Mammography does not fit all: the screening controversy in Brazil

On September 2025, Brazil's Ministry of Health updated its guidelines to guarantee access to mammography for women aged 40 to 74.¹ These recommendations differ from those of the World Health Organization (WHO), suggesting a well-established early-diagnosis strategy before implementing a mammography program.²

We reviewed the current breast cancer landscape in Brazil to put these diverging recommendations into perspective.

Brazil is the largest and most populous country in South America, with 205 million inhabitants and marked inequalities in wealth and health.³ Breast cancer accounts for 73,610 and 94,728 new cases annually according to Instituto Nacional de Câncer (INCA) and WHO, respectively.^3,4 Incidence is higher in the richer south and southeast and lower in the northern states. Unlike the declining trends seen in high-income countries, breast cancer mortality in Brazil continues to rise.⁴

A large proportion of breast cancer patients in Brazil present with advanced disease and shifting diagnoses from stages III–IV to I–II would save more lives than screening.^4,5 Despite having the necessary resources, significant barriers occur at every step of the patients’ journey —from presentation to imaging, biopsy, and treatment.⁶ As delays are linked to higher mortality, improving this trajectory is critical.

Large randomized controlled trials of mammographic screening have consistently shown that regular screening reduces breast-cancer mortality. Although the magnitude of benefit varies across trials, most report a relative mortality reduction of 20–30% in screened populations, with the strongest impact observed in women who adhere to repeated screening rounds. Mammography-based population screening is resource-intensive: it requires high-quality imaging equipment, trained radiologists, robust tracking systems, guaranteed access to biopsy and treatment, and long-term program monitoring. In low- and middle-income countries, these prerequisites are often not fully in place, meaning mammographic screening may offer limited benefit, can lead to delayed diagnosis if follow-up is irregular, and may divert scarce health resources away from more impactful interventions.

At the same time, current practice in high-income countries is evolving beyond standard 2D mammography. Tailored screening strategies enhance early detection and support long-term risk management. Digital breast tomosynthesis outperforms mammography by increasing cancer detection while reducing recall rates. For women at high risk, guidelines recommend initiating screening earlier, performing exams more frequently, incorporating breast MRI, and novel strategies such as risk-based breast cancer screening are being evaluated.

How can Brazil reconcile breast cancer screening strategies with the country's unequal incidence patterns, late-stage presentation, and heterogeneous resource availability?

Government initiatives are underway—including the “60-day law” to guarantee timely treatment, the national patient-navigation program, and the incorporation of new breast cancer therapies into the public system.

In terms of screening, a customized approach appears appropriate in resource-rich regions, where a shift to earlier stages has already occurred. However, across most of the country, the focus should be on early diagnosis strategies—community awareness, trained primary health workers, clinical breast exams, and reliable referral pathways—until the health system can sustainably support a quality-assured mammography program. The immediate priority remains clear: fast-tracking care for patients with palpable breast lesions, where accelerating access to treatment remains urgent.

Declaration of interests

JB has received honoraria for lectures, presentations, and educational events from AstraZeneca, Daiichi Sankyo, Genomic Health, Gilead, Libbs, Novartis, Pfizer, and Roche, has received support for attending meetings and/or travel from AstraZeneca, Daiichi Sankyo, Gilead, and Roche, and has participated on Advisory Boards for AstraZeneca, Daiichi Sankyo, Gilead, Lilly, and MSD. FB has no disclosures to report.