3. Screening in primary health care for the main chronic non-communicable diseases in Brazil

Brazil can move towards a population-based cervical cancer screening programme, while introducing HPV-DNA primary testing in PHC settings

In the area of cervical cancer screening, especially after the introduction of the HPV vaccine, Brazil could consider instituting primary testing for the DNA of oncogenic HPV types as novel method for screening. This would ideally require moving towards a population-based screening programme, further analysing the current epidemiology in the country and conducting a complete health technology assessment to understand the different factors that will determine the efficacy and cost-effectiveness of implementing such an organised programme. It would be important to use reliable, validated HPV tests in qualified laboratories, accredited by authorised accreditation bodies (e.g. ANVISA) and in compliance with international standards. Training for health workers would be another crucial component, along with communication strategies for women in target population.

A recent systematic review focusing in low- and middle-income countries found that cytology‐based screening was the least effective and most costly screening method, while self‐collected HPV testing was cost‐effective when it yielded population coverage gains over other screening methods. The cost of the HPV test and loss to follow‐up were also important factors (Mezei et al., 2017[17]). The European guidelines recommend the use of HPV primary testing within an organised, population-based programme for cervical cancer screening, avoiding co-testing (HPV and cytology primary testing) at any given age (von Karsa et al., 2015[18]). The American Cancer Society 2020 guidelines also recommends HPV primary testing as the preferred screening method (Fontham et al., 2020[19]).

Such a national strategy 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) (von Karsa et al., 2015[18]). Box 3.2 summarises the experience of Finland and Italy with implementing HPV testing.

Self-sampling with HPV testing has been explored as a novel strategy to increase screening coverage and could be considered in Brazil, for instance, within pilot studies. A systematic review including 34 studies, mostly from high-income countries, found greater screening uptake among HPV self-sampling participants compared with standard of care (e.g. Pap smear, visual inspection with acetic acid, clinician-collected HPV testing) (RR: 2.13, 95% CI 1.89 to 2.40). Uptake was higher when HPV self-sampling kits were sent directly to women’s homes (RR: 2.27, 95% CI 1.89 to 2.71) or offered door-to-door by a health worker (RR: 2.37, 95% CI 1.12 to 5.03). However, meta-analysis showed no statistically significant difference in linkage to clinical assessment/treatment between arms (RR: 1.12, 95% CI 0.80 to 1.57) (Yeh et al., 2019[22]). The European guidelines state that the clinical accuracy of HPV primary testing on self-collected samples is sufficient to conduct pilot programmes (von Karsa et al., 2015[18]), while the American Cancer Society did not include a recommendation about it because the Food and Drug Administration has not yet approved self-sampling (Fontham et al., 2020[19]).

Brazil already has practical experiences with using HPV-DNA testing for screening. For instance, a study evaluated HPV-DNA screening in São Paulo, including 16 102 women, finding that high-risk HPV-DNA prevalence was 14.9%, whereas cytology abnormalities were found in 7.2% of the women. HPV DNA detected a significant number of patients with premalignant lesions missed by cytology and all 16 cervical intraepithelial neoplasia positive cases were HPV-DNA+. Authors concluded that HPV genotyping may reduce the burden of colposcopic referral and that HPV-DNA testing was shown to be feasible and advantageous over current cytologic screening in the public health system (Levi et al., 2019[23]). Another study conducted in three Brazilian cities found that the most relevant barriers for a more comprehensive screening programme relates to excessive travel required to access clinics, inconvenient service hours, and lack of public education. In addition, cytology had many unsatisfactory results and low positivity, follow-up was incomplete at all steps and laboratories provided delayed cytology and biopsy results (3+ months). Finally, screening clinics did not arrange or track colposcopy referrals; colposcopy clinics received no information from referring clinics, and electronic medical records have not yet replaced paper recordkeeping, leading to errors and loss of medical records (Ribeiro et al., 2018[24]). The identification of these and other barriers would be very important for policy design and an eventual implementation phase.

Breast cancer screening can evolve to a population-based organised programme and more tools can be provided in PHC

As in the vast majority of OECD countries (see Table 3.2), Brazil can develop a population-based breast cancer screening programme. In practice, this would require an effective call-recall structure, device a screening registry and safeguard robust quality assurance at all levels. The current process for population’s registration in Brazil’s PHC goes in the direction of individually identifying the eligible target population in each area served (e.g. municipalities), so it represents an opportunity for developing organised screening programmes.

The European guidelines on breast cancer screening and diagnosis describes seven characteristics of an organised screening programme (ECIBC, 2020[25]): 1. a policy specifying target population; 2. screening method and interval; 3. an active invitation of the entire target population; 4. a team responsible for overseeing screening centres; 5. a decision structure and responsibility for health care management; 6. a quality assurance system utilising relevant data; and 7. monitoring of cancer occurrence in the target population.

Building capacity in PHC teams would be crucial. As stated by WHO guidelines (WHO, 2017[26]), early diagnosis capacities requires guidelines or protocols and sensitise providers to cancer signs and symptoms to improve diagnostic accuracy; give sufficient time to evaluate patients and train practitioners in how to diagnose cancer including use of medical devices; promote a clear communication between the provider and the patient; and develop reliable referral mechanisms. In addition, mammography machines distribution across the country should be also revised to achieve a balanced supply according to the population’s need.

Brazil could build up from local experiences that have made progress towards an organised screening programme. For instance, a breast cancer organised screening programme in the community of the Andaraí in Rio de Janeiro targeting asymptomatic women aged between 50-69 years from SUS presented a mammographic coverage rate of 70%, suggesting that a population-based screening is feasible (Gioia et al., 2018[27]).

Systematic personalised invitations and reminders from PHC teams could improve cancer screening coverage

As part of population-based organised screening programmes, Brazil could adopt a more systematic and personalised approach in inviting target populations, as has been implemented in many OECD countries. An increasing number of OECD countries send a personal invitation letter for cancer screening to each individual in the target group, issued through a registry in a systematic manner. In Brazil, however, there is no national initiative regarding such invitations, which in practice are only implemented in some local levels depending on the initiative of particular municipalities or PHC teams.

In the majority of OECD countries, the invitation letter includes information on the benefits and potential harms of cancer screening such as false-positive screening results, over-diagnosis and over-treatment, and asks for either signed or verbal informed consent for screening (IARC, 2017[28]). This practice is in accordance with international recommendations as the WHO recommends organised population-based mammography screening programmes to provide information on both benefits and risks of mammography screening so that target women are able to make an informed decision before undergoing mammography (WHO, 2014[29]). In many OECD countries, additional efforts are also made to invite people with positive screening results in the past for follow-up assessment, and in some countries such as Denmark, Finland, Germany, Ireland, Italy, the Netherlands, Spain, Sweden and the United Kingdom, appointment date is fixed for mammography in the letter to further facilitate access to cancer screening (IARC, 2017[28]; ECIBC, 2020[30]).

A systematic review identified the most effective interventions to increase participation in organised screening programmes. Interventions such as postal reminders, telephone reminders, PHC physician’s signature on invitation letter, and giving scheduled appointment instead of open appointment were all effective to increase uptake of breast, cervical and colon cancer screening. Mailing a kit for self-sampling cervical specimens increased participation in non-responders as well (Camilloni et al., 2013[31]). Another systematic review found that text messaging (short message service, SMS) appear to moderately increase screening rates for breast and cervical cancer and may have a small effect on colorectal cancer screening (Uy et al., 2017[32]). Future studies would also need to examine the cost associated with each of the invitation options and its impact in order to identify the most appropriate cost-effective strategies that may be different across regions in Brazil.

Screening in Brazil’s PHC could explore expanding to sites such as colon and lung cancer

As colorectal and lung cancer are among the most important cancers in the country (see Figure 3.4), Brazil could explore the possibility of creating national screening programmes for these cancer sites.

For colorectal cancer, which represents the third major cause of cancer mortality in Brazil for men and women, opportunistic screening is available. The recommendation in SUS is to prioritise early diagnosis actions and personalised approach for high-risk groups. Recognising Brazil’s different epidemiological and health care network realities, further studies are still needed to support the analysis of the feasibility of introducing screening in these different contexts (INCA, 2019[33]).

As reference, an increasing number of OECD countries have introduced population-based colorectal cancer screening programme for free to target population in recent years, and in many of these countries target population is the population of 50s and 60s years of age often with an upper age limit ranging between 64 and 74 (OECD, 2013[34]). The European guidelines recommend “only organised screening programmes should be implemented, as opposed to case-finding or opportunistic screening as only organised programmes can be properly quality assured”. It also states that several issues should be considered: the legal framework, the availability and accuracy of epidemiological and demographic data, the availability of quality-assured services for diagnosis and treatment, promotional efforts, a working relationship with the local cancer registry, and follow-up for causes of death at individual level (Malila, Senore and Armaroli, 2012[35]). The United States recommends that adults age 50 to 75 be screened for colorectal cancer, either with stool tests, flexible sigmoidoscopy, colonoscopy, and CT colonography (virtual colonoscopy) (USPSTF, 2021[36]), varying depending on the patient’s history and health system availability (Bibbins-Domingo et al., 2016[37]).

In relation to lung cancer, which represent the second cause of cancer deaths in Brazil (see Figure 3.4), general population screening is not currently recommended in the country and any examination should be discussed between the patient and the doctor (INCA, 2020[38]). Lung cancer screening is not common in OECD countries, but it exists in Canada, Japan and the United States. The Canadian Task Force on Preventive Health Care recommends screening for lung cancer with three consecutive annual low-dose computed tomography (LDCT) scans in high-risk individuals adults aged 55-74 years who currently smoke or quit less than 15 years ago, with a smoking history of at least 30 pack-years (CTFPHC, 2016[39]). In Japan, annual chest X-ray is recommended for people aged 40 and over, and sputum cytology is also recommended for smokers aged 50 and over who have smoked more than 600 cigarettes over their lifetime (OECD, 2019[40]). In the United States, the USPSTF released an updated recommendation in March 2021. Lung cancer screening is recommended as an annual screening with LDCT in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery (USPSTF, 2021[36]).

Brazil could develop a thorough evidence-based analysis, including cost-effectiveness studies, to identify the potential harms and benefits of implementing colorectal and/or lung cancer screening in the country, along with appropriate definitions in areas such as eligibility criteria, screening intervals, existing local initiatives, monitoring schemes and quality improvement, infrastructure and equipment, and payment mechanism.

A redesign of cancer information systems can help manage screening programmes more effectively

Brazil has developed a monitoring system for cancer screening (SISCAN), cancer care (PAINEL-Oncologia) and population-level cancer epidemiology (Population-based cancer registry), which provides a good information infrastructure base. In addition, population-based surveys (Vigitel) regularly collect screening coverage and barriers to screening in view of seeking ways to increase screening coverage.

The main challenges for the cancer information infrastructure in Brazil, including screening information, relates to coverage, interconnectedness and feedback. Coverage aims to reach the full extent of the target population for each screening programme (including actions in the private sector). Interconnection challenges relate to linking existing information systems, for which an expansion of the national health card would be fundamental. Feedback to different actors in the health system, importantly to all PHC teams, is crucial to ensure that decisions and actions are informed by regular and updated information.

A comprehensive information system based on registries, capable of following each patient individually, is essential for efficient management of screening programmes and cancer care delivery. It can identify target population who have and have not participated in the screening programmes, those who are monitored outside of the programme due to their previous diagnosis of cancer and/or genetic predisposition to specific cancer and those who do not consent to do screening. Using such a system, personalised invitations and reminders for cancer screening, which are important for increasing screening coverage, can be sent systematically to target population.

Integrated information systems generate data that need to be analysed periodically to assess the effectiveness of existing cancer screening protocols such as target group, screening frequency and/or methods and across population with different background. Brazil has started producing this data, which is also publicly available on line through DATASUS. Several OECD countries use information around cancer screening to improve quality of screening programmes as well. They provide feedback to individual providers and benchmarking is also possible. A systematic literature review supports these additional efforts as it found that provider assessment and feedback contribute to increased coverage for cervical, breast and colorectal cancer screening (Sabatino et al., 2012[41]).

Better information and communication technologies could improve public awareness and health literacy

Alongside more personalised invitation to cancer screening, Brazil could develop further communication and information-sharing strategies to improve public awareness on cancer prevention and screening and health literacy of the population. Since 2002, the Ministry of Health of Brazil has been investing annually in actions to raise awareness of cancer prevention measures, for instance, through the October Pink Campaign. The campaign consists of lighting buildings and monuments conveying the message “Prevention is necessary”, while also promoting healthy lifestyle among women, encouraging HPV vaccination, overcome fear or stigma associated with cancer, among other topics.

Municipalities, with support from the State and the Federal Government, works to promote screening tests, through campaigns using printed media, social networks and local media. During determined periods in the year, some municipalities implement mobile units, which go to communities in the most distant parts of the country as a mean of increasing screening access, diagnosis and treatment. In addition, INCA has developed manuals or flyers that are sent to PHC teams every year for informing the public in the community and at work about healthy lifestyles to prevent cancer and the importance of early detection for cancer. INCA also develops videos and written material that is publicly disseminated in websites and social media.

As systematic sharing of information related to cancer is limited, particularly for cancer without screening programmes, Brazil could also better develop information-sharing strategies to help patients to seek care, including cancer diagnostic services, at the right place at the right time. In this context, an increasing number of OECD countries have developed information-sharing platforms to better involve and enable patients in taking care of their own health and navigating through health care systems for their conditions. For example, some OECD countries including Denmark (see Box 3.3), England and Estonia have developed a platform such as a website or e-Health account to share evidence-based information on health care for different diseases including cancer throughout patient pathway with a view to promoting health literacy of the population and to support them to seek health care including cancer screening, diagnosis and treatment appropriately in a timely manner.

Brazil could develop population-based hypertension and type 2 diabetes screening targeting high-risk population groups

Several OECD countries have health check-ups for chronic conditions, usually targeted at particular groups of the population, undertaken periodically for example every five years, and sometimes provided by health care professionals other than doctors. In Estonia, health check-ups and guidance are provided by family nurses for people aged between 40 and 60 with hypertension or diabetes (Habicht et al., 2018[59]), and in 2007, Korea introduced the National Screening Programme for Transitional Ages, targeting people at age 40 and 66 (Kim et al., 2012[60]). In England, the NHS Health Check was introduced for people aged between 40 and 74 in 2009 and an invitation letter is sent every five years to those who do not already have diabetes, heart disease, or kidney disease or have not had a stroke, in order to screen them for the risk of developing chronic conditions including heart disease, stroke, kidney disease, type 2 diabetes, or dementia (available only for those above 65 and above). This check-up is often undertaken by a nurse or health care assistant (Gmeinder, Morgan and Mueller, 2017[61]; NHS, 2018[62]). Table 3.4 shows the recommendations for hypertension screening from selected evidence-based guidelines along with the latest recommendations in Brazil.

However, a recent review commissioned by WHO Europe found that the available evidence does not support the recommendation on systematic population-level screening for hypertension (Eriksen et al., 2021[66]). Instead of recommending systematic screening, the preferred alternative would be targeting those in PHC who may be at a higher risk owing to age or the presence of a risk factor (i.e. case-finding). In Brazil, a study identifying the main risk factors for developing hypertension found that the prevalence increased with age, low educational level, increased body mass index and abdominal waist, and urinary sodium excretion (Cipullo et al., 2010[67]). This type of studies in the Brazilian population could help to define the target group in order to guide future hypertension screening recommendations.

Similarly as with hypertension, diabetes screening in OECD countries is normally embedded in more general health check-ups. In Australia, for example, PHC physicians can provide health assessment for people who are at risk of developing a chronic disease. This assessment is provided to people aged between 45 and 49 once if they have at least one risk factor (lifestyle habits or a family history) for developing a chronic disease such as type 2 diabetes or heart disease. The assessment is also provided to people aged 75 and over with an interval of 12 months or longer (Department of Health, 2014[68]). In view of reducing the prevalence of lifestyle-related diseases including cancer, cardiovascular diseases and diabetes, Japan introduced the specific health check-up (Tokutei kenshin) to the population aged between 40 and 74 in 2008. All insurers in the Japanese health system are obliged to provide a specific health check-up to people in this age group every year as they are considered to have higher risks of developing lifestyle-related diseases. Insurers need to provide a nationwide standard set of health check-up items (OECD, 2019[40]). Table 3.5 shows the recommendations for diabetes mellitus type 2 screening from selected evidence-based guidelines along with the latest recommendation in Brazil.

According to the most recent scientific evidence, too much screening (e.g. by having a too wide target population) probably will not improve population health outcomes and can be an inefficient use of resources. Therefore, Brazil can aim for well-targeted hypertension and type 2 diabetes screening population-based programmes, based on its national epidemiology, health system characteristics and cost-effectiveness analysis, as an effective way to identify and manage chronic disease.

Strengthen disease management pathways with a people-centred perspective

Hypertension and diabetes screening should be just the first step in a clear disease management pathway in Brazil. Chronic disease management pathways (also called integrated care pathways), which can be embedded on clinical guidelines, should be available for all high prevalence chronic diseases, to give guidance to health care providers and patients over expectations of the care that should be delivered and received. The two existing clinical guidelines in Brazil (Ministério da Saúde, 2013[50]; CONITEC, 2020[51]) represent a very positive step towards developing best practice guidelines with explicit pathways of care. For the moment these pathways are focused on information for health professionals in PHC, but could be expanded to integrate other care providers (for example specialists, or patient-support groups), and be produced in a patient-friendly format.

Pathways of chronic disease care, produced in both patient-facing and clinician-facing formats, should clearly establish the professional responsibilities of health professionals at different stages of disease. These pathways can be used to set quality expectations for chronic diseases such as diabetes and cardiovascular disease, and standardise quality of care across Brazil. The pathways can also be used to clarify expected roles for different care providers. In the area of diabetes, clinical pathways can help by: (1) assisting to systemically evaluate the patient’s clinical presentation and risk factors; (2) choosing the most appropriate behavioural and medication interventions; and (3) providing a timeline for patient follow-up and monitoring. In short, clinical pathways will assist in the co-ordination of care and follow-up (Wong, 2017[71]).

Figure 3.16. NHS England RightCare Pathway: Diabetes, summary table

Source: NHS England (2018[72]), NHS RightCare, Diabetes pathway, https://www.england.nhs.uk/rightcare/products/pathways/diabetes-pathway

England has developed more complex pathways, which include expectations at different stages of the disease, the roles for different care providers, key interventions and target outcomes (NHS England, 2018[72]). England’s ‘NHS RightCare Pathway: Diabetes’ includes, for example, an expectation that care planning and an annual review take place for patients with both Type 1 and Type 2 diabetes, and the Pathway includes links to supportive documentation to help with care planning. In England, the expectation is that a lot of diabetes care is provided by multidisciplinary teams in community care settings, and the Pathway includes details of the services that the team would usually provide (patient education, pregnancy advice, foot protection team) (see Figure 3.16).

Alongside establishing clear chronic disease management pathways, there is a need to ensure that other levers within the system are effectively aligned with the pathway. This includes line up payment and reimbursement incentives, as well as ensuring that health professionals have the tools and capacities they need to undertake the responsibilities expected of them.

Create more capacity in PHC for screening and management of hypertension and diabetes through expanding the role of health workers

To strengthen prevention capacity and impact, Brazil should look to increase capacity in PHC. One way that several OECD countries have found to increase capacity relates to task shifting or expanding the role of other health workers (Box 3.5). Exploring whether there are ways for other health workers – for instance nurses, nutritionists or pharmacists – to play a role in delivering some of these key prevention activities is certainly a possibility for Brazil.

For example, when it comes to diabetes, nurses could have the capacity and training to conduct an initial assessment of the patient, including ensuring the capacity to do blood sugar testing in all practices and working together with doctors and other team members in follow-up activities. In general terms, nurse-provided care has shown equivalent or better quality of care across a large range of clinical outcome measures for chronic conditions, including diabetes (Maier, Aiken and Busse, 2017[73]). A systematic review found that nurse-led care was at least as effective as physician-led care in providing secondary prevention to patients with chronic conditions, where 84% of outcome parameters showed no statistically significant differences, and for the remaining 16%, secondary prevention outcomes improved in the nurse-group, primarily among patients with diabetes. In this patient group, nurse-led care was superior in preventing the onset of heart disease and it lowered cardiovascular risk (Martínez-González et al., 2015[74]).

Community pharmacists can also be considered for task shifting policies, and in most OECD countries its role has evolved substantially in recent years. Pharmacists can play a key part in giving advice to patients and supporting them to navigate their health needs and manage their care. Recent systematic reviews have shown that pharmacist involvement in care may improve health outcomes for chronic conditions such as diabetes and hypertension (Pousinho et al., 2016[75]), while it can turn to be cost-effective for health systems (Wang, Yeo and Ko, 2016[76]). In Brazil, pharmacists do not seem to have a large presence in PHC teams, even stating that pharmacists’ isolation in PHC prevails (Barberato, Scherer and Lacourt, 2019[77]). Therefore, such a policy would require a thorough analysis and planning to define the best way to invest on further introducing community pharmacists in Brazil’s PHC teams.

The health information system needs to be developed further to support targeted population-based screening for better monitoring and evaluation

Screening and other health care activities for hypertension and diabetes have the potential of generating a wealth of valuable health information, which could be used both for better managing population health, designing and targeting more effective public health interventions, and for research. However, HIPERDIA, Brazil’s health information system for hypertension and diabetes in PHC, does not collect information about screening and it is not capable of capturing the pathway of care for each patient either (e.g. referrals, waiting times, consultations with specialists, laboratory tests, medications, etc.). It is also hard for PHC teams to review and act on this information as they do not receive regular feedback, and patients cannot have access to his personal health data. It is also difficult for the system to link with other databases such as hospitalisations, death registries, etc.

Many OECD countries have nationally standardised digital medical records and they are able to use up-to-date data for monitoring and evaluation of the health system by automatically extracting data from electronic clinical records. For example, 13 countries including Canada, the Czech Republic, Denmark, Finland, Israel, Korea, New Zealand, Norway, Singapore, Sweden and the United Kingdom (England, Scotland and Wales) regularly link data from different national datasets such as hospital and mental hospital in-patient data, cancer registry data and mortality data. Using these linked data, these countries are able to actively monitor health care quality and health system performance.

In order to monitor and further develop secondary prevention strategies, Brazil needs to develop a health information system, which allows linking different data sources. Experiences of other OECD countries in developing a strong health information system within a data governance framework that protects patients’ health information privacy, which is laid out in OECD (2019[79]), would be useful for Brazil in following such paths.

A stronger health information system could also facilitate streamlining the efforts to invite target population for hypertension and diabetes screening. Currently, these screenings are largely opportunistic and there is no information about who is receiving them. Moreover, it is not possible for municipalities or PHC teams to identify whom to send the invitations. The current process for population’s registration in Brazil’s PHC represents an opportunity for developing organised screening programmes. Brazil could send personalised invitation letters, without duplication, only to those who are in the target population, and not currently undergoing treatment, and to those who have not followed up on worrying results from a previous check-up. These targeted personalised approaches are considered more effective in recruiting people in need of health check-ups (Bunten et al., 2020[80]).

In the future, Brazil could consider bundled payments as a mechanism to improve management of chronic conditions in PHC

Brazil has recently innovated on its payment scheme in PHC with the Previne Brasil programme. For the future, another alternative to explore are bundled payments, in particular, for chronic conditions. These consist of one payment per patient with a chronic illness to cover the cost of all health care services provided by the full range of providers during a specific time period. It has been introduced in OECD countries to incentivise co-ordination of care between providers, or provide a broader set of care (e.g. education, regular checks, occasional specific checks). Bundled payments can encourage collaboration within and across care settings, contribute to greater standardisation of care for example by requiring adherence to quality criteria, and can strengthen data availability by requiring the collection of monitoring indicators or integration of data systems across care settings, and control overall costs (OECD, 2016[81]).

Although the design and characteristics of bundled payments differ between OECD countries, the models developed in Australia and Canada could be of particular interest to Brazil and others. In these countries, the bundled payment accounts for patient complexity, which is an important prerequisite to encourage the participation of PHC providers (OECD, 2020[78]).