Follow-up uterine cervical cancer : study of continue assistance to patient in a health region

Objective: Discuss the context of assistance of women diagnosis with altered Pap Test in a health care unit. Methods: Cross-sectional study, held in a micro-region of Mato Grosso do Sul, Brazil. The points of attention were mapped in all levels of complexity. A form was prepared and fifty-two professionals were interviewed. Data were analyzed considering the distribution of frequencies. Results: There is incongruity between test results and interventions. Most (78%) of non-neoplastic lesions of low grade is forwarded and 21% of the lesions that should be addressed are treated at primary level. There is a lack of communication between the points of attention and lack of reference and counter-reference protocols. In 18 (54.5%) Primary Care Units, women spontaneously seek regulatory service. Conclusion: The services are not articulated, there are major errors in the follow-up.


INTRODUCTION
In recent decades, cancer became a global public health problem.The World Health Organization (WHO) estimates that, for 2030, there will be 27 million incident cases of cancer, 17 million deaths and 75 million people with the disease in the world.In Brazil, the estimative for 2015, point to the occurrence of approximately 576,580 new cases and one of the most incident type is cervical uterine cancer, with 15,590 estimated new cases 1 .
Reports of the Cervical Uterine Cancer Information System ("SISCOLO") show that Mato Grosso do Sul (MS) has been strengthening the collections of Pap Test examination in women from 25 to 59 years.In the period from 2007 to 2012 reached a ratio of 0.23 higher than the national average, which was 0.17 2 .
The magnitude of the problem and the existence of mechanisms for early detection of the disease triggered, since the 1980s, recommendations from the Ministry of Health about the use of the Pap Test as a test of choice for tracking because it favors the detection of cellular changes in initial stage.It was with the launch of Integral Assistance Program for Women's Health ("PAISM") in 1986 that emerged the guidelines for periodic examination, with rules for their operation 3 .Later, it was established the Prevention and Cancer Control National Policy in Healthcare Unit of the People with Chronic Diseases in the Health System.Thus, the responsiveness of the disease causes that the attention to women's health be a priority health policy in the country, with targets to be achieved, organized assistance in healthcare units in order to offer resolute services, preferably with early diagnosis of the disease [4][5][6] .
An effective measure for reducing the mortality is the extensive and constant tracking which can reduce deaths from cervical uterine cancer by more than 70% compared to the unassisted populations.There are two reasons for this effect: the first is that a large number of women is detected still with preinvasive disease; and the second, when the disease is detected in its invasive form, it tends to be diagnosed in the earliest stages, where the chances of cure are higher 7 .
The purpose of tracking is to detect cellular changes in the early stages so intervention procedures are timely, that is, to ensure the follow-up of these women.State data show that more than 60% of women with cellular changes of the cervix in Mato Grosso do Sul are not being followed by the healthcare unit, fact that compromises early interventions.Follow-up/treatment should be offered to women with a guarantee of assistance and articulated care route, with clearly defined roles for each point of attention, ensuring access to services and comprehensive care 8,9 .
Given the situation presented, this study aimed to analyze the assistance flow established for women with altered Pap Test result in order to improve the network of attention to women's health.

METHODS
A cross-sectional study was conducted on the network of healthcare of women, dedicated to the diagnosis of cervical uterine cancer, including the services of primary care and specialized services in the health micro-region of Nova Andradina, Mato Grosso do Sul, which covers seven municipalities: Angélica, Anaurilândia, Batayporã, Ivinhema, Nova Andradina, Novo Horizonte do Sul and Taquarussu (Figure 1).The area was chosen for having more than 70% of women without follow-up to examination results of Pap Test with alterations 2 .
The micro-region has 31 teams of the Family Health Strategy (FHS), 02 Basic Health Units distributed in seven municipalities, 02 Mixed Units, 01 Center of Medical Specialties, 01 Reference Center for Women's Health, 08 public and private hospitals, adding 204 beds to care for patients in the National Health System to serve a region of 110,883 inhabitants 10 .
A survey was carried out in official databases as reports of the National Register of Health Establishments ("CNES") and Integrated Employment Programming ("PPI") between June of 2013 and July of 2014.This research was necessary to identify services oriented to cervical uterine cancer for the region and registered and carried out procedures on each of the assistance points.From this, were established the services and professionals that would be part of the study.The interviews with professionals from the basic and specialized healthcare unit were performed between the months of December of 2013 and March of 2014.
Four different forms were prepared for the interview; 01 for primary care professionals, covering 33 Primary Care Units.A responsible for the Pap Test in each healthcare unit was interviewed; 01 to the municipal women's health coordinators in each municipality in the micro-region, seven interviews; 01 to the regulatory system in each municipality and a reference service for the region, located in the coordination of the regulatory system of Dourados, with eight respondents.A form for professionals from the specialized care in two referral hospitals, being two respondents at the University Hospital of Universidade Federal da Grande Dourados, and two in Centro de Tratamento do Câncer de Dourados, totaling four respondents.Fifty-two professionals were interviewed, comprising all the assistance and regulatory points related to assistance to women.
The four instruments had two blocks, the first, common to all, contained questions for professional characterization (gender, age group, occupation, working time and education/training to act in the area).
In the second block of the instrument intended for professionals in the basic attention was asked about the assistance flows (average time for receiving the result from Pap Test examination, registration form of result, conduct of the team, monitoring the woman forwarded to other levels of complexity, tools used and barriers faced for greater levels of complexity).

Follow-up of uterine cervical cancer
Farias ACB, Barbieri AR To the municipal coordinators of women's health was questioned how the follow-up monitoring is done to monitor the Pap Tests with altered results, which strategies adopted by the municipality to ensure the handling of cases of cervical uterine cancer.
The instrument geared to the municipal regulatory services and the region investigated the processing of referrals, receiving system and authorization thereof, form of displacement of the patient and the communication mechanism with the woman.
The instrument of specialized care for medium and high complexity sought to list the procedures performed, forms established for monitoring treatment and identification of difficulties in the sector.
The forms were developed based on the Brazilian guidelines for tracking of cervical uterine cancer (INCA 2011) and Decree 874/2013, which established the National Policy for the Prevention and Control of Cancer in the Healthcare of People with Chronic Diseases in the Unified Health System.The interviews were intended to identify the procedures and assistance at each level of care, the forwarding mechanisms at different levels and the way to monitor treatment.
The inclusion criteria for an interview were: acting directly next to the woman with regard to prevention, treatment and rehabilitation of cervical uterine cancer; coordinate at the municipal level the Control Program Cervical Cancer and act in the municipal and regional central regulation in Dourados.All professionals invited accepted to participate in the research and signed an Informed Consent.
The results were organized in Epi Info 6.04 version system and were statistically analyzed by relative frequency tables.The map above was developed with QGIS software and digital mesh of the state of Mato Grosso do Sul, available by IBGE highlighting the micro-regions of Dourados and Nova Andradina.
The research was approved by the Ethics and Research Committee of Universidade Federal do Mato Grosso do Sul, under CAAE number: 29402114.3.0000.0021.

Follow-up of uterine cervical cancer
Farias ACB, Barbieri AR

RESULTS
Data from the information systems analyzed indicate that the network of care to women in Mato Grosso do Sul has 504 primary care units distributed in 79 municipalities that perform annually 170,000 cytopathology cervical cancer tests, of which are diagnosed approximately 460 high grade changes (2.7%).Cytology cervical tests and pathological are sent to nine pathology laboratories.Secondary attention is distributed in 11 micro-regions of the state, performing around 5,437 colposcopy and 329 High Frequency Surgery (HFS) every year.The tertiary network for treatment of cancer cases are located in the municipalities-host of the four regions 11 .
For the region, are listed in databases that specialized procedures recommended by the Brazilian Guidelines for the monitoring of cervical uterine cancer are available: colposcopy examinations and biopsies; removal of the transformation zone/high frequency surgery; removing part of the uterine cervix are offered in two municipalities, Nova Andradina and Dourados.Services of radiotherapy and chemotherapy and surgery of uterine cervix are held in Dourados.
Of the 52 respondents in the existing health services in the micro-region, 47 (90.4%) were female, 40 (77%) were aged between 25 and 45 years.The remaining 12 (23%) are over 45 years old.Among the responsibility for assisting in the different levels of care, there is a predominance of nurses.Of professionals working in primary care, 33 (100%) are nurses and three (75%) in specialized attention.Of the seven municipal coordinators of women's health six (95.7%) are nurses and those responsible for the central control of the municipalities, four (50%) are social workers, followed by three (37.5%)nurses and one (12.5%)pedagogue.
In relation to the time of service of the 52 professionals, 37 (71.15%) of them had two months to five years of service; 14 (26.92%) from six to 10 years and one of them (1.93%) reported to be more than 10 years in the area.Of these, 27 (51.92%)received training/capacity to develop actions related to women's health.Of the seven municipalities in the micro-region, five are 100% coverage of the Family Health Strategy and one reaches 92%.Nova Andradina and Dourados, respectively head offices of the micro-region and the macro-region, have FHS coverage of approximately 65%.
The interviews with primary care professionals have pointed out differences between the practice and the protocol established by the Guidelines (Table 1).
There are differences between results and proposed interventions in Brazilian Guidelines for Screening.Most of the tests, 16 (48%) and 26 (78.8%) respectively, with results "atypical squamous cells undetermined probably not neoplastic" and "low-grade intraepithelial lesion" are forwarded to other levels of attention when the recommendation is to ensure that the treatment is carried out at the local level.
On the other hand, injuries that should be addressed as "atypical squamous cells of undetermined significance, when one cannot exclude high-grade intraepithelial lesion", "atypical glandular cells of undetermined significance possibly not neoplastic or when you cannot exclude high-grade intraepithelial lesion", "atypical cells of unknown origin", of the 33 primary care professionals, seven (21.2%) claim to treat at the local level.
The non-observance of protocols can be due to the lack of staff training, since 60.6% of those who act in the basic attention stated that they did not receive training.
The average time between completion of the exam and the result is of about 30 to 59 days and only eight health units (24.2%) adopt the electronic means to access the results.The results are recorded in the medical records in 33 (100%) units and 32 (96.96%) also note the outcome on the register book, producing duplicity of information.
There is no effective monitoring on the referral of women with result of Pap Test changed, when in 18 (54.5%)primary care units, professionals advise women to seek the regulation service of the municipality and 09 (27.3%) to seek directly the referral service.For the cases where it is necessary forwarding to the head office of the macro-region, all health units, 33 (100%), request that women look for the service of the municipality of origin for scheduling.The results indicate that there are no mechanisms for monitoring and follow-up observing of the health unit.
In 27 (81.8%) of health units there is no cross-reference information of assistance and/or treatment performed in women referred to specialist services.In 29 (87.9%) of them professionals reported that seek such information from the patient.
Of respondents in the health units of primary care, 25 (75.8%) reported difficulties to follow up the treatment of women with altered colpocytological exam.Among these, 14 (42.4%) reported difficulty to schedule additional tests, 11 (33.3%)state lack of places to carry out an appointment for the first consultation at other levels of complexity and nine (27.3%) reported difficulties for subsequent consultation in other levels of complexity as well as return of the patient to primary care without scheduled assistance (Table 2).
Of the seven municipal coordinators of women's health only one receives and records the test results and then delivers it to the health units and thus can monitor the following treatment of women.In six municipalities, the coordination does not record, and the results are sent directly from the laboratory to the health units.Thus, municipal coordination relies on information provided by health facilities or by the laboratory.They point out that the monitoring of the assistance is made by the Cancer System and Information ("SISCAN") or through team meetings.
According to information of the coordinators of the municipal regulation system, the patient is informed about her care schedule with the specialized care through telephone contact in six (75%) municipalities, which also notify the team of FHS, that is, there are two actions to inform the woman about her schedule: one by direct contact with the patient and the other by communication with Health Unit/FHS.Dourados, reference municipality to the others, reports the regulation service of the municipality of origin, without contact with the patient.All municipalities that refer are responsible for the transportation of women.

Follow-up of uterine cervical cancer
Farias ACB, Barbieri AR The professionals who work in medium and high complexity network are mostly nurses with training for the service of assistance to women's health.Of the four professionals from the service of medium complexity specialized attention, two claim that there is repressed demand.The reasons related to the management and structure of the service as the lack of material, equipment and professionals, as well as structure lower than the demand were cited as main reasons for non-attendance.The non-attendance of the woman on the scheduled day was another problem reported by one of the professionals.One of the concerns expressed by interviewees was the attendance of women with late diagnosis, in advanced stages, which makes difficult the treatment and the prognosis for a cure.
From the information obtained in the interviews, it was possible to outline the flow of customer service in the microregion.The municipalities of Angélica, Anaurilândia, Batayporã, Ivinhema, Novo Horizonte do Sul and Taquarussu, as well as Nova Andradina, that is a reference to the region, perform the Pap Test.When judged necessary, from the result of the test and without observing the flows defined by the Guidelines, the professionals forward/guide women to perform the removal procedures, colposcopy, clinical pathology analysis and biopsy in the Centro de Saúde da Mulher in Nova Andradina.Surgical procedures, chemotherapy and radiation are referred to the University Hospital of the Universidade Federal da Grande Dourados and Cancer Treatment Center in Dourados.

DISCUSSION
By analyzing data from "SISCAN", there is the impression of fluidity in assisting the needs of women in the state with regard to cervical health.Mato Grosso do Sul has been strengthening the collection of Pap test in women between 25 to 64 years.This is evidenced when in the period from 2007 to 2012, the average collection was of 23, higher than the national, which was 16.62 per 100,000 women.However, the mortality from malignant neoplasm of cervical uterine cancer in the state, in the same period, was 6.77 per 100 million women, while in Brazil the average was 4.57 2,12 .
Data from the National Registry of Health Establishments indicates that the micro-region of Nova Andradina has a set of points of attention to healthcare of women with all necessary services.The physical network has primary care as a gateway, followed by medium and high complexity, equipment of different technological densities spatially distributed.In reference service for medium complexity, there were reports about the lack of equipment, supplies and professionals to meet the demand.The network of primary care units were not cited information of this nature.
Paradoxically, Outpatient Information System records suggest that the supply of tests to confirm diagnosis and treatment of cancer of the uterine cervix are lower than expected.In addition, the improper routing of patients and accompanying losses of women with high-grade lesion compromise the success of screening.The average percentage of follow-up/treatment is only 9% in the country 12,13 .Such problems are singled out by respondents when mentioning the difficulty to schedule, the lack of resources and the shortage of professionals in the region.
The importance of follow-up of cervical cancer is by detection of complications; detecting residual lesions; conservative treatment institution; reducing the risk of post-treatment cancer conservative and identification of women with less need for supervision 13 .Therefore, it is as an indicator of health and qualifies assistance to women 14 .
Studies indicate failures in the exam collection, in the relationship between the physical and the social and economic conditions of women, others investigate the women's perception of examination.However, there are few studies about the followup assistance 15 .
The results point to the fact that the majority of respondents answer that there is no received training to work on attention to woman in preventing cervical cancer.The lack of preparation/ training of professionals, especially in primary care, to assistance based on protocols and flows imposed by Health System is a restlessness and brings as an outcome disorderly flows, with referrals of women who should be treated and monitored in their own basic unit and at the same time, "treat and follow" women who, according to the Brazilian Guideline should be investigated with specialized tests (colposcopy, biopsy).
Authors warn that the quality of health care offered by a system is related to the permanent education of its professionals, use of clinical protocols and defining lines of care.Thus, the appropriate follow-up of women meets the principle of comprehensive care and continuous offer.To train professionals to work in the health care system is critical to the resolution of problems and for the qualification of the care provided to the subjects 16,17 .
Continuing education contributes to the organization of services and should include the development of interventions involving access, quality of care and resoluteness.A study conducted in Teresina, identified the lack of staff training to perform the Pap Test and the activities involving the prevention and care in cervical cancer 18 .
Disclosure of the Brazilian Guidelines for screening for cervical cancer aimed to disseminate evidence-based recommendations to guide decision-making of health professionals, to facilitate the effective and organized communication between the teams and services and guide the care network 19 .For the conformation of healthcare networks are necessary protocols and aid flows to support assistance and establish the skills to the levels of primary and specialized care.This implies actions in the field of management, which would establish the responsibilities, powers and actions to be performed at each point of attention to providing inputs for their achievement and at the same time, in the healthcare field, would predict training professional to perform procedures consonant with the guidelines and protocol, ensuring resoluteness in action.
The ignorance of the Guideline by primary care directly affects the response capacity and in the confidence placed

Follow-up of uterine cervical cancer
Farias ACB, Barbieri AR by the primary services.Forwarding services of reference to interventions that can be made at the local level gives little attention to basic efficiency and slows the treatment of women 20 .
The research pointed to serious deficiencies in the communication between services and between services and users.There is a lack of routines and protocols for assistance flows which compromises the effectiveness of the healthcare network.The articulation between the different services complexities is a critical point for ensuring people's access to the necessary treatment 21 .
In 2013 the Ordinance No. 2923/Ministry of Health was published establishing financial incentives for deployment or implementation Central of Consultation and Examination Regulation was edited.In the ordinance, all health units can be requesters, since designated by the municipal manager and connected to a central control 22 .
In the same year, the Cancer Information System ("SISCAN") was implemented as an online system available for all levels of care, regulatory services, local and regional coordination.The SISCAN offers conditions for patient monitoring, generation of monitoring reports and monitoring the follow-up of patients with flows features for all levels of management 23 .
Through SISCAN, it is minimally possible to manage assistance to the woman with the request tests and view reports by the Basic Health Unit.The municipal coordination is able to access management reports, view reports and manage intramunicipals segments and monitor the local units.One of the duties of local and regional coordination established by SISCAN is to coordinate and integrate care and monitoring of follow-up.However it is not an everyday practice in the micro studied even being considered essential for the effectiveness of the system and ensuring improvements in the health status of the population 24 .An analysis of healthcare systems, on an international perspective, found that the systems are fragmented and are organized by a set of isolated points of attention and without communication, being unable to pay continuous attention to the population making it difficult for primary care exercise your care coordinator role, with quality and in full 25,26 .
Even with online systems such as SISCAN, regional and municipal governance is responsible for the establishment and functioning of assistance flow with the powers of each level.The lack of communication between the levels of attention and assistance services as identified in the survey generate interruptions and delays in treatment.Coordination of care assumes the longitude and completeness in order to care continuity and can reduce the intervals between screening and diagnosis -diagnosis and starting treatment -early treatmenteffective interventions 27 .A research in member countries of the Organization for Economic Cooperation and Development (OECD), points out that the ability for coordination of care is heavily compromised by the lack of integration between assistance levels and those with service providers.This is especially for the existence of barriers that hinder the implementation of integrated actions in levels of complexity within the health system properly 28 .
The guarantee of assistance at different levels of complexity requires the exchange of clinical information and coordination of care through protocols that need to be carried out by a management that integrates care levels involved 29,30 .
While the authors suggest that the articulation between the points of attention cannot dispense regulation mechanisms to relate social assistance units in the different levels of complexity, reference systems and counter reference should compose the municipal coordination services protocols both for forwarding women as to how to monitor the interventions.In this study, the coordination of assistance and the adjustment service does not accompany the flow of women in network and information systems are used to monitor the treatment.
The Pap test should be understood by health professionals as a sensitive technique for the detection of cervical cancer and not an end in itself, that is, it is the beginning of the intervention process.Screening techniques are applied to healthy populations or risk groups and therefore, must have wide range and coverage.Expand their coverage without offering the actions arising from the test results in an organized manner, does not change the morbidity and mortality nor human suffering.
Among the main factors to ensure success in screening, are the professional training, service monitoring, standardization of records management and operation of information systems, and proper diagnosis and monitoring of women with detected changes.However, this structure has been nonpaying in developing countries with limited effectiveness in the evaluated service 31 .
The concept of care network as a form of social organization is based on cooperation between units with autonomy, lack of hierarchy, sharing common goals, cooperation, trust, interdependence and constant and lasting exchange of resources.
From the results of this study and considering the patient as the main subject, it was possible to structure a stream of responsibilities and communication between the different assistance points which can be viewed in Figure 2. The flow developed from the guidelines and of the findings of the study, identifies the responsibilities of the different assistance allowing points outline the careful line on a continuum care keeping the patient monitored by primary health care by reducing time and giving effective assistance.
This study has limitations.It is possible that it has gaps in tracking records of women and was not the object of research the association between Pap test results with cell change and attendances on oncology services.The consequences arising from failure and omissions generated by referrals errors have not been studied.In the healthcare field, professionals cited the increased workload due to the large number of patients who come for treatment in advanced stages of the disease, without the burden of identifying the services responsible for the regulation.Despite the promulgation of Law 12,732 of 2012, which "offers on the first patient treatment with malignancy proven and sets deadline for beginning", was not the object of research the average time analysis of the result date and the start date of the treatment.It is suggested further researches.

Follow-up of uterine cervical cancer
Farias ACB, Barbieri AR The results showed that there is no guarantee of women's access to diagnosis and there is urgency in improving the care provided to women in two fundamental aspects.One of them deals with the training of workers for the actions at each level of complexity adapting the structure of services to assist with regularity in the provision of equipment.Thus, each level of attention to women's health could perform all the duties incumbent upon it according to clinical protocols, increasing the response capacity.The second aspect points to the need to improve monitoring systems between points of care, monitoring the woman permanently and putting the points provided for attention in their care network.After all, it is the health care system and not the client the responsible for guaranteeing access to assistance.

Figure 1 .
Figure 1.Map of the geographical location of the micro-region of Nova Andradina, composed of seven municipalities, part of the macro-region of Dourados, in Mato Grosso do Sul, 2014.

Figure 2 .
Figure 2. Proposal of the authors for flow and responsibilities of the different assistance points of the network of care for women with abnormal cervix.Legend: PC: Primary Care being the Family Health Strategy or primary care units; MCR: Municipal Central Regulation; MCWH: Municipal Coordination of Women's Health; HMRC; Health's Macro-Region Regulation Center; MHCS: Medium and High Complexity Services.

Table 1 .
Frequency of the conduct of professionals in the basic attention before the results of cytopathology test (CT), and the recommended actions by the Ministry of Health as parameters and non-conformities highlighted in bold.Micro-region of Nova Andradina, 2014

Table 2 .
Setting the woman assistance service in the micro-region of Nova Andradina/MS