Diretrizes para detecção precoce do câncer de mama no Brasil. III - Desafios à implementação

Abstract

The objective of the current article is to present the main challenges for the implementation of the new recommendations for early detection of breast cancer in Brazil, and to reflect on the barriers and the strategies to overcome them. The implementation of evidence-based guidelines is a global challenge, and traditional strategies based only on disseminating their recommendations have proven insufficient for changing prevailing clinical practice. A major challenge for adherence to the new guidelines for early detection of breast cancer in Brazil is the current pattern in the use of mammographic screening in the country, which very often includes young women and a short interval between tests. Such practice, harmful to the population's health, is reinforced by the logic of defensive medicine and the dissemination of erroneous information that overestimates the benefits of screening and underestimates or even omits its harms. In addition, there is a lack of policies and measures focused on early diagnosis of symptomatic cases. To overcome these barriers, changes in the regulation of care, financing, and implementation of shared decision-making in primary care are essential. Audit and feedback, academic detailing, and the incorporation of decision aids are some of the strategies that can facilitate implementation of the new recommendations.

Diretrizes para detecção precoce do câncer de mama no Brasil. II - Novas recomendações nacionais, principais evidências e controvérsias

“…The detailed methods for definition of the scope, research questions, search strategies, selection of studies, evaluation of the quality of evidence, and formulation of recommendations in the guidelines have been published elsewhere 8,9 .…”

“…This article begins with a summary of the evidence for the new guidelines and their recommendations. We also updated the original searches for the guidelines in MEDLINE 8 up to March 31, 2017. The new articles were assessed according to the same eligibility criteria originally used, and their results and implications for the new guidelines were included in the sections on evidence synthesis and discussion of this article, except for the new abstracts on the strategies for early diagnosis, whose new eligibility criteria only included systematic reviews or clinical trials.…”

“…We found no clinical trials that evaluated ultrasound screening with or without mammography, thermography, or breast tomosynthesis 8 . Concerning tomosynthesis, two systematic reviews of studies on diagnostic accuracy identified heterogeneous results for sensitivity and specificity between the studies, besides validity problems 30,31 .…”

“…As for the breast awareness strategy 9 , the studies either included other interventions alongside breast cancer warning signs awareness-raising, for example encouragement for screening mammography, thus preventing the evaluation of this strategy's efficacy per se or considered surrogate endpoints with no clinical relevance 8,36 . On the other hand, no harms associated with this strategy were identified.…”

“…The new guidelines for early detection of breast cancer in Brazil were based on systematic literature reviews of the risks and possible benefits of various early detection strategies 8,9 . The current article's objective is to present the new guidelines and a summary of the evidence for the recommendations, discussing the main controversies in light of the best and most current available evidence.…”