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Resumo(s)
O cancro constitui, neste século, um dos principais problemas de saúde pública, com implicações sociais e económicas significativas. Globalmente, é responsável por aproximadamente 16,8% de todas as mortes e por 22,8% das mortes atribuídas a doenças não transmissíveis. O cancro do colo do útero (CCU) é um dos problemas de saúde pública mais significativos para a população feminina em todo o mundo, sendo o quarto cancro mais comum em termos de incidência e mortalidade nas mulheres, com uma estimativa de 662.301 novos casos e 342.000 mortes em todo o mundo em 2022, segundo a World Health Organization (WHO) 2023. Caracterizado pela sua elevada incidência e mortalidade, particularmente em países de Índice de Desenvolvimento Humano (IDH) baixo ou médio, este tipo de cancro está maioritariamente associado à infeção persistente pelo vírus do papiloma humano (HPV), e estima-se que mais de 90% dos casos de CCU sejam atribuídos aos genótipos de alto risco deste agente viral (HPV-hr).
O CCU é um problema de saúde significativo também em Portugal, onde em 2020, foi determinada uma incidência e mortalidade padronizada por idades de 10,7 e 3,2/100 000 mulheres-ano, respetivamente. De acordo com os dados do The Global Cancer Observatory (IARC/WHO) 2024, a Incidência e Mortalidade em Portugal por CCU em 2022, foram de 897 e 459, respetivamente, tendo sido nesse ano, o 8.º cancro mais frequente entre as mulheres e o 3.º cancro mais frequente entre as mulheres entre os 15 e os 44 anos. A taxa de mortalidade por CCU em Portugal, situa-se nos níveis muitos altos de IDH.
A WHO recomenda a implementação de programas de rastreio organizados, baseados na população, como a estratégia mais eficaz para a prevenção do CCU. No entanto, o rastreio oportunístico continua a desempenhar um papel importante na prevenção secundária do CCU em muitos países, incluindo Portugal, complementando os esforços do programa de rastreio, colmatando as dificuldades de acesso ao rastreio organizado, assim como possibilitando a liberdade de decisão e a oportunidade da escolha das mulheres na sua vigilância e cuidados de saúde.
A WHO reconhece atualmente três métodos principais para o rastreio do CCU: a citologia convencional (teste de Papanicolaou), a inspeção visual com ácido acético (VIA) e o teste de deteção do DNA do HPV. Cada um destes métodos tem as suas especificidades, vantagens e limitações. O contexto epidemiológico e os recursos de cada país determinam a escolha e a implementação de uma estratégia de rastreio adequada.
A WHO estabeleceu metas globais para a eliminação do CCU como problema de saúde pública, incluindo:
90% das meninas vacinadas contra o HPV até os 15 anos
70% das mulheres rastreadas com um teste de alta precisão aos 35 e aos 45 anos
90% das mulheres identificadas com doença cervical recebendo tratamento
Portugal implementou em 2017 um programa nacional de rastreio baseado na pesquisa de HPV, como teste de rastreio primário, para mulheres com idades dos 25 aos 60 anos.
No entanto, este programa não está totalmente implementado em todas as regiões, o que contribui para as dificuldades que o programa atravessa, com apenas 64 % das mulheres elegíveis a participarem no Rastreio em 2022, pelo que é lícito afirmar que o rastreio oportunístico (ou de conveniência) tem um papel importante na prevenção do CCU.
Os trabalhos efetuados, de que resultaram os artigos científicos publicados, expressão dos estudos levados a cabo com a experiência do programa de rastreio da ULSCB (das mulheres que foram incluídas no programa de rastreio oportunístico na Consulta de Ginecologia do Hospital da Covilhã), são a base do contributo que se pretende deixar para a melhoria da eficácia da prevenção secundária do CCU em Portugal.
Pretenderam esses estudos, apesar das suas limitações, nomeadamente a dimensão da amostra: i) avaliar o risco de HSIL em mulheres com teste de HPV-hr (não 16 e/ou 18) positivos repetidos e com citologia NILM; ii) verificar se é válido dispensar a realização da citologia nos casos de teste de HPV positivo para HPV 16 e HPV 18; iii) e desenvolver uma técnica laboratorial, que permita uma deteção adequada e pouco dispendiosa, para a determinação do genótipo do HPV em material parafinado.
Em conclusão, Portugal tem um programa de rastreio organizado baseado no teste de HPV, mas o rastreio oportunístico continua a ser uma ferramenta importante na prevenção secundária do CCU, especialmente para alcançar populações não cobertas pelo programa organizado. A integração eficaz de ambas abordagens, juntamente com a vacinação contra o HPV, afigura-se crucial para atingir as metas da OMS e reduzir significativamente a incidência e mortalidade por CCU no país.
Cancer is one of the major public health problems of this century, with significant social and economic implications. Globally, it is responsible for approximately 16.8% of all deaths and 22.8% of deaths attributed to non-communicable diseases. Cervical cancer (CC) is one of the most significant public health problems for women worldwide, being the fourth most common cancer in terms of incidence and mortality in women, with an estimated 662,301 new cases and 342,000 deaths worldwide in 2022, according to the World Health Organization (WHO) 2023. Characterized by its high incidence and mortality, particularly in low or medium Human Development Index (HDI) countries, this type of cancer is mostly associated with persistent infection by the human papillomavirus (HPV), and it is estimated that more than 90% of CC cases are attributed to high-risk genotypes of this viral agent (HPV-hr). CC is also a significant health problem in Portugal, where in 2020, an age-standardized incidence and mortality rate of 10.7 and 3.2/100,000 women-years, respectively, were determined. According to data from The Global Cancer Observatory (IARC/WHO) 2024, the incidence and mortality rate in Portugal due to CC in 2022 was 897 and 459, respectively. CC is the 8th most common cancer among women and the 3rd most common cancer among women aged 15 to 44. The mortality rate from CC in Portugal is at very high levels of HDI. The World Health Organization (WHO) recommends the implementation of organized, population-based screening programs as the most effective strategy for the prevention of CC. However, opportunistic screening continues to play an important role in the secondary prevention of CC in many countries, including Portugal, complementing the efforts of the screening program, overcoming difficulties in accessing organized screening, as well as enabling women's freedom of decision and the opportunity to choose their health surveillance and care. WHO currently recognizes three main methods for CC screening: conventional cytology (Pap test), visual inspection with acetic acid (VIA) and HPV DNA detection testing. Each of these methods has its specificities, advantages and limitations, and the epidemiological context and resources of each country determine the choice and implementation of an appropriate screening strategy. The WHO has set global goals for eliminating CC as a public health problem, including: • 90% of girls vaccinated against HPV by age 15 • 70% of women screened with a high-precision test when they reach ages 35 and 45 • 90% of women identified with cervical disease receiving treatment In 2017, Portugal implemented a national screening program based on the primary HPV test for women aged 25 to 60 years. However, this program is not fully implemented in all regions, which contributes to the current challenges in organized screening, resulting in only 64% of eligible women participating in screening in 2022. Thus, it is fair to say that opportunistic (or convenience) screening has an important role in preventing CC. The work undertaken (documented in published scientific articles), is the result of the studies carried out from the ULSCB screening program (of women who were included in the opportunistic screening program at the Gynecology Consultation at Hospital da Covilhã). This work forms the basis of the contribution we intend to make towards improving the effectiveness of secondary prevention of CC in Portugal. These studies, despite their limitations, such as the small sample size, aimed to: i) evaluate the risk of HSIL in women with repeated positive HPV-hr test (not 16 and/or 18) and with NILM cytology; ii) verify whether it is valid to waive cytology in cases of a positive HPV test for HPV 16 and HPV 18; iii) and develop a laboratory technique, which allows adequate and cheap detection, for HPV genotyping in paraffin material. In conclusion, Portugal has an organized screening program based on HPV testing, but opportunistic screening remains an important tool in the secondary prevention of CC, especially to reach populations not covered by the organized program. Effective integration of both approaches, together with HPV vaccination, appears crucial to achieve WHO targets and significantly reduce CC incidence and mortality in the country.
Cancer is one of the major public health problems of this century, with significant social and economic implications. Globally, it is responsible for approximately 16.8% of all deaths and 22.8% of deaths attributed to non-communicable diseases. Cervical cancer (CC) is one of the most significant public health problems for women worldwide, being the fourth most common cancer in terms of incidence and mortality in women, with an estimated 662,301 new cases and 342,000 deaths worldwide in 2022, according to the World Health Organization (WHO) 2023. Characterized by its high incidence and mortality, particularly in low or medium Human Development Index (HDI) countries, this type of cancer is mostly associated with persistent infection by the human papillomavirus (HPV), and it is estimated that more than 90% of CC cases are attributed to high-risk genotypes of this viral agent (HPV-hr). CC is also a significant health problem in Portugal, where in 2020, an age-standardized incidence and mortality rate of 10.7 and 3.2/100,000 women-years, respectively, were determined. According to data from The Global Cancer Observatory (IARC/WHO) 2024, the incidence and mortality rate in Portugal due to CC in 2022 was 897 and 459, respectively. CC is the 8th most common cancer among women and the 3rd most common cancer among women aged 15 to 44. The mortality rate from CC in Portugal is at very high levels of HDI. The World Health Organization (WHO) recommends the implementation of organized, population-based screening programs as the most effective strategy for the prevention of CC. However, opportunistic screening continues to play an important role in the secondary prevention of CC in many countries, including Portugal, complementing the efforts of the screening program, overcoming difficulties in accessing organized screening, as well as enabling women's freedom of decision and the opportunity to choose their health surveillance and care. WHO currently recognizes three main methods for CC screening: conventional cytology (Pap test), visual inspection with acetic acid (VIA) and HPV DNA detection testing. Each of these methods has its specificities, advantages and limitations, and the epidemiological context and resources of each country determine the choice and implementation of an appropriate screening strategy. The WHO has set global goals for eliminating CC as a public health problem, including: • 90% of girls vaccinated against HPV by age 15 • 70% of women screened with a high-precision test when they reach ages 35 and 45 • 90% of women identified with cervical disease receiving treatment In 2017, Portugal implemented a national screening program based on the primary HPV test for women aged 25 to 60 years. However, this program is not fully implemented in all regions, which contributes to the current challenges in organized screening, resulting in only 64% of eligible women participating in screening in 2022. Thus, it is fair to say that opportunistic (or convenience) screening has an important role in preventing CC. The work undertaken (documented in published scientific articles), is the result of the studies carried out from the ULSCB screening program (of women who were included in the opportunistic screening program at the Gynecology Consultation at Hospital da Covilhã). This work forms the basis of the contribution we intend to make towards improving the effectiveness of secondary prevention of CC in Portugal. These studies, despite their limitations, such as the small sample size, aimed to: i) evaluate the risk of HSIL in women with repeated positive HPV-hr test (not 16 and/or 18) and with NILM cytology; ii) verify whether it is valid to waive cytology in cases of a positive HPV test for HPV 16 and HPV 18; iii) and develop a laboratory technique, which allows adequate and cheap detection, for HPV genotyping in paraffin material. In conclusion, Portugal has an organized screening program based on HPV testing, but opportunistic screening remains an important tool in the secondary prevention of CC, especially to reach populations not covered by the organized program. Effective integration of both approaches, together with HPV vaccination, appears crucial to achieve WHO targets and significantly reduce CC incidence and mortality in the country.
Descrição
Palavras-chave
HPV Cancro do Colo do Útero Rastreio Prevenção Secundária Cervical Cancer Screening Secondary Prevention