Breast cancer: delays in SUS protocol punish patients

Cancer is a “democratic” disease. Men and women, rich and poor, adults, the elderly and even children can suffer from a disruption of cell growth resulting in a tumor and, in many cases, death. Breast cancer is most common among women. According to information from the National Cancer Institute (Inca), in 2021 alone 66,280 people should be diagnosed with this type of cancer, and it is estimated that 18,295 of them will die as a result of this disease.

However, the treatment of breast tumors varies greatly depending on where it is performed. It is estimated that the SUS is up to 20 years behind in terms of supplemental health, offered by health plans. In September 2020, the Brazilian Institute of Geography and Statistics (IBGE) showed that 71.5% of Brazilians, or more than 150 million people, need SUS for any treatment.

Patients with similar diagnoses not only receive very different medications, but also go through different treatment times. In the private network and in less than a month the person is diagnosed and undergoes surgery to remove the tumor. In SUS, this same process – which should take a maximum of 60 days by law – can take more than three months. Meanwhile, the cancer is progressing.

Volunteer president of the Brazilian Confederation of Charities for Breast Health Support (Femama), breast cancer specialist Mayra Kalifi recalls that the longer treatment takes, the more the cancer will worsen. In addition, cases diagnosed in SUS become more advanced, being at stages where the drug gap is larger.

“According to our medical management manual, we always have to give the best to our patient. Some colleagues in the public network find themselves without medication. It is a very tragic situation,” says the doctor, who heads the department of mammology at Moinhos de Vento Hospital, in Porto Alegre.

old remedy – “Although medicine has increasingly personalized cancer treatment, at SUS we still use the same prescription for almost all patients. When we talk about treatment, it is necessary to talk about surgery, radiotherapy and systemic therapy, which are drugs”, explains Rafael Calix, Scientific Director of Oncoguia, a civil society organization that leads the struggle of patients.

According to Kaliks, the problem begins with surgery: the SUS does not pay for breast asymmetry or breast implants after the operation, that is, the patient’s quality of life is already affected earlier. There is another difficulty with radiotherapy: most patients require treatment, but many are unable to due to lack of equipment and huge waiting lists to fulfill all requests.

The biggest difference between public and private, the abyss between treating those who pay for health insurance and those who rely on SUS, are the drugs, especially those indicated for patients with advanced breast cancer, which has already spread to other parts of the body.

For 70% of patients with metastatic breast cancer, there is a class of drugs called cyclin inhibitors, which are not available on the SUS. When this drug is introduced with hormonal therapy, the time to disease control is extended from 13 months to 30 months. Medicines make it possible for women to live longer. But, unfortunately, this is not an option in the public network, ”confirms Kalix.

And the problem doesn’t just focus on breast cancer. Oncologist Gilberto Amorim, member of the Breast Oncology Committee of the Brazilian Society of Clinical Oncology (SBOC), notes that with regard to lung cancer, for example, treatment has been discontinued in the public network since the 1990s.

“There are specific medicines that have been in the private health sector for decades, and they are not in the SUS. In melanoma, immunotherapy has been used in the private sector for more than 5 years. He stresses that the general treatment is the same as when I started attending in 1994. This is unacceptable. “. There are Brazilian studies that show that patient outcomes are worse in the general network. “It’s very perverted seeing this happen and not fighting it,” says the oncologist.

Establishment difficulties In order for a drug to be incorporated and used in SUS, it must be approved by Anvisa and submitted to the National Committee for the Integration of Technologies in the Unified Health System (Conitec). “Incorporating or not integrating technology is related to ATS, which is a complex process that goes beyond the cost-effectiveness of a drug. It includes economic analysis and comparative studies between already listed drugs and new drugs,” explains oncologist Fernando Malouf, founder of Instituto Vencer o Câncer.

However, despite the fact that laws dictate the maximum period of analysis and the availability of treatment, it is not often adhered to. In the specific case of cancer, Calix says those responsible for judging incorporation processes often say that cancer drugs are not good, or have unwanted side effects — often ignoring the international consensus.

“There is an ideological bias in evaluating cancer treatments at Conitec. Medicines are believed to be a way for laboratories to make money. The government enters and the government leaves, and this understanding persists, destroying public oncology in Brazil,” Calix laments.

The Director of Oncoguia compares oncology with other branches of medicine to illustrate the problem: Rheumatology and hepatitis C have modern treatments at SUS, with a delay of at most two years. Meanwhile, oncology is twenty years behind schedule. It is said that the price is very high, but the Brazilian government is the largest buyer of drugs in the world. Can you imagine the power of negotiation? “

Amorim, of SBOC, agrees. “The committee, unfortunately, has ended up with political bias over the years. Many people who are not qualified to be there are blocking access. The impact of cancer patients is great, because there are a lot of people, but when the government wants it, they succeed in bargaining brutally,” as he says.

The oncologist says there is chaos in the drug consolidation system in general, but in the end, what Brazil needs is a state policy for dealing with cancer patients, which is already in place for AIDS, for example. It’s pink October, a pink light is being put on Congress, but what is actually being done to improve access and early diagnosis? We have a 30-day law to diagnose, compliance is minimal, and you can’t blame the coronavirus,” says an SBOC representative.

The article contacted the Department of Health to inquire about and negotiate delays in drug analysis, but was responded with a note stating only Conitec’s functions, without clarifying the issues raised.

Differences within the SUS

If the abyss runs deep when comparing treatment at SUS and treatment offered by health plans, it is also in the public service itself. Since the purchase of medicines is done by hospitals and municipalities, and the schedule of some procedures has not been updated in decades, although some treatments are, in theory, available through the SUS, it is not a fact for the patient.

“SUS Trio. Therefore, countries with larger health infrastructure have better treatment conditions. The study “My SUS is different from your SUS”, published in the Brazilian Journal of Oncology 2017, showed that there are significant differences in the standard of systemic treatment for the four most common types of cancer among SUS treatment centers”, explains the oncologist Maalouf.

The difference can happen in the same city, with some public hospitals getting charitable funds to improve care, while others are not even able to afford what the SUS advocates. Amorim, of SBOC, provides the example of the Hospital de Amor, in Barrettos, a reference in the treatment of cancer by SUS.

The situation, which is bad in SUS, tends to get worse: In addition to the lack of initiatives to try to solve the problem, the epidemic has made access to a diagnosis more difficult, and patients who come to the health service today have more advanced and difficult-to-treat tumors. The economic crisis also meant that many people had to abandon the health plan to start relying solely on public health.

It is estimated that during the pandemic, 4,000 new cases of breast cancer were not diagnosed, but there are no indications of any specific effort by health authorities to locate these women. Also, in this period, the inclusions of new technologies have been delayed,” says Malouf, of the Fencer O’Cancer Institute. Calix believes that the number of new patients is likely to overburden the system, and cancer mortality is likely to increase in the coming years.” An unspeakable tragedy,” he points out.

Challenges also in complementary health

Although far ahead of SUS, supplemental health also has its share of problems and is far from perfect. The National Agency for Complementary Health (ANS) regulates the medicines to be incorporated into health plans.

In private health, the battle now is for the PL of oral chemotherapy, a bill that provides for the immediate integration of oral chemotherapy drugs into the private network. This is already happening with injectable drugs for cancer, and has mobilized the medical community to make the general rule also for drugs that come in pill form.

However, the project was rejected by President Jair Bolsonaro (there is no party), who claimed that there is no forecast for the source of funds for these combined companies – even though the PL is for the private network, and does not include any public resources. Now, lobby Congress to overturn the veto and put the matter back on the agenda.