The Pap smear, carried out preventively by women at gynecological consultations, has now been replaced by the HPV (Human Papilloma Virus) test in the public health network of Indaiatuba, in the interior of São Paulo, and could become a successful model for other Brazilian municipalities .
The replacement task is part of the Cervical Cancer Tracking Program, called Preventive, a pioneering initiative in the country led by the Unicamp Women's Hospital (Caism) and coordinated by the director of the Faculty of Medical Sciences (FCM), Luiz Carlos Zeferino, and the director of the Oncology Division of the Women's Hospital - Caism, Júlio César Teixeira.
There is no longer a Pap smear test in health centers in Indaiatuba since last year. Even some doctors in private clinics have adopted the use of the HPV test as a routine, because cervical cancer is sexually transmitted by the papilloma virus.
With the change in the test, the collection – which occurred every three years – will be carried out every five years, in cases of a negative result for this virus. If the test is positive, additional tests will be requested, and the patient will be monitored at shorter intervals until clinical resolution.
One of the bottlenecks in offering the Pap smear test is the excessive use by some women, who perform it more frequently than necessary. Furthermore, two thirds of Pap smear tests in the Unified Health System (SUS) take place outside the recommended age (under 25 years), where the incidence of this cancer is rare. On the other hand, only 15% to 30% of women between the ages of 25 and 64 have a Pap smear.
The municipality carried out 10 Pap smear tests per year, with 16% of women taking the test under the age of 25. “In one year of the HPV program, 7.400 tests were carried out and those carried out outside the age group fell from 16% of cases to 0,8%”, reveals Teixeira. The expectation with the HPV test is that, at the end of five years, the duration of the program, between 25 and 30 thousand collections will be achieved, which is equivalent to coverage of 80% of women undergoing gynecological monitoring aged between 25 and 64 years old. Indaiatuba has a population of just over 240 thousand inhabitants.
In the new system, the collection of material will continue to be carried out as in the Pap smear (also called oncotic cytology), obtaining content from the cervix. However, instead of the content going onto the slide, it will be added to a liquid capable of making DNA available to detect different types of HPV in the cervix. Today, the HPV test is processed automatically at Caism using unique equipment in the State of São Paulo: the Cobas 480.
The difference between the two exams is that the Pap smear took at least two months for the results to be returned to the woman. The HPV test is delivered to the patient between 7 and 14 days. While the Pap test detects lesions on the cervix, the HPV test identifies the presence of the virus before a significant lesion occurs. According to Teixeira, research indicates that the HPV test is more effective than the Pap smear and this has already been proven in the USA and Europe, where this initiative originates. In Brazil, it was only done in private clinics.
Cancer
Zeferino mentions that he sought to find out, in the Metropolitan Region of Campinas, which city would have the best conditions to implement a tracking control program. Indaiatuba stood out as the best information system in the State of São Paulo, a fundamental tool for organizing the city's health. Along with the challenge of creating this organization, another challenge will be demonstrating the cost/benefit ratio of the new method in the SUS. The idea is to avoid the exam outside the stipulated age and range. Zeferino states that in Brazil, every 90 minutes, a woman dies from this pathology. “If we detect precursor lesions and HPV, by monitoring these women, it will be possible to prevent this cancer”, he highlights.
In countries such as the United Kingdom and northern Europe, cervical cancer prevention has managed to reduce cancer with better control of the information system, so that if women do not go to their appointment, they receive a letter to visit the doctor. If the result changes, they are also quickly informed. According to the director of FCM, almost everyone will have contact with this virus at some point in their lives. The good news is that almost all people eliminate it within 24 months. In some, it remains active for more than 10 years, favoring the appearance of pre-cancerous lesions and cancer.
“The Pap smear has been important up until now, to detect cells suggestive of pre-cancer lesions”, comments Teixeira. As these lesions take time to develop, a possible Pap smear failure ends up being corrected by repeating the test. Cytology is collected twice a year and then every three years in the public network. In the HPV test, the failure is smaller because the test is processed by machines and aims to detect viral DNA.
Zeferino, however, highlights that the HPV test is still more expensive than the Pap smear, “however, when it is carried out at a longer interval and with the same number of tests, it will end up having a more effective cost and, perhaps, even lower in the future. long term."
Another benefit is the simplification of the process. When the Pap smear was collected in Basic Health Units, the doctor and nurse filled out seven documents. Now, they fill out a request on a web platform, print a test identification label and forward the material to Caism. The report with the result is digital and leaves the equipment and goes into the patient's medical record. There are practically no more papers and there is a communication system between Indaiatuba and Caism that is important for organizing the program, coordinating the correct performance of tests and monitoring women with altered tests.
Zeferino also explains that this work has four perspectives: that of researchers, women, managers and professionals who will provide the service. “The municipality must advance the information system, carrying out an active search for women. The Family Health Program team does this, and altered exams are monitored by community agents. Soon, these women will no longer be anonymous to the system.”
Vaccine
In addition to the technical advantages of the new test, today there is the HPV vaccine. It is offered to young people aged 9 to 14, thanks to the National Immunization Program. The teenager can be immunized for the rest of his life, after taking two doses, which prevents HPV 16 and 18, two viruses that cause 70% of cancers. Another 12 viruses account for 30%. Indaiatuba had low vaccination coverage. Unicamp program coordinators observed that children aged 9 and 10 (83%) were enrolled in municipal schools. Then they started to develop vaccinations in schools. They obtained authorization from the National Immunization Program to equalize the ages of boys and girls. This change would only happen in 2020.
Male children can also be affected by HPV, causing cancer of the penis and anal canal. There are also less common cancers such as mouth and oropharynx cancers, which may have other causes, but some are caused by HPV. These other organs, with the vaccine, also end up being protected.
Preventative screening and vaccination actions against HPV are considered to have a high impact on the health of the population, and Indaiatuba will be one of the first to eradicate diseases caused by HPV. Those who are taking the vaccine, in ten years' time, will have fewer occurrences and fewer changes due to HPV, emphasizes Zeferino, meaning that the best preventive tests are DNA tests. Additionally, the Indaiatuba program should generate information to assist managers in making decisions and updating their prevention programs. Countries similar to Brazil will also benefit from this type of information.
