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Fatores limitadores e facilitadores para o controle do câncer de colo de útero: uma revisão de literatura
Cervical cancer control limiting factors and facilitators: a literature review

Viviane Aparecida Siqueira Lopes
Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca (Ensp). Programa de Pós-Graduação Stricto Sensu em Saúde Pública - Rio de Janeiro (RJ), Brasil. Universidade Federal Fluminense (UFF). Departamento de Serviço Social de Campos (SSC) – Campos dos Goytacazes, Rio de Janeiro (RJ), Brasil.
vivianeviviane@uol.com.br

José Mendes Ribeiro
Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca (Ensp), Departamento de Ciências
Sociais – Rio de Janeiro (RJ), Brasil.
ribeiro@ensp.fiocruz.br

RESUMO: Este artigo revisa os fatores limitadores e facilitadores do acesso aos serviços públicos de saúde no Brasil na área da atenção ao câncer de colo de útero (CCU). Nessa revisão, foram utilizadas a base de dados bibliográficos MEDLINE (interface com Biblioteca Virtual de Saúde/BVS e PubMed) e os portais LILACS e SciELO. Buscou-se publicações referentes ao período 2011-2016, a partir do uso de termos específicos das fontes consultadas, relativos à ‘neoplasias do colo do útero’ e ‘acesso aos serviços de saúde’. Foram inicialmente encontrados 704 artigos, mas considerando os critérios adotados foram selecionados 31 artigos, dos quais 19 artigos foram incluídos. Aspectos facilitadores do acesso como ampla cobertura do exame Papanicolaou e cobertura de biopsias equivalente ao número de preventivos alterados foram mencionados. Entretanto, aspectos limitadores de acesso como periodicidade inadequada do Papanicolau, dificuldades para agendamento de consultas e exames, alto índice de estadiamento avançado e atrasos no diagnóstico e no início de tratamento, também foram apresentados.
PALAVRAS-CHAVE: Acesso aos serviços de saúde. Neoplasias do colo do útero. Sistema Único de Saúde. Brasil. Revisão.

ABSTRACT: This paper reviews the limiting factors and facilitators of access to Brazilian cervical cancer care public health services. This review employed bibliographic database MEDLINE (interface with the Virtual Health Library/BVS and PubMed) and LILACS / SciELO portals. We sought publications for the period 2011-2016 based on the use of specific terms from the sources consulted, regarding “cervical neoplasms” and “access to health services”. We found 704 papers initially, which were shortlisted to 31 following adopted criteria, which were further reduced to 19 papers to make up the final selection. Access facilitating aspects such as wide coverage of the Pap smear test and coverage of biopsies equivalent to the number of altered prevention tests were mentioned. However, access limiting aspects such as inadequate Pap smear’s periodicity, difficulties in scheduling appointments and exams, high rate of advanced staging and delays in diagnosis and treatment onset were also reported.
KEYWORDS: Access to health services. Cervical neoplasms. Unified Health System. Brazil. Review.


INTRODUCTION
Cervical cancer (CC) is an important public health issue, causing the death of 5,430 women in Brazil in 2013. Some 16,340 new cases are expected to occur, with an estimated risk of 15.85 cases for every 100,000 women .
This cancer is mainly caused by persistent infection via sexually transmitted oncogenic subtypes of the Human Papillomavirus (HPV), which is responsible for about 70% of cervical cancers . Its primary prevention, therefore, involves the use of condoms and HPV vaccination associated with health promotion actions; and its secondary prevention, or early detection, is consistent with the early diagnosis, through the Pap smear test, targeting the female population aged 25-64 years.
CC control in the public sector corresponds to management and health professionals actions, organized according to the hierarchical levels of the Unified Health System (SUS), in an articulated way, establishing health care in the perspective of integrality. Thus, CC control is guided by a line of care , , that signals the care flow and the corresponding protocols and clinical guidelines regarding the degrees of disease development.
Health care modalities correspond to basic and specialized care - medium and high complexity, namely: promotion, prevention, diagnosis, treatment, rehabilitation and palliative care. Promotion refers to cross-sectional actions to promote better health to the population, control diseases and health problems, including actions that increase information and curb difficulties of access to health services. Prevention involves the aforementioned actions.
For the cases with altered Papanicolaou, diagnosis is consistent with the accomplishment of tests for diagnostic investigation, such as colposcopies, biopsies, among others. The treatment involves performing oncological surgeries, radiotherapy, chemotherapy and brachytherapy. Rehabilitation includes multiprofessional action aimed at reestablishing physical-organic functionalities harmed by the disease. Palliative care is consistent with low, medium and high complexity actions and procedures, aiming at suffering prevention and relief – symptom control, pain relief, spiritual support, caregiver support – along with cases of non-clinical response to treatments performed and, therefore, life-threatening. ,
CC control is restrained by socioeconomic and cultural inequalities and by the health system’s performance level, and access to health services is one of the realms underpinning this performance.
Access to health services refers to the process of seeking health services by individuals with health needs, and the concomitant response that these services generate to such needs, expressed through the care provided to subjects, that is, access health services relates to the established relationship between individuals/community and health services. , ,
The health services are set in a local, regional and/or national context, facilitating or limiting this access and its good organization, and the practices developed in these services are guided by precepts defining the health policy in the territory of the study, programs and specific policies of each health area and/or type/group of illness.12
Studies on access to health services may be included in a “restricted realm”, that is, they only focus on the relationship between the demand for and access to health services. However, some studies go one step further, also involving continuity of care, set in an “intermediate realm”. Other more comprehensive studies build on the process that begins with the desire to obtain health care, seeking health services, entering facilities thereof, through continuity of care, achieving its results, and is understood as a “broad realm”13. The latter are consistent with the definition of access as the “use of health services appropriate to people’s needs at the appropriate time and place.”13
These studies analyze - in an isolated or articulated way - the provision of health services; the characteristics of the relationship between demand and use of health services, recognizing aspects and/or realms that act as facilitators or obstructors of this use by potential users; and the results of the provision of health services. From the perspective of the second mentioned aspect, Donabedian showed two realms to be analyzed, namely, socio-organizational and geographical. The first concerns social, cultural, political and/or economic conditions; and the second refers to time-space, expressed in the physical distance between users and services. Travassos and Castro13 corroborating and broadening them, denominated such realms as access barriers, specified in geographical, financial, organizational and information barriers.
Regarding the results, Andersen and Aday11 acknowledge the satisfaction of health service users as a type of result of the process to access these services, which is corroborated by Donabedian14 and reaffirmed in Andersen12. Donabedian understands not only the satisfaction of users, but also the quality of services as expressions of the close relationship between structure and process of implementation of health actions being the results of this relationship.
Therefore, this review sought to synthesize findings from Brazilian studies on access to Brazilian public health services in cervical cancer care in the period 2011-2016, identifying the limiting factors and/or facilitators of such access. Thus, it aimed to highlight the barriers to access to health services for CC control and to record advances related to this access, signaled in papers addressing the Brazilian public health system and published in a recent period related to secondary prevention or early detection, diagnosis and treatment of CC.

METHODS:

This study was outlined from the criteria established in the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA), considering the flowchart and the PRISMA checklist , . Thus, it had a guiding question about the search for papers and the analysis, namely: What are the limiting factors and/or facilitators of access to health care services for cervical cancer?
The collection of papers was carried out in the bibliographic MEDLINE database (interface with the Virtual Health Library/BVS and PubMed) and in the portals LILACS (interface with the BVS) and SciELO Brazil.
In the LILACS portal and the MEDLINE/BVS database, the search terms used in Portuguese were “acesso aos serviços de saúde” AND ‘câncer de colo de útero’ OR ‘neoplasia de colo de útero’ OR ‘câncer cervicouterino’ OR ‘câncer cervical’ OR ‘câncer de colo uterino’; and the following filters were used: publication type: paper, year of publication: 2011 to 2016; country as subject: Brazil; limits: female. In MEDLINE / PubMed, the search involved the English terms: ‘access of health services’ OR ‘health services accessibility’ AND ‘uterine neoplasms’ OR ‘cervical cancer’ AND ‘Brazil’ AND ‘2011-2016’ (year of publication). In the SciELO Brazil portal, the search terms in Portuguese were only ‘acesso aos serviços de saúde’, with only use of filters referring to the year of publication, because the association with the Portuguese term ‘neoplasia de colo de útero’ or synonyms did not produce results.
The selection of papers was guided by the following inclusion criteria: papers whose titles and/or abstracts indicate it is a study about access to health services for cervical cancer (CC) care, in the public health sector, related to prevention, diagnosis and/or treatment. Such papers could study access to services meaning entry into health services and/or continuity of care and coverage regarding CC care. Coverage refers to the “extent of a health measure” such as the proportion of women who underwent a Pap smear test in a particular year and territory. The coverage of a health action is associated with compliance with the provision of this action and, therefore, with access to and use of health services. However, it can also mean the possibility of obtaining health care actions, which may or may not occur17. In this review, the included papers that addressed ‘coverage’ were in tune with the first meaning mentioned above.
Papers were identified in March 2017. Studies were screened by reading and analyzing the titles and abstracts of all the papers identified in each database, guided by inclusion and exclusion criteria. In the eligibility stage, after defining the papers to be included from each database, duplicate papers were excluded. We then proceeded to read in full the included studies and elaborated the synthesis of the main information in a spreadsheet, to enable descriptive and critical analyses. The review of papers sorted them according to milestones of the CC control care line, namely: ‘prevention’, ‘diagnosis and/or treatment’.
RESULTS AND DISCUSSION

Features of the revised papers

Of the 704 papers initially identified on access to health services for cervical cancer (CC) treatment published in the period 2011-2016, 19 were included in this review (Figure 1). The excluded papers extrapolated the adopted eligibility criteria, referring to other diseases and policies or other objects of studies related to cervical cancer (CC), such as mortality, survival and quality/adequate action of health professionals in health care.
(Figura 1).
Approximately 3.2 papers/year were published; most were in Portuguese (78.9%). The most important journals were published by the Cadernos de Saúde Pública, the Revista Brasileira de Ginecologia e Obstetrícia and the Revista Saúde em Debate, which published 26.3%, 21% and 21% of the papers, respectively. (Table 1).
Access was mostly addressed in terms of hindrances to the early detection of cervical cancer, corresponding to 63.2% of the papers. Limits on access to CC diagnosis and treatment were addressed by 36.8% of the papers. In papers that dealt with early detection, the objects of study referred to Pap smears and/or factors related to failure to perform this test (58.3%) and to early detection of the poor and/or vulnerable segments of the population (41.7%). In the papers that addressed diagnosis and/or treatment, the objects of study were CC integrality/continuity of care (57.1%), factors related to late diagnosis (28.6%) and waiting time for treatment (14.3%). (Table 1).
The quantitative study design was predominant (73.7% of papers). All papers that emphasized the CC early detection adopted the quantitative approach, unlike papers that stressed CC diagnosis and/or treatment, which were diversified, since 57.1% of them elaborated their analyses from a qualitative approach, followed by those who adopted a quantitative (28.6%) and both quantitative and qualitative (14.3%) approaches. The interview was the most used data source and method (73.7% of papers), followed by documentary analysis (31.6%), use of secondary databases (21%), direct or participant observation (10.5%) and previous research data (10.5%), and it should be noted that approximately 47.4% of papers used the combination of more than one method/source. (Table 1).
(Quadro 1)
Access to services for the early detection of cervical cancer

Most of the papers related to the prevention of cervical cancer indicated a Pap smear coverage of more than 80% of the study population, with an increase in this coverage, especially among vulnerable segments or those with low compliance with the preventive examination, such as women that are single, black and with a low level of schooling. However, one of the papers pointed to high rates of non-performance of Pap smear and a large number of cases in advanced staging, which reinforces the importance of performing the preventive exam and refers to the evidence of segments of the female population even under these circumstances. Coverage and adequate periodicity of Pap smears are restrained by the socioeconomic and demographic disparities, with a predominance of opportunistic tracking. , , , (Table 2)
Most women know the ‘preventive examination’, but even so, some women do not. The appropriate periodicity, on the other hand, is not widely known , and the lack of information is a barrier to its compliance.
CC screening is influenced by social and subjective-cultural factors experienced by women, the organizational context and the characteristics of health professionals’ actions. (Table 2). Thus, organizational barriers and social, economic, cultural and racial inequalities hinder such action.18,22, , , , , , , , , ,

Access to services for the diagnosis of cervical cancer

The diagnosis of cervical cancer occurs late in Brazil, with ‘advanced-stage cases’ especially associated with age equal to or greater than 50 years, due to the fact that patients live without a partner, are black and have a low educational level . With regard to advanced-stage diagnosis, Nascimento and Silva detected 78.9% of the women studied in the intermediate stages and 5% in the advanced stages of the disease, corroborating with the perspective that more advanced ages and social and racial inequalities are correlated with a higher CC risk and prevalence.
The limited access to cervical cancer (CC) diagnosis services was related to organizational barriers and limited action by health professionals.32, , The biopsy examination that was crucial to the diagnostic conclusion was compatible with the number of altered Pap smears, which were more frequent in younger women. However, the most severe diagnoses of both cytology and biopsy have prevailed in women of a later age.31,37
The adequate coverage of biopsies, however, did not ensure continuity of treatment, due to weaknesses in the reception and bond and difficult access to treatment.37 In addition, delaying tumor staging often prolongs the onset of disease treatment.35 (Table 2)
Access to services for treatment of cervical cancer

Cervical cancer treatment may involve surgery, chemotherapy, radiotherapy and/or brachytherapy, and it is predominantly performed in the Unified Health System (SUS)19. In Brazil, there is a legal definition of the maximum term for the initiation of treatment by the SUS of 60 days from the establishment of the diagnosis obtained with the biopsy result . According to Nascimento e Silva35, this period was considered taking into account the onset of radiotherapy, by most of the “patients”. The same study evidenced equitable access to radiotherapy, that is, waiting time for the start of radiotherapy was lower as the cases were diagnosed with increased advanced stages. (Table 2).
The maximum term for initiation of cancer treatment in Brazil mentioned above is a valid parameter used in some studies, but Nascimento e Silva35 emphasize that the treatment should occur as soon as possible and should not adopt the 60 days defined by law as the deadline. This term has relevance in terms of legal interpellation, but there are countries with a deadline of less than 30 days, as in the case of Canada.
The limits of access to services for CC treatment were eminently of an organizational realm. The reception and bond were favorable aspects, since they were pointed out as practices found in the oncological treatment stage, performed only at this stage of the care line. In addition to these, other aspects favoring oncological treatment were indicated30,32. (Table 2).
Thus, the results shown by the papers included in this review have implications for the cervical cancer care policy regarding the CC prevention, diagnosis and treatment, with a view to its improvement. (Table 3).
Regarding the assurance of timely access (Table 3), it is worth mentioning that opportunistic tracking should be associated to population screening in a complementary manner. The latter refers to a systematized action, allowing greater control of actions and information regarding tracking, including the coverage achieved, which signals a greater effectiveness, equity and efficiency. However, due to the difficulties of accessing health services in this review, part of the women in the target age range of the population screening programs may not participate in it. Thus, timely actions are relevant for early detection, that is, the one performed when the woman seeks the health service for another reason and the health professional seizes the opportunity to perform the Pap smear test.

FINAL CONSIDERATIONS:
Cervical cancer (CC) control has been advancing in Brazil, as there are records of a greater coverage of Pap smears, compatibility among the number of biopsies and of altered Pap smears and CC oncological treatment, mainly by the Unified Health System (SUS).
However, segments of the female population that have never undergone a preventive examination, who do not know or do not comply with the indicated periodicity of this examination were registered. These facts may in some cases be associated with individual issues, such as fear and shame, which is difficult to resolve, but also with issues related to public management and/or health professionals, which are challenges to this management.
In this regard, in cross-sectional terms to cervical cancer control, emphasis was placed on the need to evaluate the operation of the service network, to ensure integrality of care, to create care coordination mechanisms, to ensure a process between services with ease and promotion of the reception-bond across the whole CC care line.
Among the specific suggestions regarding CC prevention were tracking, especially among women in situation of poverty and/or vulnerability, who are more than 50 years of age and living in places distant from the health services; expanded access to health services; and assurance of privacy of the users in the services. Regarding the diagnosis in particular, it is necessary to reduce the time to complete CC diagnosis and defining tumor staging. With regard to treatment, there is also a need to ensure its onset in the shortest possible time, with rapid access to examinations for treatment planning and reduction of geographical barriers of access, decentralizing reference centers for treatment in order to reduce territorial and/or regional inequalities.

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