Challenges of Treating Merkel Cell Carcinoma in Brazil

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Treating Merkel cell carcinoma (MCC) presents significant challenges due to the disease's aggressive nature, low survival rates, and rising incidence over the last decades. Despite advancements in treatment, numerous barriers persist, especially in developing countries. Brazil, home to half of South America's population, sees 75% of its citizens relying on the public health system [1], Sistema Único de Saúde (SUS). Although SUS aims to provide comprehensive health care to all Brazilians, several factors contribute to significant inequality and disparity, resulting in suboptimal care. Limited access to modern treatment options, such as immunotherapy, is a major issue. Additionally, overburdened healthcare facilities, a scarcity of specialized multidisciplinary teams, and delays in initiating cancer treatment further complicate the situation. For example, the recently published RT2030 [2] project underscores the urgent need to increase the number of radiation oncologists, technicians, and radiation therapy installations to meet Brazil's oncology treatment demands by 2030. These combined factors negatively impact oncological outcomes for MCC patients and require urgent measures to ensure adequate care, especially within the Brazilian public healthcare system. The increasing global incidence of MCC is partly due to population aging as well as improvements in diagnostic techniques. However, the scarcity of epidemiological data on MCC in Brazil hampers specific healthcare decision-making and the development of targeted healthcare policies. A population-based study revealed that over 50% of MCC cases in Brazil were diagnosed at Stage III or IV [3], suggesting that delays in diagnosis and treatment contribute to the higher frequency of advanced disease. An analysis of clinicaltrials.gov indicated that while there are 44 trials recruiting MCC patients globally, only one is recruiting in Brazil [4]. This is in stark contrast to melanoma studies, with 11 trials currently open in Brazil. Given that the infrastructure and care pathways required for melanoma treatment are similar to those needed for MCC, there is potential for greater participation in MCC trials by the Brazilian medical community. Several actions can enhance the quality of care for MCC patients in Brazil. First, creating standardized care protocols and providing up-to-date information to providers is essential to ensure consistent care across the country. Recently, the Brazilian Society of Surgical Oncology proposed an MCC care flowchart tailored to the Brazilian healthcare system, published in Journal of Surgical Oncology [5]. Establishing a centralized support network and a prospective database for rare tumors can also aid in managing MCC. Additionally, optimizing treatment plans through inter-institutional multidisciplinary tumor boards can improve patient outcomes. Increasing the participation of Brazilian reference centers in multicenter clinical trials can contribute to comprehensive and quality care for MCC patients in Brazil. Efforts by Brazilian medical societies aim to improve medical education and optimize MCC patient care, especially in the community and outside reference centers. These actions promote awareness and greater integration with the healthcare system and between specialties. The challenges faced in treating MCC in Brazil are comparable to those in other countries with same backgrounds and hurdles. This letter calls for international collaboration and potential discussion forums to optimize comprehensive and multidisciplinary care strategies for MCC patients.

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