Comment

Initiatives in cancer control from Brazils Ministry of Health

Paul Goss and colleagues Commission1 shows the challenge in analysing the situation of cancer control in Latin America: large population diversity, socioeconomic and epidemiological factors, and the scarcity of studies with similar methodologies, all compound the complexity of the situation. These ndings are supported by Simon and colleagues study,2 which shows that early detection of breast cancer is low in Brazil and needs to be increased to levels in other countries. However, national data from all cancer registries in Brazil show that early detection of breast cancer (stages 0II) is 598%,3 similar to that in the USA (60%).1 Brazil has a large territory and faces complex and challenging social inequalities that aect the aims of the Brazilian National Health System (SUS) in delivering a universal, comprehensive, and high quality health-care service. However, substantial progress has been made in the past 10 years in Brazil; for instance, Pap smears have now reached coverage levels of 87% in some parts of the country, and more than 80% across all regions.4 In 2011, Brazil also increased the age for cervical cancer screening to older populations, increasing the age limit from 25 years to 64 years.5 Although mammography coverage has also increased in the country, especially in women from low-income households, regional dierences remain.4 Mammography coverage in Brazils capital cities increased from 712% in 2007, to 733% in 2011.6 A national programme for mammography quality was set up in 2011, and more than 4 million mammograms were done annually. In 2012, 12 million Pap tests, 26 million chemotherapy procedures, 10 million radiotherapy sessions, and roughly 530 000 surgical procedures were done in the SUS.7 Access to medicines is part of the fundamental right to health and pharmaceutical care provided free of charge throughout the SUS. More than 500 standardised drugs are available and delivered free of charge by the Brazilian Ministry of Health. Cancer treatment is free at all levels (radiotherapy, chemotherapy, and hormone therapy), as are drugs for smoking cessation, the hepatitis B vaccine, and other health interventions. These drugs are available to the entire population, including patients with private health plans.8 Brazil is one of the few countries in the world that supports and implements the exibilities of the Trade-Related Intellectual Property Rights (TRIPS)
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Agreement and the World Trade Organizations Doha Declaration, including for access to medicines for noncommunicable diseases (NCDs) for all in need, as stated in WHO negotiations at the UN high-level meeting. NCDs are a worldwide epidemic; therefore, the debate about intellectual ownership of new therapies and access to low-cost, high-quality, safe, and eective medicines and technologies needs to be advanced;9 however, this important issue was not addressed in the Commission.1 In March, 2011, a plan to strengthen the network of prevention, diagnosis, and treatment of cancer was launched in Brazil by the Ministry of Health.5 Radiotherapy resources will be expanded and services created in 48 hospitals, and Brazils Ministry of Health will modernise 32 existing services. Therefore, the ministry will purchase 80 new linear accelerators; the largest acquisition of any country in the past few years. These devices will be mainly distributed in the northern and northeastern regions of the country thus reducing inequalities.5 Because of the magnitude of NCDs, which are responsible for 72% of deaths in Brazil, the Ministry of Health launched the strategic action plan to tackle NCDs, prioritising actions and investments to reduce these diseases and their risk factors.5,8,10 Brazils tobacco prevention programme has reduced smoking prevalence from 348% in 1989, to 172% in 2008.4,8,10 Findings from telephone surveys in Brazilian state capitals conrmed the decline in prevalence between 2006 and 2011.6 In 2011, the government approved new laws,

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which established smoke-free environments, increased cigarette taxes to 85%, and required posting of warnings on packaging.8,10 These actions have contributed to a 20% decline in rates of NCDs between 1996 and 2007. The long-term goal is to reduce mortality from NCDs by 2% per year.5,8 Great challenges exist in Brazil and in the many other countries of Latin America and the Caribbean, but it is important to emphasise the need for improvements in information systems and registries to ensure that cancer-related policies are robust. Brazil has a strong commitment to addressing NCDs, and will continue to work tirelessly to support patients with cancer. Jarbas Barbosa da Silva Jr*, Helvecio Miranda Magalhaes Jr
Secretaria de Vigilncia em Sade, Ministrio da Sade do Brasil, Braslia 70070-600, Brazil (JBdS, HMM) Jarbas.barbosa@saude.gov.br
JBdS is Secretary of Health Surveillance of the Brazilian Ministry of Health and HMM is Secretary of Health Care. We declare that we have no concts of interest. 1 2 Goss, PE, Lee BL, Badovinac-Crnjevic T, et al. Planning cancer control in Latin America and the Caribbean. Lancet Oncol 2013; 14: 391436. Simon S, Bines J, Barrios C, et al. Clinical characteristics and outcome of treatment of Brazilian women with breast cancer treated at public and private institutionsThe AMAZONE Project of the Brazilian Breast Cancer Study Group (GBECAM). 32nd Annual CTRC-AACR San Antonio Breast Cancer Symposium; San Antonio, TX, USA; Dec 1013, 2009. Abstr 3082.

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Instituto Nacional de Cancer (INCA). Perl da morbimortalidade brasileira do cncer da mama. Informativo de Vigilancia do Cancer. N. 2 janeiro/abril 2012. Nov 28, 2012. http://www1.inca.gov.br/inca/ Arquivos/comunicacao/informativo_vigilancia_cancer_n2_2012_ internet.pdf (accessed Feb 26, 2013). Instituto Brasileiro de Geograa e Estatstica (IBGE). Pesquisa Nacional por Amostra de Domiclios. Panorama da Sade no Brasil: acesso e utilizao dos servios, condies de sade e fatores de risco e proteo sade (PNAD 2008). Rio de Janeiro: IBGE; 2010. Brasil Ministrio da Sade. Plano de aes estratgicas para o enfrentamento das doenas crnicas no transmissveis (DCNT) no Brasil, 20112022. Braslia: Ministrio da Sade; 2011. http://portal. saude.gov.br/portal/saude/prossional/area.cfm?id_area=1818 (accessed Feb 26, 2013). Brasil Ministrio da Sade. Secretaria de Vigilncia em Sade. Vigitel Brasil 2011: vigilncia de fatores de risco e proteo para doenas crnicas por inqurito telefnico. Braslia: Ministrio da Sade, 2012. Ministrio da Sade. DATASUS. Informaes em Sade. http://www2. datasus.gov.br/DATASUS/index.php?area=0202 (accessed Feb 22, 2013). Malta DC. de Morais Neto Otaliba L, da Silva Jr JB. Apresentao do plano de aes estratgicas para o enfrentamento das doenas crnicas no transmissveis no Brasil, 2011 a 2022. Epidemiol Serv Sade 2011; 20: 42538. Hogerzeil HV, Liberman J, Wirtz VJ, et al, on behalf of The Lancet NCD Action Group. Promotion of access to essential medicines for non-communicable diseases: practical implications of the UN political declaration. Lancet 2013; 381: 68089. Bonita R, Magnusson R, Bovet P, et al, on behalf of The Lancet NCD Action Group. Country actions to meet UN commitments on non-communicable diseases: a stepwise approach. Lancet 2013; 381: 57584.

Planning cancer controla Mexican perspective

As a former Secretary of Health in Mexico, I welcome the publication of The Lancet Oncology Commission1 on cancer control in Latin America and the Caribbean. I would like to add some comments from a Mexican perspective. The processes of demographic and epidemiological transition around the world pose several threats and challenges to health systems related to increases in life expectancy, ageing of populations, and a shift in the way people get sick and die, from communicable diseases to chronic, non-communicable diseases (NCDs), of which cancer is a major component.2 Such changes pose great challenges for health systems in Latin America and the Caribbean.3 The authors of The Lancet Oncology Commission1 state in the introductory section that Latin America in poorly equipped to deal with the alarming rise in cancer incidence. This statement is accurate, but eorts are in place to deal with the challenge. As mentioned in the Commission, part of the problem is the lack of comprehensive national cancer plans in many countries. Of the more than 40 countries in the region, only a few have plans, which are mostly oriented against specic cancers (eg, breast, cervical, or prostate cancers). Specic cases of health reform are analysed by Goss and colleagues. In Mexico, health reform through Seguro Popular has increased the ability of the system to cope with cancer. No women with breast cancer has to stop treatment because of nancial issues, vaccination of girls in the fth grade of elementary school against human papillomavirus (HPV) is part of the national immunisation programme, the quality of infrastructure to provide care has increased (from mammography machines and linear accelerators to completely new oncological units and hospitals), and out-of-pocket expenditure for treatment has diminished.4 The distribution of infrastructure and human resources is concentrated in big urban areas throughout Latin America and the Caribbean, and unless there is a change in the social determinants of health related to NCDs and cancer, we will be unable to correct these disparities. Physicians and other health personnel
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