Dialogues in Health 7 (2025) 100235

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Dialogues in Health
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Cracking the code: Pioneering early detection and management of breast

cancer in the Brazilian public healthcare system
Arn Migowski a,b,* , Ruffo Freitas-Junior c , Jose Bines d,e, Angela Marie Jansen f,
Angélica Nogueira-Rodrigues g,h , Maria del Pilar Estevez-Diz i , Mariana Rico-Restrepo j,
Gayatri Sanku f, André Mattar k
a
Division of Clinical Research and Technological Development, Research and Innovation Coordination, National Cancer Institute (INCA), Ministry of Health, Rio de
Janeiro-RJ, Brazil
b
Professional Master’s Program in Health Technology Assessment, Education and Research Coordination, Instituto Nacional de Cardiologia (INC), Ministry of Health,
Rio de Janeiro-RJ, Brazil
c
CORA – Advanced Center for Diagnosis of Breast Diseases, Federal University of Goias, Goiania, GO, Brazil
d
Instituto Nacional de Câncer, Rio de Janeiro, Brazil
e
Instituto D’Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil
f
Americas Health Foundation, Washington, DC, USA
g
Research Center, UFMG - Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
h
Brazilian Group of Studies in Breast Cancer (GBECAM), Dom Oncologia and Grupo Oncoclínicas, Belo-Horizonte, MG, Brazil
i
Oncologia Clínica do Instituto do Câncer do Estado de São Paulo ’Octávio Frias de Oliveira’ – ICESP, São Paulo, Brazil
j
Americas Health Foundation, Bogota, Colombia
k
Mastology, Hospital da Mulher SP, Oncoclinicas São Paulo, Brazil

A R T I C L E I N F O A B S T R A C T

Keywords: Breast cancer (BC) remains a significant health concern in Brazil, particularly within its public healthcare system,
Brazil the Unified Health System, known by its Portuguese acronym “SUS”, with early detection being one of the main
Breast cancer challenges. A review of literature and policy documents was conducted to evaluate the performance and chal­
Breast cancer diagnosis
lenges of BC screening and early diagnosis in SUS. Brazilian experts in BC early detection attended a three-day
Early Detection of Cancer
Equitable access
meeting to discuss the challenges of SUS’s existing early detection program and provide recommendations for
Policy recommendations surmounting them. The study identified that Brazil’s current opportunistic BC screening model perpetuates issues
Regional disparities with access to screening and regional disparities, while also generating low effectiveness and inefficiency. It also
Mass screening highlights several causes of delays in early diagnosis and treatment. The conclusions suggest an urgent need for
Health Inequities an organized national BC screening program, in addition to the implementation of early diagnosis strategies, with
Public Health Systems Research multifaceted interventions, including urgent referral guidelines for suspected cases, training of key health pro­
fessionals, patient navigation, and one-stop breast clinics. Implementing these changes could alleviate the eco­
nomic strain on the healthcare system while improving patient outcomes.

1. Introduction The Brazilian College of Radiology and Diagnostic Imaging, the

Brazilian Society of Mastology, and the Brazilian Federation of Gyne­
Breast cancer (BC) is a significant global public health issue, and the cology and Obstetrics Association strongly support the implementation
World Health Organization’s Global Breast Cancer Initiative (WHO- of annual mammography screening for women aged 40–74 years who
GBCI), established in 2021, highlights the urgent need to strengthen have an average risk profile. Additionally, they endorse the develop­
healthcare systems and scale services to address its increasing burden. ment of tailored screening protocols for older women and those classi­
This initiative advocates for sustainable, cost-effective, and equitable fied as high-risk [2–4].
early detection and treatment services for BC, particularly in low- and In contrast, the national guidelines for breast cancer screening (BCS),
middle-income countries [1]. introduced by the Brazilian Ministry of Health (MoH) in 2015 and

* Corresponding author at: National Cancer Institute (INCA), Ministry of Health, Rua André Cavalcanti 37, Centro, Rio de Janeiro, RJ, Brazil.
E-mail address: arnmigowski@[Link] (A. Migowski).

[Link]
Received 23 February 2025; Received in revised form 4 August 2025; Accepted 25 August 2025
Available online 26 August 2025
2772-6533/© 2024 Published by Elsevier Inc. CC BY-NC-ND 4.0 This is an open access article under the CC BY-NC-ND license
([Link]
A. Migowski et al. Dialogues in Health 7 (2025) 100235

updated in 2018, recommend biennial screening for women aged 50–69 can also be attributed to unequal coverage between SUS and the private
and strategies to promote early diagnosis of symptomatic cases. Within healthcare system (both included in survey estimates) and, conversely,
the Brazilian Unified Health System (known by its Portuguese acronym to incomplete data from information systems [11].
SUS), which provides universal healthcare to over 200 million citizens A study comparing the number of required screening mammograms
and serves as the sole healthcare provider for 75 % of the population, to those performed by SUS in 2019 shows a 45⋅1 % deficit in exams
BCS mammograms are offered at no cost, including to individuals needed to screen the target population, with deficits ranging from 31⋅4
outside the target population. Despite this, participation rates in the % in the South to 70⋅5 % in the North [12]. The 2019 NHS indicated that
target population remain below 50 % in certain regions, significantly regions with BCS mammograms (North, Northeast, Central-West)
diverging from the MoH‘s objective of achieving a 70 % coverage rate experienced the most significant increase since 2013, demonstrating
[5,6]. some progress in reducing inter-regional disparities. However, in­
Organized population-based screening, which invites all women equalities persist, with coverage in the Southeast at 65⋅2 % compared to
within the target population to undergo mammograms, has been proven 43⋅2 % in the North [9].
to reduce BC mortality [7]. However, Brazil’s current approach is If all SUS screening mammograms were performed on the target
characterized by an opportunistic screening model, where mammo­ population, the deficit would decrease to 14⋅8% nationwide, with a
grams are recommended only during medical consultations for unre­ 6⋅2% excess in the Southern region [13]. The latest NHS indicates that
lated issues, when women proactively seek screening, or as diagnostic 60⋅0 %of women aged 40–49 had undergone a mammogram, with
mammograms to investigate suspicious signs and symptoms [8]. This 43⋅5% through SUS and 49⋅7% having had one less than two years
paper aims to respond to the WHO-GBCI’s “call to action” and critically before the interview [9]. However, this is likely an overestimation. A
examines the prevailing landscape of BC early detection and manage­ summary of barriers and solutions to improve BCS in Brazil is presented
ment in Brazil, proposing actionable strategies to enhance outcomes in Fig. 1.
within the public healthcare system. In Brazil, difficulties accessing healthcare have led to a significant
portion of BC cases being diagnosed at advanced stages. In 2000, 41⋅2%
2. Methods of cases were identified at stages III and IV. A multicenter study high­
lighted that most patients were diagnosed at stages II (53⋅5%) and III
Americas Health Foundation (AHF) assembled a panel of six Brazil­ (23⋅2%) [5]. Although existing cost-effectiveness models in Brazil do not
ian experts in BC early detection and management who were selected for consider the potential harms such as overdiagnosis and overtreatment
their prominence in scientific publications, their role as opinion leaders and lead time bias effects on benefits estimation, a national study
on BC control in the country, and their diverse background, including confirmed that the benefits, particularly in terms of avoided deaths,
breast surgery, clinical oncology, epidemiology, public health, imple­ substantially outweigh these risks with biennial screening for women
mentation science, and evidence based-medicine. AHF tasked each aged 50–69 [14]. However, the absolute benefit observed in Brazil is
expert with writing a short paper using the literature and their experi­ approximately half that estimated in the UK, using similar methods [14].
ence on one of the following topics: screening and early diagnosis of Furthermore, the impact on quality of life linked to false-positive results,
breast cancer; barriers to accessing mammography; cancer policy and overdiagnosis and overtreatment must also be considered when assess­
disease burden; treatment, and the financial burden of breast cancer in ing the impact of screening [14,16].
Brazil. After completing their papers, the panel convened for a three-day
meeting in July 2024 to collectively analyze the data, debate, and
combine their short manuscripts into a single comprehensive paper.
They also discussed implementation challenges for SUS and provided
recommendations to address them.

2.1. Role of the funding source

The organization and implementation of the workshop and manu­

script preparation were carried out by AHF, a 501(c) (3) nonprofit or­
ganization dedicated to improving healthcare throughout the Latin
American Region, and were supported by an unrestricted grant from
MSD. MSD had no influence on the design, implementation, or content
of this manuscript.

3. Results

3.1. Screening and early diagnosis of breast cancer in Brazil

Contradictory findings have emerged when comparing nationwide

mammogram surveys. Data from the National Health Survey (NHS)
indicate relatively high mammogram coverage across Brazil, while
studies based on Health Information Systems report much lower rates.
The 2019 NHS revealed that 58⋅3% of women aged 50–69 had under­
gone at least one mammogram in the prior two years, an increase from
54⋅3% in 2013 [9]. Additionally, the percentage of women aged 50–69
who had never had a mammogram decreased from 31⋅5% in 2013 to
24⋅2% in 2019. These NHS findings suggest that screening coverage in
Brazil may be higher than in many countries included in a global cancer
screening repository, only falling behind some European nations [10]. Fig. 1. Barriers to an Effective Breast Cancer Screening and Solutions. This
However, NHS self-reported data may be overestimated, and the dis­ diagram outlines the primary barriers and corresponding solutions identified in
crepancies in coverage from studies based on information systems data the breast cancer screening process in Brazil.

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A. Migowski et al. Dialogues in Health 7 (2025) 100235

3.2. Barriers to accessing breast cancer early detection and management 3.2.2. Early diagnosis
Early diagnosis and prompt initiation of treatment are critical, as
3.2.1. Screening timely detection facilitates therapeutic interventions that significantly
While the availability and geographic distribution of mammography improve patient survival rates. The effectiveness of early diagnosis relies
equipment have improved nationwide, the primary challenge remains on the establishment of a comprehensive healthcare network, the
the underutilization of this equipment, with only 29% of capacity enhancement of regulatory frameworks, and the integration of tele­
currently in use. This gap in utilization is predominantly due to a lack of health services[17]. Furthermore, population-based parameters should
adequately trained personnel, which is the leading factor contributing to be used to organize the healthcare network to ensure access to diag­
the nationwide deficit exceeding 70% in diagnostic mammograms and nostic tests and treatment [18,19]. Substantial evidence supports the
biopsies, thereby severely limiting early detection of BC [15]. Address­ connection between early diagnosis and timely treatment initiation,
ing underutilization will require enhancements to training programs for positively impacting patient outcomes. For instance, Denmark success­
both technical personnel and radiologists to effectively address these fully optimized its healthcare system during the pre-screening era,
productivity gaps and ensure equitable access to screening services. significantly reducing tumor size and improving survival rates [8,16].
(Fig. 1). Although BCS remains a contentious issue due to potential harm-benefit
imbalances and costs, early diagnosis strategies are essential for

Fig. 2. Patient Journey and Barriers to Early Diagnosis and Treatment of Breast Cancer in Brazil. This figure illustrates the patient journey and highlights the causes
of delays in diagnosis and treatment along with potential solutions.

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addressing the high incidence of advanced-stage tumors within SUS. Reference Services, outlining the procedures that should be available
Furthermore, advancements in adjuvant therapies have reduced the [35]. The procedures for screening, monitoring, and diagnostic confir­
lethality associated with palpable lesions, underscoring the need for a mation of BC within SUS are recorded in the Cancer Information System
multifaceted approach [16,18,19]. [34]. Additionally, the MoH treatment guidelines define molecular
classification, staging, and treatment of BC [36]. These guidelines are
3.2.3. Treatment not limited to treatments incorporated into SUS, leaving the decision to
Early-stage BC treatment significantly improves outcomes. Timely each service [37]. In 2024, this model of oncology guidelines was
interventions like surgery, radiation, and systemic therapies can effec­ revised by the MoH, linking the recommendations to a prior assessment
tively eradicate cancer, thereby reducing the risk of recurrence. Survival of their incorporation into SUS. The draft of the new treatment guide­
rates are significantly higher for patients diagnosed with early-stage BC. lines was presented for public consultation in February 2024 [34].
According to the American Cancer Society [20], the 5-year relative
survival rate for localized BC is approximately 99%, compared to 28% 3.2.5. Financial burden and socioeconomic impact of breast cancer in
for metastatic breast cancer (mBC). Furthermore, early detection often Brazil
allows for less aggressive treatments, such as lumpectomy with radiation The financial burden of managing BC, particularly within the Bra­
instead of mastectomy, potentially avoiding chemotherapy. This zilian Unified Health System (SUS), stems from extensive hospitalization
approach typically results in fewer side effects and an improved post- costs, access inequities, and significant delays in diagnosis and
treatment quality of life [21]. Regarding healthcare costs, treating treatment.
early-stage BC is less expensive than managing late-stage disease, as BC not only imposes significant health challenges but also creates a
early interventions can prevent the need for more extensive and costly substantial economic burden in Brazil. Approximately 70% of BC-
treatments [22]. Only 51⋅2% of SUS patients began treatment within 60 related deaths occur among economically productive women (<69
days after being diagnosed with BC [23] defined by law as the maximum years old), contributing to immense personal and social losses [6,38]. A
allowable time interval [24,25]. The causes of treatment delays and recent study estimated a loss of 25⋅3 million years of potential produc­
proposed solutions are multifaceted, as depicted in Fig. 2. tive life due to gynecological and breast cancer-related deaths between
SUS provides access to oncologic treatments, including surgery, 2001 and 2030, along with a staggering US$26⋅8 billion loss in pro­
radiotherapy, chemotherapy, hormone therapy, and select targeted ductivity. Nearly half of these premature deaths were attributable to BC
therapies. In Brazil, trastuzumab is available in neoadjuvant, adjuvant, [38].
and metastatic settings for HER2 3+ patients. However, many effective Therefore, efforts to reduce BC mortality would result in substantial
therapies for higher-risk early-stage BC are unavailable through SUS. social and economic benefits. While advances in treatment have
Treatments such as pembrolizumab, pertuzumab, olaparib, and TDM-1 improved outcomes, the delays in diagnosis, treatment inequities, and
have demonstrated survival improvements but are inaccessible in the variability in access to life-saving therapies persist, exacerbating this
public system, representing a gap in optimal care [26–28]. These burden. Addressing these systemic issues offers an opportunity to
treatments are only accessible to patients with private insurance improve survival rates and reduce the economic and social impacts of
coverage, despite the official incorporation of some of them. This BC.
disparity underscores ongoing challenges in equitable access to state-of-
the-art BC treatments within Brazil’s healthcare systems. It is also 3.3. Screening and early diagnosis
essential to consider the need for proper multidisciplinary breast cancer
management to improve outcomes and successful local experiences The role of BCS in reducing BC mortality is well-established. An
should be encouraged and replicated [29]. Breast cancer early detection, organized, population-based BCS program targeting women aged 50–69
whether by screening or improved early diagnosis, will not shift mor­ years at regular intervals has demonstrated effectiveness in improving
tality curves unless correct and timely treatment is also provided. early-stage diagnosis and reducing mortality. Women who have never
been screened would benefit the most from such programs. In Brazil,
3.2.4. Cancer policy and burden of disease validated tools, such as a scale to predict non-adherence to screening,
Improving cancer policy and reducing the burden of BC in Brazil are available to better guide interventions [39,40].
requires a multifaceted approach that includes regulatory and infra­ However, the effectiveness of early diagnosis strategies is limited by
structure support. The National Policy for Cancer Prevention and Con­ geographic, socioeconomic, and systemic barriers. Regional disparities
trol was established in 2013 [30]. A 2023 law further emphasized access in early-stage diagnoses are stark, with rates ranging from 40⋅2%–53⋅5%
to oncologic treatment and introduced the National Navigation Program in different regions [41]. In the northern, northeastern, and midwestern
for Cancer Patients, which is currently pending regulation. The National regions, advanced-stage diagnoses are more common, correlating with
Breast Cancer Early Detection program does not officially exist within systemic inequities [41]. Mortality rates inversely correlate with metrics
the structure of the Brazilian MoH. Although the program was created in such as gynecologist density and the Human Development Index [41,].
a ministerial ordinance in 2022, it was revoked the following year. It was This highlights the urgent need for system-wide efforts to ensure equi­
not approved in the tripartite inter-managerial chamber, resulting in the table healthcare access across Brazil.
absence of a dedicated budget for the program [31]. Delays between diagnosis and the initiation of treatment further
Unlike some other nations, Brazil does not have a law mandating BCS undermine outcomes. A study in southern Brazil revealed an average
programs [10] instead, there is legislation that recommends cancer wait time of 104 days from diagnosis to first treatment, with 85⋅1% of
screening for women and girls from puberty onwards, including BCS surgical patients waiting over 60 days [43,44]. Conversely, efforts such
with mammography [32]. The National Mammography Quality Pro­ as São Paulo’s One-Stop Clinic, which incorporates oncology consulta­
gram was established in 2012 but its implementation is still incipient tions at the first visit, successfully reduced wait times to less than 60
[5,11]. The optimal percentage of BI-RADS® 0 mammograms is between days [17]. Expanding such initiatives could significantly improve
5 and 12 % [33] however, approximately half of all Brazilian states timeliness and outcomes nationwide.
report mammogram rates above this desirable level [33].
The MoH Guidelines for Early Detection of Breast Cancer in Brazil 3.4. Advancements in BC treatment
currently recommend biennial mammograms for women aged 50–69
and include early diagnosis strategies for all age groups, as well as While adjuvant therapy advances have enhanced survival, they have
shared decision making for women aged 40–49 who seek screening not reduced the importance of early detection. Instead, these in­
[8,68]. A federal ordinance established the Breast Cancer Diagnosis novations complement early diagnosis strategies. Timely access to

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A. Migowski et al. Dialogues in Health 7 (2025) 100235

surgery, adjuvant therapy, and systemic treatments is critical to 4. Discussion

improving outcomes. For instance, in São Paulo, prioritized assessments
for highly suspicious cases successfully demonstrate the value of Herein, we presented recommendations for strategies to tackle bar­
reducing time-to-treatment [45]. riers to improve BC’s early detection and management in Brazil. We
A significant disparity exists between SUS and private healthcare believe that these strategies also apply to many low- and middle-income
systems. For example, 33⋅5% of SUS patients present with stage III BC, countries, as identified in a recent systematic review [55]. Several
compared to just 14⋅7% of private healthcare patients [46,47]. studies conducted in Africa, Asia and Latin America demonstrate bar­
As of now, post-incorporation studies evaluating the real-world riers to early diagnosis, such as lack of breast cancer awareness and
impact of technologies like trastuzumab within SUS remain limited, access barriers to health services similar to those described here, as well
emphasizing the need to monitor and assess new therapeutic in­ as barriers that delay the time between diagnosis and initiation of
terventions across all stages of BC [42]. treatment [55]. These results demonstrate that the barriers and strate­
gies to overcome them to improve breast cancer control presented here
have transferability and generalizability to other low- and middle-
3.5. Role of genetics and personalized medicine income countries, particularly in relation to underserved populations.
Consistent evidence from multiple studies supports the efficacy of
Genetic testing has become increasingly important in identifying BCS and early diagnosis in detecting early-stage BCs, thus improving
high-risk populations and guiding therapy decisions. Twenty to 30% of overall prognosis and treatment options [56,57]. By identifying smaller,
BC patients in Brazil carry germline mutations in high-penetrance genes more treatable tumors, physicians can decrease the need for systemic
such as BRCA1 and BRCA2 [48,49]. Identifying these mutations has treatment and enable less invasive surgical treatment options
implications not only for systemic and surgical treatments but also for [50,51,58–62]. From a health economics perspective, organized
screening other neoplasms and offering specialized monitoring for at- screening can be cost-effective as it saves medical costs through early
risk family members. cancer detection and treatment, potentially reducing healthcare
Structured clinical genetics networks could enhance risk stratifica­ spending on advanced cancer treatments [63,64]. Although some early
tion and counseling, targeting the 1% of individuals who account for detection policies and programs exist in Brazil, implementation efforts
5–10% of BC cases [7]. For example, modeling studies have demon­ and accountability must be improved to achieve the desired results.
strated the cost-effectiveness of gene-based screening strategies for Brazil is a large country with significant regional disparities in
BRCA1/2 in women with a high familial risk, suggesting favorable in­ healthcare, where access to mammography machines and treatment
cremental cost-effectiveness ratios in SUS [50,51]. services varies widely across regions [65]. A recent study showed that
women who participated in the last two BCS rounds before diagnosis had
the largest reduction in BC deaths, while missing either of the two prior
3.6. Radiotherapy and conservative treatments rounds significantly increased their risk [59]. The “Pink October”
campaign increased mammograms performed in October and the
Efforts to promote breast-conserving surgery and reduce mastectomy following months, suggesting we should perform similar actions
rates in Brazil remain complicated by systemic barriers and access in­ throughout the year [66]. A subgroup analysis of a recent clinical trial in
equities. Over the past decades, SUS has documented trends in surgical India suggested the efficacy of biennial clinical breast examinations in
practices, including an increase in lumpectomies alongside fluctuating reducing advanced-stage diagnoses and mortality rates among women
rates of mastectomies (with or without axillary lymphadenectomy) [52]. over 50 in low- and middle-income countries. Given Brazil’s extensive
However, these trends are difficult to quantify due to procedural primary healthcare infrastructure, implementing a similar approach of
reporting constraints and the ecological design of data analysis. active population targeting, qualified clinical examinations, and sys­
Improved access to adjuvant radiotherapy may help mitigate un­ tematic (Fig. 3) follow-up could yield comparable improvements in BC
necessary aggressive surgeries, further enhancing the uptake of con­ outcomes across the nation’s diverse regions [67]. Mobile screening
servative interventions. The impact on quality of life has been significant units are acceptable options to improve access in rural areas, as long as
for patients treated primarily with lumpectomy or radiotherapy. For the quality of mammograms and integration with services for diagnostic
instance, patients treated at a Brazilian Oncology Reference Hospital confirmation and treatment are guaranteed.[69]
had a mean score of 75 out of 100 [53] on the Global Health Scale of Although the focus of discussions on breast cancer control in Brazil
Quality of Life (WHOQOL), compared to 62 out of 100 [54] in a different tends to be on age range recommendations and screening interval and
radiotherapy center. These findings highlight the importance of focusing coverage, it is essential that this debate be expanded to include essential
on quality of life while optimizing BC care across various institutions. aspects such as the quality of the entire process, including mammo­
graphic screening itself, but also diagnostic confirmation and treatment.
Furthermore, it is essential to guarantee access to diagnosis and treat­
3.7. Sociodemographic inequities and access barriers ment, rather than focusing solely on expanding screening, and it is
necessary to guarantee the comprehensiveness of the entire line of care
Sociodemographic factors such as urban residence, higher education, both for the women screened and to ensure early diagnosis of women
media access, female-headed households, health insurance, and socio­ with suspicious signs and symptoms. The deficit of procedures for
economic status correlate with increased healthcare utilization,[40,41]. diagnostic confirmation is widespread in the SUS, reaching 90.8%
However, access barriers persist, particularly in the underserved regions deficit in the necessary number of core biopsies and 80.6% deficit in
of northern, northeastern, and midwestern Brazil [41]. These disparities surgical biopsies in the central-west region and 88.5% deficit in anato­
contribute to poorer outcomes for lower-income populations treated in mopathological exams in the north, with the impact on the diagnostic
SUS. investigation of women with suspected signs and symptoms being
Regional differences in survival rates between the public and private especially worrisome [12]. This shows that it is not enough to invest
healthcare systems also highlight inequities. Addressing these dispar­ only in mammographic screening, but rather to think systematically
ities requires strengthening public-sector access to diagnostics, early about increasing the production capacity of all these procedures, which
intervention, and novel treatments. For example, expanding access to requires medium- and long-term planning for the training and retention
preoperative oncology consultations and reducing diagnostic delays of specialist doctors in the health system, as well as the structuring of
could drastically improve treatment outcomes for underserved reference services for diagnostic confirmation.
populations. Although several barriers described here need to be acknowledged, it

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A. Migowski et al. Dialogues in Health 7 (2025) 100235

Woman notified by letter, app or primary

healthcare agent
Notification of normal findings o ers peace
of mind. Woman notified by mail at
appropriate interval for next screening
Normal findings
Organized Population-based Program
Woman notified by letter, app or
primary healthcare agent
Perform additional
Inconclusive findings mammographic views, review
previous mammograms, or
conduct a breast ultrasound

Letter/App Appointment Screening Woman notified by letter, app or

invitation Woman makes an mammogram primary healthcare agent
Women without a appointment when Conducted at
mammogram in the
Woman schedules an appointment at
convenient and Screening Center
last two years available
the Diagnostic Reference Center
receive a letter
Abnormal findings
informing them that
they should
schedule a breast
cancer screening Mammogram results

Evaluate the program comprehensively by utilizing both process and outcome indicators
Conduct audits and provide feedback to facilitate an ongoing process of improvement

Fig. 3. Flowchart of an Ideal Organized Population-Based Breast Cancer Screening Program in Brazil. This figure outlines the step-by-step process of an organized
population-based breast cancer screening program in Brazil.

is necessary to recognize that there has been a progressive improvement outreach initiatives is essential for ensuring these programs are effec­
in stage distribution in the last two decades in the SUS, reaching a tively executed, reaching underserved populations and ultimately
percentage of 59% of invasive breast cancers diagnosed in early stages I reducing the disease burden. A robust monitoring and evaluation
or II in 2019 [5], very close to the minimum standard recommended by framework will also be necessary to track progress and identify areas for
WHO-GBCI of diagnosis at least 60% of invasive breast cancers pre­ improvement.
senting as stages I or II[70]. However, the COVID-19 pandemic had a Additionally, stark regional variations in access to quality training
significant impact, leading to a reduction in screening, diagnostic for using existing diagnostic tools persist, particularly within SUS. These
confirmation and surgical treatment of breast cancer in the country, disparities are compounded by barriers between the quality of training
causing a setback in early detection with consequences for the coming in urban versus rural residencies and ultimately greatly influence service
years [71]. utilization and early-stage diagnosis rates. The findings underscore the
An important limitation of this article is that the analysis performed importance of implementing comprehensive public health strategies
refers to the current situation. With population aging[72] and also with prioritizing equitable care access. However, the current opportunistic
increased exposure to risk factors such as obesity,[73] it is likely that the BCS model limits the potential benefits of early detection, particularly in
magnitude of breast cancer incidence will increase in Brazil over the underserved regions. Advancements in systemic treatments offer
next decade. This further increases the importance of prioritizing promising avenues for personalized treatment.
addressing the challenges and barriers presented in this article. Although the experts and the literature present controversies about
Another important point is the identification of research gaps and the screening coverage figures in the country and choosing the best
how future research could explore these aspects in more depth. In screening protocol, there was consensus among experts on the need to
particular, research on how to best implement complex interventions overcome several barriers both to replace the current opportunistic
that address the organization of the health system. For example, the best screening model in the country for a population-based program, as well
ways to speed up diagnostic investigation and how to avoid problems as to overcome several barriers to advance early diagnosis strategies and
that may arise when implementing urgent referral protocols for inves­ better access to treatment. By prioritizing these efforts, Brazil can reduce
tigating cases with suspicious signs and symptoms. Another aspect that the burden of BC.
has not been sufficiently studied is the best way for one-stop breast
clinics to operate and how to implement their articulation with both CRediT authorship contribution statement
primary care and oncology treatment centers. Prospective studies eval­
uating the implementation of screening strategies, early diagnosis and Arn Migowski: Writing – review & editing, Writing – original draft,
improved access to treatment should be carried out to monitor the Visualization, Validation, Investigation, Formal analysis. Ruffo Freitas-
effectiveness of these recommendations. Junior: Writing – review & editing, Writing – original draft, Validation,
Investigation, Formal analysis. Jose Bines: Writing – review & editing,
5. Conclusion Validation, Investigation, Formal analysis. Angela Marie Jansen:
Writing – review & editing, Visualization, Project administration,
The rapidly evolving landscape of early BC diagnosis and care in Methodology. Angélica Nogueira-Rodrigues: Writing – review &
Brazil underscores profound disparities and urgent challenges that must editing, Validation, Investigation, Formal analysis. Maria del Pilar
be confronted to enhance patient outcomes. Despite establishing Estevez-Diz: Writing – review & editing, Validation, Investigation,
numerous early detection policies, Brazil has yet to realize its full po­ Formal analysis. Mariana Rico-Restrepo: Writing – review & editing,
tential. To achieve the desired outcomes, there must be a significant Visualization, Methodology, Conceptualization. Gayatri Sanku:
improvement in the implementation process, with greater emphasis on Writing – review & editing, Project administration, Methodology. André
systematic accountability and sustained efforts. Strengthening coordi­ Mattar: Writing – review & editing, Writing – original draft, Validation,
nation between policymakers, healthcare providers, and community Investigation, Formal analysis.

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A. Migowski et al. Dialogues in Health 7 (2025) 100235

Declaration of competing interest and lecture fees, and travel reimbursement. Angelica Nogueira Rodri­
gues reports a relationship with Novartis that includes: consulting or
The authors declare the following financial interests/personal re­ advisory and speaking and lecture fees. Jose Bines reports a relationship
lationships which may be considered as potential competing interests: with Novartis that includes: consulting or advisory. Andre Mattar re­
Arn Migowski reports financial support was provided by Americas ports a relationship with Novo Nordisk that includes: equity or stocks.
Health Foundation. Ruffo de Freitas Junior reports financial support was Angelica Nogueira Rodrigues reports a relationship with Pfizer that in­
provided by Americas Health Foundation. Maria Del Pilar Estevez-Diz cludes: consulting or advisory and speaking and lecture fees. Jose Bines
reports financial support was provided by Americas Health Founda­ reports a relationship with Pfizer that includes: consulting or advisory.
tion. Mariana Rico-Restrepo reports financial support was provided by Ruffo de Freitas Junior reports a relationship with REBRACAM that in­
Americas Health Foundation. Angelica Nogueira Rodrigues reports cludes: board membership. Angelica Nogueira Rodrigues reports a
financial support was provided by Americas Health Foundation. Andre relationship with Roche that includes: consulting or advisory and
Mattar reports financial support was provided by Americas Health speaking and lecture fees. Andre Mattar reports a relationship with
Foundation. Jose Bines reports financial support was provided by Roche that includes: speaking and lecture fees. Jose Bines reports a
Americas Health Foundation. Ruffo de Freitas Junior reports a rela­ relationship with Roche that includes: consulting or advisory. Arn
tionship with AstraZeneca that includes: consulting or advisory, paid Migowski: reports a relationship with Brazilian Society of Medical
expert testimony, speaking and lecture fees, and travel reimbursement. Oncology that includes: board membership.
Angelica Nogueira Rodrigues reports a relationship with AstraZeneca The other authors declare that they have no known competing
that includes: consulting or advisory and speaking and lecture fees. financial interests or personal relationships that could have appeared to
Andre Mattar reports a relationship with AstraZeneca that includes: influence the work reported in this paper.
equity or stocks. Jose Bines reports a relationship with AstraZeneca that
includes: consulting or advisory. Angelica Nogueira Rodrigues reports a Acknowledgments
relationship with Brazilian Group of Gynecology Oncology that in­
cludes: board membership. Angelica Nogueira Rodrigues reports a The authors thank Ms. Thais Vidal, BA, for her assistance in English
relationship with Brazilian Society of Medical Oncology that includes: language-editing the manuscript. Funding for this manuscript was pro­
board membership. Angelica Nogueira Rodrigues reports a relationship vided by Americas Health Foundation, through an unrestricted grant
with Latin American Cooperative Oncology Group that includes: board from MSD.
membership. Andre Mattar reports a relationship with Clinergy that
includes: consulting or advisory. Ruffo de Freitas Junior reports a rela­ Data availability
tionship with Daiichi Sankyo Inc. that includes: speaking and lecture
fees and travel reimbursement. Angelica Nogueira Rodrigues reports a The data used for this study will be made available on request to the
relationship with Daiichi Sankyo Inc. that includes: consulting or advi­ corresponding author.
sory and speaking and lecture fees. Andre Mattar reports a relationship
with Daiichi Sankyo Inc. that includes: speaking and lecture fees. Jose References
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