A Dissertation submitted to the Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, to fulfil the requirement to acquire a degree of Master of Science in Medicine Johannesburg 30 September 2014 / Background In South Africa cervical cancer has an age standardised incidence rate of 23 per 100 000 in women below the age of 35 and 76 per 100 000 amongst women over 35. The National Department of Health (NDoH) introduced the national cervical cancer screening policy guidelines in 2000, with the aim to screen 70% of women aged between 30 and 59 over a 10-year period. Health managers at provincial and district level were expected to implement this policy at their respective levels. Research has shown that implementing national health policies is often challenging due to management weaknesses, including the lack of guidelines or tools on how managers should plan and allocate budget for services. Aim The aim of this study is to develop and test an approach to planning and budgeting that would assist health managers to follow a rational process to plan and estimate budget requirements for implementing the cervical cancer screening policy at subnational level. Method This study was conducted in three districts in South Africa. The study was conducted in four phases. A situational analysis of budgeting practices was conducted in the first phase, to describe existing planning and budget allocation practices for cervical cancer screening programmes in the study sites and identify any existing gaps. The process requirements for implementing a cervical cancer screening programme were then identified prospectively in the second phase. Informed by the situation analysis and the process requirements, a computer-based planning and budget estimation program was developed in the third phase and tested through interviews with key informants in the fourth phase of the study. Results The situational analysis revealed a lack of involvement of interviewed programme managers at all the levels, in planning and budgeting for implementing cervical cancer screening programmes. The participants’ descriptions of budget allocation processes indicated that there was no defined process for allocating budget to services and the allocations were not specifically informed by assessed programme needs in their respective areas of jurisdiction. Process requirements for cervical screening were identified and documented for the following aspects of a cervical screening programme: calculating target population to inform planning for service provision, staff and equipment audits, equipment and supplies, material required for systems functioning (e.g., tools, forms, guidelines), transport and communication systems, community information education and communication (IEC) strategies, staff training, laboratory services and services for the treatment of High grade Squamous Intraepithelial Lesions (HSIL). A computerbased planning and budget estimation program, which could enable managers to define and quantify resources needed to implement a cervical screening programme was developed, informed by the documented process requirements. The testing of the computerised planning and budget estimation program indicated that the program could improve planning and help managers to estimate budget requirements for implementing cervical screening. Respondents indicated that the program was relatively easy to use and also felt that it could potentially be useful for programme planning as follows: a) it could serve as a tool for programme needs assessment, b) it could facilitate rational budget estimations, c) managers could use it as a bottom-up tool to motivate for resources, and d) managers could use it to refute inadequate budget allocations where possible. Conclusion The findings of the situational analysis support existing literature in revealing very little if any change in relation to inherent challenges in implementing cervical cancer screening services in South Africa. The findings of this study are relevant for public health programme planning and budgeting beyond cervical screening. Since managers at sub-national level are delegated to implement policy, it is imperative that they are provided with tools that may guide them to plan and budget for services on the basis of needs in their areas of jurisdiction. This study provides one such tool.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / O controle do cÃncer de mama fundamenta-se no mapeamento do risco, no planejamento e na implementaÃÃo de aÃÃes que visam à detecÃÃo de tumores cada vez menores, proporcionando melhorar a assistÃncia à saÃde, diminuindo os gastos desnecessÃrios e estimulando o desenvolvimento de estratÃgias educativas. Objetivou-se avaliar os efeitos da aplicaÃÃo de um manual educativo relacionado aos exames de detecÃÃo precoce do cÃncer de mama para mulheres. Trata-se de um estudo quase-experimental, realizado no municÃpio de Fortaleza-Ce em uma Unidade BÃsica de SaÃde. A populaÃÃo do estudo foi composta por mulheres cadastradas na referida unidade que realizaram o exame de prevenÃÃo ginecolÃgica, nos meses de abril e maio de 2011, destinados para a primeira etapa da coleta de dados, sendo baseada no nÃmero de atendimentos ginecolÃgicos mensais, totalizando uma amostra de 294 mulheres, distribuÃdas equitativamente em grupo intervenÃÃo-GI e grupo controle-GC. A coleta de dados foi feita atravÃs de uma entrevista por meio de um formulÃrio do tipo inquÃrito CAP (conhecimento, atitude e prÃtica), elaborado baseado no conhecimento dos exames de detecÃÃo precoce e na realizaÃÃo correta dos mesmos, alÃm de caracterÃsticas sÃcio-demogrÃficas das participantes e informaÃÃes sobre fatores de risco para cÃncer de mama nestas mulheres. O estudo foi desenvolvido em duas fases para o GI (inquÃrito CAP prÃ-intervenÃÃo acompanhado de uma sessÃo educativa do manual com leitura posterior dos mesmos pelas participantes e consulta de retorno com preenchimento do inquÃrito CAP pÃs-intervenÃÃo) e, uma fase para GC (inquÃrito CAP). O material educativo aplicado trata-se de um manual de orientaÃÃes a mulheres mastectomizadas onde foram utilizados os dois primeiros capÃtulos que correspondem a explicaÃÃes voltadas para os exames de detecÃÃo precoce. Para a anÃlise estatÃstica, utilizou-se o programa SPSS versÃo 16.0 e os dados foram tabulados, processados e analisados, em tabelas. Os testes estatÃsticos foram selecionados de acordo com a necessidade da anÃlise dos dados, a fim de alcanÃar os objetivos propostos, com confiabilidade e validade do instrumento. ApÃs anÃlise dos dados observou-se a homogeneidade dos dois grupos, mostrando a associaÃÃo das variÃveis sociodemogrÃficas e das variÃveis relacionadas aos fatores de risco para o desenvolvimento de cÃncer de mama. Contudo, puderam-se observar diferenÃas significativas nos escores, no que se refere ao grau de conhecimento, atitude e a prÃtica em relaÃÃo à realizaÃÃo dos exames de detecÃÃo precoce do cÃncer de mama, quando comparados apÃs aplicaÃÃo da intervenÃÃo educativa, notando-se que o grupo intervenÃÃo pÃs-manual mostrou a maioria das variÃveis comparativas superiores Ãs do grupo controle e Ãs do grupo intervenÃÃo antes do manual, isto Ã, apÃs a aplicaÃÃo do manual educativo, houve mudanÃas significantes voltadas para o diagnÃstico precoce do cÃncer de mama. O estudo tornou-se relevante à medida que propÃs avaliar uma estratÃgia de educaÃÃo em saÃde, a fim minimizar as lacunas do conhecimento e a realizaÃÃo dos exames de detecÃÃo precoce do cÃncer de mama e, dessa forma, melhorar a assistÃncia à saÃde mamÃria. Nesse sentido, comprova-se a tese de que a intervenÃÃo educativa, com a utilizaÃÃo de um manual educativo sobre detecÃÃo precoce do cÃncer de mama para mulheres, possibilitou importantes resultados na promoÃÃo da saÃde mamÃria, atravÃs da prevenÃÃo secundÃria. / The control of breast cancer is based on risk mapping, planning and implementation of actions aimed to detect increasingly smaller tumors, providing better health care, reducing unnecessary spending and stimulating the development of educational strategies. The objective was to assess the effects of the application of an educational handbook related to early detection tests of breast cancer for women. This is a quasi-experimental study carried out in Fortaleza-CE, Brazil, in a Basic Health Unit. The study population consisted of women registered in this unit who underwent preventive gynecological examination in April and May 2011, intended for the first stage of data collection, being based on the number of gynecologic examination per month, totaling a sample of 294 women, equally distributed in intervention group and control group. Data collection happened through an interview by a KAP (knowledge, attitude and practice) survey, developed based on knowledge of early detection tests and the correct performance of them, as well as socio-demographic characteristics of participants and information about risk factors for breast cancer in these women. The study was developed in two phases for the intervention group (pre-intervention KAP survey followed by an educational session of the manual and later reading by the same participants and a return visit to post-intervention KAP), and a phase for the control group (KAP survey). The educational material used is a manual of guidelines for mastectomized women where we used the first two chapters that correspond to explanations focused on early detection tests. For statistical analysis we used SPSS program version 16.0 and data was tabulated, processed and analyzed in tables. Statistical tests were selected according to the need for data analysis, in order to achieve the proposed objectives, with reliability and validity of the instrument. After data analysis we observed the homogeneity of both groups, showing the association of socio-demographic variables and variables related to risk factors for developing breast cancer. However, we could verify significant differences in scores, regarding the degree of knowledge, attitude and practice on the performance of examinations for early detection of breast cancer, when compared after application of the educational intervention, noticing that the post-manual intervention group presented most of the comparative variables higher than the control group and the intervention group before the handbook, which means, after the implementation of an educational handbook, there were significant changes addressed at early diagnosis of breast cancer. The study became relevant once it proposed to assess a health education strategy, in order to minimize the gaps in knowledge and performance of the examinations for early detection of breast cancer, thus improving breast health care. In this sense, we prove the thesis that the educational intervention using an educational handbook on early detection of breast cancer for women, allowed significant results in promoting breast health through secondary prevention.

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第18907号 / 社医博第65号 / 新制||社医||9(附属図書館) / 31858 / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 川上 浩司, 教授 富樫 かおり, 教授 武藤 学 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

研究背景： / 2009年起，中國政府發起並資助了一項覆蓋全國31個省221個鄉村、針對100萬名農村婦女的細胞學及肉眼觀察宮頸癌篩查試點項目。國家及地方政府需要對可行的篩查策略進行衛生經濟學評估，為下一步擴大規模的篩查提供政策依據。 / 研究目標： / 應用人群特異性Markov模型，對巴氏塗片及肉眼觀察的宮頸癌篩查策略進行成本效果及成本效用兩方面的衛生經濟學評估，進而為中國農村婦女宮頸癌篩查政策的制定提供依據。 / 研究方法： / 本論文工作建立了Markov人群動態擬合模型，該模型能夠整合與中國農村宮頸癌流行情況相吻合的成本及健康狀況的數據，進而用於擬合20年內35-59歲中國農村婦女在有/無篩查幹預下的成本、效用和效果。本文分析的八個備選篩查策略包括：採用醋酸染色肉眼觀察（VIA）或傳統細胞學（巴氏塗片）分別進行10年，5年，3年及1年一次的篩查。 / 本文從社會學角度出發，成本數據涵蓋篩查、診斷及治療過程中產生的直接及間接成本。模型在結構上綜合了已被廣泛認可的宮頸癌自然發展史模型，以及宮頸癌及其癌前病變（CIN）在中國農村進行篩查和治療的標準臨床路徑。模型輸入參數盡可能地使用了能夠反映中國農村婦女人群特異性的數據。通過對比國家報告數據與模型預測結果，本文從全死因死亡率、宮頸癌死亡率及宮頸癌發病率三個方面驗證了模型的可信度。 / 模型的結局變量包括：累計成本、累計生命年(LYs)、累計質量調整生命年(QALYs)、預期宮頸癌死亡率及發病率降低百分比(%)、CIN 相對風險、宮頸浸潤癌相對風險，增量成本效用比(ICUR, 表述為每挽救一個質量調整生命年消耗的成本)及增量成本效果比(ICER, 表述為每挽救一個生命年消耗的成本)等。與無篩查幹預相比，我們界定ICUR及ICER小於三倍人均國內生產總值（76,824元，2009年)的優勢策略為‘具有成本效益’的選擇，並將其中ICUR和ICER最低的策略，定義為‘最具成本效益’的策略，將具有最大健康效益的策略（挽救最多質量調整生命年或生命年的策略），定義為‘最有效’的策略。同時，我們對可能影響決策的不確定因素進行了敏感性分析。 / 結果： / 與無篩查幹預相比，肉眼觀察及巴氏塗片篩查均能夠減少宮頸癌患病例數，進而顯示出一定的健康效益。較短的篩查間隔具有更高的健康效益。模型預測在不同的篩查策略幹預下，宮頸癌死亡率和發病率分別有望降低6.67-31.95%和5.12-24.71%，預期CIN發病相對風險為0.89-0.98，預期宮頸癌發病相對風險為0.73-0.95。篩查幹預對健康的保護作用在本研究中得到了證實。 / 成本效用分析顯示，10年一次的肉眼觀察策略最具成本效益，其次為5年一次、3年一次、1年一次的肉眼觀察篩查策略及1年一次的巴氏塗片篩查策略。與無篩查幹預相比，如上策略每挽救一個質量調整生命年消耗的成本為11,921至26,069元（1,892-4,138美元，2012年）。同時成本效果分析也顯示，10年一次的肉眼觀察策略最具成本效益，其次為5年一次的肉眼觀察策略及5年一次的巴氏塗片篩查策略。同樣與無篩查幹預相比，如上策略每挽救一個生命年消耗的成本為37,211至68,226元（5,906-18,830美元，2012年）。 / 對於某一既定策略，相應的ICUR和ICER受當地經濟狀況相關因素的影響最大，這些因素包括治療成本、篩查成本和成本貼現率。從檢測技術水平上看，肉眼觀察對分析結果的影響小於巴氏塗片，原因是前者敏感度範圍較小。篩查覆蓋率、初篩陽性隨訪率、診斷陽性治療率也都與相應的ICUR和ICER呈負相關性。敏感性分析結果顯示本文中模型對於健康結局的預測，及相關的衛生經濟學分析，受自然史模型中HPV感染和CIN之間轉移概率的不確定性的影響最大。HPV感染與CIN間的進展和逆轉概率是該項模型研究的核心參數。 / 結論： / 本文中成本效用和成本效果分析均顯示，相較於傳統的細胞學篩查策略，採用間隔時間較長（10年或5年）的肉眼觀察篩查策略，對一般發病地區的35-59歲的農村婦女來說，是更具‘成本效益’的選擇。對於宮頸癌高發地區，其篩查頻率可以提高到1年一次。1年一次的巴氏塗片篩查策略，是最有效的篩查策略，可以挽救最多的生命。但採用該策略時，應在財政預算允許的前提下，確保篩查技術和項目完成的質量。 / 篩查項目的高覆蓋率，對篩查陽性患者良好的隨訪和診治，初篩檢測技術平均水平以上的表現，以及較低的篩查和治療成本是確保篩查項目具備成本效益優勢的核心因素。本文完成的成本效用及成本效果分析，能夠為公共衛生決策提供重要的輔助作用。 / Background: / A Chinese government-sponsored cytology/visual inspection pilot cervical cancer screening program covered 10 million rural women in 221 counties of 31 provinces was initiated in 2009. Both the local and national governments in China need health economic evaluations of feasible strategies so as to make better policies for the next-step enlarging screening. / Objectives: / To perform health economic evaluations of Pap smear and visual inspection cervical cancer screening strategies using population-specific Markov modeling cost-utility (CUA) and cost-effectiveness (CEA) analyses, in order to assist screening policy making for women in rural China. / Methods: / Markov simulation models were developed to synthesize the evidence on costs and health outcomes related to cervical cancer epidemiology in rural China, and applied to predict the long-term utility, effectiveness and costs for hypothetical cohorts of 35-59 years old rural Chinese women, with or without the presence of screening over 20 years. The eight alternative screening strategies assessed were visual inspection with acetic acid (VIA) or traditional cytology (Pap smear) each with ten-year, five-year, three-year and one year screening intervals. / The study was conducted from the societal perspective, thus both directed and non-direct costs related to screening, diagnosis and treatment interventions were considered. The model structures incorporated with the well-accepted the natural history model of cervical cancer and the standard clinical pathway of screening and treatment interventions for precancerous lesions (CIN) and cervical cancer in real practice in rural China. Population-specific data were used as much as possible to be the model inputs. The model estimates were validated by comparison of our predictions of all-cause mortality, cervical cancer mortality and cervical cancer incidence with the national reported data. / Outcome variables included cumulative cost, life years (LYs), quality-adjusted life years (QALYs), predicted reduction(%) in cervical cancer mortality and incidence, relative risk of CIN, relative risk of cervical cancer, incremental cost-utility ratio (ICUR, presented as cost per QALY saved) and incremental cost-effectiveness ratio (ICER, presented as cost per life year saved). Compared with no screening, not-dominated strategies with ICUR and ICER less than three times China’s GDP per capita (76,824 CNY, 2009) were considered to be ‘cost-effective’ options. Among the identified ‘cost-effective’ options, the strategy with lowest ICUR or ICER was defined as the most cost-effective strategy, and the strategy with the highest health benefit (largest QALY saved or life year saved) was defined as the most effective strategy. Sensitivity analyses were conducted to test the effect of uncertainties on decision making. / Results: / All of the VIA and Pap smear screening strategies of showed certain benefits due to the decreased number of women developing cervical cancer, when compared with no screening. A trend for shorter screening interval to have greater benefit was also found. Cervical cancer mortality and incidence were expected to be reduced by 6.67-31.95% and 5.12-24.71% with different screening strategies. And the predicted relative risks of CIN and invasive cervical cancer of 0.89-0.98 and 0.73-0.95, respectively, also demonstrated the protective effect of screenings. / Modeling cost-utility analysis identified ten years VIA screening as the most cost-effective strategy followed by VIA screening with five-, three- and one year interval and Pap smear screening with a one year interval. Compared with no screening, the incremental costs per QALY saved of these strategies ranged from 11,921 to 26,069 Yuan (1,892-4,138 US dollars, 2012). In the meanwhile, modeling cost-effectiveness analysis also identified ten-years VIA screening as the most cost-effective strategy followed by VIA screening with five-year intervals and Pap smear screening with five-year intervals. Compared with no screening, the incremental costs per life year saved of these strategies ranged from 37,211 to 68,226 Yuan (5,906-18,830 US dollars, 2012). / Both ICUR and ICER of a selelected strategy were greatest influnced by factors related to variations in local economies , including treatment cost, screening cost and discounting rate of the cost. The influence of primary test performance of VIA was rather less than that of Pap smear due to the narrower ranges of the VIA sensitivities. Screening coverage, follow-up rate and treatment rate were also negatively associated with ICUR and ICER. Health outcome predictions and health economic analyses were mostly influenced by the uncertainties in HPV infection and CIN transitions in the natural history. Progression and regression probabilities between HPV infection and CIN were considered to be the key parameters of the simulation models. / Conclusions: / Baseline CUA and CEA results suggested that in comparison with traditional cytology screening strategies, organized VIA screening with long intervals (ten or five years) were more cost-effective options than for 35-59 years old women in normal incidence areas of rural China. The VIA screening interval can be shorten to one year in high incidence areas. Pap smear strategy with one year interval can be utilized as the most effective strategy with most lives saved when budget allows and the performances of program and test are ensured. / High coverage of the screening program, good management of screening positives, average or above performance of primary test, and lower screening and treatment costs are key elements for a cost-effective screening program. Cost-utility and cost-effectiveness analyses, such as the one conducted in this thesis study, can be considered important adjuncts to policy decision-making about public health objectives. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Li, Xue. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 388-401). / Abstracts also in Chinese; appendixes includes Chinese. / Abstract of thesis --- p.i / 中文摘要 --- p.v / ACKNOWLEDGEMENTS --- p.viii / TABLE OF CONTENTS --- p.1 / LIST OF TABLES --- p.8 / LIST OF FIGURES --- p.11 / ABBREVIATIONS --- p.12 / Chapter CHAPTER 1 --- INTRODUCTION --- p.14 / Chapter 1.1 --- Epidemiological patterns and disease burden of cervical cancer --- p.14 / Chapter 1.1.1 --- Cervical cancer incidence and mortality worldwide --- p.14 / Chapter 1.1.2 --- Risk factors for cervical cancer --- p.15 / Chapter 1.1.2.1 --- Human Papillomavirus (HPV) --- p.15 / Chapter 1.1.2.2 --- Parity --- p.16 / Chapter 1.1.2.3 --- Smoking --- p.16 / Chapter 1.1.2.4 --- Human Immunodeficiency Virus (HIV) --- p.17 / Chapter 1.1.2.5 --- Contraception --- p.17 / Chapter 1.1.2.6 --- Sexual behavior, nutrition and other factors --- p.18 / Chapter 1.1.3 --- Disease burden of cervical cancer in China --- p.18 / Chapter 1.1.3.1 --- Epidemiology of Cervical Cancer in China --- p.18 / Chapter 1.1.3.2 --- Cervical cancer in different geographic areas of China --- p.20 / Chapter 1.2 --- The need for cost-effectiveness analysis of cervical screening strategies in China --- p.21 / Chapter 1.2.1 --- Cervical cancer prevention in China --- p.21 / Chapter 1.2.2 --- Why do we need a modeling cost-effectiveness analysis? --- p.23 / Chapter 1.3 --- Natural history of cervical cancer --- p.25 / Chapter 1.3.1 --- Terminology --- p.25 / Chapter 1.3.2 --- Natural history of cervical cancer --- p.27 / Chapter 1.4 --- Secondary prevention strategies of cervical cancer --- p.29 / Chapter 1.4.1 --- Screening tests --- p.29 / Chapter 1.4.1.1 --- Cervical cytology --- p.29 / Chapter 1.4.1.2 --- Visual Inspection --- p.32 / Chapter 1.4.1.3 --- HPV testing --- p.36 / Chapter 1.4.2 --- Summary of different screening strategies all over the world --- p.37 / Chapter CHAPTER 2 --- LITERATURE REVIEW --- p.40 / Chapter 2.1 --- Background --- p.40 / Chapter 2.2 --- Objectives of the literature review --- p.41 / Chapter 2.3 --- Search strategies and results --- p.41 / Chapter 2.3.1 --- Search strategies --- p.41 / Chapter 2.3.2 --- Inclusion and exclusion criteria --- p.42 / Chapter 2.4 --- Literature results summary --- p.44 / Chapter 2.4.1 --- Methodology, target population and analytical perspective --- p.44 / Chapter 2.4.2 --- Screening test and program performance --- p.47 / Chapter 2.4.3 --- Cost and utility estimation --- p.49 / Chapter 2.4.4 --- Model parameter sources and validation --- p.53 / Chapter 2.4.5 --- Alternatives and identified cost-effective strategies --- p.58 / Chapter 2.5 --- Conclusions --- p.63 / Chapter CHAPTER 3 --- OBJECTIVES --- p.64 / Chapter 3.1 --- General Objectives --- p.64 / Chapter 3.2 --- Alternative cervical cancer screening strategies in this study --- p.64 / Chapter 3.3 --- Decision rules for recommended cost-effective options --- p.65 / Chapter 3.4 --- Analytical perspective and time horizon --- p.65 / Chapter 3.5 --- Objectives --- p.66 / Chapter 3.6 --- Analytical scenario in this study --- p.66 / Chapter 3.6.1 --- Patterns of cervical screening program delivery in rural China --- p.67 / Chapter 3.6.2 --- Demographic profile of the simulated hypothetical cohort --- p.67 / Chapter 3.6.3 --- Summary of model assumptions --- p.68 / Chapter 3.6.3.1 --- Assumptions related to screening performance and clinical practice --- p.68 / Chapter 3.6.3.2 --- Assumptions related to epidemiological characteristics of cervical cancer --- p.68 / Chapter 3.6.3.3 --- Assumptions related to economic evaluation --- p.69 / Chapter CHAPTER 4 --- METHODOLOGY --- p.70 / Chapter 4.1 --- Alternative strategies in this study --- p.70 / Chapter 4.2 --- Markov Model Developments and Applications --- p.72 / Chapter 4.2.1 --- General introduction of Markov Transition Model --- p.72 / Chapter 4.2.2 --- Structure of Markov models --- p.76 / Chapter 4.2.2.1 --- Natural history model of cervical cancer --- p.76 / Chapter 4.2.2.2 --- Structure of Pap smear and Visual Inspection screening models --- p.82 / Chapter 4.2.2.3 --- Structure of precancerous lesion and invasive cancer treatment models --- p.83 / Chapter 4.2.2.4 --- Interaction of the models --- p.85 / Chapter 4.2.3 --- Demographic profile of the hypothetical cohort --- p.86 / Chapter 4.2.4 --- Probabilities --- p.88 / Chapter 4.2.4.1 --- Identification and converting between rate and probability --- p.89 / Chapter 4.2.4.2 --- Initial probabilities --- p.90 / Chapter 4.2.4.3 --- Transition probabilities --- p.91 / Chapter 4.2.5 --- Screening, diagnosis and treatment characteristics --- p.101 / Chapter 4.2.5.1 --- Screening program characteristics --- p.101 / Chapter 4.2.5.2 --- Diagnosis test performance --- p.104 / Chapter 4.2.5.3 --- Precancerous lesions treatment characteristics --- p.104 / Chapter 4.2.5.4 --- Invasive cancer and treatment characteristics --- p.106 / Chapter 4.2.6 --- Model validation --- p.111 / Chapter 4.3 --- Cost data collection --- p.112 / Chapter 4.3.1 --- Perspective of study --- p.112 / Chapter 4.3.2 --- Selection of study sites --- p.113 / Chapter 4.3.3 --- Screening cost data collection --- p.113 / Chapter 4.3.4 --- Treatment cost data collection --- p.115 / Chapter 4.4 --- Cost-utility analysis and cost-effectiveness analysis --- p.117 / Chapter 4.4.1 --- General introduction of these two analyses --- p.117 / Chapter 4.4.2 --- Utility Estimates --- p.118 / Chapter 4.4.3 --- Screening utility and effectiveness evaluation --- p.120 / Chapter 4.4.4 --- Cost-effectiveness and cost-utility analysis method --- p.122 / Chapter 4.5 --- Time horizon and discounting rate --- p.125 / Chapter 4.6 --- Summary of modeling assumptions --- p.126 / Chapter 4.6.1 --- Assumptions related to screening performance and clinical practice --- p.126 / Chapter 4.6.2 --- Assumptions related to epidemiological characteristics of cervical cancer --- p.127 / Chapter 4.6.3 --- Assumptions related to economic evaluation --- p.128 / Chapter 4.7 --- Sensitivity analysis --- p.128 / Chapter 4.8 --- Ethical approval --- p.129 / Chapter CHAPTER 5 --- RESULTS --- p.130 / Chapter 5.1 --- Model validation --- p.130 / Chapter 5.2 --- Cost analysis results --- p.134 / Chapter 5.2.1 --- Screening costs results --- p.134 / Chapter 5.2.2 --- Treatment cost results --- p.136 / Chapter 5.2.3 --- The proportional costs breakdown for different screening strategies --- p.139 / Chapter 5.3 --- Utility estimation results --- p.141 / Chapter 5.4 --- Cost-utility analysis results --- p.144 / Chapter 5.4.1 --- Baseline analysis --- p.144 / Chapter 5.4.2 --- Influence of screening program performance --- p.148 / Chapter 5.4.2.1 --- Coverage of the screening program --- p.148 / Chapter 5.4.2.2 --- Follow up rate and treatment rate of positives --- p.155 / Chapter 5.4.3 --- Influence of screening test performance --- p.159 / Chapter 5.4.4 --- Influence of costs --- p.165 / Chapter 5.4.4.1 --- Influence of screening costs --- p.165 / Chapter 5.4.4.2 --- Influence of treatment costs --- p.168 / Chapter 5.4.5 --- Influence of discounting --- p.171 / Chapter 5.4.6 --- Summary of factors and their influences on the baseline CUA results --- p.174 / Chapter 5.5 --- Cost-Effectiveness analysis results --- p.180 / Chapter 5.5.1 --- Baseline analysis --- p.180 / Chapter 5.5.1.1 --- Life year saved --- p.181 / Chapter 5.5.1.2 --- Cervical cancer mortality reduction --- p.185 / Chapter 5.5.1.3 --- Cervical cancer incidence reduction --- p.187 / Chapter 5.5.1.4 --- Relative risk of CIN and cervical cancer --- p.189 / Chapter 5.5.1.5 --- Effectiveness summary of alternative screening strategies on the hypothetical 100,000 rural Chinese women --- p.191 / Chapter 5.5.2 --- Factors that influence the CEA results --- p.195 / Chapter 5.5.2.1 --- Best scenario analysis --- p.196 / Chapter 5.5.2.2 --- Worst scenario analysis --- p.201 / Chapter 5.5.2.3 --- Summary of the possible ranges of costs and effectiveness in different scenarios --- p.206 / Chapter 5.6 --- Sensitivity analysis --- p.209 / Chapter 5.6.1 --- Sensitivity analysis of Cost-Utility analysis results --- p.209 / Chapter 5.6.1.1 --- Tornado analysis --- p.209 / Chapter 5.6.1.2 --- One-way sensitivity analysis --- p.213 / Chapter 5.6.2 --- Sensitivity analysis of Cost-Effectiveness analysis results --- p.220 / Chapter 5.6.2.1 --- Tornado analysis --- p.220 / Chapter 5.6.2.2 --- One-way sensitivity --- p.224 / Chapter 5.6.3 --- Summary of sensitivity results --- p.236 / Chapter CHAPTER 6 --- SUMMARY, DISSICUSSION AND CONCLUSIONS --- p.240 / Chapter 6.1 --- Summary of Markov model development and validation --- p.240 / Chapter 6.1.1 --- Category and source summary of input parameters --- p.240 / Chapter 6.1.2 --- Model validation --- p.244 / Chapter 6.2 --- Summary of modeling results --- p.245 / Chapter 6.2.1 --- Summary of Cost-Utility Analysis --- p.245 / Chapter 6.2.1.2 --- Baseline analysis findings --- p.245 / Chapter 6.2.1.2 --- Influential factors on the cost-effective manner of alternative strategies --- p.246 / Chapter 6.2.2 --- Summary of Cost-Effectiveness Analysis --- p.250 / Chapter 6.2.2.1 --- Baseline analysis findings --- p.251 / Chapter 6.2.2.2 --- Possible ranges for cost and effectiveness of alternative strategies under different scenarios --- p.253 / Chapter 6.2.3 --- Summary of CUA and CEA findings --- p.257 / Chapter 6.2.4 --- Summary of sensitivity analysis --- p.259 / Chapter 6.2.4.1 --- Important variables on health outcome predictions --- p.259 / Chapter 6.2.4.2 --- Sensitive variables to the baseline CUA and CEA recommendations --- p.260 / Chapter 6.2.4.3 --- Overview of the sensitivity analysis --- p.263 / Chapter 6.3 --- Discussion --- p.264 / Chapter 6.3.1 --- Alternative strategies of cervical cancer screening in rural China --- p.264 / Chapter 6.3.1.1 --- Target ages --- p.265 / Chapter 6.3.1.2 --- Screening intervals --- p.266 / Chapter 6.3.1.3 --- Feasible primary screening tests --- p.267 / Chapter 6.3.1.4 --- Service delivering patterns --- p.269 / Chapter 6.3.1.5 --- Time horizon of this thesis study --- p.270 / Chapter 6.3.2 --- Transition probability estimation --- p.271 / Chapter 6.3.3 --- Screening and treatment cost estimation --- p.276 / Chapter 6.3.3.1 --- Representativeness of the selected counties --- p.276 / Chapter 6.3.3.2 --- Screening costs of VIA and Pap smear --- p.277 / Chapter 6.3.3.3 --- Treatment costs --- p.279 / Chapter 6.3.4 --- Utility estimation --- p.280 / Chapter 6.3.4.1 --- Instrument selection --- p.280 / Chapter 6.3.4.2 --- Utility estimation between studies --- p.281 / Chapter 6.3.5 --- Baseline cost-utility and cost-effectiveness analyses --- p.283 / Chapter 6.3.6 --- Sensitivity Analysis --- p.284 / Chapter 6.3.7 --- Strengths and limitations --- p.286 / Chapter 6.3.7.1 --- Limitations --- p.286 / Chapter 6.3.7.2 --- Strengths --- p.288 / Chapter 6.4 --- Policy implications --- p.289 / Chapter 6.4.1 --- How to manage a cost-effective cervical cancer screening program? --- p.289 / Chapter 6.4.2 --- How can VIA screening be adopted? --- p.290 / Chapter 6.4.3 --- How can Pap smear screening be adopted? --- p.291 / Chapter 6.4.4 --- Framework for policy decision making --- p.292 / Chapter 6.5 --- Conclusions --- p.295 / Chapter APPENDIX --- p.300 / Chapter Appendix 1-1 --- The 2001 Bethesda System* --- p.300 / Chapter Appendix 1-2 --- The FIGO Staging for cervical cancers* --- p.301 / Chapter Appendix 1-3 --- Cervical Cancer Screening Program in different countries --- p.302 / Chapter Appendix 4-1 --- WHO World Standardized Population Distribution (%) --- p.305 / Chapter Appendix 4-2 --- Summary of transition probabilities literature review --- p.306 / Chapter Appendix 4-3 --- Price Indices from 1978 to 2010 --- p.326 / Chapter Appendix 4-4 --- Screening Cost Questionnaire --- p.327 / Chapter Appendix 4-5 --- Programmatic Cost Survey Questionnaire --- p.339 / Chapter Appendix 4-6 --- Treatment Cost Survey Questionnaire --- p.342 / Chapter Appendix 4-7 --- EQ-5D Algorism (UK) --- p.344 / Chapter Appendix 4-8 --- Chinese Version of EQ5D----HQOL score questionnaire --- p.345 / Chapter Appendix 5-1 --- Calibrated variables and its final settings --- p.348 / Chapter Appendix 5-2 --- Cervical cancer new cases and deaths all over the world in 2008 --- p.349 / Chapter Appendix 5-3 --- Data distribution of CIN2-3 and cervical cancer treatment costs --- p.350 / Chapter Appendix 5-4 --- Relative risk of CIN and cervical cancer by age groups of alternative screening strategies --- p.361 / Chapter Appendix 5-5 --- Influence of discounting rate of life years on the CEA results --- p.363 / Chapter Appendix 5-6 --- Tornado analysis results based on the effect on QALYs predictions --- p.367 / Chapter Appendix 5-7 --- Tornado analysis results based on the effect on life-year predictions --- p.372 / Chapter Appendix 6-1 --- Summary of Markov Model Inputs and Sources --- p.377 / REFERENCE --- p.388

O rastreamento para o cÃncer do colo uterino e o planejamento familiar sÃo prÃticas preventivas de relevÃncia em saÃde da mulher em idade fÃrtil. A atenÃÃo bÃsica ainda privilegia o ciclo gravÃdico-puerperal e a prevenÃÃo da neoplasia maligna do colo, ficando o planejamento familiar em segundo plano. Contudo, a despeito da melhor cobertura na realizaÃÃo da citologia cervicovaginal, as taxas de mortalidade pela neoplasia persistem elevadas. Persistem, tambÃm, taxas altas de gestaÃÃo na adolescÃncia, de abortamentos e iniquidades em saÃde. O objetivo do projeto foi caracterizar a situaÃÃo de saÃde reprodutiva de mulheres em idade fÃrtil de uma comunidade urbana de baixa renda em Fortaleza, priorizando a realizaÃÃo da citologia e o uso de mÃtodos contraceptivos. Tratou-se de estudo transversal por entrevistas domiciliares com 244 mulheres de 13 a 52 anos. A anÃlise exploratÃria inicial permitiu estabelecer correlaÃÃes atravÃs do teste do qui-quadrado de Pearson para as variÃveis nominais e ANOVA para mÃdias e desvios padrÃes. Para expressar a magnitude das associaÃÃes foram calculadas razÃes de chance (odds ratio) como expressÃes das razÃes de prevalÃncia utilizando regressÃo logÃstica simples e mÃltipla. Dentre as entrevistadas com atividade sexual e 25 anos ou mais, 90,3% realizaram citologia no mÃximo a cada trÃs anos, 59,3% anualmente. Correlacionaram-se positivamente à periodicidade anual o trabalho remunerado (OR=2,63; IC95%: 1,49-4,64) e a condiÃÃo de ter tido no mÃximo uma gestaÃÃo (OR=2,60; IC95%: 1,11-6,08). Quanto ao planejamento familiar, pouco mais da metade das mulheres (51,9%) usava algum mÃtodo e 39,5% delas nÃo foram orientadas por mÃdico ou enfermeiro. Predominou utilizaÃÃo de anticoncepcionais orais (40,4%) e condom (28,7%). A renda familiar de R$ 800,00 ou superior associou-se à maior chance de contracepÃÃo orientada por profissional adequado (OR=3,3, IC95%: 1,28-8,54), contrariamente à histÃria de abortamento (OR=0,32, IC95%: 0,13-0,82). Observou-se alta frequÃncia de realizaÃÃo da citologia cervicovaginal, inclusive anualmente e fora da faixa etÃria recomendada pelo MinistÃrio da SaÃde. Houve baixa prevalÃncia de anticoncepÃÃo, oferta insuficiente quanto à variedade e elevada proporÃÃo de mulheres que nÃo recebeu orientaÃÃo adequada para o uso de mÃtodos contraceptivos. Renda familiar e abortamento prÃvio foram fatores associados ao planejamento familiar orientado por profissional adequado, enquanto o trabalho remunerado e o fato de ter tido no mÃximo uma gestaÃÃo foram associados à coleta anual de citologia para prevenÃÃo do cÃncer do colo uterino. / Cervical cancer screening and family planning are relevant preventive health practices for women of childbearing age. Primary care still privileges gestational period and cervical neoplasia prevention over family planning. Nevertheless, despite improvements on the coverage for cervicovaginal cytology, cervical neoplasia mortality rates show only slight decrease. High rates of teenage pregnancy, abortions and health iniquities persist. The project aimed to portrait the reproductive health situation of childbearing aged women from a low income urban community in Fortaleza, prioritizing cytology procedures and the use of contraceptive methods. This was a cross-sectional study carried out through home interviews with 244 women from the age of 13 to 52 years old. The initial exploratory analysis allowed establishing correlations through the chi-square test for nominal variables and ANOVA for means and standard deviations. Odds ratios as expressions of prevalence ratios were obtained to express the magnitude of the associations using simple and multiple logistic regression. Amongst sexually active women and aged 25 years or more, 90.3% underwent cytology at least every 3 years, and 59.3% did it annually. Cytology annual frequency positively correlated to remunerated employment (OR=2.63; IC95%: 1.49-4.64) and to the condition of having had the maximum of one pregnancy (OR=2.60; IC95%: 1.11-6.08). Regarding family planning, just over half of women (51.9%) used any contraception and 39.5% of them were not guided by doctors or nurses. Oral contraceptives (40.4%) and condom (28.7%) predominated as current contraceptive methods. Family income of R$ 800.00 or above positively correlated with contraception guided by an appropriate professional (OR=3.3, IC95%: 1.28-8.54) and negatively correlated to a history of previous abortion (OR=0.32, IC95%: 0.13-0.82). High rates of cervicovaginal cytology were observed, even annually and out of the age group suggested by the Health Ministry. There was a low rate of contraception, insufficient offer as to methods variety and a high proportion of women who did not received adequate guidance on the use of contraceptive methods. Family income and previous abortion were associated to family planning guided by a qualified professional, whilst remunerated employment and having had the maximum of one pregnancy were associated to annual cytology screening to prevent cervix neoplasia.

Submitted by Rafael Santana (rafael.silvasantana@ufpe.br) on 2017-04-11T17:51:30Z No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) DISSERTAÇÃO PPGGES MARIANA FRAGOSO - BIBLIOT. (1).pdf: 1525984 bytes, checksum: 4b14ff8ab52533beac252ef888d0461a (MD5) / Made available in DSpace on 2017-04-11T17:51:30Z (GMT). No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) DISSERTAÇÃO PPGGES MARIANA FRAGOSO - BIBLIOT. (1).pdf: 1525984 bytes, checksum: 4b14ff8ab52533beac252ef888d0461a (MD5) Previous issue date: 2016-09-22 / O Programa Nacional de Melhoria do Acesso e da Qualidade é um programa de âmbito nacional que traz a proposta de promover a melhoria da qualidade assistencial nos serviços públicos de saúde e o acesso oportuno, representa um novo paradigma na qualificação assistencial da principal porta de entrada do Sistema Único de Saúde. Este programa é formado por 47 indicadores de saúde, contudo, impulsionou-se a avaliação do impacto da política a um dos indicadores de desempenho da área da saúde da mulher, o qual referencia ao rastreamento precoce do Câncer de Colo do Útero. Pois, sabe-se que a maioria dos estudos realizados sobre a temática da cobertura do exame citopatológico focaliza-se nas grandes cidades das Regiões Sul e Sudeste. Assim, justificou-se que a incorporação de práticas avaliativas de impacto de programas nacionais aos serviços de saúde pública é uma necessidade que se afigura nas políticas públicas. Para tal, o estudo teve o objetivo de avaliar o impacto desta política sobre o indicador de rastreamento precoce do câncer do colo do útero no estado de Alagoas, no período de 2011 a 2014. Para mensurar este efeito utilizou o método estatístico chamado Diferenças em Diferenças e as análises estatísticas foram realizadas através do Software STATA versão 12.0 Special Edition. Aos resultados encontrados mediante as estimações das equações divididas em três modelos de regressão linear, o Modelo (1) apresentou um impacto positivo e estatisticamente significante a 1%, esse sinal positivo mostra o efeito entre o quantitativo de exames realizados pelas mulheres dos municípios participantes do programa foi de 5.410 exames a mais que as não participantes, um aumento médio percentual de 52% da Razão. Ao Modelo (2), a este foram incluídas as variáveis de controle socioeconômicas e demográficas, o efeito do programa captado no coeficiente estimador foi de 5.227 e a despeito da significância estatística mostrou-se a 1%, apresentando um aumento de 51% da Razão. Por fim, o Modelo (3), este foram incluídos os principais desfechos como variáveis independentes, o efeito encontrado foi de 5.049 e estatisticamente significante a 1%, verificou-se que o programa conseguiu assegurar aos usuários a garantia da melhoria do acesso oportuno ao rastreamento precoce e manteve o aumento médio percentual em media dos 50% da Razão. Neste sentido, o estudo apontou boas perspectivas para o fortalecimento da atenção básica através desta nova estratégia consolidadora e atribuiu ao programa os movimentos quantitativos positivos identificados, de forma que o programa potencializou as mudanças no processo de rastreio precoce e que puderam contribuir para a melhoria do acesso e da assistência. Com isso, o Ministério da Saúde espera que as taxas de incidência e mortalidade desta patologia venham diminuir, ocorrendo uma queda das estimativas local, regional e até mesmo nacional para o biênio 2016/2017. / The National Program of access improvement and health basic attention has as the purpose promoting the enhancement of access and care quality in the public health services. Also, this Program represents a new model in providing the better care of the main entrance of health unique system. It is formed by 47 health indicators, although, Although, boosted to assess the impact of policy to one of the performance indicators in the area of women's health, which it refers to early screening of cervical cancer. Therefore, it is known that the majority of studies on the issue of coverage of cervical cancer screening focuses in large cities of the South and Southeast. Thus, it is appropriate that the incorporation of assessment practices impact of national programs for public health services is a necessity which appears in public policy. For such, this research aimed to evaluate the impact of this policy about the early detection of cervical cancer in Alagoas, since 2011 to 2014. To measure this effect, the research used the statistical method called ‘Differences in Differences’ and the statistical analysis were made through the Software ‘STATA version 12.0 Special Edition’. The results found by the estimates of equations divided into three linear regression models, the model (1) had a positive impact and statistically significant at 1%, the positive sign shows the effect of the quantitative tests performed by the women of the participating municipalities program was 5,410 tests more than non-participants, increase average percentage of 52% of Reason. The model (2), this was included socioeconomic and demographic control variables, the effect of the captured program in estimator coefficient was 5.227 and despite the statistical significance was found to be 1%, with a 51% increase of Reason. While the model (3), this the main outcomes as independent variables were included, the effect of the program was found to be 5.049 and statistically significant at 1%, it was found that the program could provide users with the assurance of improving timely access to early screening and kept the average percentage increase in average 50% of Reason. Based on this, the study reveals important perspectives to the improvement of health basic attention through this new strategy in health unique system and gives the program the positive quantitative movements identified, so that the program leveraged changes in the early screening process and that could contribute to the improvement of access and assistance. Thus, the Ministry of Health expects incidence rates and mortality of this disease will decrease, causing a drop in place estimates, regional and even national for the biennium 2016/2017.

O câncer de mama é a neoplasia maligna mais prevalente entre as mulheres no mundo e representa 23% de todos os cânceres femininos. Buscou-se avaliar a implementação de um programa de rastreamento mamográfico para as mulheres que vivem na área de Barretos usando uma unidade móvel (UM) e uma unidade fixa (UF). Um total de 54.238 mulheres com idade entre 40 a 69 anos reside nesta área e são elegíveis para a participação no programa. Os dados epidemiológicos das mulheres foram examinadas entre 01 de abril de 2003 e 31 de março de 2005. A análise estatística foi constituída pela avaliação das freqüências dos parâmetros clínicos e as características do tumor usando o teste de Qui-quadrado com correção de Bonferroni, com valor de confiança de p<0,05. Um total de 17.964 mulheres (media de 51 anos de idade) foram efetivamente examinadas por mamografia, o que representou 33,1% de todas as mulheres elegíveis (18,6 exames por dia na UF e 26,3 na UM). Setenta e seis casos foram diagnosticados como câncer de mama (41, ou 54%, no UM), o que representa 4,2 casos de câncer de mama para cada 1.000 exames. Foi observada diferença significativa na detecção de câncer entre mulheres com idade entre 50-59 e 60-69 anos (p<0,001) e com idade entre 40-49 e 60-69 anos (p<0,001). Não foram observadas diferenças entre 40 a 49 e 50-59 anos (p = 0,164). O programa de rastreamento mamografico é viável no território nacional e os resultados preliminares são animadores / Breast cancer is the most prevalent malignancy among women worldwide and enrolls 23% of all female cancers. We sought to evaluate the implementation of a screening program for women who living in Barretos county area using a mobile unit (MU) and a fixed unit (FU). A total of 54,238 women aged 40 to 69 years is living in this area and are eligible for breast screening. Epidemiologic-based data supported the study design and the women were examined from April 01, 2003 to March 31, 2005. Statistical analysis supported the evaluation of clinical parameters frequencies and tumor characteristics using Chi-test and Bonferroni correction test, with confidence value of p<0,05. Overall of 17,964 women (media of 51 years old) were effectively examined by mammogram which represented 33,1% of all eligible women (18,6 in RA and 26,3 exams in MU per day). Seventy-six cases were diagnosed as breast cancer (41, or 54%, at MU), which represents 4,2 cases of breast cancer for each 1.000 exams. It was observed significant difference of cancer detection between women aged 50 to 59 and 60 to 69 yrs (p<0, 001) and between women aged 40 to 49 and 60 to 69 yrs (p<0,001). No differences were observed between aged 40 to 49 and 50 to 59 yrs (p=0,164). The program for mammogram screening is feasible to be implementing in Brazil territory and the preliminary results are encouraging

Introdução: O câncer de próstata é a neoplasia maligna não-cutânea mais frequente nos homens brasileiros. Seu rastreamento é tema controverso na literatura, e a maioria das entidades médicas não recomenda sua realização a partir dos 70 anos. Não existem estudos sobre suas características nessa faixa etária da população brasileira, que não é submetida a rastreamento ativo sistemático. Objetivos: Avaliar a prevalência e critérios de agressividade do câncer de próstata diagnosticado por rastreamento ativo em homens com idade inferior e superior a 70 anos no Brasil. Pacientes e métodos: Estudo transversal retrospectivo incluindo 17.571 voluntários no Brasil, submetidos a rastreamento ativo através de toque retal e dosagem sérica do antígeno prostático específico (PSA), entre janeiro de 2004 e dezembro de 2007. Os critérios de indicação para a biópsia foram: PSA>4,0ng/ml, ou PSA entre 2,5 e 4,0ng/ml com relação PSA livre/total <=15%, ou toque retal suspeito. Todos os homens rastreados foram divididos em dois grupos etários: grupo A, entre 45 e 69 anos; grupo B, acima de 70 anos. Os grupos foram comparados com relação a prevalência e critérios de agressividade da doença (valor do PSA sérico, escore de Gleason da biópsia e estadiamento clínico TNM). Resultados e discussão: A prevalência do câncer de próstata na nossa amostra foi de 3,71%. O grupo dos homens com mais de 70 anos apresentou prevalência da doença 2,9 vezes maior (RP 2,90; p <0,001), o valor médio de PSA foi mais elevado nos acometidos (17,28ng/ml no grupo B versus 9,54ng/ml no grupo A), assim como ocorreu maior chance de haver portadores de câncer com PSA acima de 10,0ng/ml (OR 2,63; p=0,003). No grupo de homens com mais de 70 anos também houve uma prevalência 3,59 vezes maior do padrão histológico mais agressivo (Gleason 8-10: RP 3,59; p<0,001) e maior prevalência de doença metastática (RP 4,95; p<0,05). Conclusão: O rastreamento do câncer de próstata nos homens com idade acima de 70 anos e expectativa de vida superior a 10 anos pode ser relevante no Brasil. Neste grupo etário detectamos uma maior prevalência desta doença, quando comparado ao grupo de idade entre 45 e 69 anos. Nosso estudo também demonstrou que o grupo de homens com mais de 70 anos possui maior probabilidade de apresentar doença de alto risco ao diagnóstico (PSA sérico mais elevado e em faixas de maior risco; escore de Gleason 8 a 10 e disseminação metastática à distância mais frequentes) / Background: Prostate cancer (PC) is the leading non-cutaneous malignancy among Brazilian men. PC may present as an indolent or aggressive life-threatening disease. There is no consensus in the literature regarding PC screening, and most medical organizations do not recommend it over the age of 70 years old. There are no studies in the literature addressing this topic in the Brazilian population. Objectives: To compare the prevalence and the aggressiveness of prostate cancer diagnosed, by active screening, in men under and over 70 years. Patients and methods: We performed a retrospective cross-sectional study including 17,571 volunteers. Screening was performed by digital rectal examination and prostatespecific antigen (PSA) measurement. Individuals who met the criteria for PC suspicion (PSA>4.0ng/ml, or PSA 2.5-4.0ng/ml with free/total PSA ratio <=15%, or suspicious digital rectal examination) underwent prostate biopsy. Those diagnosed with cancer were staged. The screened men were stratified by age in two groups: group A, between 45 and 69 years old, and group B, over 70 years old. The groups were compared regarding PC prevalence and its aggressiveness criteria (seric PSA value, Gleason score from biopsy and TNM staging). Results and discussion: The prevalence of prostate cancer was 3.71% in all population. The group of men over 70 years old had disease prevalence 2.9 times higher (RP 2.90; p<0.001); higher mean PSA value in men diagnosed with prostate cancer (17.28ng/ml vs. 9.54ng/ml); and greater likelihood to present PC when PSA level was above 10.0ng/ml (OR 2.63; p=0.003), when compared with men between 45 and 69 years old. The group of men aged over 70 years also presented a prevalence of histologic aggressive disease 3.59 times higher (Gleason 8-10: RP 3.59, p<0.001) and greater prevalence of metastatic disease (RP 4,95; p<0,05). Conclusion: Our study reveals that men over 70 years old presented a higher prevalence of prostate cancer and a higher probability to present high-risk disease at diagnosis (higher PSA; Gleason score 8-10 and metastatic disease more frequent), when compared to men aged 45-69 years. Screening for prostate cancer in men aged over 70 years and life expectancy over 10 years may be relevant in Brazil

Introdução: O câncer de mama é um problema de saúde publica, sendo a maior causa de morbidade e mortalidade de câncer em mulheres de todo mundo. O rastreamento mamográfico mostrou-se efetivo na redução na mortalidade por câncer de mama em países desenvolvidos, entretanto ainda não é consenso a idade de início do rastreamento mamográfico. Objetivo: Verificar o impacto do rastreamento mamográfico em mulheres entre 40-49 anos na região de Barretos. Casuística e métodos: Este é um estudo observacional transversal que incluíram mulheres assintomáticas com idade entre 40-69 anos que foram submetidas a rastreamento mamográfico entre os anos de 2003 a 2007. As mulheres com exames classificadas pelo sistema BI-RADS em zero, quatro ou cinco foram convocados para investigação. Foram descritas as freqüências absolutas e relativas das variáveis e suas diferenças analisadas pelo teste de qui-quadrado sendo escolhido o nível de significância p <0,05. Foi realizado análise de regressão logística para avaliar o risco de câncer de mama em relação à idade. Resultados: 27.133 mulheres com idades entre 40-69 foram selecionadas, 52% (14.082) das mamografias foram feitas em mulheres de 40 a 49 anos. Foram detectados 132 casos de câncer de mama em mulheres de 40 a 69 anos sendo 49 casos entre mulheres de 40 a 49. A estimativa de risco de câncer de mama entre mulheres de 40 e 49 anos (OR 0,43 [IC95% 0,28 - 0,66]) foi significativamente menor do que entre 60-69 anos. Dos casos de câncer de mama em mulheres de 40 a 49 anos 55% eram iniciais (Estádio Clínico 0-I) enquanto que no período anterior ao rastreamento eram 13%. Conclusões: O rastreamento mamográfico realizado na Região de Barretos mostrou menor risco de câncer de mama nas mulheres de 40 a 49 anos em relação às mulheres entre 60 e 69 anos. O estudo mostrou ainda que o rastreamento aumentou o número de casos iniciais (Estádio Clínico 0-I) entre as mulheres de 40 e 49 anos em relação ao período anterior ao rastreamento / Introduction: Breast cancer is a public health problem, being the major cause of morbidity and mortality of cancer in women worldwide. The mammographic screening was effective in reducing mortality from breast cancer in developed countries, but consensus is not yet the age of onset of mammographic screening. Objective: Investigate the impact of mammographic screening in women aged 40-49 years in Barretos region. Methods: This is a cross sectional observational study that included asymptomatic women aged 40-69 years who underwent screening mammography between the years 2003 to 2007. Women with tests classified by the BI-RADS at zero, four or five were summoned for investigation. We described the absolute and relative frequencies of the variables and their differences were analyzed by chi-square was chosen significance level p <0.05. Was performed logistic regression analysis to assess the risk of breast cancer in relation to age. Results: 27,133 women aged 40-69 were selected, 52% (14 082) of mammograms were performed in women 40 to 49 years. We detected 132 cases of breast cancer in women aged 40 to 69 years with 49 cases among women 40 to 49. The estimated risk of breast cancer among women between 40 and 49 years (OR 0.43 [95% CI 0.28 to 0.66]) was significantly lower than 60-69 years. Cases of breast cancer in women aged 40 to 49 years 55% were early (clinical stage 0-I) while in the period prior to screening was 13%. Conclusions: The screening mammography performed in the region Barrie showed a lower risk of breast cancer in women aged 40 to 49 years for women between 60 and 69 years. The study also showed that screening increased the number of initial cases (clinical stage 0-I) among women aged 40 to 49 years in the period prior to screening

Introdução: O câncer de mama é um problema de saúde publica, sendo a maior causa de morbidade e mortalidade de câncer em mulheres de todo mundo. O rastreamento mamográfico mostrou-se efetivo na redução na mortalidade por câncer de mama em países desenvolvidos, entretanto ainda não é consenso a idade de início do rastreamento mamográfico. Objetivo: Verificar o impacto do rastreamento mamográfico em mulheres entre 40-49 anos na região de Barretos. Casuística e métodos: Este é um estudo observacional transversal que incluíram mulheres assintomáticas com idade entre 40-69 anos que foram submetidas a rastreamento mamográfico entre os anos de 2003 a 2007. As mulheres com exames classificadas pelo sistema BI-RADS em zero, quatro ou cinco foram convocados para investigação. Foram descritas as freqüências absolutas e relativas das variáveis e suas diferenças analisadas pelo teste de qui-quadrado sendo escolhido o nível de significância p <0,05. Foi realizado análise de regressão logística para avaliar o risco de câncer de mama em relação à idade. Resultados: 27.133 mulheres com idades entre 40-69 foram selecionadas, 52% (14.082) das mamografias foram feitas em mulheres de 40 a 49 anos. Foram detectados 132 casos de câncer de mama em mulheres de 40 a 69 anos sendo 49 casos entre mulheres de 40 a 49. A estimativa de risco de câncer de mama entre mulheres de 40 e 49 anos (OR 0,43 [IC95% 0,28 - 0,66]) foi significativamente menor do que entre 60-69 anos. Dos casos de câncer de mama em mulheres de 40 a 49 anos 55% eram iniciais (Estádio Clínico 0-I) enquanto que no período anterior ao rastreamento eram 13%. Conclusões: O rastreamento mamográfico realizado na Região de Barretos mostrou menor risco de câncer de mama nas mulheres de 40 a 49 anos em relação às mulheres entre 60 e 69 anos. O estudo mostrou ainda que o rastreamento aumentou o número de casos iniciais (Estádio Clínico 0-I) entre as mulheres de 40 e 49 anos em relação ao período anterior ao rastreamento / Introduction: Breast cancer is a public health problem, being the major cause of morbidity and mortality of cancer in women worldwide. The mammographic screening was effective in reducing mortality from breast cancer in developed countries, but consensus is not yet the age of onset of mammographic screening. Objective: Investigate the impact of mammographic screening in women aged 40-49 years in Barretos region. Methods: This is a cross sectional observational study that included asymptomatic women aged 40-69 years who underwent screening mammography between the years 2003 to 2007. Women with tests classified by the BI-RADS at zero, four or five were summoned for investigation. We described the absolute and relative frequencies of the variables and their differences were analyzed by chi-square was chosen significance level p <0.05. Was performed logistic regression analysis to assess the risk of breast cancer in relation to age. Results: 27,133 women aged 40-69 were selected, 52% (14 082) of mammograms were performed in women 40 to 49 years. We detected 132 cases of breast cancer in women aged 40 to 69 years with 49 cases among women 40 to 49. The estimated risk of breast cancer among women between 40 and 49 years (OR 0.43 [95% CI 0.28 to 0.66]) was significantly lower than 60-69 years. Cases of breast cancer in women aged 40 to 49 years 55% were early (clinical stage 0-I) while in the period prior to screening was 13%. Conclusions: The screening mammography performed in the region Barrie showed a lower risk of breast cancer in women aged 40 to 49 years for women between 60 and 69 years. The study also showed that screening increased the number of initial cases (clinical stage 0-I) among women aged 40 to 49 years in the period prior to screening