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2015; 61(1):1
1
EDITORIAL
Thoughts on breast cancer in Brazil
R
eflexões
sobre
o
câncer
de mama
no
B
rasil
C
arlos
A
lberto
R
uiz
1
, R
uffo
F
reitas
-J
unior
2
1President of the Brazilian Society of Mastology (2011-2013)
2President of the Brazilian Society of Mastology (2014-2016)
http://dx.doi.org/10.1590/1806-9282.61.01.001
In Brazil, a continuous increase in the incidence of
breast cancer has been observed, with the projection of
over 57,000 new cases in 2014. Unfortunately, the mor-
tality projection due to this type of cancer in the country
is also high, and approximately 13,000 Brazilian women
will have their lives cut short by the disease.
Approximately 30-40% of breast cancers diagnosed
in this country are detected with sizes above 3 cm, also
with axillary node involvement by the tumor. This find-
ing is important because breast cancer takes on average
8 to 10 years to reach 1 cm, which in principle would al-
low us sufficient time for early diagnosis. From this di-
mension, if nothing is done, it can lead to death within
three years, but the patient rarely dies of local problems,
but as a result of metastases, mainly to bones, liver, lungs,
and eventually to the central nervous system. The risk of
metastasis is known to be directly proportional to tumor
size.
This makes early diagnosis critical. Diagnosis at an
early stage and proper treatment can provide up to 95%
chance of cure. However, to achieve these numbers, it is
important that mammograms are performed annually
from the age of 40 years, which may have an impact on
mortality reduction of up to 35%, as demonstrated in
large controlled studies. Other major advantages of ear-
ly diagnosis are that in most cases there will be no need
to remove the breast and the indication for chemothera-
py will be reduced.
The modern treatment of breast cancer is complex
and customized, requiring surgery with oncologic and
aesthetic refinement, radiotherapy, chemotherapy, endo-
crine therapy and immunotherapy with monoclonal an-
tibodies. Access to all these treatment modalities ensures
the best possible results, while if any of these procedures
is not done properly, the others may be compromised,
leading to less effective results.
In Brazil, there are approximately 18,000 women over
the age of 40 years who in theory would be entitled by law
to receive yearly mammograms. Nevertheless, only 5% to
30% of them get mammogram screening under the Uni-
fied Health System (SUS), which on average in the coun-
try does not quite cover 25% of what it should. There is
no qualification, access, information, education, invest-
ment, structure or willingness.
When comparing mortality from breast cancer be-
tween developed countries and developing countries we
observe an increase of 40% on the latter, indicating that
being born in a poor country leads to significant increase
in mortality, which is the sad situation seen in Brazil.
While the mortality rate decreases in developed coun-
tries, including the US, UK and many others, recent work
conducted by the Mastology Research Network of Goiás
indicates that mortality from breast cancer in Brazil is
stable over the past 15 years, with an incredible inequal-
ity between states, which is also reflected in the country’s
macro-regions. Mortality continues to grow in Brazil’s
North, Northeast and Midwest, while the reduction in
mortality is already perceived in the Southeastern and
Southern regions, probably due to greater access to treat-
ment and, especially, early diagnosis. In these two regions,
locally advanced tumors are less frequent than in other
regions. Investing in structure is fundamental to every-
thing in health, especially in relation to chronic diseases,
which includes breast cancer. The problem is not a short-
age of doctors, but the lack of infrastructure and ade-
quate diagnostic and treatment centers. There is no plan
to secure trained doctors in small towns and not suitable
conditions for good service in most cities in the interior
of this vast country.
What we see when we look at what happens in our
country, comparing the capital cities and the interior in
terms of mortality rate, is identical to what we see when
comparing developed and developing countries. That is,
compared to the country side, the chance of cure is high-
er in state capitals, except for the state of São Paulo.
Another big difference is in health standards in Bra-
zil; comparing private medicine with public medicine we
find even more striking differences. A recent study by the
Gbecam group (Amazona Project) pointed out that the
diagnosis of breast cancer occurs at a later stage in the
public service and, as a result, more women die from breast
cancer in public services than in private. The authors