Medicina de precisão/medicina personalizada: análise crítica dos movimentos de transformação da biomedicina no início do século XXI / Medicina de precisión/medicina personalizada: análisis crítico de los movimientos de transformación de la biomedicina a inicios del siglo XXI / Precision medicine/personalized medicine: a critical analysis of movements in the transformation of biomedicine in the early 21st century

O grande desenvolvimento da pesquisa em genômica nas últimas décadas tem gerado muitas expectativas com relação ao seu impacto na biomedicina. Observa-se o crescente investimento em pesquisa na medicina personalizada ou de precisão, que busca customizar a prática médica com foco no indivíduo baseando-se na utilização de testes genéticos, identificação de biomarcadores e desenvolvimento de medicações alvo. O movimento da medicina personalizada ou de precisão, no entanto, é polêmico e tem suscitado um importante debate entre seus defensores e críticos. Este ensaio teve por objetivo discutir os pressupostos, promessas, limites e possibilidades da medicina personalizada ou de precisão com base em uma revisão da literatura recente situando o debate sobre o tema. A revisão aponta que muitas das promessas da medicina personalizada ou de precisão ainda não se concretizaram. Se por um lado houve enorme avanço no conhecimento sobre os mecanismos moleculares das patologias e o desenvolvimento de medicamentos que impactaram significativamente o tratamento de alguns tipos de câncer, até o momento não há evidências de que este padrão se reproduzirá em outras doenças complexas. A medicina personalizada ou de precisão deve gerar desenvolvimentos incrementais em áreas específicas da medicina, existindo, no entanto, vários obstáculos para sua generalização. O alto custo das novas biotecnologias pode agravar as desigualdades em saúde, tornando-se um problema para a sustentabilidade dos serviços de saúde, especialmente em países de média e baixa rendas. A ênfase na medicina personalizada ou de precisão pode levar ao deslocamento de recursos financeiros de iniciativas menos custosas e com maior impacto em saúde pública.

El gran desarrollo de la investigación en genómica en las últimas décadas ha generado muchas expectativas en relación con su impacto en la biomedicina. Se observa la creciente inversión en investigación en medicina personalizada o de precisión, que busca hacer a medida la práctica médica, centrándose en el individuo, basándose en la utilización de pruebas genéticas, identificación de biomarcadores y desarrollo de medicamentos diana. El movimiento de la medicina personalizada o de precisión, no obstante, es polémico y ha suscitado un importante debate entre sus defensores y críticos. Este ensayo tuvo como objetivo discutir los presupuestos, promesas, límites y posibilidades de la medicina personalizada o de precisión, en base a una revisión de la literatura reciente, situando el debate sobre este tema. La revisión apunta que muchas de las promesas de la medicina personalizada o de precisión todavía no se concretizaron. Si por un lado hubo un enorme avance en el conocimiento sobre los mecanismos moleculares de las patologías, y el desarrollo de medicamentos que impactaron significativamente el tratamiento de algunos tipos de cáncer, hasta el momento no hay evidencias de que este patrón se reproducirá en otras enfermedades complejas. La medicina personalizada o de precisión debe generar desarrollos incrementales en áreas específicas de la medicina, existiendo, no obstante, varios obstáculos para su generalización. El alto coste de las nuevas biotecnologías puede agravar las desigualdades en salud, convirtiéndose en un problema para la sostenibilidad de los servicios de salud, especialmente en países de media y baja renta. El énfasis en la medicina personalizada o de precisión puede llevar al desplazamiento de recursos financieros de iniciativas menos costosas y con mayor impacto en salud pública a otras de esta índole.

The enormous development of genomics research in recent decades has raised great expectations concerning its impact on biomedicine. There has been growing investment in research in personalized or precision medicine, which aims to customize medical practice with a focus on the individual, based on the use of genetic tests, identification of biomarkers, and development of targeted drugs. However, the personalized or precision medicine movement is controversial and has sparked an important debate between its defenders and critics. This essay aims to discuss the assumptions, promises, limits, and possibilities of personalized or precision medicine based on a review of the recent literature situating the debate on the theme. The review indicates that many of the promises of personalized or precision medicine remain unfulfilled. While there has been huge progress in knowledge on the molecular mechanisms of diseases and the development of drugs that have significantly impacted the treatment of some types of cancer, thus far there is no evidence that this same pattern will be reproduced in other complex diseases. Personalized or precision medicine is expected to generate incremental developments in specific areas of medicine, but there are obstacles to its generalization. The high cost of new biotechnologies can exacerbate health inequalities and become a problem for health services' sustainability, especially in low and middle-income countries. The emphasis on personalized or precision medicine may shift funds away from less costly interventions that have greater public health impact.

Health inequities and cancer survival in Manizales, Colombia: a population-based study / Inequidades en salud y supervivencia al cáncer en Manizales, Colombia: un estudio de base poblacional

Abstract Objective: To analyze differences in survival of breast, cervical, lung, prostate and stomach cancer by health insurance regime (HIR) and socioeconomic position (SEP) in an intermediate city in a middle-income country. Methods: All patients with breast, cervix uteri, lung, prostate and stomach cancer diagnosed between 2003 and 2007 and characterized by the Manizales population-based Cancer Registry (MCR) were included and followed up to a maximum of 5 years for identifying deaths. Survival probabilities estimated by HIR were defined according to the type of affiliation at the date of diagnosis, and by socioeconomic stratification of residence (SS) as indicator of SEP, stratifying for other prognostic factors using Kaplan-Meier methods. Cox proportional hazard models were fitted for multivariate analysis. Results: A total of 1,384 cases and 700 deaths were analyzed. Five-year observed survival was 71.0% (95% IC: 66.1-75.3) for breast, 51.4% (95% IC: 44.6-57.9) for cervix, 15.4% (95% IC: 10.7-20.8) for lung, 71.1% (95% IC: 65.3-76.1) for prostate and 23.8% (95% IC: 19.3-28.6) for stomach. Statistically significant differences in survival by HIR were observed for breast, lung, prostate, and stomach - with poorer survival for the subsidized and uninsured patients. Differences by SS were observed for lung and prostate. Differences in survival by HIR were independent of SS, and viceversa. Conclusions: Important inequities in cancer survival exist related to HIR and SEP. Possible explanations include underlying comorbidities, late stage at diagnosis, or barriers to timely and effective treatment.

Resumen Objetivo: Analizar la supervivencia de pacientes con cáncer de mama, cuello uterino, pulmón, próstata y estómago según régimen de aseguramiento en salud (RAS) y posición socioeconómica (PSE) en una ciudad intermedia de un país de medianos ingresos. Métodos: Se incluyeron todos los pacientes con cáncer de mama, cuello uterino, pulmón, próstata y estómago diagnosticados entre 2003 y 2007 y caracterizados por el Registro Poblacional de Cáncer de Manizales, quienes fueron seguidos hasta un máximo de cinco años para identificar los fallecimientos. Las probabilidades de supervivencia estimada según RAS fueron definidas de acuerdo con el tipo de afiliación al momento del diagnóstico, y según el estrato socioeconómico de la residencia como indicador de PSE, estratificando por otros factores pronósticos y utilizando el método de Kaplan-Meier. Para el análisis multivariado se ajustaron modelos de riesgos proporcionales de Cox. Resultados: Se analizaron en total 1.384 casos y 700 muertes. La supervivencia observada a cinco años fue 71.0% (IC 95%: 66.1-75.3) para cáncer de mama, 51.4% (44.6-57.9) para cuello uterino, 15.4% (10.7-20.8) para pulmón, 71.1% (65.3-76.1) para próstata, y 23.8% (19.3-28.6) para estómago. Se observaron diferencias estadísticamente significativas en la supervivencia según RAS para mama, pulmón, próstata y estómago, con supervivencia más pobre en los pacientes del régimen subsidiado y no asegurados. Se observaron diferencias por estrato socioeconómico en los cánceres de pulmón y próstata. Las diferencias por RAS fueron independientes del estrato socioeconómico y viceversa. Conclusiones: Existen importantes inequidades en la supervivencia de pacientes con cáncer relacionadas con el RAS y con la PSE. Las posibles explicaciones incluyen comorbilidades subyacentes, diagnóstico tardío y barreras para el acceso al tratamiento oportuno y efectivo.

Economic analysis of costs with enteral and parenteral nutritional therapy according to disease and outcome / Análise econômica dos custos com terapia nutricional enteral e parenteral conforme doença e desfecho

ABSTRACT Objective To conduct an economic analysis of enteral and parenteral diet costs according to the type of disease and outcome (survivors versus deaths). Methods It is a cross-sectional, observational, retrospective study with a qualitative and quantitative design, based on analysis of hospital accounts from a healthcare insurance provider in the Southern region of Brazil. Results We analyzed 301 hospital accounts of individuals who used enteral and parenteral diets. The total cost of the diet was 35.4% of hospital account total costs. The enteral modality accounted for 59.8% of total dietary costs. The major costs with diets were observed in hospitalizations related to infections, cancers and cerebro-cardiovascular diseases. The major costs with parenteral diet were with admissions related by cancers (64.52%) and dementia syndromes (46.17%). The highest ratio between total diet costs with the total of hospital account costs was in dementia syndromes (46.32%) and in cancers (41.2%). The individuals who died spent 51.26% of total of hospital account costs, being 32.81% in diet (47.45% of total diet value and 58.81% in parenteral modality). Conclusion Enteral and parenteral nutritional therapies account for a significant part of the costs with hospitalized individuals, especially in cases of cancers and dementia syndromes. The costs of parenteral diets were higher in the group of patients who died.

RESUMO Objetivo Realizar uma análise econômica de custos da terapia nutricional enteral e parenteral, conforme o tipo de doença e o desfecho (sobreviventes versus óbitos). Métodos Estudo transversal, observacional, retrospectivo, com estratégia qualitativa e quantitativa, a partir da análise de contas hospitalares de uma operadora de saúde da Região Sul do Brasil. Resultados Foram analisadas 301 contas hospitalares de usuários que utilizaram dieta enteral e parenteral. O custo total com dieta foi de 35,4% do custo total das contas hospitalares. A modalidade enteral representou 59,8% do custo total em dieta. Os maiores custos com dieta foram observados em internações relacionadas a infecções, cânceres e doenças cérebro-cardiovasculares. Os maiores custos com dieta parenteral foram observados nas internações relacionadas aos cânceres (64,52%) e às síndromes demenciais (46,17%). A maior relação entre o custo total com dieta e o custo total da conta foi na síndrome demencial (46,32%) e no câncer (41,2%). Os usuários que foram a óbito consumiram 51,26% dos custos totais das contas, sendo 32,81% com dieta (47,45% do valor total com dieta e 58,81% do custo na modalidade parenteral). Conclusão As terapias nutricionais enteral e parenteral representaram uma parte importante dos custos no tratamento de indivíduos hospitalizados, principalmente nos casos dos cânceres e nas síndromes demenciais. O custo com dieta parenteral foi maior no grupo de usuários que foram a óbito.

A família da criança com câncer: necessidades sócio-econômicas / La familia del niño con cáncer: necesidades socioeconómicas / The family of the child with cancer: socioeconomic needs

Resumo OBJETIVOS Identificar as variáveis socioeconômicas que influenciam as famílias da criança com câncer. MÉTODOS Pesquisa de natureza quantitativa, descritiva e correlacional com 128 famílias de crianças com câncer. Foram utilizados três instrumentos: "Questionário de avaliação do impacto na família de crianças com câncer", "Escala de Satisfação com o Suporte Social" e "Escala de Graffar". RESULTADOS As famílias revelam gastos econômicos acrescidos com a doença devido aos deslocamentos para o hospital e à medicação. A perda de rendimento por parte de um dos progenitores também agrava o impacto econômico da doença. As famílias com maiores necessidades de apoio e menor suporte social apresentam maior impacto econômico. CONCLUSÃO O suporte social assume um papel importante no decréscimo das necessidades econômicas incitadas pela doença. Os enfermeiros devem identificar as necessidades econômicas das famílias e tornar-se parte da rede de apoio das mesmas, sendo fonte de suporte para que as mesmas consigam fortalecer-se no cuidar.

Resumen OBJETIVO Identificar las variables socioeconómicas que influencian a las familias del niño con cáncer. MÉTODOS Investigación de naturaleza cuantitativa, descriptiva y correlacional llevada a cabo con 128 familias de niños con cáncer. Fueronutilizados tres instrumentos: "Cuestionario de evaluación del impacto en la familia de niños con cáncer", "Escala Satisfacción del Soporte Social" y "Escala de Graffar". RESULTADOS Las familias revelan un aumento en los gastos económicos con la enfermedad debido a los desplazamientos hacia el hospital y a la medicación. La pérdida de ingresos por parte de uno de los progenitores también empeora el impacto económico de la enfermedad. Las familias con mayores necesidades de apoyo y menor soporte social presentan mayor impacto económico. CONCLUSIÓN El soporte social asume un papel importante en la reducciónde las necesidades económicas incitadas por la enfermedad. Los enfermeros deben identificar las necesidades económicas de las familias y convertirse en parte de la red de apoyo de las mismas, siendo fuente de soporte para que las mismas consigan fortalecerse en el cuidar.

Abstract OBJECTIVE To identify the socioeconomic variables which influence the families of the child with cancer. METHODS Quantitative, descriptive, correlational research with 128 families of children with cancer. Three instruments were used: "Questionnaire assessing the impact on the family of children with cancer", "Social Support Satisfaction Scale", and "Graffar Scale". RESULTS Families report increased economic spending due to the disease, with the displacements to hospital and medication. The loss of income by one of the parents also exacerbates the economic impact of the disease. Families with greater support needs and lower social support present greater economic impact. CONCLUSION The social support assumes an important role in the decrease of the economic needs incited by the disease. Nurses must identify the economic needs of the families and become part of the support network of them, being a source of support so they can strengthen themselves in caring.

Perfil socioeconómico de familias de niños diagnosticados con cáncer / Socioeconomic profiles of families of children diagnosed with cancer

INTRODUCCIÓN: El cáncer es una enfermedad que demanda grandes recursos en el área médica y psicosocial. En Chile, cada año, se diagnostica cáncer a 500 niños; la sobrevida a 5 años es similar a países de altos ingresos (75%). El ingreso económico de los países es un factor relevante dado que se correlaciona con la sobrevida de los enfermos de cáncer de forma directamente proporcional. En el caso de Chile los costos de la enfermedad están cubiertos por el Sistema de Salud. Fundación Nuestros Hijos, institución privada sin fines de lucro, asiste integralmente a los niños con cáncer atendidos en el Hospital Exequiel González Cortés, entre otros. OBJETIVO: Describir la situación socioeconómica de las familias de niños diagnosticados de cáncer en el Hospital Exequiel González Cortés, durante el año 2011. MÉTODO: Estudio observacional descriptivo. Del total de 69 niños diagnosticados ese año se incluyeron 57 niños, 12 fueron excluidos: 6 por ser recaída de enfermedad oncológica y 6 por no contar con todos los datos. RESULTADOS: el 54% [n=31) fue diagnosticado de Leucemia; la edad promedio fue de 6 años; 35% (n=20) provenía de la Región de O'Higgins, Chile; 32% (n= 18) de las madres y 95% (n=40) de los padres tenía algún tipo de trabajo remunerado; el ingreso familiar promedio mensual era equivalente a 579 dólares (por debajo del promedio nacional 1.621 dólares), per cápita de 116 dólares. El 35% de las familias compartía casa con otras familias. CONCLUSIONES: Las condiciones económicas y sociales de estas familias, podrían poner en riesgo la sobrevida de sus hijos enfermos de cáncer, si no cuentan con soporte suficiente que permitan acceder de forma apropiada al tratamiento.

INTRODUCTION: Cancer is a disease that requires a great number of medical and psychosocial resources. Each year in Chile, 500 children are diagnosed with cancer, and the 5-year survival rates are similar to those of high-income countries (75%). National income is a crucial factor, given that it is directly related to cancer survival rates. In Chile, the Health System covers the medical costs of the disease. Fundación Nuestros Hijos (Our Children Foundation), a nonprofit organization, gives comprehensive assistance to children with cancer that are treated in Hospital Exequiel Gonzáles Cortés, among other centers. PURPOSE: To describe the socioeconomic situation of families who have children diagnosed with cancer, who were treated in Hosptial Exequiel González Cortés in 2011. METHODOLOGY: For this descriptive and observational study, of the 69 children who were diagnosed with cancer in Hospital Exequiel Gonzáles Cortés during 2011, 57 were included in the study, and 12 were excluded: 6 because they were suffering relapse of a previously treated oncologica disease, and the other 6 because all of their necessary data were not available. RESULTS: Of the 57 children included in the study, 54% (n=31) were diagnosed with leukemia; the average age of the children was 6 years; and 35% (n=20) of patients came from the O'Higgins Region of Chile. Additionally, 32% (n=18) of the children's mothers and 95% (n=40) of their fathers had paid employment; the average monthly family income was equivalent to USD$579 (lower than the national average USD$1,621), and USD$116 per capita. It was found that 35% of the children's families shared their home with other families. CONCLUSIONS: These families' economic and social conditions could be a risk factor for the survival of their children with cancer, if they do not have sufficient support to access appropriate treatment.

Eficiencia de los procesos administrativos para la gestión del Fondo de Protección contra Gastos Catastróficos en México / Administrative efficiency in the Mexican Fund for the Prevention of Catastrophic Expenditures in Health

Resumen: Objetivo: Mostrar que el régimen administrativo de hospitales de especialidad influye en la eficiencia de los procesos administrativos para operar el Fondo de Protección contra Gastos Catastróficos (FPGC), para la atención de cáncer de mama, cáncer cérvicouterino y leucemia linfoblástica aguda. Material y métodos: La variable para estimar la eficiencia del proceso administrativo fue el tiempo entre la notificación del caso y el reembolso. Para su estimación se realizaron entrevistas semiestructuradas con actores clave involucrados en la gestión de casos financiados por el FPGC. Se organizó también un grupo de expertos para emitir recomendaciones de mejora. Resultados: Los hospitales de especialidad con un esquema descentralizado mostraron menor tiempo en el proceso administrativo en contraste con el modelo administrado por los Servicios Estatales de Salud, donde los tiempos fueron mayores y donde hubo mayores niveles de intermediación. Conclusiones: El modelo de hospitales especializados con un esquema descentralizado es más eficiente debido a que tiene mayor autonomía.

Abstract: Objective: To show that the administrative regime of specialized hospitals has some influence on the administrative processes to operate the Mexican Fund for Catastrophic Expenditures in Health (FPGC, in Spanish), for providing health care to breast cancer, cervical cancer and child leukemia. Materials and methods: The variable for estimating administrative efficiency was the time estimated from case notification to reimbursement. For its estimation, semistructured interviews were applied to key actors involved in management of cancer care financed by FPGC. Additionally, a group of experts was organized to make recommendations for improving processes. Results: Specialized hospitals with a decentralized scheme showed less time to solve the administrative process in comparison with the model on the hospitals dependent on State Health Services, where timing and intermediation levels were higher. Conclusions: Decentralized hospitals administrative scheme for specialized care is more efficient, because they tend to be more autonomous.

Estimating the indirect costs associated with the expected number of cancer cases in Mexico by 2020 / Estimación del costo indirecto asociado con el número esperado de casos de cáncer en México al año 2020

Abstract Objective: To estimate the indirect costs generated by adults with cancer in Mexico from 2002-2020. Materials and methods: Using information from national sources and the national cancer incidence from GLOBOCAN, we estimated income lost due to premature death (ILPD), short-term benefits (STBs), disability pensions (DPs), and opportunity costs for the carer (OCCs) generated by patients with cancer. Amounts were reported in Mexican pesos. Results: We estimated 23 359 deaths and 216 679 new cases of cancer by 2020, which would be associated with a total indirect cost of 20.15 billion Mexican pesos. Men are expected to generate 54.9% of these costs. ILPD is expected to comprise the highest percentage of the cost (60%), followed by OCCs (22%), STBs (17%) and DPs (1%). Conclusions: From an economic perspective, the results emphasize the need to strengthen preventive interventions and early detection of cancer among adults to reduce its effect on the productivity of Mexico.

Resumen Objetivo: Estimar el costo indirecto generado por población mexicana adulta con cáncer en el periodo 2002-2020. Material y métodos: Utilizando información 2002-2013 de fuentes nacionales y de incidencia de GLOBOCAN, se estiman para 2002-2020 los ingresos perdidos por muerte prematura (IPMP), subsidios de corto plazo (SCP), pensiones de invalidez (PD) y costo de oportunidad del cuidador (COC) generados por pacientes con cáncer, reportándose montos en millones de pesos (mdp) mexicanos. Resultados: Se estiman 23 359 muertes y 216 679 casos nuevos de cáncer para 2020, con un costo indirecto total de 20 148 mdp, del cual 54.9% corresponde a hombres. IPMP contribuye en mayor medida (60%), seguida por COC (22%), SCP (17%) y PD (1%). Conclusiones: Los resultados apoyan, desde la perspectiva económica, la necesidad de robustecer el proceso de prevención y detección temprana de los cánceres en adultos para reducir su impacto en la productividad del país.

The burden of disease of cancer in the Mexican Social Security Institute / La carga de la enfermedad debida al cáncer en el Instituto Mexicano del Seguro Social

Abstract: Objective: To estimate the disease burden of cancer in the affiliate population of the Mexican Social Security Institute (Instituto Mexicano del Seguro Social, IMSS) in 2010 by delegation. Materials and methods: The Disability-Adjusted Life Years (DALYs), Years of Life Lost (YLL) due to premature mortality and Years Lived with Disability/Disease (YLD) for 21 specific cancers and a subgroup of other malignant neoplasms were calculated based on the methodology of the Global Burden of Disease Study (GBD) for each of the 35 delegations of the IMSS. Results: In 2010, cancer represented the fifth overall leading cause of disease burden in IMSS affiliates (16.72 DALYs/1000 affiliates). A total of 75% of the cancer disease burden in each delegation is due to ten specific cancers, particularly breast cancer, which ranks first in 82% of the delegations. Prostate cancer; tracheal, bronchial, and lung cancers; leukemia, and colorectal and stomach cancers occupy the second to fourth positions in each delegation. With the exception of breast and prostate cancer, for which the contribution of YLD to the DALYs was higher than 50%, the greatest contribution to the DALYs of the other cancers was premature mortality, which accounted for more than 90% of the DALYs in some cases. Conclusion: The results obtained in this study allow for the identification of intervention priorities with regard to cancer at the institutional level and also for the focus at the delegation level to be placed on cancers ranking in the top positions for disease burden.

Resumen: Objetivo: Estimar, por delegación, la carga de enfermedad debida al cáncer en la población derechohabiente del Instituto Mexicano del Seguro Social (IMSS) para el año 2010. Material y métodos: Se calcularon los años de vida perdidos ajustados por discapacidad (AVISA), los años perdidos por muerte prematura (APMP) y los años vividos con discapacidad (AVD) para 21 cánceres específicos y un subgrupo de otras neoplasias malignas, con base en la metodología del Global Burden of Disease Study (GBD) para cada una de las 35 delegaciones en las que se divide el IMSS al interior del país. Resultados: En el año 2010, el cáncer representó la quinta causa de carga de enfermedad en derechohabientes del IMSS (16.72 AVISA/1000 derechohabientes). El 75% de la carga de enfermedad por cáncer en cada delegación se debe a diez cánceres específicos entre los que destaca el cáncer de mama, que ocupa el primer lugar de importancia en 82% de las delegaciones. Los cánceres de próstata, tráquea, bronquios y pulmón, leucemias, de colon y recto, así como el de estómago, se ubican entre las segundas y cuartas posiciones en cada delegación. Con excepción del cáncer de mama y de próstata, cuya contribución de los AVD a los AVISA fue superior a 50%, en los demás cánceres la mayor contribución fue debida a la mortalidad prematura, en algunos superior a 90% de los AVISA. Conclusión: Los resultados obtenidos en este estudio permiten identificar las prioridades de intervención en materia de cáncer a nivel institucional y focalizarlas a nivel delegacional para los cánceres que ocupan los primeros lugares de carga de enfermedad.

Estimativa da carga do tabagismo no Brasil: mortalidade, morbidade e custos / Estimación de la carga de enfermedad atribuible al tabaquismo en Brasil: mortalidad, morbilidad y costos / The burden of smoking-related diseases in Brazil: mortality, morbidity and costs

Os avanços no controle do tabagismo no Brasil podem ser verificados na redução da prevalência nas últimas duas décadas. As estatísticas de óbitos, ocorrência de eventos e custos diretos atribuíveis às doenças tabaco-relacionadas não são estimadas com frequência no país. O objetivo deste artigo foi estimar a carga do tabagismo em 2011, em termos de mortalidade, morbidade e custos da assistência médica das principais doenças tabaco-relacionadas. Desenvolveu-se um modelo econômico baseado em uma microssimulação probabilística de milhares de indivíduos através de coortes hipotéticas que considerou a história natural, os custos diretos em saúde e a qualidade de vida desses indivíduos. O tabagismo foi responsável por 147.072 óbitos, 2,69 milhões anos de vida perdidos, 157.126 infartos agudos do miocárdio, 75.663 acidentes vasculares cerebrais e 63.753 diagnósticos de câncer. O custo para o sistema de saúde foi de R$ 23,37 bilhões. O monitoramento da carga do tabagismo é uma importante estratégica para informar aos tomadores de decisão e fortalecer a política pública de saúde.

Los avances en el control del tabaquismo en Brasil pueden reflejarse en la reducción de la prevalencia observada en las últimas dos décadas. Las estadísticas de muertes, incidencia de eventos y costos directos atribuibles a las enfermedades, relacionadas con el tabaquismo, no han sido estimadas frecuentemente en el país. El objetivo de este estudio fue estimar la carga del tabaquismo en el año 2011, en términos de mortalidad, morbilidad y costos de asistencia médica para las patologías relacionadas con el tabaquismo. Se construyó un modelo de microsimulación probabilístico que incorpora la historia natural, los costos y la calidad de vida de los individuos. En 2011, el tabaquismo fue responsable de 147.072 muertes prematuras, 2,69 millones de años de vida perdidos, 157.126 infartos de miocardio, 75.663 accidentes cerebro-vasculares y 63.753 diagnósticos de cáncer. El costo directo fue de R$ 23,37 mil millones. El monitoreo de la carga de enfermedad atribuible al tabaquismo es una importante estrategia para informar a los responsables de las políticas públicas de salud.

Advances in tobacco control in Brazil can be reflected in the decrease in prevalence over the past two decades. Death statistics and the occurrence of events and direct costs attributable to tobacco-related diseases have not been frequently estimated in the country. The goal of this article is to estimate the burden of smoking in 2011 regarding mortality, morbidity and medical care costs of the main tobacco-related diseases. A probabilistic microsimulation health economic model was built. The model incorporates the natural history, costs and quality of life of all the tobacco-related adult-specific diseases. Smoking was accountable for 147,072 deaths, 2.69 million years of life lost, 157,126 acute myocardial infarctions, 75,663 strokes, and 63,753 cancer diagnoses. The direct cost for the health system was of BRL 23.37 billion. The monitoring of tobacco-related burden is an important strategy to guide decision-makers and to strenghten health public policies.

Los orígenes caribeños del Sistema Nacional de Salud Pública en los EEUU: una aproximación global a la historia de la medicina y de la salud pública en Latinoamérica / The Caribbean origins of the National Public Health System in the USA: a global approach to the history of medicine and public health in Latin America

Este artículo define la historia global en relación con historia de la medicina y la salud pública. Defiende que una aproximación global a la historia abre un espacio para reverberaciones transmitidas desde la periferia geográfica hacia regiones occidentales, las cuales, tradicionalmente, han dominado la historiografía moderna. Analiza dos intervenciones médicas, en el Caribe, a finales del siglo XIX y principios del XX, y señala que estos sucesos tuvieron profundas consecuencias en los EEUU. Los logros alcanzados en el Caribe, en lo relativo al control de la fiebre amarilla y del anquilostoma, además de servir de modelo para campañas sanitarias en el sur de los EEUU, impulsaron la centralización de la salud pública norteamericana bajo el control centralizador del gobierno federal.

This article defines global history in relation to the history of medicine and public health. It argues that a global approach to history opens up a space for examining the reverberations transmitted from the geographic periphery towards western regions, which have traditionally dominated modern historiography. It analyzes two medical interventions in the Caribbean in the late nineteenth and early twentieth century, showing how these events had profound consequences in the USA. The successes achieved in the Caribbean in terms of yellow fever and ancylostoma control, as well as providing a model for health campaigns in the southern USA, inspired the centralization of public health in North America under the centralizing control of the federal government.

A snapshot of cancer in Chile: analytical frameworks for developing a cancer policy

INTRODUCTION: The South American country Chile now boasts a life expectancy of over 80 years. As a consequence, Chile now faces the increasing social and economic burden of cancer and must implement political policy to deliver equitable cancer care. Hindering the development of a national cancer policy is the lack of comprehensive analysis of cancer infrastructure and economic impact. OBJECTIVES: Evaluate existing cancer policy, the extent of national investigation and the socio-economic impact of cancer to deliver guidelines for the framing of an equitable national cancer policy. METHODS: Burden, research and care-policy systems were assessed by triangulating objective system metrics -epidemiological, economic, etc. - with political and policy analysis. Analysis of the literature and governmental databases was performed. The oncology community was interviewed and surveyed. RESULTS: Chile utilizes 1% of its gross domestic product on cancer care and treatment. We estimate that the economic impact as measured in Disability Adjusted Life Years to be US$ 3.5 billion. Persistent inequalities still occur in cancer distribution and treatment. A high quality cancer research community is expanding, however, insufficient funding is directed towards disproportionally prevalent stomach, lung and gallbladder cancers. CONCLUSIONS: Chile has a rapidly ageing population wherein 40% smoke, 67% are overweight and 18% abuse alcohol, and thus the corresponding burden of cancer will have a negative impact on an affordable health care system. We conclude that the Chilean government must develop a national cancer strategy, which the authors outline herein and believe is essential to permit equitable cancer care for the country.

The Economic Burden of Cancers Attributable to Metabolic Syndrome in Korea / 예방의학회지

OBJECTIVES: Metabolic syndrome is an important etiologic factor in the development of certain types of cancers. The economic cost of the treatment of cancer has been steadily increasing. We therefore estimated the economic burden of cancers attributable to metabolic syndrome in Korea. METHODS: We reviewed metabolic syndrome-related cancers and relative risk and then calculated population attributable fractions. We analyzed insurance claims data for metabolic syndrome-related cancers in 2012 in order to estimate the direct costs associated with these cancers, including hospitalization, outpatient visits, transportation costs, and caregivers' costs as well as indirect costs such as loss of productivity due to cancer treatment and premature death. RESULTS: In 2012, 18 070 patients in Korea had cancers attributable to metabolic syndrome. The economic burden was USD 199.8 million and the direct and indirect costs were USD 124.5 million and USD 75.3 million, respectively. CONCLUSIONS: We estimated the economic burden of cancers attributable to metabolic syndrome in Korea and the efforts are necessary to reduce this burden.

Cultural adaptation to Brazil of the questionnaire Costs of caring for children with cancer / Adaptação cultural do instrumento Costs of caring for children with cancer para o Brasil / Adaptación cultural del instrumento Costs of caring for children with cancer para Brasil

OBJECTIVE: to present the cultural adaptation of the questionnaire Costs of caring for children with cancer, offering a valid and reliable tool to assess the economic repercussions of childhood cancer for Brazilian families. METHOD: it is a methodological research with a cross-sectional design. The methodological framework to validate the questionnaire was a combined process that included seven steps: translation to Portuguese; first translated consensus version; evaluation by Expert Committee; consensus on the Expert Committee version; back-translation; consensus of back-translated versions; semantic validation. The study was conducted in two phases: phase one was the translation and back-translations process, with five expert committee members. Phase two was the semantic validation, with 24 participants, who answered an instrument about their impressions of the questionnaire and suggested modifications. RESULTS: in phase one, items were included, excluded, and replaced to make the content equivalent and valid for use with Brazilian context. In phase two, the majority of the participants were mothers, who made suggestions about the relevance and clarity of the items in the questionnaire. CONCLUSIONS: the authors discussed these recommendations and made adaptations, turning the questionnaire into a valid and reliable tool for application. .

OBJETIVO: realizar a adaptação cultural do questionário Costs of caring for children with cancer que possa resultar em um instrumento válido e confiável para avaliar as repercussões econômicas do câncer infantojuvenil para famílias brasileiras. MÉTODO: este é um estudo metodológico de delineamento transversal. O percurso metodológico para validar este instrumento foi um processo combinado que incluiu sete etapas: tradução para o português; primeira versão consensual traduzida; avaliação pelo Comitê de Especialistas; versão consensual do Comitê de Especialistas; retrotradução; versão consensual da retrotradução e validação semântica. O estudo foi realizado em duas fases: a primeira fase abrangeu os processos de tradução e retrotradução e contou com um Comitê de Especialistas de cinco membros. A segunda fase compreendeu a validação semântica, com 24 participantes que responderam a um instrumento a respeito de suas impressões sobre o questionário e sugeriram modificações. RESULTADOS: na primeira fase, incluíram-se, excluíram-se e substituíram-se itens para adaptar o instrumento ao contexto brasileiro. Na segunda fase, a maioria dos participantes eram mães que fizeram sugestões sobre a relevância e a clareza dos itens do questionário. CONCLUSÃO: as autoras discutiram as recomendações e fizeram adaptações, tornando o questionário válido e confiável para aplicação. .

OBJETIVO: realizar la adaptación cultural del cuestionario Costs of caring for children with cancer, que pueda resultar en un instrumento válido y confiable para evaluar las repercusiones económicas del cáncer infanto-juvenil para familias brasileñas. MÉTODO: estudio metodológico de diseño trasversal. La trayectoria metodológica para validar este instrumento fue un proceso combinado que incluyó siete pasos: traducción al portugués; primer consenso de la versión traducida; evaluación por el Comité de Expertos; versión de consenso del Comité de Expertos; retro-traducción; consenso de las versiones retro-traducidas; validación semántica. El estudio se realizó en dos etapas: la primera fue la traducción y retro-traducción, con cinco participantes en el Comité de Expertos. La segunda fase fue la validación semántica, 24 participantes respondieron un instrumento en el que indicaron sus impresiones sobre el cuestionario y sugirieron modificaciones. RESULTADOS: en la primera fase, ítems fueron incluidos, excluidos y sustituidos para mejor adaptación al contexto brasileño. En la segunda fase, la mayoría de los participantes era madres, quienes hicieron sugerencias sobre la pertinencia y claridad de los ítems del cuestionario. CONCLUSIÓN: tras discusión entre las autoras sobre las sugestiones propuestas, fueron efectuadas adaptaciones, haciendo el cuestionario válido y confiable para aplicación. .

Metronomic therapy: Chemotherapy revisited.

Cytotoxic antiproliferative chemotherapeutic agents are the mainstay of treatment in cancers. Chemotherapy is usually administered every 2–3 weeks. Along with acute toxicity and long‑term effects of cumulative doses, this strategy potentially allows regrowth of the tumor in the interval period and leads to the emergence of resistant populations of tumor cells. Moreover, even with intense chemotherapy, the outcome is stagnating for most of the tumors. There has been recent interest in the use of chemotherapy in fractionated doses which is far below the maximum tolerated dose. This is called metronomic scheduling of chemotherapy. Here, we review the biology and evidence for metronomic chemotherapy.

Repercussões do câncer infantil para o cuidador familiar: revisão integrativa / Impact of childhood cancer for family caregivers: integrative review / Repercusión del cáncer infantil a los cuidadores familiares: revisión integradora

Trata-se de uma revisão integrativa da literatura com o objetivo de identificar as repercussões do câncer infantil para o cuidador familiar. A pesquisa foi realizada nas bases de dados LILACS, PubMed, SciELO, Adolec e Cochrane, buscando-se artigos em português, inglês e espanhol, publicados entre 2005 e 2010, usando os descritores: cuidadores, criança, câncer e enfermagem. Foram obtidos dezoito artigos. A análise das publicações selecionadas permitiu a identificação de quatro categorias temáticas: sentimentos vivenciados pelo cuidador familiar; repercussões físicas e psicológicas do sofrimento do cuidador familiar; Impacto financeiro do câncer infantil na vida do cuidador e necessidade de apoio social ao cuidador familiar. Conclui-se que os prejuízos à vida do cuidador podem fragilizar a relação criança/cuidador necessitando efetiva atuação da equipe de saúde no intuito de oferecer suporte, acompanhamento e orientação.

This is an integrative review that aimed to identify the repercussions of childhood cancer for the family caregiver. The research was done in the databases LILACS, PubMed, SciELO, Adolec and Cochrane, searching articles in English, Portuguese and Spanish; published between 2005 and 2010; using the descriptors: caregivers, children, cancer and nursing. Eighteen articles was found. Through the analysis four themes were identified: feelings experienced by family caregivers; physical repercussions and psychological distress of family caregivers; financial impact of childhood cancer in the caregiver's life, and need for social support to family caregivers. It was concluded that the damage to the caregiver's life can weaken the relationship between child/caregiver, determining the need of effective performance of the health team to offer support, guidance and monitoring.

Se trata de una revisión integradora de la literatura que tuvo el objetivo de identificar los efectos del cáncer infantil para el cuidador familiar. El estudio se llevó a cabo en las bases de datos LILACS, PubMed, SciELO, Adolec y Cochrane, buscándose artículos en portugués, inglés y español, publicados entre 2005 y 2010, con las palabras clave: cuidadores, niños, cáncer y enfermería. La búsqueda resultó en 18 artículos seleccionados. El análisis de las publicaciones seleccionadas permitió la identificación de cuatro temas: los sentimientos experimentados por los cuidadores familiares; las repercusiones físicas y psicológicas del sufrimiento de los cuidadores familiares; el impacto financiero de cáncer en la vida del cuidador y la necesidad de apoyo social para los cuidadores familiares. Se concluye que el daño a la vida del cuidador puede debilitar el vínculo niño/cuidador que requieren una acción eficaz del equipo de salud con el fin de ofrecer apoyo, orientación y supervisión.

Disability Weights for Cancers in Korea

This study renewed the estimation of disability weights for cancers in Korea, reflecting the nation's economic and medical-technological development during the past 10 yr. Thirty-two medical doctors evaluated disability weights for 24 major cancers based on the visual analogue scale (VAS) method. To check the intra-rater reliability, a correlation was calculated between 2011 and 2012 medians. To assess the inter-rater reliability, a correlation was estimated between oncologist and non-oncologist medians. To assess the inter-method reliability, a correlation was calculated between medians on VAS and Person-Trade-Off approaches. Moreover, findings in this study were compared to those in 2003 research. Spearman correlation was used and the 1% significance level was applied. Disability weights were relatively high for pancreas cancer (0.90), gallbladder cancer (0.81), mouth and oropharynx cancer (0.80), and esophagus cancer (0.80). Conversely, they were relatively low for breast cancer (0.37), prostate cancer (0.33) and thyroid cancer (0.10). All the inter-rater reliabilities were higher than 0.7. Indeed, the intra-rater and inter-method reliabilities were 0.752 and 0.927, respectively. Above all, disability weights for major cancers went down in Korea during 2003-2012, reflecting the progress of medical technology and the growth of cancer survival.

Management of Cancer Survivors in Clinical and Public Health Perspectives: Current Status and Future Challenges in Korea

The number of cancer survivors is increasing dramatically. Many cancer survivors face lifetime risks associated with their cancer therapy, with a significant proportion at risk for serious morbidity and premature mortality. Concerns regarding the long-term physical, psychosocial, and economic effects of cancer treatment on cancer survivors and their families are increasingly being recognized and addressed by public and private sector. This article summarizes economic burden of cancer survivors, main post-treatment health problems including secondary primary cancer and comorbidities, health behaviors such as smoking, exercise and physical activity, nutrition, and psychosocial problems. Faced with various health and psychosocial problems specific to this population, several healthcare and policy models are being suggested to address these issues, including 'shared care model' and 'integrative supportive care service delivery system for cancer survivors'. More effort is needed to make the cancer survivorship agenda a reality, attended by a wide variety of stakeholders including researchers, patients, providers, and policy makers.