Geometry data of the fuel rods and guide tubes.
\r\n\t
",isbn:"978-1-83969-561-2",printIsbn:"978-1-83969-560-5",pdfIsbn:"978-1-83969-562-9",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,hash:"65f2a1fef9c804c29b18ef3ac4a35066",bookSignature:"Dr. Luis Loures",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10756.jpg",keywords:"Urban Processes, Urban Patterns, Redevelopment Strategies, Landscape, Land Transformation, Urban Models, Urban Evolution, Urban Organisation, Legislation, Sustainable Development, Green Infrastructure, Regional Planning",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 23rd 2021",dateEndSecondStepPublish:"March 22nd 2021",dateEndThirdStepPublish:"May 21st 2021",dateEndFourthStepPublish:"August 9th 2021",dateEndFifthStepPublish:"October 8th 2021",remainingDaysToSecondStep:"14 days",secondStepPassed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"Dr. Loures has worked on pioneering research on circular planning applied to post-industrial landscape redevelopment. Since he graduated he has published several peer-reviewed papers at the national and international levels and he has been a guest researcher and lecturer both at Michigan State University (USA) and at the University of Toronto (Canada) where he has developed part of his Ph.D. research with the Financial support from the Portuguese Foundation for Science and Technology (Ph.D. grant).",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"108118",title:"Dr.",name:"Luis",middleName:null,surname:"Loures",slug:"luis-loures",fullName:"Luis Loures",profilePictureURL:"https://mts.intechopen.com/storage/users/108118/images/system/108118.png",biography:"Luís Loures is a Landscape Architect and Agronomic Engineer, Vice-President of the Polytechnic Institute of Portalegre, who holds a Ph.D. in Planning and a Post-Doc in Agronomy. Since he graduated, he has published several peer reviewed papers at the national and international levels and he has been a guest researcher and lecturer both at Michigan State University (USA), and at University of Toronto (Canada) where he has developed part of his Ph.D. research with the Financial support from the Portuguese Foundation for Science and Technology (Ph.D. grant).\nDuring his academic career he had taught in several courses in different Universities around the world, mainly regarding the fields of landscape architecture, urban and environmental planning and sustainability. Currently, he is a researcher both at VALORIZA - Research Centre for Endogenous Resource Valorization – Polytechnic Institute of Portalegre, and the CinTurs - Research Centre for Tourism, Sustainability and Well-being, University of Algarve where he is a researcher on several financed research projects focusing several different investigation domains such as urban planning, landscape reclamation and urban redevelopment, and the use of urban planning as a tool for achieving sustainable development.",institutionString:"Polytechnic Institute of Portalegre",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"8",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Polytechnic Institute of Portalegre",institutionURL:null,country:{name:"Portugal"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"10",title:"Earth and Planetary Sciences",slug:"earth-and-planetary-sciences"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"205697",firstName:"Kristina",lastName:"Kardum Cvitan",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/205697/images/5186_n.jpg",email:"kristina.k@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"5962",title:"Estuary",subtitle:null,isOpenForSubmission:!1,hash:"43058846a64b270e9167d478e966161a",slug:"estuary",bookSignature:"William Froneman",coverURL:"https://cdn.intechopen.com/books/images_new/5962.jpg",editedByType:"Edited by",editors:[{id:"109336",title:"Prof.",name:"William",surname:"Froneman",slug:"william-froneman",fullName:"William Froneman"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophanides",surname:"Theophile",slug:"theophanides-theophile",fullName:"Theophanides Theophile"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"42479",title:"Enriched Gadolinium Burnable Poison for PWR Fuel – Monte Carlo Burnup Simulations of Reactivity",doi:"10.5772/53381",slug:"enriched-gadolinium-burnable-poison-for-pwr-fuel-monte-carlo-burnup-simulations-of-reactivity",body:'Nuclear power plant utilities have to make business in a very competitive market. Therefore, some of them may have interest to increase the competitiveness through the use of nuclear fuels which could achieve very high burnups, beyond 70 GWd/Ton. In order to reach and surpass this value may be necessary to work with uranium enrichments higher than the traditional 5% limit. Make real such nuclear fuels demands heavy investments in R&D.
Advanced PWR nuclear fuels that will be able to burn well beyond 70 GWd/Ton necessarily need to have, among other things, uranium enrichments higher than 5%, thus leading to the necessity of using extremely efficient burnable poisons. Gadolinium oxide, also known as Gadolinia (Gd2O3) is currently used as burnable poison for PWR fuel. The fabrication processes, properties and behavior of Gadolinia mixed in UO2 fuel are well known and well established. Seven Gadolinium isotopes naturally exist on earth. From these, only two isotopes, the Gd-155 and Gd-157 have extremely high thermal neutron absorption cross sections.
Burnable poisons containing gadolinium have the undesirable effect of reducing the thermal conductivity of UO2-Gd2O3 fuel and thus leading to higher temperature profiles in the fuel. In order to avoid such hot spots the currently available PWR rods use lower U-235 enrichment in all fuel pellets containing gadolinium. The use of gadolinium enriched in the most important isotopes, Gd-155 and Gd-157, to absorb neutrons, may permit to reduce the content of Gadolinia (Gd2O3) in the pellets and thus to improve the thermal conductivity of the fuel rods. This could permit to use the same U-235 enrichment in both types of fuel pellets, the ones with UO2-Gd2O3 and those with only UO2.
This Chapter has the objective to theoretically investigate the neutronic behavior of PWR fuels that would use UO2-Gd2O3 compositions in which the gadolinium content is enriched from the natural abundance to a 100% Gd-155 and Gd-157 isotopes. The Monte Carlo burnup codes system Monteburns [1] is used to perform the simulations. They will evaluate only the effects that modifications in the fuel composition produce over the curves of reactivity x burnup. Indeed, the infinite neutron multiplication factor (kinf) is used to plot the curves instead reactivity. The first set of these simulations aims to estimate the effects of variations in the contents of natural gadolinium and in the uranium enrichment. In the next set, the gadolinium content and the uranium enrichment are fixed, and the gadolinium isotopic compositions are modified by changing the enrichment of Gd-155 and Gd-157 until 100% to each isotope. This procedure is repeated to uranium enrichments going from 2.85% to 15%. After all, one last set of simulations evaluates the influence of the 100% Gd-155 and 100% Gd-157 enriched Gadolinia content. All the results are presented graphically and discussed. Finally, the optimized fuel composition is presented.
Figure 1 shows the 3x3 lattice of infinite fuel pin cells used in the simulations. One fuel rod containing the burnable poison (UO2-Gd2O3) is located at the centre of the lattice and it is surrounded by seven rods containing standard fuel (UO2) and one empty position (control rod guide tube). This geometry is kept to all the simulations. Only the isotopic compositions of the UO2 and UO2-Gd2O3 pellets are changed to the several cases simulated. As the 3x3 lattice is infinite the reflexive boundary condition was assumed.
Infinite fuel pin cells 3x3 lattice.
The simulations were done considering that the fuel rods have the same geometric characteristics of the rods used in the AREVA FOCUS 16x16 fuel elements. Design data for this fuel is presented in [2]. Table 1 show some of the characteristics of the fuel rods adopted in the simulation model. Table 2 shows the thermal power and the uranium mass loaded in a typical 1300 MWe PWR reactor. These parameters are necessary to calculate the average specific power used in the burnup calculations. Table 3 presents the atomic number densities used in the model for water and cladding material (Zircalloy-4 was used instead of PCA-2B due the lack of information for this alloy).
\n\t\t\t\tParameter\n\t\t\t | \n\t\t\t\n\t\t\t\tUnit\n\t\t\t | \n\t\t\t\n\t\t\t\tValue\n\t\t\t | \n\t\t
\n\t\t\t\t\n\t\t\t\t\tFuel Rods\n\t\t\t\t\n\t\t\t | \n\t\t\t\n\t\t\t | \n\t\t |
Outer diameter of cladding | \n\t\t\tcm | \n\t\t\t1.0750 | \n\t\t
Inner diameter of cladding | \n\t\t\tcm | \n\t\t\t0.9300 | \n\t\t
Active length | \n\t\t\tcm | \n\t\t\t390.00 | \n\t\t
Pitch | \n\t\t\tcm | \n\t\t\t1.430 | \n\t\t
Cladding Material | \n\t\t\t\n\t\t\t | PCA-2B | \n\t\t
\n\t\t\t\t\n\t\t\t\t\tFuel Pellets\n\t\t\t\t\n\t\t\t | \n\t\t\t\n\t\t\t | \n\t\t |
Outer diameter | \n\t\t\tcm | \n\t\t\t0.9110 | \n\t\t
\n\t\t\t\t\n\t\t\t\t\tGuide tubes\n\t\t\t\t\n\t\t\t | \n\t\t\t\n\t\t\t | \n\t\t |
Outer diameter | \n\t\t\tcm | \n\t\t\t1.38 | \n\t\t
Thickness | \n\t\t\tcm | \n\t\t\t0.0700 | \n\t\t
Cladding Material | \n\t\t\t\n\t\t\t | PCA-2B | \n\t\t
Geometry data of the fuel rods and guide tubes.
\n\t\t\t\tParameter\n\t\t\t | \n\t\t\t\n\t\t\t\tValue\n\t\t\t | \n\t\t
Thermal power (MW) | \n\t\t\t4000 | \n\t\t
Uranium mass (Ton) | \n\t\t\t~ 111 | \n\t\t
Thermal power and uranium mass of a typical 1300 MWe PWR reactor
MATERIAL Nuclide | \n\t\t\t\n\t\t\t\tAtoms/barn.cm\n\t\t\t | \n\t\t
ZIRCALOY-4 | \n\t\t\t\n\t\t |
Natural Cromium | \n\t\t\t7.5891e-05 | \n\t\t
Natural Iron | \n\t\t\t1.4838e-04 | \n\t\t
Natural Zirconium | \n\t\t\t4.2982e-02 | \n\t\t
WATER | \n\t\t\t\n\t\t |
H-1 | \n\t\t\t6.6242e-02 | \n\t\t
O-16 | \n\t\t\t3.3121e-02 | \n\t\t
Atomic number densities of cladding and cooling materials.
Finally, Table 4 presents the theoretical compositions of the several simulated fuels. These fuels are the alloys in which the uranium and gadolinium enrichments and the contents of Gadolinia and uranium dioxide are modified. In the simulations these compositions refer to the UO2-Gd2O3 rod in the center of the 3x3 lattice and the UO2 rods surrounding it. The calculation of the atomic number densities of the nuclides of Uranium, Gadolinium and Oxygen in fresh fuels to the several inputs was automatized by a MS Excel electronic spreadsheet.
Important to mention that the inputs 0050 (0.0% Gadolinia and 5.0% U235 enrichment for UO2-Gd2O3 rod) and 7028 (7.0% gadolínia and 2.8% U235 enrichment for UO2-Gd2O3 rod) refer to real (commercial) FOCUS [2] fresh fuels and are always used to compare the behavior of the others theoretical fuels simulated.
Some studies regarding sensitivities of the neutron cross sections to temperatures were performed and presented in [3, 4]. These studies led to the conclusion that the MCNP [5] pointwise neutron cross sections data library.66c can be used satisfactorily by Monteburns to simulate the fuel burnup of the lattice in spite of this set of cross sections data be processed at room temperature (293 K). As shown in [4] the results for overall production and destruction of the main nuclides during the burnup are similar if using library.66c or other libraries processed at higher temperatures.
In the simulations the rods were irradiated until around 90 GWd/ton. This total burnup was divided into several intervals with the burnup step values increasing since 0.5 until 25 days. Nuclides which the atom fraction, weight fraction, fraction of absorption, and fraction of fission greater than 10-4 were considered important nuclides and therefore its one group cross section were calculated for each burnup step. Sensitivities studies were performed to determine this importance fraction. However, there are a few nuclides with the importance fraction greater than 10-4 to which the one group cross sections were not calculated due to the lack of data in the MCNP standard libraries. The MCNP.66c pointwise neutron cross sections data were used preferably.
\n\t\t\t\tUO2-Gd2O3\n\t\t\t\t\n\t\t\t | \n\t\t\t\n\t\t\t\tUO2\n\t\t\t\t\n\t\t\t | \n\t\t||||
\n\t\t\t\tInput Name\n\t\t\t | \n\t\t\t\n\t\t\t\tGd2O3 Content(%)\n\t\t\t | \n\t\t\t\n\t\t\t\tComposition\n\t\t\t | \n\t\t\t\n\t\t\t\t(%U-235)\n\t\t\t | \n\t\t\t\n\t\t\t\tUO2 Content (%)\n\t\t\t | \n\t\t\t\n\t\t\t\t(%U-235)\n\t\t\t | \n\t\t
0050 | \n\t\t\t0 | \n\t\t\tNatural | \n\t\t\t5.0 | \n\t\t\t100 | \n\t\t\t5.0 | \n\t\t
1050 | \n\t\t\t1.0 | \n\t\t\tNatural | \n\t\t\t5.0 | \n\t\t\t99.0 | \n\t\t\t5.0 | \n\t\t
2045 | \n\t\t\t2.0 | \n\t\t\tNatural | \n\t\t\t4.5 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
3038 | \n\t\t\t3.0 | \n\t\t\tNatural | \n\t\t\t3.8 | \n\t\t\t97.0 | \n\t\t\t5.0 | \n\t\t
4035 | \n\t\t\t4.0 | \n\t\t\tNatural | \n\t\t\t3.5 | \n\t\t\t96.0 | \n\t\t\t5.0 | \n\t\t
5033 | \n\t\t\t5.0 | \n\t\t\tNatural | \n\t\t\t3.3 | \n\t\t\t95.0 | \n\t\t\t5.0 | \n\t\t
6031 | \n\t\t\t6.0 | \n\t\t\tNatural | \n\t\t\t3.1 | \n\t\t\t94.0 | \n\t\t\t5.0 | \n\t\t
7028 \n\t\t\t | \n\t\t\t7.0 | \n\t\t\tNatural | \n\t\t\t2.8 | \n\t\t\t93.0 | \n\t\t\t5.0 | \n\t\t
hgd4015 | \n\t\t\t2.0 | \n\t\t\t40%Gd-155 and 15% Gd-157 | \n\t\t\t2.8 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
hgd6010 | \n\t\t\t2.0 | \n\t\t\t60%Gd-155 and 10% Gd-157 | \n\t\t\t2.8 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
hgd8005 | \n\t\t\t2.0 | \n\t\t\t80%Gd-155 and 05% Gd-157 | \n\t\t\t2.8 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
hgd9900 | \n\t\t\t2.0 | \n\t\t\t100%Gd-155 and 0% Gd-157 | \n\t\t\t2.8 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
hgd1540 | \n\t\t\t2.0 | \n\t\t\t15%Gd-155 and 40% Gd-157 | \n\t\t\t2.8 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
hgd1060 | \n\t\t\t2.0 | \n\t\t\t10%Gd-155 and 60% Gd-157 | \n\t\t\t2.8 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
hgd0580 | \n\t\t\t2.0 | \n\t\t\t05%Gd-155 and 80% Gd-157 | \n\t\t\t2.8 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
hgd0099 \n\t\t\t | \n\t\t\t2.0 | \n\t\t\t0%Gd-155 and 100% Gd-157 | \n\t\t\t2.8 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
gd4015 | \n\t\t\t2.0 | \n\t\t\t40%Gd-155 and 15% Gd-157 | \n\t\t\t5.0 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
gd6010 | \n\t\t\t2.0 | \n\t\t\t60%Gd-155 and 10% Gd-157 | \n\t\t\t5.0 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
gd8005 | \n\t\t\t2.0 | \n\t\t\t80%Gd-155 and 05% Gd-157 | \n\t\t\t5.0 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
gd9900 | \n\t\t\t2.0 | \n\t\t\t100%Gd-155 and 0% Gd-157 | \n\t\t\t5.0 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
gd1540 | \n\t\t\t2.0 | \n\t\t\t15%Gd-155 and 40% Gd-157 | \n\t\t\t5.0 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
gd1060 | \n\t\t\t2.0 | \n\t\t\t10%Gd-155 and 60% Gd-157 | \n\t\t\t5.0 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
gd0580 | \n\t\t\t2.0 | \n\t\t\t05%Gd-155 and 80% Gd-157 | \n\t\t\t5.0 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
gd0099 \n\t\t\t | \n\t\t\t2.0 | \n\t\t\t0%Gd-155 and 100% Gd-157 | \n\t\t\t5.0 | \n\t\t\t98.0 | \n\t\t\t5.0 | \n\t\t
gdx4015 | \n\t\t\t2.0 | \n\t\t\t40%Gd-155 and 15% Gd-157 | \n\t\t\t6.0 | \n\t\t\t98.0 | \n\t\t\t6.0 | \n\t\t
gdx6010 | \n\t\t\t2.0 | \n\t\t\t60%Gd-155 and 10% Gd-157 | \n\t\t\t6.0 | \n\t\t\t98.0 | \n\t\t\t6.0 | \n\t\t
gdx8005 | \n\t\t\t2.0 | \n\t\t\t80%Gd-155 and 05% Gd-157 | \n\t\t\t6.0 | \n\t\t\t98.0 | \n\t\t\t6.0 | \n\t\t
gdx9900 | \n\t\t\t2.0 | \n\t\t\t100%Gd-155 and 0% Gd-157 | \n\t\t\t6.0 | \n\t\t\t98.0 | \n\t\t\t6.0 | \n\t\t
gdx1540 | \n\t\t\t2.0 | \n\t\t\t15%Gd-155 and 40% Gd-157 | \n\t\t\t6.0 | \n\t\t\t98.0 | \n\t\t\t6.0 | \n\t\t
gdx1060 | \n\t\t\t2.0 | \n\t\t\t10%Gd-155 and 60% Gd-157 | \n\t\t\t6.0 | \n\t\t\t98.0 | \n\t\t\t6.0 | \n\t\t
gdx0580 | \n\t\t\t2.0 | \n\t\t\t05%Gd-155 and 80% Gd-157 | \n\t\t\t6.0 | \n\t\t\t98.0 | \n\t\t\t6.0 | \n\t\t
gdx0099 \n\t\t\t | \n\t\t\t2.0 | \n\t\t\t0%Gd-155 and 100% Gd-157 | \n\t\t\t6.0 | \n\t\t\t98.0 | \n\t\t\t6.0 | \n\t\t
gdd4015 | \n\t\t\t2.0 | \n\t\t\t40%Gd-155 and 15% Gd-157 | \n\t\t\t10.0 | \n\t\t\t98.0 | \n\t\t\t10.0 | \n\t\t
gdd6010 | \n\t\t\t2.0 | \n\t\t\t60%Gd-155 and 10% Gd-157 | \n\t\t\t10.0 | \n\t\t\t98.0 | \n\t\t\t10.0 | \n\t\t
gdd8005 | \n\t\t\t2.0 | \n\t\t\t80%Gd-155 and 05% Gd-157 | \n\t\t\t10.0 | \n\t\t\t98.0 | \n\t\t\t10.0 | \n\t\t
gdd9900 | \n\t\t\t2.0 | \n\t\t\t100%Gd-155 and 0% Gd-157 | \n\t\t\t10.0 | \n\t\t\t98.0 | \n\t\t\t10.0 | \n\t\t
gdd1540 | \n\t\t\t2.0 | \n\t\t\t15%Gd-155 and 40% Gd-157 | \n\t\t\t10.0 | \n\t\t\t98.0 | \n\t\t\t10.0 | \n\t\t
gdd1060 | \n\t\t\t2.0 | \n\t\t\t10%Gd-155 and 60% Gd-157 | \n\t\t\t10.0 | \n\t\t\t98.0 | \n\t\t\t10.0 | \n\t\t
gdd0580 | \n\t\t\t2.0 | \n\t\t\t05%Gd-155 and 80% Gd-157 | \n\t\t\t10.0 | \n\t\t\t98.0 | \n\t\t\t10.0 | \n\t\t
gdd0099 \n\t\t\t | \n\t\t\t2.0 | \n\t\t\t0%Gd-155 and 100% Gd-157 | \n\t\t\t10.0 | \n\t\t\t98.0 | \n\t\t\t10.0 | \n\t\t
gdq4015 | \n\t\t\t2.0 | \n\t\t\t40%Gd-155 and 15% Gd-157 | \n\t\t\t15.0 | \n\t\t\t98.0 | \n\t\t\t15.0 | \n\t\t
gdq6010 | \n\t\t\t2.0 | \n\t\t\t60%Gd-155 and 10% Gd-157 | \n\t\t\t15.0 | \n\t\t\t98.0 | \n\t\t\t15.0 | \n\t\t
gdq8005 | \n\t\t\t2.0 | \n\t\t\t80%Gd-155 and 05% Gd-157 | \n\t\t\t15.0 | \n\t\t\t98.0 | \n\t\t\t15.0 | \n\t\t
gdq9900 | \n\t\t\t2.0 | \n\t\t\t100%Gd-155 and 0% Gd-157 | \n\t\t\t15.0 | \n\t\t\t98.0 | \n\t\t\t15.0 | \n\t\t
gdq1540 | \n\t\t\t2.0 | \n\t\t\t15%Gd-155 and 40% Gd-157 | \n\t\t\t15.0 | \n\t\t\t98.0 | \n\t\t\t15.0 | \n\t\t
gdq1060 | \n\t\t\t2.0 | \n\t\t\t10%Gd-155 and 60% Gd-157 | \n\t\t\t15.0 | \n\t\t\t98.0 | \n\t\t\t15.0 | \n\t\t
gdq0580 | \n\t\t\t2.0 | \n\t\t\t05%Gd-155 and 80% Gd-157 | \n\t\t\t15.0 | \n\t\t\t98.0 | \n\t\t\t15.0 | \n\t\t
gdq0099 \n\t\t\t | \n\t\t\t2.0 | \n\t\t\t0%Gd-155 and 100% Gd-157 | \n\t\t\t15.0 | \n\t\t\t98.0 | \n\t\t\t15.0 | \n\t\t
1551510 | \n\t\t\t1.0 | \n\t\t\t100%Gd-155 | \n\t\t\t15.0 | \n\t\t\t99.0 | \n\t\t\t15.0 | \n\t\t
1551515 | \n\t\t\t1.5 | \n\t\t\t100%Gd-155 | \n\t\t\t15.0 | \n\t\t\t98.5 | \n\t\t\t15.0 | \n\t\t
1551520 | \n\t\t\t2.0 | \n\t\t\t100%Gd-155 | \n\t\t\t15.0 | \n\t\t\t98.0 | \n\t\t\t15.0 | \n\t\t
1551525 | \n\t\t\t2.5 | \n\t\t\t100%Gd-155 | \n\t\t\t15.0 | \n\t\t\t97.5 | \n\t\t\t15.0 | \n\t\t
1551530 | \n\t\t\t3.0 | \n\t\t\t100%Gd-155 | \n\t\t\t15.0 | \n\t\t\t97.0 | \n\t\t\t15.0 | \n\t\t
1551540 \n\t\t\t | \n\t\t\t4.0 | \n\t\t\t100%Gd-155 | \n\t\t\t15.0 | \n\t\t\t96.0 | \n\t\t\t15.0 | \n\t\t
1571510 | \n\t\t\t1.0 | \n\t\t\t100% Gd-157 | \n\t\t\t15.0 | \n\t\t\t99.0 | \n\t\t\t15.0 | \n\t\t
1571515 | \n\t\t\t1.5 | \n\t\t\t100% Gd-157 | \n\t\t\t15.0 | \n\t\t\t98.5 | \n\t\t\t15.0 | \n\t\t
1571520 | \n\t\t\t2.0 | \n\t\t\t100% Gd-157 | \n\t\t\t15.0 | \n\t\t\t98.0 | \n\t\t\t15.0 | \n\t\t
1571525 | \n\t\t\t2.5 | \n\t\t\t100% Gd-157 | \n\t\t\t15.0 | \n\t\t\t97.5 | \n\t\t\t15.0 | \n\t\t
1571530 | \n\t\t\t3.0 | \n\t\t\t100% Gd-157 | \n\t\t\t15.0 | \n\t\t\t97.0 | \n\t\t\t15.0 | \n\t\t
1571540 | \n\t\t\t4.0 | \n\t\t\t100% Gd-157 | \n\t\t\t15.0 | \n\t\t\t96.0 | \n\t\t\t15.0 | \n\t\t
Enrichments and Gadolinia contents of the fuels.
The results of the various simulations will be graphically presented in the next pages. The subtitles, on right side of the graphs, indicate the input simulated as showed in Table 4. The focus of the analyses is to estimate the behavior of the fuel reactivity as a function of the burnup for the 3x3 lattice of fuel rods. Figure 2 shows the evolution of the infinite neutron multiplication factor (kinf) for fuels with natural Gadolinia content from 0 to 9.9% and different uranium enrichment. As expected, the higher reactivity peak found is to the fuel without any Gadolinia (input 0050) and the peak occurs at zero burnup. The greater is the content of Gadolinia in the fuel the smaller is the reactivity of the fresh fuel. In addition, for all fuels containing Gadolinia the reactivity peak is observed after some days of irradiation and not at zero burnup condition. These peaks moves to the right (to higher burnups) as the Gadolinia content increases.
Infinite neutron multiplication factor as a function of burnup – changing Gadolinia content and %U-235.
The results presented in this section refer to Gadolinia contents in fuels lower than 7%. Usually this content is the limit to commercial fuels in order to avoid stronger effects affecting the thermal conductivity. As a starting point is used 2.0% Gadolinia content like recommended in [6]. In addition, the natural composition of the gadolinium in the simulations is modified to represent enrichments of Gd-155 and Gd-157 in the range from 5.0% to 100%.
Figure 3 (zoomed to the first 450 days of burnup in Figure 4) shows the evolution of kinf as a function of burnup to the 3x3 lattice to: UO2-Gd2O3 fuel rod, enriched 2.8% in U-235, and the seven UO2 fuel rods surrounding it enriched 5.0% in U-235. The zoomed Figure 4 shows clearly that all simulated fuels have the reactivity peak lower than the peak observed to the reference fuel 0050 that is free of Gadolinia. The lowest reactivity peak was found to the other reference fuel (7028 - natural Gadolinia) and its curve is very close to the curve of the fuel with 100% Gd-155. Such results are very exciting to proceed simulating fuels having higher U-235 enrichments until to find a composition to which the reactivity peak is close to the 0050 fuel. Figures 5 to 15 show the results of these simulations to U-235 enrichments in the range of 5.0% to 15.0% (subtitles are always as Table 4).
Infinite neutron multiplication factor as a function of burnup – 2.0% Gd2O3, 2.8% U-235, changing Gd-155 and Gd-157 enrichments.
Zoom of Figure 3 (beginning of burnup interval).
Increasing the U-235 enrichment of the UO2-Gd2O3 fuel rod to 5.0%, Figures 5 and 6 are obtained. One can notice a slight growth in reactivity of the compositions simulated and the curves for the eight inputs, after the peaks region, started to decouple from 7028 curve towards the 0050 curve.
Infinite neutron multiplication factor as a function of burnup – 2.0% Gd2O3, 5.0% U-235, changing Gd-155 and Gd-157 enrichments.
Zoom of Figure 5 (beginning of burnup interval).
Next step of the simulations considered 6.0% of U-235 enrichment in the fuel. Figure 7 plots the results (Figure 8 zoomed it until 600 days). As expected, the reactivities of the fuels containing enriched gadolinium continue growing and surpass the 0050 curve after a few hundred days of burnup. However, the reactivity peak for the 0050 is, so far, the greatest.
Infinite neutron multiplication factor as a function of burnup – 2.0% Gd2O3, 6.0% U-235, changing Gd-155 and Gd-157 enrichments.
Zoom of Figure 7 (beginning of burnup interval).
The simulations are going to continue while the reactivity peak of the 0050 reference fuel is not exceeded. Figure 9 (and Fig. 10) shows the results for fuel compositions with 10% U-235. The reference fuel 0050 still has the greatest reactivity peak but the others gadolinium enriched compositions are getting closer. Furthermore, it is clearly evident the reactivity gain of the gadolinium enriched fuels for higher burnups as well as the flattening of its reactivity peaks.
Infinite neutron multiplication factor as a function of burnup – 2.0% Gd2O3, 10.0% U-235, changing Gd-155 and Gd-157 enrichments.
Zoom of Figure 9 (beginning of burnup interval).
The next three figures are plots of the gadolinium enriched fuels having 15.0% of U-235. Figure 11 shows the whole burnup interval, and the Figures 12 and Fig. 13 are the zoomed, respectively, in the beginning and at the end of the burnup interval. They show that the reactivity peaks of the gadolinium enriched fuels finally come close to the 0050 peak. In addition, Figure 11 shows very clearly the reactivity gain of these fuels, compared to the reference fuels, in the whole burnup interval. Reference fuel 0050, for instance, after around 500 days of burnup, has its reactivity reduced to a value that the gadolinium enriched fuels will achieve only after around 1700 days. Finally, it is extremely important to notice that the fuel compositions with higher enrichments in Gd-155 have the reactivity peak more flattened than the others and the reactivity peaks occurs at zero burnup, just like the fuels without burnable poison. Therefore, the next analyses are going to focus in compositions with 100% Gd-155 (compositions with 100% Gd-157 will be studied too, just for comparison).
Infinite neutron multiplication factor as a function of burnup – 2.0% Gd2O3, 15.0% U-235, changing Gd-155 and Gd-157 enrichments.
Zoom of Figure 11 (beginning of burnup interval).
Zoom of Figure 11 (end of burnup interval).
Thus far, the studies performed have shown that a fuel composition with 2% Gd2O3 and 98% UO2, enriched at 15% U-235 and at 100% Gd-155 is able to keep high reactivities at very long burnups. Furthermore, the reactivity peak of this composition occurs at zero burnup and it is a bit lower than the peak for the reference fuel. Nevertheless, this 2% Gadolinia content was settled based in [6]. Therefore, it is necessary to evaluate changes in such parameter.
The Figure 14 presents the evolution of the reactivity for compositions with 100% Gd-155 and 15.0% U-235 enrichments and Gadolinia contents from 1.0% to 4.0%, as listed in Table 4. Figure 15 shows the same results for a composition with 100% Gd-157. It is observed from these figures that when the gadolinium content is reduced to 1% the reactivity peaks surpass the maximum value achieved by the reference fuel 0050. However, this reactivity peak is not exceeded by fuel compositions with Gadolinia content within 1.5% to 4.0%. Moreover, it is very evident the advantage of using enrichments of 15% U-235 and 100% Gd-155 (instead of 100% Gd-157) due to the absence of reactivity peaks after the fresh fuel condition.
Strictly from the neutronic point of view, fuel compositions having the Gadolinia content within 1.5% to 4.0%, high Gd-155 enrichment (~100%) and percentage of U-235 around 15% can be technologically very attractive to keep the reactivity at high and stable levels, even for very long burnups. Nevertheless, this study is incomplete for neither has thermal-hydraulic nor thermo-mechanical analyses of these fuels. The physical model may also be improved towards a whole reactor core instead of a simple lattice. It is also absent any economic analysis regarding uranium and gadolinium at these levels of enrichment. These problems can be addressed in future works.
Finally, Figure 16 is presented to show clearly the evolution of fuel compositions having 100% Gd-155 and 2.0% Gd2O3 in different U-235 enrichments.
Infinite neutron multiplication factor as a function of burnup – 100% Gd-155, 15% U-235 and changing content of Gd2O3.
Infinite neutron multiplication factor as a function of burnup – 100% Gd-157, 15% U-235 and changing content of Gd2O3.
Infinite neutron multiplication factor as a function of burnup – fuel compositions having 100% Gd-155, 2.0% Gd2O3 and different U-235 enrichments.
Monte Carlo Burnup codes system Monteburns was used to simulate 3x3 lattices of rods containing several fuel compositions with different enrichments and contents of uranium and gadolinium oxides. The greater is the content of Gadolinia in the fuel the smaller is the reactivity of the fresh fuel. In addition, for fuels containing Gadolinia the reactivity peak is observed after some days of irradiation and not at zero burnup condition. These peaks moves to higher burnups as the Gadolinia content increases. The rise of the uranium-235 enrichment in the fuel can compensate the reduction of reactitivity due to the use of Gadolinia as burnable poison and even lead to higher burnups and longer cycles. It was found that fuel compositions having the Gadolinia content within 1.5% to 4.0%, 100% Gd-155 enrichment and 15% U-235 enrichment may keep high and stable levels of reactivity for very long burnups. In addition, the reactivity peak occurs at zero burnup, just like the fuels without any burnable poison, and the Gadolinia content is within a range that can be able to avoid the undesired effect in the fuel thermal conductivity.
Thus far, strictly from the neutronic point of view, fuel compositions having the Gadolinia content within 1.5% to 4.0%, high Gd-155 enrichment (~100%) and U-235 enrichment around 15% can be technologically very attractive. Nevertheless, additional analyses of thermal-hydraulic and thermo-mechanical properties for these fuels are needed. These problems can be addressed in future works as well as an economic analysis regarding uranium and gadolinium at these levels of enrichment and the physical model can be improved towards a whole reactor core model.
According to data from the World Health Organization (WHO), the number of deaths due to cancer will increase up to 45% between 2008 and 2030 and 70% of those deaths will occur in developing countries [1]. To try and change this scenario, the WHO recommends the implementation of cancer control programs that must include cost-effective measures on healthy life style, vaccination programs and screening programs [2]. A screening program consists in a set of coordinated actions with the objective of reducing cancer mortality through early stage diagnosis in an asymptomatic population, with adequate referral to diagnostic and treatment facilities. These programs have four main components: the definition and recruitment of the target population, adequate offer of diagnostic tests with quality assurance, guaranteed offer of follow up exams and biopsies to confirm findings from the initial diagnostic tests, and referral to treatment facilities and timely navigation through the health system [3]. Although screening programs present the potential benefit of reducing mortality, they are not risk-free. The main risks of such a program are the false-positive and false-negative results, and also the occurrence of over diagnosis. All these can lead to clinical and psychological repercussions and, also, to the increase in the health care system expenditure. To address this issue, the Public Health Agency of Canada performed a study to estimate the harms of the local breast cancer-screening program in 7 years, according to age, and the main results can be seen in Table 1 [4].
Age Range | 40–49 years old | 50 to 59 years old | 60 to 69 years old | 70 to 74 years old |
---|---|---|---|---|
Screening strategy | Annual mammogram | Mammogram every two years | Mammogram every two years | Mammogram every two years |
Women that will not have cancer | 993 | 988 | 979 | 968 |
Women that will have cancer | 7 | 12 | 21 | 32 |
Unnecessary biopsies | 43 | 37 | 35 | 30 |
False-positive results | 294 | 294 | 256 | 219 |
Overdiagnosis | 3 | 3 | No reliable data | No reliable data |
Deaths prevented by screening | <1 | 1 | 1 | 2 |
Number needed to screen to prevent one cancer-related death | 1724 | 1333 | 1087 | 645 |
Benefits and harms of mammographic breast cancer screening [4].
In this text, we will use Brazil as a model to discuss screening programs in the developing countries. In the Brazilian setting, breast cancer is the most frequent type of cancer, responsible for 16,724 deaths in 2017 and with an estimate of 66,280 new cases in 2020 [5]. This scenario, however, has some peculiarities when compared to developed countries in the North America or Europe; 41.1% of all cases in Brazil happen in women younger than 50 years old and the majority of the operable cases is diagnosed in locally advanced stages, being 53.3% of the cases in stage II and 23.2% in stage III [6]. These characteristics are not typical of a country with a well-established breast cancer-screening program. The strategy adopted in Brazil states that women over 50 should get a mammogram every two years between 50 and 69 years old [7]. However, due to the early age of diagnosis that we observe in this developing country, we can argue that more than 40% of the diagnosed women are not eligible to the screening program in the first place. Moreover, the late presentation at diagnosis raises the hypothesis that the current screening program is not effective or that the patients do not have proper access to it. Added to that, the mortality due to breast cancer in Brazil has been increasing in the last decades [8]. All these issues taken together generate an ethical dilemma to be explored, once the investment of public resources in an ineffective program impacts negatively the whole society. This way, more effective resources reallocation strategies should be implemented to address this dilemma.
In this chapter we will discuss the breast cancer screening programs in developing countries and the main evidence regarding the barriers in the access to the healthcare system. Beyond that, we will address the main ethical questions related to breast cancer screening from the Rawls’s distributive justice [9] perspective, from the utilitarianism concepts [10, 11] and from the principles of autonomy and non-maleficence. Lastly, we will propose the support to an alternative approach to breast cancer in developing countries, maximizing the cost–benefit ratio in the use of public resources.
The U.S. Preventive Services Task Force (USPSTF) is an independent volunteer panel of American experts that develops recommendations regarding the efficacy of preventive services to asymptomatic patients. These recommendations are based on both benefits and harms that programs might cause, without consideration to the cost of the intervention. Current data about mammographic screening are solid regarding the benefits of this strategy when used in women over 50 years old and the USPSTF recommends a mammogram every two years, in women between 50 and 74; however, this same agency does not consider that there is enough evidence to support mammographic screening from 40 to 49 years old in asymptomatic patients without increased risk to breast cancer [12]. This recommendation is due to the fact that screening in this age range results in a smaller number of prevented deaths when compared to more advanced ages; also leads to a larger number of unnecessary biopsies; and to the possibility of psychological problems, like anxiety, because of the large number of false-positive results. While mammographic screening of 10,000 asymptomatic women between 50 and 59 years old can prevent 8 breast cancer deaths, the same strategy adopted in asymptomatic women between 40 and 49 years old would prevent only 3 breast cancer deaths [13, 14]. Another harm associated with mammographic screening of an asymptomatic population considered by the USPSTF when issuing their recommendation is the occurrence of over diagnosis. Although it is extremely complex to calculate the proportion of diagnosed cases that would never evolve to cancer, the best estimates from randomized clinical trials suggest the occurrence of over diagnosis in 20% of the cases due to mammographic screening [15].
Another agency that carefully evaluated the cost–benefit ratio of mammographic screening in asymptomatic women between 40 and 49 years old was the Ontario Health Technology Advisory Committee through a systematic review of the literature [16]. This work included an evaluation of the USPSTF report [17], the Canadian Preventive Services Task Force (CPSTF) report [18], a Cochrane systematic review [19], five health technology assessments and eight randomized clinical trials [20, 21, 22, 23, 24, 25, 26, 27] with the objective to assess the reduction of the breast cancer mortality in this age range attributable to mammographic screening. This agency reached a similar conclusion as the USPSTF that the mammographic screening in an asymptomatic population between 40 and 49 years old is not effective in reducing breast cancer mortality and that the harms associated with this intervention, like exposure to radiation, high rate of false-negatives leading to delays in diagnosis and high rate of false-positives with associated psychological harmful effects should not be overlooked.
The Brazilian College of Radiology (BCR) and Brazilian Society of Mastology (BSM) however issued a different recommendation, based on different published articles of international literature and methodologically inferior to the ones evaluated and with a clear selection bias [25, 28, 29]. In these studies, it was demonstrated a breast cancer mortality reduction between 18% and 38% in the studied populations. The main point to justify the recommendation of mammographic screening for asymptomatic women between 40 and 49 years old is to emphasize that in this developing country there is a higher proportion of breast cancer patients in this age range when compared to developed countries [30]. Despite the fact that it is a recommendation for Brazil, it did not include a single Brazilian study in the analysis. This scenario is repeated throughout Latin America as it has been shown in a report by The Economist Intelligence unit. Cancer care registries are lacking in Latin America due to insufficient coverage of the population and also due to low quality [31]. Without local high-quality data, it is impossible to perform local health technology assessments and the decision-making process is jeopardized.
Carefully considering the recommendations of these three different countries with very diverse populations, we can conclude that although mammographic screening in women between 40 and 49 provide a modest benefit in reducing breast cancer mortality, the occurrence of adverse effects is more pronounced.
We can also note that the BCR and BSM adopt a paternalistic approach, reflecting the principle of beneficence. In the meantime, the USPSTF and the CPSTF advocate that the screening decision should be shared with the patient. This way, patients that are more risk averse could opt out of the screening program and patients that value more the potential benefits could opt in, following the principles of non-maleficence and autonomy. However, what we must ask is whether it is possible to convey important information regarding the risks associated with a screening program in a clear and, more important, neutral manner. In this sense, it is of utmost importance that the autonomy principle is respected and that patients are not manipulated to undergo tests or treatments which they do not agree with, due to the use of biased information.
Addressing this issue, Biddle introduced the concept of epistemic risk, defined as the risk of error that comes up at any moment in the process of knowledge production [32]. These errors can happen because of biases during the data collection step and also because of decisions made in scenarios of uncertainty. These decisions reflect the set of values of the involved researchers and have consequences to human health and to the definition of public policies. Rudner agrees with this argument and suggests that it’s impossible to prove any hypothesis with full certainty, as there is always a possibility of error. This way, researchers must judge what is the necessary amount of data to accept or reject a hypothesis and this judgment depends on the set of values of the researcher and on the importance of the consequences an error can lead to [33]. Pramesh et al. discuss such a conflict in depth when they justify the necessity of a randomized clinical trial to prove a hypothesis raised by a cross-sectional study, as they believe the data gathered in the latter is not sufficient to support the decision-making process [34].
The reasoning to support a mammographic screening program for asymptomatic women below the age of 50 is not free of the risk of epistemic risks. One kind of epistemic risk associated with to mammographic screening is the inductive risk, defined as the risk of incorrectly accept or reject a hypothesis based on the available evidence [35]. Breast surgeons must accept or reject that a patient has a disease, frequently a ductal carcinoma in situ (DCIS), that will evolve causing symptoms and death based on evidence that does not guarantee the veracity of this hypothesis. That happens mostly because of the lack of evidence to predict which cases of DCIS will evolve to become invasive carcinomas. Another epistemic risk, the one in the gathering of data of breast biopsies, occurs in the evaluation of the differential diagnosis between atypical hyperplasia and DCIS. While the first ones are treated with a small surgical procedure, the latter requires surgical excision followed by radiation therapy and, in some cases, endocrine therapy for 5 years. This way, an error committed by the pathologist might lead to an enormous impact in the treatment of the patients. As pathologists have different formations and different experience backgrounds, and as the biopsy evaluation is a subjective process, this is an epistemic risk that is hard to be assessed. In order to try and decrease the odds of such an error is the development of image analyses software. Mercan et al. evaluated 240 breast biopsies comparing the performance of three experienced pathologists and an automated image analysis method. In this study, the automated method performed better than the pathologists in differentiating atypical hyperplasia and DCIS, becoming a promising alternative for the near future [36]. As we saw in these two examples, the information conveyed to the patients eligible to screening are not obtained in the absence of the researchers personal judgment and values. Thus, more than just respecting the autonomy principle in the shared decision-making process, healthcare workers must convey not only the necessary information but also their values and personal beliefs used by them to define their diagnostic and therapeutic decisions. As long as there is ambiguity in the results of mammographic screening studies in asymptomatic women below the age of 50, the priority should be debating the advantages and disadvantages of this strategy, instead of discrediting their opponents [37].
In Brazil, as in many developing countries, there is no public policy to the implementation of an organized mammographic screening program. As mentioned previously, there is a recommendation from the Brazilian National Cancer Institute (INCA) for mammogram every two years for women between 50 and 69 years old [7] and the main medical societies recommend an annual mammogram for women starting at 40 years of age [30].
This difference in recommendations happens due to complex interactions between the country’s decision makers’ interests, beliefs, perspectives and personal values. In the present scenario, with this disparity of recommendations, patients present late stage diagnosis, worse than the ones observed in Norway before the implementation of the local mammographic screening program (Table 2) [38].
Stage | Brazil (n = 22,527) | Norway (n = 26,883) |
---|---|---|
I | 21.3% | 48.5% |
II | 35.2% | 38.5% |
III | 25.2% | 5.3% |
IV | 8.9% | 6.5% |
Unknown | 1.6% | — |
Prevalence of breast cancer according to stage in the state of São Paulo between 2000 and 2017, and in Norway before the implementation of mammographic screening.
Adapted from Tiezzi et al. [38].
To evaluate the necessity to expand the INCA’s recommendation to other age ranges, Brito et al. analyzed all breast cancer cases, all DCIS cases and all breast cancer related deaths in the city of Aracaju between 1998 and 2014, dividing pages according to age groups [39]. The breast cancer incidence trends remained stable over the studied period across all age groups. Both incidence and cancer-specific mortality in that municipality were similar to the ones observed in countries with the same human development index. The authors concluded that, as these rates remained stable in all age groups, including the ones in which screening is recommended, the investment of public resources to screen women below the age of 50 or over the age of 69 is not justifiable.
A broader study by Rodrigues et al. evaluated retrospective data regarding mammograms between 2008 and 2016 in the public health system [40]. Around nineteen million mammograms were performed in this period with an increase in coverage of 14.5% annually between 2008 and 2012 followed by a stable period between 2012 and 2017. The population coverage of mammogram varied in the period from 14.4% to 24.2% of the target population. This number is far from the 70% coverage recommended by the WHO, necessary to effectively reduce breast cancer-specific mortality [41]. Rodrigues et al. also evaluated the number of mammogram machines available in the country, their geographical distribution and the total number of exams performed in 2016 [42]. In this study, it was demonstrated that Brazil has 4628 machines with a capacity of 14,279,654 exams per year. In 2016, however, only 4,073,079 exams were performed, 29% of the total capacity, displaying a clear under-use of the available infrastructure. The low coverage of the target population with the stable trend in the past few years associated with the under-use of the available infrastructure raises the hypothesis of the existence of barriers to access to the healthcare system.
The Barretos Cancer Hospital adopted an alternative to improve the coverage of the screening program with the use of mobile mammogram machines in trucks reaching 108 municipalities in the northeastern region of São Paulo, targeting women between 40 and 69 years old. Greenwald et al. evaluated the efficacy of this initiative from 2010 to 2015 [43] and, in this period, 122,634 women were evaluated with a coverage of 54.8% of the target population, referral of 12.25% of these women were referred for additional exams with a cancer detection rate of 3,63/1000 women. 92.51% of the referrals to treatment centers were successfully accepted. The results obtained by this program are very promising, showing the potential to be expanded to other regions and other countries.
Brazil is a developing country with a population of 209.3 million inhabitants with enormous social and economical disparities between its 5 regions [44]. Moreover, there are also inequalities in the distribution of human resources and health infrastructure with a significant variation in the number of hospital beds and physicians dedicated to oncological patients leading to significant differences in health outcomes [8]. Another source of outcome variability is the duality of access to the healthcare system. Every Brazilian citizen has unrestricted access to the public health system (PHS) and the richer portion of the population also has access to private healthcare providers through out-of-pocket direct expending or through healthcare insurance companies. This duality of the system is perverse in a way that it perpetuates the idea that a small portion of the population has access to state-of-the-art diagnostic and treatment facilities while the majority of the population, around 71%, depends exclusively on the PHS with all its limitations. When comparing this two scenarios, we observe a striking difference in the initial stage of the breast cancer patients; the majority of the patients seen in the private setting is diagnosed with early stage tumors, whereas the majority of patients that depend on the PHS is diagnosed with locally advanced tumors [45], a clear indication that difficulties to access the healthcare system are the main obstacles to early detection. 37% of the breast cancer cases diagnosed in the PHS are stage III or IV while in the private sector this number falls to 16.2% [46]. These data are corroborated by national studies that showed intervals of 75 to 185 days between initial symptom presentation and initial biopsy [45] and a median interval of 113.4 days between indication and initiation of radiation therapy [47]. For comparison purposes, patients seen in the private setting can have diagnostic tests and start treatment in less than 30 days.
To identify the main barriers to access to the PHS, Vieira et al. conducted a systematic review of the literature identifying 30 publications on this topic [48]. In a general analysis, it has been identified an underuse of mammogram machines on the north and northeast regions of the country and a mammogram coverage of only 35% of the Brazilian women, most of them in the private setting. The main issues related with not having a mammogram performed are non-white ethnicity, low educational level, low familiar income and not having health insurance. Another interesting finding of this study is that normally the treatment of breast cancer is performed in big cities and patients end up traveling more than 100 miles from their residences to the hospitals [49]. Even before the start of treatment, patients have to face delays of more than 60 days in 36.9% of the cases, because of inefficient referral and navigation. The main issues related with delays in the initiation of treatment were non-white ethnicity, not having a partner, low educational level, early stage breast cancer and dependence of the PHS [50]. Exclusive dependence on the PHS and non-white ethnicity were also associated with higher breast cancer-specific mortality [51].
Considering the inefficacy of the screening programs in developing countries and the lack of solid evidence supporting screening of asymptomatic women below the age of 50 years old, we recommend resources reallocation to improve access to the healthcare system and the implementation of a fast track between diagnostic and treatment facilities to symptomatic patients, based on the hierarchical flow proposed by Migowski et al. (Figure 1) [52]. This algorithm proposes three different actions: educational activities in primary care facilities to raise awareness regarding breast cancer and also the potential benefits and harms of mammographic screening; to offer the option of screening mammogram to asymptomatic women aged 50 to 69 during their visit to the primary healthcare provider; and to promote priority access to symptomatic patients, without the need of prior scheduling, in which the ones with suspicious lesions will be referred to diagnostic facilities. This recommendation is supported by Rawls’ two principles of justice [9]. The first principle governs that all persons have equal rights and freedoms. The second principle governs that the adoption of policies that generate social or economical inequalities is only acceptable if it favors the least advantaged portion of society. The promotion of educational activities proposed by Migowski et al. [52] is supported by Rawls’ first principle since it standardizes the access to a basic right, education. The second part of the recommendation is justified by Rawls’ second principle of justice. The adoption of a fast track to symptomatic patients, removing the need of a prior appointment or referral, promotes the reallocation of public resources to remove barriers in the access to care, reducing delays in diagnosis and treatment and, therefore, reducing inequalities in favor of the least advantaged part of the population that relies solely in the public health system. Although the recommendation favors a part of the population, it does not violate individual rights, as asymptomatic patients will still have access to screening mammogram in their routine visits to their primary healthcare providers. Moreover, the proposed recommendation promotes equal access to breast cancer diagnosis and treatment as it removes the age boundaries, starting to provide care to women below the age of 50 years old, an age range responsible for a large amount of new cases in developing countries and that were not previously included in the past recommendation [6].
Hierarchical flow to promote early diagnosis and treatment of breast cancer. Adapted from Migowski et al. [52].
Let us consider for a moment a hypothetical scenario in which the healthcare system works perfectly without any access barriers. Even in this setting, mammographic screening as it is currently suggested would not be ideal in developing countries. The current evidence that recommends mammographic screening is not unanimous and large randomized clinical trials did not show a robust mortality reduction attributable to it [13, 53]. Moreover, even if these studies showed a significant mortality reduction attributable to screening mammogram, their results would hardly be applicable to the developing countries’ realities. Those studies were conducted in countries with high human development index (HDI) and in the context of organized screening. Brazil and most developing countries have lower HDIs and promote opportunistic screening due to the weak organizational structure of the healthcare system. This way, the international studies that assessed the effectiveness of mammographic screening lack the necessary external validity to be applied in developing countries. A recent article published by Vale et al. suggested, that the opportunistic screening program employed in the state of São Paulo, Brazil, promoted an increase in early stage diagnosis without, however, presenting data regarding mortality reduction [54]. Without data showing mortality reduction attributable to the screening program it is impossible to conclude whether this model is effective or not. Adding up to that data we have some concerning facts associated with screening women between the age of 40 and 49; we observe that less than one death from breast cancer is avoided for every one thousand screening mammograms performed; two hundred and ninety-four false-positive results (Table 1) generate additional diagnostic procedures leading to economical impact to the health system and also physical and psychological impacts to the patients. Based on everything that was exposed in this paragraph, we can conclude is not adequate from Bentham’s and Mill’s utilitarianism perspective [10, 11].
In this context, with the shortage of resources to invest in an organized mammographic screening program and without solid data to justify its implementation, can we accept a sub-optimal program? On the one hand, the inexistence of a screening program can lead to the increase in the number of cases diagnosed in late stages, for which the treatment options might be inaccessible and, sometimes, ineffective. On the other hand, developing countries, such as Brazil, sometimes lack the necessary infrastructure to perform timely screening mammograms to the whole eligible population and the consequent breast biopsies of lesions identified through screening [55]. In order to consider a screening program adequate, it must be acceptable, accessible, and sustainable, it must promote equity and it must be economically efficient to the target population [56]. As it has been demonstrated in this chapter, the Brazilian mammographic screening program is not accessible, since the coverage does not reach 30% of the target population [42]. This program is not sustainable either since there is a huge delay between the identification of an abnormal mammogram and the necessary biopsy to confirm the diagnostic. Due to the incapacity to adequately follow-up and refer patients with abnormal findings, the risk of a false-positive result must be considered clinically and ethically relevant. Finally, it’s been demonstrated that mammographic screening in developing countries is not cost-effective when compared to the alternative of treating patients with palpable initial lesions [57, 58]. Contemplating all these issues, Sedhom et al. argued that clinical examination of the breast with fast referral to avoid delays in diagnosis and treatment, although not a screening program, must be considered a more pragmatic and adequate choice than screening mammogram in developing countries [59].
When weighing the benefits and harms of a mammographic screening program in a developing country, in a context where breast cancer-specific mortality has been increasing in the past few decades, it is extremely hard to justify increasing the age range to women aged 40 to 49 years old from an utilitarian perspective, since the amount of resources to establish and make the system work adequately is prohibitive. An alternative strategy that promotes easy access and fast referral of symptomatic patients, relegating a secondary role to mammographic screening, favors a larger and more vulnerable part of the population that depends solely on the PHS. This reallocation of resources to favor the least advantaged members of society is not only ethically justifiable but also a way of promoting social justice.
Rodrigo Goncalves has received consultation fees from EMS Pharmaceuticals in 2019 and 2020 and from Novartis in 2019, not related to the topics of this chapter.
The remaining authors do not have any conflicts of interest to disclose.
This is a brief overview of the main steps involved in publishing with IntechOpen Compacts, Monographs and Edited Books. Once you submit your proposal you will be appointed a Author Service Manager who will be your single point of contact and lead you through all the described steps below.
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