Despite the cervical cancer uterus Being a preventable disease, mortality from the condition has increased in Brazil in the last ten years. According to data from the Mortality Information System (SIM/SUS), the rate rose from 5.2 per 100,000 inhabitants in 2012 to 6.4 in 2022, representing an increase of 23%. It is also worth remembering that this is the third most prevalent type of cancer among women, excluding non-melanoma skin tumors, according to the National Cancer Institute (Inca).
According to Eduardo Cândido, member of the Gynecological Oncology Commission of the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo), more than 90% of cervical cancer cases develop from papillomavirus (HPV) infection, with subtypes 16 and 18 represent the majority of cases – in total, 200 subtypes are identified.
He states that around 70% to 80% of the population comes into contact with HPV at some point in their lives, mainly through sexual activity. Although most virus infections are resolved by the immune system, some persist, which can result in the development of lesions and, eventually, the development of cancer.
In the assessment of Angélica Nogueira, clinical oncologist and member of the Women’s Leadership Committee of the Brazilian Society of Clinical Oncology (SBOC), the difficulty in reducing both the prevalence and mortality from the disease indicates a continued need for awareness about the importance of screening tests. early screening, condom use and HPV vaccination.
She explains that HPV precursor lesions, which affect the cervix, are considered pre-cancerous and do not cause symptoms, being visible only through a Pap smear. Now, when symptoms become noticeable, such as bleeding, strong-smelling discharge, pain during sexual intercourse and recurring infections, it means that the problem has already progressed to cervical cancer.
In Brazil, the recommendation is that, between the ages of 25 and 64, cis women, trans men and non-binary people identified as female at birth undergo a Pap smear every three years. The exam, which is offered free of charge by the Unified Health System (SUS), can reduce 60% to 90% of cases of this type of tumor.
However, 20% of the target audience in Brazilian capitals never took the exam, according to a survey by the Umane Primary Health Care Observatory, a civil association dedicated to supporting public health initiatives. “This is certainly one of the main indicators why we have not achieved a reduction in cases or mortality”, observes Angélica.
The use of condoms and vaccination are considered essential measures to prevent the onset of cervical cancer. In Brazil, there are two types of vaccine available so far:
- Quadrivalent vaccine: available on the SUS, it is recommended for girls and boys aged 9 to 14; transplanted men and women; cancer patients receiving chemotherapy and radiotherapy; patients with HIV/AIDS, and victims of sexual violence.
- Nonavalent vaccine: Available on the private network, it is recommended for children and adults aged 9 to 45.
The quadrivalent vaccine protects against types 6, 11, 16 and 18 of HPV, while the nonavalent vaccine also protects against oncogenic subtypes 31, 33, 45, 52 and 58. Considering subtypes 16 and 18, the most relevant when it comes to cervical cancer, the first vaccine offers 70% effectiveness in prevention, while the second offers protection of up to 90%.
The problem is that, as with pap smear testing rates, HPV vaccination rates are also below ideal.
According to data from the Ministry of Health, 87.08% of Brazilian girls between 9 and 14 years of age received the first dose of the vaccine in 2019. In 2022, coverage fell to 75.81%. Among boys, the numbers are also worrying: vaccination coverage fell from 61.55% in 2019 to 52.16% in 2022.
It is worth mentioning that, in addition to cervical cancer, HPV can cause other types of cancer, such as vaginal, anal, penile and oropharyngeal cancer. For this reason, the vaccine is also recommended for cis men, trans women and non-binary people assigned male at birth.
“Furthermore, it is a way to break the infection cycle. From the moment you get vaccinated, you also rid your partner of the virus”, highlights Cândido.
Vaccination coverage challenges
In the opinion of pediatrician Mônica Levi, president of the Brazilian Society of Immunizations (SBIm), suboptimal vaccination coverage is associated with a failure in communication.
Taking into account that the target audience is boys and girls aged 9 to 14, Mônica’s assessment is that there should be more strategic communication, which takes into account the interests of this age profile, in order to highlight the importance of the vaccine and its safety for teens and pre-teens.
Furthermore, for oncologist Angélica, vaccination coverage against HPV is lower than desired due to the taboo created by those responsible that the vaccine can contribute to the early initiation of sexual life.
“There are already studies that demystify this idea. What parents need to keep in mind is that HPV can develop into different types of cancer, especially in adulthood. That’s why the vaccine is so necessary,” said the expert.
For Mônica, a way to overcome the problem would be the union between the Ministry of Health and the Ministry of Education. This idea is linked to the vaccination rates achieved in 2014, the first year of HPV vaccination in Brazil. “At that time, the vaccine was administered in schools and we reached 90% coverage. When it was removed from educational institutions in 2015, coverage fell by 20%,” she describes.
SUS has a new diagnostic test
Considering the challenges related to cervical cancer, the Ministry of Health adopted, in March this year, a new approach in the SUS for the early detection of HPV. The new technology uses molecular tests to identify the virus, using genetic material collection (in some situations, directly from the cervix).
Furthermore, the technology makes it possible to carry out the test every five years, in contrast to the recommendation of HPV screening through a Pap smear every three years.
In Mônica’s view, molecular testing can be considered a high-performance exam, as the genetic material is analyzed by machines, minimizing the need for human intervention. “Despite the effectiveness of the Pap smear, it is sensitive to the quality and technique used. Furthermore, problems such as breakage or misplacement of the blades can occur,” says Mônica.
But the specialist reinforces the importance of the Pap smear, as other problems can be detected through this test. And she makes a point of remembering, once again, the role of immunization. “The ideal scenario is to be protected from the disease. Therefore, vaccination remains essential, regardless of the quality of the tests,” she added.
