Disparities in diagnosis and management of myelodysplastic syndromes in a brazilian cancer center: A comparison between public and private healthcare systems.

Abstract Introduction: Disparities in access to healthcare services are well-documented in Brazil, where a mixed public-private system often leads to unequal resource distribution. Prior studies have demonstrated differences in service utilization and health expenditures between the Brazilian public health system (SUS) and private healthcare providers. However, no studies to date have specifically examined how these disparities affect patients with myelodysplastic syndromes (MDS), particularly regarding diagnostic timelines, access to molecular testing, treatment options, and outcomes. This study aims to characterize and compare the diagnostic and therapeutic profiles of MDS patients treated within the public and private systems in a Brazilian cancer center. Methods: We performed a retrospective cohort study of patients diagnosed with MDS between 2014 and 2024 at a tertiary cancer center in Brazil. Patients were categorized by healthcare system (SUS vs. private). Variables analyzed included age at diagnosis, time from symptom onset to diagnosis, MDS subtype (de novo vs. therapy-related), cytogenetic and mutational profiles (karyotype and NGS panel), treatment modalities (supportive care, disease-modifying agents, hematopoietic stem cell transplantation), and duration of follow-up. Results: Among the 96 patients included, 32 (33.3%) were treated in the public system and 64 (66.7%) in the private sector, a 2:1 ratio. The overall median age at diagnosis was 70 years. The highest level of education among SUS patients was high school, while within the private group, 50% of patients were college graduates. The median time from cytopenia investigation to diagnosis was 165 days in the SUS group versus 30 days in the private group. None of the SUS patients underwent an NGS molecular panel for more appropriate risk stratification, compared to 35 (54%) of the private sector patients who did. Of the total number of patients, 53 (55%) were classified as having therapy-related MDS due to a history of oncological treatment with radiotherapy and/or chemotherapy (26 from SUS and 27 from private). The most common mutations in the private sector patient panels were SF3B1 (22%), ASXL1 (14%), RUNX1 (14%), TP53 (11.4%), U2AF1 (11.4%), and TET2 (11.4%). In the M-IPSS risk assessment, 6 (17%) were classified as very low risk, 2 (5%) as low risk, 3 (8.5%) as low-intermediate risk, 5 (14.2%) as high-intermediate risk, 6 (17%) as high risk, 5 (14.2%) as very high risk, and 29 (45%) were at unknown risk. In the R-IPSS analysis, the public sector group showed: 8 (25%) patients as very low risk, 8 (25%) as low risk, 2 (6%) as intermediate risk, 8 (25%) as high risk, 4 (12.5%) as very high risk, and 2 (6%) as unknown. Regarding treatment, 20 (62%) SUS patients received first-line treatment with erythropoietin, and only 2 underwent consolidation with allogeneic transplant. In the private sector group, the median number of lines of treatment was 1 (maximum: 3), with treatments ranging from erythropoietin (31%), azacitidine (20%), a combination of venetoclax and hypomethylating agent (7%), luspatercept (3%), to lenalidomide (1.5%). Sixteen (25%) private sector patients underwent consolidation with allogeneic transplant. During the entire follow-up (median of 15 months), 24 patients presented transformation to Acute Myeloid Leukemia (8 from the SUS and 16 from the private sector). Conclusions: This study highlights significant disparities in the diagnosis and therapeutic management of MDS patients between Brazil's public and private healthcare systems. Although the underlying disease biology appeared similar, reduced access to timely diagnosis, molecular testing, and advanced therapies in the public system may contribute to poorer outcomes. Our findings provide real-world evidence from a developing country context and underscore the urgent need for health equity strategies in hematologic care.