Fatores associados ao tempo de acesso para o tratamento do câncer de mama no Distrito Federal, Brasil
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Data
2017-02-14
Autores
Barros, Ângela Ferreira [UNESP]
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Universidade Estadual Paulista (Unesp)
Resumo
O objetivo geral deste estudo foi verificar os fatores socioeconômicos, clínicos e relacionados à organização dos serviços associados ao tempo para acesso aos tratamentos do câncer de mama. Foi realizado um estudo de coorte com 600 mulheres com diagnóstico de câncer de mama internadas para tratamento clínico e/ou cirúrgico dessa doença que realizaram o primeiro tratamento em nove hospitais públicos do Distrito Federal. Não foram incluídos casos prevalentes de câncer de mama e casos que apresentavam doença metastática identificada em exames de estadiamento antes do início do tratamento. Todas as participantes foram entrevistadas entre setembro de 2012 e setembro de 2014. Os dados clínicos foram preenchidos com dados do prontuário. Em um segundo momento, realizou-se nova revisão do prontuário e/ou contato telefônico para obter informações sobre os tratamentos após a cirurgia e evolução clínica. O seguimento das mulheres ocorreu até fevereiro de 2016. Esta pesquisa foi aprovada pelo Comitê de Ética em Pesquisa da Secretaria de Estado de Saúde do Distrito Federal pelo parecer nº 99.313. As mulheres apresentavam, em média, 53,3 anos (± 12,5) ao diagnóstico e a maioria se declarou com a cor da pele parda (46,4%), referiu ter em média 7,9 anos de estudo (± 4,6), renda familiar média de R$ 2.079,01 (± R$ 2.489,23), residir no Distrito Federal (65,8%). Dentre as mulheres que buscaram os serviços de saúde a partir da autoidentificação dos sintomas sugestivos de câncer de mama, o intervalo de tempo entre o início do sintoma e a primeira consulta apresentou mediana de 39 dias (intervalo interquartílico: 14-123 dias). Na análise multivariada, esse intervalo de tempo > 90 dias apresentou associação estatisticamente significativa com anos de estudo (OR: 0,95; IC 95%: 0,91-0,99), não realização de mamografia e/ou ultrassonografia mamária nos dois anos anteriores ao diagnóstico de câncer de mama (OR: 1,95; IC 95%: 1,25-3,03) e estadiamento mais avançado (OR: 1,74; IC 95%: 1,10-2,75). Em relação ao itinerário terapêutico percorrido nos serviços de saúde e o intervalo de tempo entre a primeira consulta e o início do tratamento (mediana 160 dias), verificou-se que esse período foi maior entre mulheres com a cor da pele parda ou negra (p<0,001), menor escolaridade (p=0,001), menor renda familiar (p=0,045); que realizaram a primeira consulta na atenção primária quando comparado às que realizaram em serviços de saúde suplementar (p<0,001); e aquelas atendidas em mais de dois serviços de saúde (p=0,003). A implementação do agendamento de consulta com especialista, através da regulação assistencial, proporcionou redução do tempo para início do tratamento (p<0,001). Em relação à evolução clínica da doença, após um seguimento médio de 30,6 meses, não se observou associação estatisticamente significativa da recidiva do câncer de mama com os intervalos de tempo estudados. Conclui-se que os intervalos de tempo para acesso aos serviços de saúde para diagnóstico e tratamento do câncer de mama no Distrito Federal foram associados a características socioeconômicas, clínicas e relacionados à organização dos serviços, porém não apresentaram associação com a evolução clínica da doença.
The main objective of this study was to verify the socioeconomic, clinical and related factors related to the organization of the services associated with the time to access breast cancer treatments. A cohort study was conducted with 600 women with breast cancer admitted for clinical and/or surgical treatment in nine public hospitals in the Brazilian Federal District. Breast cancer prevalent cases and patients with metastatic disease identified by staging tests before treatment were excluded. All participants were interviewed between September 2012 and September 2014. Clinical data were abstracted from the medical records during hospital admission. In a second moment, further review of the medical records and / or telephone contact was made to get information about treatments after surgery and clinical outcome. Patients were follow-up until February 2016. This study was approved by the Ethics Committee of the Brazilian Federal District Secretary of Health (Approval number 99,313). The mean age at diagnosis was 53.3 years (± 12,5) and the great majority self-declared with mixed heritage (46.4%). The average years of study was 7.9 (± 4.6) years, their family income average was R$ 2,079.01 (± R$ 2,489.23) and were living in the Brazilian Federal District (65.8%). Among women who self-identified suggestive symptoms of breast cancer, the time interval between onset of symptom and the first medical visit presented a median of 39 days (interquartile range: 14-123 days). In the multivariate analysis, this time interval longer than 90 days were significantly associated with years of education (OR: 0.95; 95% CI: 0.91-0.99), those who did not performe mammography and/or breast ultrasound in the two years prior breast cancer diagnosis (OR: 1.95; 95% CI: 1.25 - 3.03) and patients with more advanced stages (OR: 1.74; 95% CI: 1.10 - 2.75). Regarding the treatment pathways in health care system and the interval between the first medical visit and the first treatment (median 160 days), we observed that this interval was longer among women with mixed heritage (p <0.001), lower level of education (p = 0.001), lower family income (p = 0.045); those who had the first medical visit in the primary care compared to those that used private health services (p <0.001); and those that used more than two health services (p = 0.003). The introduction of the scheduled consultation with a medical expert in the area provided a reduction of time to treatment (p <0.001). Regarding the clinical course of the disease, after a mean follow-up of 30.6 months, we did not observe significant association of breast cancer recurrence with the time intervals. In conclusion, the time intervals for access to health services for diagnosis and treatment of breast cancer in the Federal District were associated with socioeconomic, clinical and organizational characteristics of the services; however they were not associated with clinical evolution.
The main objective of this study was to verify the socioeconomic, clinical and related factors related to the organization of the services associated with the time to access breast cancer treatments. A cohort study was conducted with 600 women with breast cancer admitted for clinical and/or surgical treatment in nine public hospitals in the Brazilian Federal District. Breast cancer prevalent cases and patients with metastatic disease identified by staging tests before treatment were excluded. All participants were interviewed between September 2012 and September 2014. Clinical data were abstracted from the medical records during hospital admission. In a second moment, further review of the medical records and / or telephone contact was made to get information about treatments after surgery and clinical outcome. Patients were follow-up until February 2016. This study was approved by the Ethics Committee of the Brazilian Federal District Secretary of Health (Approval number 99,313). The mean age at diagnosis was 53.3 years (± 12,5) and the great majority self-declared with mixed heritage (46.4%). The average years of study was 7.9 (± 4.6) years, their family income average was R$ 2,079.01 (± R$ 2,489.23) and were living in the Brazilian Federal District (65.8%). Among women who self-identified suggestive symptoms of breast cancer, the time interval between onset of symptom and the first medical visit presented a median of 39 days (interquartile range: 14-123 days). In the multivariate analysis, this time interval longer than 90 days were significantly associated with years of education (OR: 0.95; 95% CI: 0.91-0.99), those who did not performe mammography and/or breast ultrasound in the two years prior breast cancer diagnosis (OR: 1.95; 95% CI: 1.25 - 3.03) and patients with more advanced stages (OR: 1.74; 95% CI: 1.10 - 2.75). Regarding the treatment pathways in health care system and the interval between the first medical visit and the first treatment (median 160 days), we observed that this interval was longer among women with mixed heritage (p <0.001), lower level of education (p = 0.001), lower family income (p = 0.045); those who had the first medical visit in the primary care compared to those that used private health services (p <0.001); and those that used more than two health services (p = 0.003). The introduction of the scheduled consultation with a medical expert in the area provided a reduction of time to treatment (p <0.001). Regarding the clinical course of the disease, after a mean follow-up of 30.6 months, we did not observe significant association of breast cancer recurrence with the time intervals. In conclusion, the time intervals for access to health services for diagnosis and treatment of breast cancer in the Federal District were associated with socioeconomic, clinical and organizational characteristics of the services; however they were not associated with clinical evolution.
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Palavras-chave
Neoplasias da mama, Acesso aos Serviços de Saúde, Diagnóstico tardio, Tempo para o tratamento, Recidiva, Breast neoplasms, Health Services Accessibility, Delayed diagnosis, Time-to-treatment, Recurrence