Seguimento de mulheres rastreadas para o câncer de colo do útero no Sistema Único de Saúde segundo raça/cor da pele, região e capitais

Abstract

The aim of this dissertation was to analyze racial inequalities in access to the cervical cancer screening program within the Unified Health System (SUS) using data from the Cancer Information System (SISCAN) in Brazil, including its regions and capitals. To achieve this, the dissertation was divided into two articles. The first article presents a cross-sectional study to assess screening coverage among women aged 25 to 64 who were attended by SUS and registered in SISCAN, categorized by race/skin color in Brazil, its regions, and capitals. A screening coverage indicator was calculated from 2021 to 2023 by race/skin color in women aged 25 to 64, using the number of exams divided by the mid-period population and multiplied by 100. The results of this study demonstrated racial and regional disparities in screening coverage, with the highest coverage observed among white women (33.95%) compared to non-white women (28.82%) and Indigenous women (27.42%). The highest coverage rates were found in the South and Southeast regions for white women, in the Northeast and Southeast for non-white women, and in the North, Southeast, and South for Indigenous women. Furthermore, the capitals followed the regional patterns observed. The second article presents a retrospective cohort study of women aged 25 to 64 with abnormal screening results, as recorded in SISCAN. The median times between screening and diagnostic investigation for women with high-grade squamous intraepithelial lesions or more severe abnormalities, as well as the repetition of exams for low-grade squamous intraepithelial lesions and Atypical Squamous Cells of Undetermined Significance (ASC-US) was estimated using the Kaplan-Meier method. The factors associated with delays in diagnostic investigation for each type of lesion were assessed through multinomial logistic regression. The median time until the repetition of the exam for low-grade lesions and ASC-US was 174 days, with shorter times in the Southeast (170 days) and South (170 days) regions, and longer times in the capitals (183 days). For high-grade or more severe lesions, the median time between the abnormal screening result and histopathological examination for diagnostic confirmation in Brazil was 70 days. This period was longer in the North (117 days), Northeast (97 days), and Midwest (77 days) regions, as well as in the capitals (82 days), and for non-white women (83 days) and Indigenous women (114 days). Regarding the factors associated with delays in clinical management for low-grade lesions and ASC-US, delays were mainly associated with basic healthcare coverage below 50% (OR: 1.41; 95% CI: 1.18-1.69). For high-grade or more severe lesions, delays were more likely among non-white women (OR: 1.34; 95% CI: 1.18-1.52), residents of the North (OR: 1.60; 95% CI: 1.24-2.06) and Northeast (OR: 2.76; 95% CI: 2.24-3.41) regions, and women living in municipalities with low/very low HDI (OR: 1.90; 95% CI: 1.45-2.49). The findings highlight significant racial and regional inequalities in access to cervical cancer screening program services within the Unified Health System, underscoring the need for improvements in cancer control and women's health policies