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This paper describes a model of integrated reproductive health care services for women at the primary health care level, put into practice at the Pérola Byington Hospital, São Paulo, Brazil, from 1991 to 1998. Some 2,000 women from poor social strata, whose health condition was poor, were being seen every day in the last two years of the programme, including new consultations and women with a previous attendance returning. Women were attended first by nurse-assistants, who had been trained to screen for the most frequent gynaecological problems, and then a physician. Because doctors spent less time with each patient, four times as many women could be seen. Programmes were set up for the diagnosis and treatment of gynaecological cancers, STDs, HIV/AIDS, hypertension and other degenerative disorders such as diabetes. Screening and treatment programmes for cervical and breast cancer achieved significant improvements in the stage at which a diagnosis was made, allowing more lives to be saved. This model also succeeded in decreasing the costs for these health services per woman seen.

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The objective of this study was to demonstrate the importance of the practical application of the concept of reproductive health in São Paulo, Brazil, from 1991 to 1998 at the Pérola Byington Hospital with a new model of Primary Health Care (PHC) in which 2000 women/day, separated into two groups and over 45 years, was attended by nurses trained to detect the most frequently occurring gynecological problems supervised by doctors, who finalized the visit of each patient. The results demonstrated the advantages and viability of this strategy and also the bad health conditions of the women. Based on the high incidence of different kind of diseases detected, programs were set up for the diagnosis and treatment of gynecological cancer, STD, AIDS, hypertension, diabetes, etc. The results of two of these control programs, cervical cancer and breast cancer, demonstrated a significant increase in the diagnosis of early lesions. An economic study demonstrated an obvious and significant impact of this model not only in saving lives, but also in decreasing financial expenses in health.

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OBJECTIVE: To evaluate a simple reconstructive procedure used in combination with a modified oncological approach to the treatment of invasive vulvar cancer. Local and systemic morbidity, length of hospital stay, local recurrence, and mortality were evaluated. METHODS: Between September 1995 and January 1997, 19 patients underwent radical vulvectomy and inguinal lymphadenectomy with a modified oncological approach. The modified approach consisted of a triple incision: two inguinal incisions, shorter and following force lines of the groin, and a third incision around the vulvar lesion. Vulvectomy included a 2-cm safety margin around the tumor, based on clinical examination and anatomical-pathological frozen sections of the specimen. This procedure was always followed by perineal reconstruction with V-Y flaps by the plastic surgery team. Median follow-up was 12 months. The complication rate and lengths of hospital stay were evaluated and compared with those in a similar group in which radical vulvectomy was performed associated with two long longitudinal incisions in the groin. The data were statistically analyzed. RESULTS: The perineal and inguinal dehiscence rates in group A (traditional approach) were 68.4% and 78.94%, respectively. The same rates in group B (modified approach), were 10.5% and 36.84%, respectively. Mean hospital stay was 39.5 days in group A (traditional) vs. 14.0 days in group B (modified). At 30 months' median follow-up, the rate of local recurrence in group A (traditional) was 42.0%; at 12 months' median follow-up, local recurrence in group B (modified) was 26.3%. CONCLUSIONS: In this study, the use of V-Y flaps in combination with a modified oncological approach significantly reduced local complication rates and lengths of hospital stay, while observing oncological principles.

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PIP: In Brazil, cervical cancer is the second most common cancer in women (20.1% of all cancers in women) after skin cancer (24.3%). It is responsible for about 5% of all cancer deaths among women in the State of Sao Paulo. The cervical cancer mortality rate does not differ among regions in Brazil, even though most health services are in metropolitan areas. In 1968, the Cervical Cancer Control Program began in Campinas. Its first phase (1968-1972) was characterized by a low number of Papanicolaou tests and a very high frequency of altered cervical cytologies. The second phase (1972-1978) was characterized by a higher number of repeat Pap tests, a high number of treatments of cervical benign lesions, and a lower frequency of altered cytologies. Geographical expansion of the program to 84 cities in the region (population of 3.5 million) characterizes the current phase, which corresponds with another increase in the frequency of altered cytologies. 85% of patients were in stages II, III, and IV before 1968 compared to only 3% after 1984. Before 1968, no one had cervical intraepithelial neoplasia while most cases (86%) had it after 1984. Therefore, the program achieved its goal of reversing the diagnosis of cervical cancer in the incurability phase to the treatable phase in the region of Campinas. In 1986, the State Health Secretariat of Sao Paulo began implementing a similar cervical cancer control program which was organized into the primary, secondary, and tertiary care levels. It increased its coverage of Pap tests from 8.38% in 1986 to about 40% in 1990. 82% of women who had undergone a consultation at Perola Byington Hospital had a Pap test during the last 2 years and almost all of these women (99%) knew that the Pap test should be repeated. Obstacles faced by the 2 programs included an increased demand in initial stages for specialized care (i.e., surgery), great exit of technicians and professionals from programs to the private sector, and inadequate follow-up of detected cases.^ieng

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