data and were included women in the target age range of the screening. The coverage and prevalence of non-screening were assessed according to sociodemographic, behavioral and health characteristics.

RESULTS

Data from 22,580 women were included. About 17.1% of women did not take the Pap test in the three previous years. Women in the age groups of 35-44, 45-54 and 55-64 years showed a higher prevalence of having the test compared to those aged 25-34 years (p<0.05). The following factors were associated with the non-attendance: women with less than 12 years of study (p<0.05), who declared not having a partner (p<0.0001), residents of Northeast, Midwest and North regions (p<0.05), malnourished (p=0.017), who self-assessed their health as negative and presented at least one negative health behavior (p<0.0001).

CONCLUSION

Despite the high coverage of this screening, it remains unsatisfactory in population subgroups, such as women living without a partner, with low educational level, malnourished, who self-assessed their health status as negative, and with at least one negative health behavior.

A organização do rastreamento do câncer do colo uterino por uma equipe de Saúde da Família no Rio de Janeiro, Brasil

Introdução: O rastreamento organizado do câncer do colo do útero ainda é um desafio a ser vencido em todo o Brasil. Objetivo: Descrever a intervenção de uma equipe de Saúde da Família para a melhoria da qualidade das ações de rastreamento desta condição. Métodos: A intervenção foi estruturada a partir das recomendações nacionais para o rastreamento do câncer do colo do útero e das evidências disponíveis na literatura para aumento da participação popular em programas de rastreamento. Funcionalidades do sistema de prontuário eletrônico local foram fundamentais para a viabilização da proposta. A partir da reorientação de práticas assistenciais e administrativas, foi estabelecido e mantido por 15 meses um programa organizado de rastreamento do câncer do colo do útero nesta equipe de Saúde da Família. Resultados: No mês anterior ao início da intervenção, as equipes da unidade de saúde e da área programática apresentavam uma cobertura média de 10% da população alvo rastreada. Ao final de 15 meses, a equipe-intervenção atingiu uma cobertura de 44%, em contraste com a média de 22% das demais equipes da unidade, e 25% da área programática. Conclusões: Quando uma equipe de Saúde da Família empreende esforços para a organização do rastreamento do câncer do colo do útero, bons resultados podem ser alcançados no aumento da cobertura populacional. Esperamos que outras equipes possam se beneficiar da divulgação desta experiência e tomem para si a responsabilidade de organizar o rastreamento do câncer do colo do útero, impactando positivamente sobre a saúde de suas comunidades.