Inequality in the treatment of lung cancer within the unified public health system in Brazil

Introduction: Lung cancer is the most common cancer diagnosed worldwide (excluding nonmelanoma skin cancer) and is the leading cause of global cancer related deaths. In Brazil, it is the fourth most common cancer, with an estimated 32.560 new cases a year. A lack of standardization in systemic cancer therapy among patients in the public health system can lead to inequalities in outcomes.

Objective: This study aims to identify differences in systemic cancer therapy comparing treatment protocols among institutions and with the protocol recommended by the Brazilian Ministry of Health (MS), the World Health Organization (WHO), Essential Medicines List, the Magnitude of Clinical Benefit Scale (MCBS) from the European Society for Medical Oncology (ESMO) guidelines.

Methods: Between September 2023 and January 2024, a national cross-sectional study was conducted by requesting systemic lung cancer therapy protocols from all public cancer centers, using Brazil’s Freedom of Information Law (Law nº 12.527/2011).

Results: A total of 95 responses from all five regions cancer centers were received and 43 regarding lung cancer protocols. In the adjuvant setting of patients with NSCLC without driver mutation, the treatments offered are 100% adequate considering availability of chemotherapy, but only 6% of the cancer centers offer immunotherapy. In the setting of definitive treatment with concomitant chemoradiation, none of the centers offer immunotherapy, but all of them offer the proper chemotherapy regimens. In the metastatic setting, 100% of the centers comply with the chemo regimens, and 51% of the centers offer targeted therapies for EGFR mutations, and 2% for ALK fusion (treatments that exclude 2nd or 3rd generation drugs, such as Osimertinib, Alectinib or Brigantinib). Furthermore, no center reported offering treatment with targeted therapies for molecular alterations including ROS-1, RET, MET, HER-2, BRAF, NTRK and KRAS G12C.

Conclusion: Within the context of outdated guidelines by the Ministry of Health, cancer centers do offer all chemotherapy drugs. Only half of the centers offer the recommended EGFR-targeted therapy. Immunotherapy, not yet recommended by the MH or by WHO-EML but universally recommended by international guidelines such as ESMO, has very limited availability among the cancer centers. The observed inequality contradicts one of the cornerstones of the Brazilian public health system and warrants further discussion of this issue.

Corresponding author: Luciana Holtz de Camargo Barros (e-mail: pesquisa@oncoguia.org.br).