Disparities in female breast cancer mortality rates in Brazil between 1980 and 2009

Age-Period-Cohort Study of Breast Cancer Mortality in Brazil in State Capitals and in Non-Capital Municipalities from 1980 to 2019

Breast cancer was identified as the cancer with the highest mortality rate among women in Brazil. This study analyzed the effects of age, period and birth cohort on the breast cancer mortality rate for Brazilian women, comparing state capitals and non-capital municipalities. Population and deaths data were extracted from the Brazilian Unified Health System database for women aged 30 years or older, for the years between 1980 and 2019. The effects were analyzed using the age-period-cohort model. Age effect on breast cancer mortality is observed in the model through higher mortality rates at older ages. Period effect is similar in all regions in the form of a marked increase in the rate ratio (RR) in non-capital municipalities by period than in state capitals. The RR of birth cohorts in the state capitals remained stable (north, northeast and central-west regions) or decreased followed by an increase in the most recent cohorts (Brazil as a whole and the southeast and south regions). The RR for the other municipalities, however, showed a progressive increase in the cohorts for all regions. Policies and actions focused on breast cancer in women should consider these differences among Brazilian regions, state capitals and other municipalities.

Breast Cancer Treatment Delay in SafetyNet Health Systems, Houston Versus Southeast Brazil

Background

Breast cancer outcomes among patients who use safety-net hospitals in the highly populated Harris County, Texas and Southeast Brazil are poor. It is unknown whether treatment delay contributes to these outcomes.

Methods

We conducted a retrospective cohort analysis of patients with non-metastatic breast cancer diagnosed between January 1, 2009 and December 31, 2011 at Harris Health Texas and Unicamp’s Women’s Hospital, Barretos Hospital, and Brazilian National Institute of Cancer, Brazil. We used Cox proportional hazards regression to evaluate association of time to treatment and risk of recurrence (ROR) or death.

Results

One thousand one hundred ninety-one patients were included. Women in Brazil were more frequently diagnosed with stage III disease (32.3% vs. 21.1% Texas; P = .002). Majority of patients in both populations had symptom-detected disease (63% in Brazil vs. 59% in Texas). Recurrence within 5 years from diagnosis was similar 21% versus 23%. Median time from diagnosis to first treatment defined as either systemic therapy (chemotherapy or endocrine therapy) or surgery, were comparable, 9.9 weeks versus 9.4 weeks. Treatment delay was not associated with increased ROR or death. Higher stage at diagnosis was associated with both increased ROR and death.

Conclusion

Time from symptoms to treatment was considerably long in both populations. Treatment delay did not affect outcomes.

Impact

Access to timely screening and diagnosis of breast cancer are priorities in these populations.

Race disparities in mortality by breast cancer from 2000 to 2017 in São Paulo, Brazil: a population-based retrospective study

Background

In Brazil, inequalities in access may interfere with cancer care. This study aimed to evaluate the influence of race on breast cancer mortality in the state of São Paulo, from 2000 to 2017, contextualizing with other causes of death.

Methods

A population-based retrospective study using mortality rates, age and race as variables. Information on deaths was collected from the Ministry of Health Information System. Only white and black categories were used. Mortality rates were age-adjusted by the standard method. For statistical analysis, linear regression was carried out.

Results

There were 60,940 deaths registered as breast cancer deaths, 46,365 in white and 10,588 in black women. The mortality rates for 100,000 women in 2017 were 16.46 in white and 9.57 in black women, a trend to reduction in white (p = 0.002), and to increase in black women (p = 0.010). This effect was more significant for white women (p < 0.001). The trend to reduction was consistent in all age groups in white women, and the trend to increase was observed only in the 40–49 years group in black women. For ‘all-cancer causes’, the trend was to a reduction in white (p = 0.031) and to increase in black women (p < 0.001). For ‘ill-defined causes’ and ‘external causes’, the trend was to reduce both races (p < 0.001).

Conclusion

The declared race influenced mortality rates due to breast cancer in São Paulo. The divergences observed between white and black women also were evident in all cancer causes of death, which may indicate inequities in access to highly complex health care in our setting.

Breast Cancer Incidence Trends in Isfahan Province Compared with those in England over the Period 2001-2013

BACKGROUND

Figures from Iranian cancer registries indicate that Isfahan ranks first in female breast cancer incidence. Although few previous studies have examined whether the breast cancer incidence trend in Isfahan province has increased over a given period of time, this study employed a joint point regression analysis to answer the same question. Moreover, it compared the data of Isfahan province, from a developing country, with those of England, as a representative of developed countries, and tried to explain the causes of the differences observed between the trends.

METHODS

This repeated cross-sectional study was conducted on the data of 6057 women in Isfahan province and of 141,011 women in England with breast cancer over the years 2001-2013. The incidence rates were calculated using direct standardization method and based on the 2013 standard European population. For an analysis of the trends in breast cancer incidence rates, Joint Point Regression program, version 4.3.1.0, released in April 2016, was employed.

RESULTS

The mean age-standardized incidence rate (ASR) was calculated to be 34.7 per100,000 population over the years 2001 to 2013, which indicated an increase from 22 to 68 in Isfahan province. The corresponding mean ASR for England has also risen from 147.5 to 170.1 per 100,000 women during the same time period. The average annual percentage changes (AAPCs) for Isfahan and England were also calculated to be 9.6 and 1.1, respectively. This indicated an increasing trend in breast cancer incidence rates for Isfahan province over the period in question.

CONCLUSIONS

The drastic discrepancy in breast cancer incidence rates between these two regions may be attributed to differences in an improved cancer registry system in Iran and women's developing awareness of the cancer over time.

Inequalities in the burden of female breast cancer in Brazil, 1990-2017

Background

Breast cancer is the most frequently diagnosed cancer in women and the leading cause of cancer death among females worldwide. In recent decades, breast cancer death rates have been stable or decreasing in more developed regions; however, this has not been observed in less developed regions. This study aims to evaluate inequalities in the burden of female breast cancer in Brazil including an analysis of interregional and interstate patterns in incidence, mortality and disability-adjusted life years (DALYs) rates from 1990 to 2017, and mortality-to-incidence ratio (MIR), and their association with the Socio-demographic Index (SDI).

Methods

Using estimates from the global burden of disease (GBD) study, we applied a spatial exploratory analysis technique to obtain measurements of global and local spatial correlation. Percentage changes of breast cancer incidence, mortality, and DALYs rates between 1990 and 2017 were calculated, and maps were developed to show the spatial distribution of the variables. Spatial panel models were adjusted to investigate the association between rates and SDI in Brazilian states.

Results

In Brazil, while breast cancer mortality rate have had modest reduction (−4.45%; 95% UI: −6.97; −1.76) between 1990 and 2017, the incidence rate increased substantially (+39.99%; 95% UI: 34.90; 45.39). Breast cancer incidence and mortality rates in 1990 and 2017 were higher in regions with higher SDI, i.e., the most developed ones. While SDI increased in all Brazilian states between 1990 and 2017, notably in less developed regions, MIR decreased, more notably in more developed regions. The SDI had a positive association with incidence rate and a negative association with MIR.

Conclusion

Such findings suggest an improvement in breast cancer survival in the period, which may be related to a broader access to diagnostic methods and treatment. This study also revealed the inequality in breast cancer outcomes among Brazilian states and may guide public policy priorities for disease control in the country.

Realizing the right to health in Brazil's Unified Health System through the lens of breast and cervical cancer

Background

Health is recognized as a fundamental right in Brazil’s constitution. In the absence of a clearly defined benefit packages of healthcare services that are financed under the Unified Health System (Sistema Único de Saúde, SUS), courts have become important in adjudicating coverage decisions. Empirical assessments of equity and the right to health tend to focus on simple measures of access. However, these empirical perspectives belie the significant inequalities and rights violations that arise in the case of more complex health needs such as cancer. To shed light on these issues, this paper focuses on the care pathways for breast and cervical cancer and explores access and quality issues that arise at different points along the care pathway with implications for the realization of the right to health in Brazil.

Method

A mixed method approach is used. The analysis is primarily based on a quantitative analysis of national representative administrative data principally from the cervical and breast cancer information systems and the hospital cancer registry. To gain more insights into the organization of cancer care, qualitative data was collected from the state of Bahia, through document analysis, direct observation, roundtable discussions with health workers (HWs), and structured interviews with health care administrators.

Results

The paper reveals that the volume of completed screening exams is well below the estimated need, and a tendency toward lower breast cancer screening rates in poorer states and for women in the lowest income brackets. Only 26% of breast cancer cases and 29% of cervical cancer cases are diagnosed at an early stage (stage 0 or I), thereby reducing the survival prospects of patients. Waiting times between confirmed diagnosis and treatment are long, despite new legislation that guarantees a maximum of 60 days. The waiting times are significantly longer for patients that follow the recommended patient pathways, and who are diagnosed outside the hospital.

Conclusion

The study reveals that there are large variations between states and patients, where the poorest states and patients fare worse on key indicators. More broadly, the paper shows the importance of collecting data both on patient characteristics and health system performance and carry out detailed health system analysis for exposing, empirically, rights violations and for identifying how they can be addressed.

Electronic supplementary material

The online version of this article (10.1186/s12939-019-0938-x) contains supplementary material, which is available to authorized users.

Clinical pathways of breast cancer patients treated in the Federal District, Brazil

OBJECTIVE

To identify the clinical pathways of women with breast cancer treated in public hospitals, and to analyze the factors that influence the time interval between the first appointment and the start of therapy.

METHODS

A cross-sectional study was conducted with 600 women with breast cancer treated in nine public hospitals in the Brazilian Federal District. Patients were interviewed between September 2012 and September 2014. Simple and multiple logistic regression models were adjusted to evaluate the variables associated with the time interval studied. The most frequent pathway was the one that started in primary care with following care in the therapy service (28.9%). In the multiple adjustment, factors associated to a longer time interval between the first appointment and therapy were: lower family income (OR = 1.89; 95%CI 1.32-2.68), the first appointment in public services (OR = 1.78; 95%CI 1.20-2.64), care in more than two health services in the clinical pathway (OR = 1.71; 95%CI 1.19-2.44); and obtaining the anatomopathological analysis of the biopsy in public services instead of private health services (OR = 1.87; 95%CI 1.29-2.71). Independently, the implementation of specialist appointment scheduling, with care regulation, was associated with a shorter time interval between first appointment and therapy (OR = 0.33; 95%CI 0.16-0.65).

CONCLUSIONS

We observed that multiple pathways were covered by women with breast cancer treated in public services of the Federal District. Socioeconomic iniquities and several aspectos of the pathways covered were associated with a longer time interval between the first appointment and the start of breast cancer therapy.

Prognostic factors and overall survival of breast cancer in the city of Goiania, Brazil: a population-based study

OBJECTIVE

to analyze the overall survival and prognostic factors of women with breast cancer in the city of Goiânia.

METHODS

this is a retrospective, cross-sectional, observational study that included women with malignant neoplasms of the breast identified by the Goiânia Population-based Cancer Registry. The variables studied were age at diagnosis, tumor size, staging, axillary lymph node involvement, tumor grade, disease extent, hormone receptors, and c-erb-B2 oncoprotein. We performed overall survival analyzes of five and ten years.

RESULTS

we included 2,273 patients in the study, with an overall survival of 72.1% in five years and 57.8% in ten years. In the multivariate analysis adjusted for tumor size, the factors that influenced the prognosis were axillary lymph nodes, histological grade, progesterone receptor, c erb B2, T staging and disease extension.

CONCLUSION

overall survival in ten years is below that observed in other countries, and possibly reflects what happens with the majority of the Brazilian population. The prognostic factors found in this population follow the same international patterns.

Abdominal Adiposity and Physical Inactivity Are Positively Associated with Breast Cancer: A Case-Control Study

OBJECTIVE

To examine whether breast cancer is associated with body composition and level of physical activity, considering the menstrual status.

METHODS

This was a case-control study with 116 women recently diagnosed with breast cancer and 226 controls. Body composition was assessed by dual-energy X-ray absorptiometry, and cardiometabolic risk was assessed by conicity index and waist-to-height ratio. The short version of the International Physical Activity Questionnaire was used to estimate the level of physical activity. All analyses were adjusted for age and BMI.

RESULTS

The total body fat percentage, android body fat, android-gynoid ratio, and waist circumference were positively associated (p < 0.05), whereas the percentage of lean body mass (p <0.05) and the level of physical activity (p < 0.01) were inversely associated with breast cancer in premenopausal women. Among postmenopausal women, physical activity decreased the chance of developing breast cancer by 49% (95% CI = 0.29 to 0.92, p = 0.02).

CONCLUSION

A low percentage of lean body mass and high abdominal adiposity in the premenopausal period increase the chances of developing breast cancer. Regular physical activity is inversely associated with breast cancer in pre- and postmenopausal women.

Risk factors of breast cancer and knowledge about the disease: an integrative revision of Latin American studies

The aim of this integrative review was to compare Latin American literature about risk and knowledge on breast cancer. Of 47 studies selected, 20 were about knowledge or awareness and 27 about risk of breast cancer. English was the dominant language in studies about risk, whereas studies about knowledge were mainly written in Spanish or Portuguese. Studies about knowledge were all cross- sectional, whereas case- control studies dominated authors' interest about risk of breast cancer. Studies about knowledge were mainly focused on early detection of the disease and the most common study objective was breast self- examination (N = 14). In contrast, few studies about risk of breast cancer focused on early detection (N = 5). Obesity and overweight (N = 14), family history (N = 13), decreased parity (N = 12), and short breastfeeding duration (N = 10) were among the most frequent identified risk factors. Socio- economic factors such as income and educational level had variable effects on breast cancer risk and affected also knowledge of women about risk factors and early detection. Present results indicated that studies about risk of breast cancer were more often based on a better sound analytical background, compared to studies about knowledge, which were mostly descriptive.

Breast cancer related perceptions and practices of health professionals working in Brazil's network of primary care units

In 2004 the Brazilian National Cancer Institute (INCA) established breast cancer screening guidelines for women in Brazil: annual clinical breast exam for women age 40-49 and biennial mammogram for women age 50-69. Healthcare provider's adherence to these guidelines is currently unknown. The objective of this study is to describe the perceptions and practices related to breast cancer screening among physicians, nurses, and health unit coordinators working in the network of primary healthcare units (HCUs) in Brazil. In 2011, 1600 primary HCUs were randomly sampled from all regions in Brazil. At each HCU the coordinator and one health professional were asked to participate in a telephone survey to gathered information on their knowledge, attitudes, and practices related to breast cancer screening. Participation rates for coordinators, physicians, and nurses were 78%, 34%, and 65% respectively. Health unit coordinators identified numerous barriers that prevent patients from receiving appropriate screening, many (44%) were unaware of INCA cancer screening guidelines. Despite a high perceived impact of INCA guidelines, a majority of physicians and nurses did not follow them. Most physicians and nurses recommended mammograms on an annual basis (~75%) and 50.9% of nurses and 25.1% of physicians initiated routine breast cancer screening in women under age 40. Physicians and nurses in Brazil screen at younger ages and more frequently than recommended by INCA guidelines. Given that primary HCUs are the source of health care for many women, interventions that educate healthcare providers on the appropriate ages and intervals for breast cancer screening may prove useful.

[Breast cancer mortality in Brazilian municipalities and associated factorsMortalidad por cáncer de mama en municipios brasileños y factores asociados]

Objetivo.

Analisar o comportamento da mortalidade por câncer de mama nos municípios brasileiros e avaliar a influência de fatores socioeconômicos e demográficos sobre as taxas e mortalidade.

Métodos.

Foram calculadas taxas de mortalidade, padronizadas por faixa etária e corrigidas por causas mal definidas, centradas em 1990, 2000 e 2010. Posteriormente, foram estimados modelos de regressão, com dados em painel, que permitiram verificar o grau de associação entre os fatores de interesse e a taxa de mortalidade pela doença.

Resultados.

Verificou-se uma tendência de crescimento da mortalidade no país. Contudo, os modelos indicaram que a mortalidade poderia ter diminuído (tendência negativa), principalmente no Sudeste e Sul, caso alguns fatores associados à doença (por exemplo, nível de renda, educação, longevidade, taxa de fecundidade, gastos em saúde, infraestrutura, entre outros) tivessem permanecido constantes durante o período considerado. Observou-se que a mortalidade por câncer de mama apresentou associação positiva/significativa com a longevidade e negativa/significativa com o nível de gastos públicos em saúde. A mortalidade foi maior nas regiões Sul e Sudeste, nos municípios com mais de 500 000 habitantes e naqueles onde a população é inferior a 5 000.

Conclusões.

O crescimento da renda per capita, a elevação da expectativa de vida e a diminuição da taxa de fecundidade podem estar associados a elevadas taxas de mortalidade por câncer de mama e a uma tendência de crescimento na mortalidade por esse câncer nos municípios brasileiros.

Breast cancer screening in Brazil. Barriers related to the health system

Objective:

Identify factors related to the health system that lead to a late diagnosis of breast cancer in Brazil.

Method:

We performed a systematic review in the PubMed and LILACS databases using as keywords "Breast cancer," "system of health" and "Brazil or Brasil." We evaluated the content of the articles using the PRISMA methodology based on PICTOS. The final date was 12/16/2015. We were able to identify 94 publications in PubMed and 43 publications in LILACS. After assessing the title and summary, and excluding 21 repeated publications, we selected 51 publications for full evaluation. At this stage, we excluded 21 articles, with 30 publications remaining for study.

Results:

The population coverage is low, and there are problems related to the quality of mammography. Patients with lower income, nonwhite and less educated are more vulnerable. We observed punctual and initial experiences in breast cancer screening. Diagnosis and treatment flows must be improved. The inequality in mortality reflects the differences related to screening structure and treatment. Better results are observed in well-structured services.

Conclusion:

There are several barriers in the health system leading to advanced stage at diagnosis and limiting the survival outcomes. The establishment of a rapid and effective order for diagnosis and treatment, based on hierarchical flow, are important steps to be improved in the public health context.

Can MTHFR C677T and A1298C Polymorphisms Alter the Risk and Severity of Sporadic Breast Cancer in Brazilian Women?

INTRODUCTION

Polymorphisms in the methylenetetrahydrofolate reductase gene (MTHFR) modify the risk and severity of sporadic breast cancer (BC). In this context, the MTHFR C677T and A1298C polymorphisms have been associated with risk and severity of sporadic BC.

PATIENTS AND METHODS

In total, 253 women with BC and 257 controls were enrolled in this study. Polymorphisms were analyzed using restriction fragment length polymorphism - polymerase chain reaction. Epidemiology, tumor characteristics, and reproductive factors were considered in the analysis. Statistical tests included the χ² test, the Fisher exact test, and the Mann-Whitney and Kruskal-Wallis tests, or parametric equivalents.

RESULTS

MTHFR polymorphisms were not a risk factor for BC. The 677CC genotype was associated with distant metastasis (odds ratio [OR] = 5.311; 95% confidence interval [CI] = 1.124-25.09) and lower estrogen receptor expression, whereas the 1298AA genotype was associated with stage 0 (OR = 0.244; 95% CI = 0.077-0.771) and increased estrogen receptor expression. In haplotype analysis, 677CC/1298AA was associated with hypertension (OR = 1.979; 95% CI = 1.036-3.782), and 677CT/1298AC was associated with invasive carcinoma of no special type (OR = 0.472; 95% CI = 0.243-0.918) and stage 0 (OR = 3.476; 95% CI = 1.341-10.47).

CONCLUSION

The MTHFR C677T and A1298C polymorphisms do not alter the risk of BC, but are associated with the clinical severity of BC.

Knowledge about Risk Factors for Breast Cancer and Having a Close Relative with Cancer Affect the Frequency of Breast Self-Examination Performance

BACKGROUND

Breast cancer incidence and mortality rates are increasing in North-Eastern Brazil and the patients with the disease often presented at advanced stages. The present study was focused on identifying variables that affect women's frequency of breast self- examination (BSE) performance.

MATERIALS AND METHODS

Data on BSE, socio-economic parameters and risk factors for breast cancer were obtained from 417 women from a community in North-Eastern Brazil by a self-informant method. To identify independent variables that affect frequency of BSE, nominal logistic regression analysis was performed.

RESULTS

Of 417 women, 330 (79.3%) reported performing BSE. Compared to high-income women, BSE performance by low-income women every month was 7.69 (OD=0.130; CI 95%: 0.044- 0.0386; p=0.000) times lower. Women who did not live in a stable union performed BSE each month 2.73 (OD=0.366; CI 95%: 0.171-0.782; p=0.010) less often than those living in a stable union. BSE performance every month and every six months or every year by women with poor knowledge about risk factors for breast cancer was 3.195 (OD=0.313; CI 95%: 0.141- 0.695; p=0.004) times and 2.028 (OD=0.493; CI 95%: 0.248- 0.979; p=0.043) times lower, compared to women with good knowledge. Participants who had a close relative with cancer performed BSE every month and every six months or every year 2.132 (OD=0.469; CI 95%: 0.220-0.997; p=0.049) times and 2.337 (OD=0.428; CI 95%: 0.219-0.836; p=0.013) times less often, compared to those women without close relatives with cancer.

CONCLUSIONS

The results of this study indicated that income, marital status, knowledge about risk factors and having a close relative with breast cancer, affect the frequency of BSE performance. Information about risk factors in public health campaigns could additionally strengthen avoidance behaviour and also motivate BSE performance.

The Rise in Mortality from Breast Cancer in Young Women: Trend Analysis in Brazil

Introduction

Breast cancer is the most common cause of cancer death among women.

Objective

The objective of this study was to analyze time trends in overall mortality from breast cancer in Brazil, Brazilian regions and States.

Methods

This is an exploratory study, of the time series of deaths from breast cancer contained in the Mortality Information System (SIM), of women living in Brazil, Brazilian regions and States, from 1996 to 2013. For the trend analysis, the polynomial regression model was used, and a significant trend was considered when the estimated model obtained a p value <0.05.

Results

There was a tendency of increased mortality from breast cancer in Brazilian women (average increase of 0.18 per year; p <0.001), with regional differences, particularly in the age group 20–49 years (0.07 per year; p <0.001). The age group 50–69 years remained constant but had high average rates (37.14).

Conclusion

More effective planning is needed to focus on the different scenarios of the Brazilian regions. Screening strategies for the incidence and mortality from breast cancer must also be rethought according to age group in the country.

[Compliance to imatinib therapy in patients with chronic myeloid leukemia in Henan province and its influence on cytogenetic response at 12 months]

OBJECTIVE

To observe the compliance to Imatinib (IM) 400 mg/d in 513 patients with chronic myeloid leukemia chronic phase (CML- CP) referred to Henan Province Tumor Hospital from March 2013 through March 2015 and its influence on cytogenetic response at 12 months.

METHODS

Of 513 patients with CML-CP from Henan province, 456 cases covered by the new rural cooperative medical insurance, and 57 cases by other medical insurances. Patients were told the importance of regular monitoring after receiveing IM treatment, including bone marrow , BCR- ABL fusion genes and chromosomes. All patients were followed up for 12 months, according to the circumstances of the periodic review, to be subjected into good or poor compliance groups. Chi-square test was used to compare CCyR rate at 12 months and Sokal score difference of the distribution of risk between two groups. Diagnosis to IM treatment duration, level of education, personal income, convenience of residence to the hospital' s traffic, age and gender were recorded, the Cox single and multiple factors analyses were implied to probe the factors affecting CCyR 12 months.

RESULTS

After receving IM 400 mg/d treatment for 12 months, the CCyR rate in good compliance group (82.2% ) was significantly higher than in poor compliance one (50.9%) (P<0.001). Sokal scores of risk stratification were 121, 132, 101, respectively in good compliance group; which were as of 58, 61, 40, respectively in poor compliance group, the difference of disease risk between the two groups was not statistical significance (P=0.721). Sokal score, annual income, level of education and diagnosis to treatment duration were positively related with the 12 months CCyR rate by the Cox single factor analysis (P<0.05). Level of education (B=0.457,P=0.018), income (B=0.267,P= 0.035) and treatment compliance (B=0.587,P=0.026) were independent risk factors for the 12 months CCyR rate by the Cox multiple factor analysis.

CONCLUSIONS

Patients in CML-CP with good compliance achieved satisfactory responses when receving IM treatment for 12 months. Low education, low income and poor treatment compliance were independent risk factors for the CCyR rate at 12 months.

Breast cancer survival and health iniquities

Breast cancer is the most frequent neoplasm in women, and some studies have shown social inequalities in incidence and survival, which are poorly investigated in Brazil. To assess iniquity in prognosis, a hospital-based cohort study was carried out. Follow-up was made by active search in medical records and in the Mortality Information System, phone calls, and consultation on Individual Tax-Collection Record status. Survival functions were estimated by the Kaplan-Meier method, and the Cox proportional hazards model was employed for prognostic assessment. Disease-specific survival was estimated at 76.3% (95%CI: 71.9-81.0) in 5 years. Women seen at public facilities had worse prognosis (HR = 1.79; 95%CI: 1.09-2.94), which was particularly due to the disease being diagnosed at a more advanced stage. These findings point to inequalities of access to screening actions, as women of lower social conditions with later diagnostic and therefore with worse prognostic.

The accuracy of the SONOBREAST statistical model in comparison to BI-RADS for the prediction of malignancy in solid breast nodules detected at ultrasonography

OBJECTIVE

The objective of the present study was to compare the accuracy of SONOBREAST for the prediction of malignancy in solid breast nodules detected at ultrasonography with that of the BI-RADS system and to assess the agreement between these two methods.

STUDY DESIGN

This prospective study included 274 women and evaluated 500 breast nodules detected at ultrasonography. The probability of malignancy was calculated based on the SONOBREAST model, available at www.sonobreast.com.br, and on the BI-RADS system, with results being compared with the anatomopathology report.

RESULTS

The lesions were considered suspect in 171 cases (34.20%), according to both SONOBREAST and BI-RADS. Agreement between the methods was perfect, as shown by a Kappa coefficient of 1 (p<0.001). SONOBREAST and BI-RADS proved identical insofar as sensitivity (95.40%), specificity (78.69%), positive predictive value (48.54%), negative predictive value (98.78%) and accuracy (81.60%) are concerned. With respect to the categorical variables (BI-RADS categories 3, 4 and 5), the area under the receiver operating characteristic (ROC) curve was 94.41 for SONOBREAST (range 92.20-96.62) and 89.99 for BI-RADS (range 86.60-93.37).

CONCLUSIONS

The accuracy of the SONOBREAST model is identical to that found with BI-RADS when the same parameters are used with respect to the cut-off point at which malignancy is suspected. Regarding the continuous probability of malignancy with BI-RADS categories 3, 4 and 5, SONOBREAST permits a more precise and individualized evaluation.

Knowledge about mammography and associated factors: population surveys with female adults and elderly

The purpose of this paper is to describe the knowledge about mammography and to identify associated factors in female adults and elderly. Data were obtained from two population surveys, one with female adults and another with elderly women from Florianópolis (SC) in 2009 - 2010. A descriptive analysis of the variables was carried out, the appropriate mean of responses about mammography was estimated and crude and adjusted Poisson regression was conducted to identify associated factors. Among adults, 23.1% answered all of the questions appropriately and the appropriate average responses was 7.2 (95%CI 7.1 - 7.3) in a total of 9. In the adjusted model, older age, higher education and income were associated with knowledge about mammography. For the elderly, 15.3% answered all questions appropriately and the average of appropriate responses was 6.4 (95%CI 5.2 - 6.5) and the factors associated with knowledge about mammography in the adjusted model were younger age groups, increased education and income, and identification of mammography as the main diagnostic method for breast cancer. Information about mammography can neither be transmitted in a clear way nor be easily understood; there are also demographic and socioeconomic differences concerning the knowledge about the exam.

Análise dos determinantes que influenciam o tempo para o início do tratamento de mulheres com câncer de mama no Brasil

Este estudo teve como objetivo analisar o intervalo de tempo entre o diagnóstico e o início do tratamento do câncer de mama em mulheres e seus determinantes. Foi realizado um estudo de coorte retrospectiva com 137.593 mulheres diagnosticadas em 239 unidades hospitalares do Brasil entre 2000 a 2011. Em 63,1% dos casos, o intervalo entre o diagnóstico e o tratamento foi de até 60 dias. No país, as mulheres mais suscetíveis ao atraso foram não brancas (OR = 1,18; IC95%: 1,13-1,23), sem companheiro (OR = 1,05; IC95%: 1,01-1,09), com menos de oito anos de estudo (OR = 1,13; IC95%: 1,08-1,18), com doença em estadiamento inicial (OR = 1,27; IC95%: 1,22-1,32), tratadas de 2006 a 2011 (OR = 1,54; IC95%: 1,47-1,60) e provenientes do sistema público de saúde (OR = 1,19; IC95%: 1,13-1,25). Na análise estratificada foi observada a variabilidade dos fatores entre as regiões do Brasil. A identificação de fatores associados à demora no início do tratamento poderá possibilitar a elaboração de propostas de intervenções destinadas a grupos populacionais específicos.

Low educational level but not low income impairs the achievement of cytogenetic remission in chronic myeloid leukemia patients treated with imatinib in Brazil

OBJECTIVES

In Brazil, imatinib mesylate is supplied as the first-line therapy for chronic myeloid leukemia in the chronic phase through the public universal healthcare program, Sistema Único de Saúde (SUS). We studied the socio-demographic factors that influenced therapy success in a population in the northeast region of Brazil.

METHODS

Patients with chronic myeloid leukemia from the state of Piauí were treated in only one reference center. Diagnosis was based on WHO 2008 criteria. Risk was assessed by Sokal, Hasford and EUTOS scores. Patients received 400 mg imatinib daily. We studied the influence of the following factors on the achievement of complete cytogenetic response within one year of treatment: age, clinical risk category, time interval between diagnosis and the start of imatinib treatment, geographic distance from the patient's home to the hospital, years of formal education and monthly income.

RESULTS

Among 103 patients studied, the median age was 42 years; 65% of the patients had 2-9 years of formal education, and the median monthly income was approximately 100 US$. Imatinib was started in the first year after diagnosis (early chronic phase) in 69 patients. After 12 months of treatment, 68 patients had a complete cytogenetic response. The Hasford score, delay to start imatinib and years of formal education influenced the attainment of a complete cytogenetic response, whereas income and the distance from the home to the healthcare facility did not.

CONCLUSION

Patients require additional healthcare information to better understand the importance of long-term oral anticancer treatment and to improve their compliance with the treatment.

Effect of tamoxifen and raloxifene on the proliferative activity of the breast epithelium in premenopausal women

OBJECTIVES

To compare the effects of tamoxifen and raloxifene on the proliferative activity of normal breast tissue in premenopausal women as measured by Ki-67/MIB-1 expression.

STUDY DESIGN

A total of 48 women with benign breast nodules and a recommendation for surgical removal of the lesion took part in this study. They were randomized to use tamoxifen or raloxifene for 22 days, after which they were submitted to surgery. During the surgical procedure, a 1-cm fragment of normal breast tissue was removed to study Ki-67 expression.

RESULTS

The mean percentage ratios between immunolabeled and non-labeled cells were 2.02 ± 1.09 and 3.13 ± 3.23 for the tamoxifen and raloxifene groups, respectively. There was no statistically significant difference between the tamoxifen (n = 16) and raloxifene (n = 14) groups in relation to the immunohistochemical analysis of Ki-67 (P = 0.205).

CONCLUSION

The results of this study showed no difference between tamoxifen and raloxifene with respect to the potential of these drugs to reduce the proliferative activity of the normal breast epithelium in premenopausal women.

Frequency and associated factors of axillary web syndrome in women who had undergone breast cancer surgery: a transversal and retrospective study

Background

Breast cancer is the most common malignancy among women. Surgical treatment is an essential part of therapy, which still includes chemotherapy, radiotherapy and hormone therapy. The increase in early cancer detection and less aggressive treatment has made longer survival rates possible for women with this neoplasia. Morbidities after treatment have subsequently aroused particular interest in the scientific community in order to minimize their effects and provide increased quality-of-life for these patients. The present study aimed at investigating one of these morbidities: axillary web syndrome, which occurs after axillary surgical management.

Methods

From December 2011 to September 2012, according to the inclusion and exclusion criteria, 97 patients, who had been surgically treated for breast cancer, were enrolled, interviewed, and submitted to a specific physical exam. An investigation of the axillary cords, characteristic of this syndrome, was performed in all patients.

Results

The axillary web syndrome was diagnosed in 28.86% of the women. Higher risk of triggering the syndrome has been associated with younger age (21.7%), longer time between first treatment and data collection (29.3%), greater number of resected lymph nodes (149.7%) and surgical management medical teams (113.2%).

Conclusions

One can conclude that axillary web syndrome was associated with younger age, greater time elapsed since surgery, surgical management of medical staff and number of resected lymph nodes.

Further studies are needed to review prior-to-surgery and post-operative follow-up, to properly assess the effects of surgery in the axilla on homeostatic balance, not only in the ipsilateral upper limb, but also assess their compensatory consequences throughout the body.

Temporal trends in female breast cancer mortality in Brazil and correlations with social inequalities: ecological time-series study

Background

Breast cancer is the most common cause of death from cancer in women in less developed regions. Therefore, the objective of this study was to provide data on the temporal trends in female breast cancer mortality between 1990 and 2011 and to evaluate its association with the social inequalities present in Brazil.

Methods

Breast cancer mortality data and estimates for the resident population were obtained from the Brazilian National Health Service database for the 1990–2011 period. Age-standardized mortality rates were calculated (20–39, 40–49, 50–69 and ≥70 years) by direct standardization using the 1960 standard world population. Trends were modeled using joinpoint regression model and linear regression. The Social Exclusion Index and the Human Development Index were used to classify the 27 Brazilian states. Pearson’s correlation was used to describe the association between the Social Exclusion Index and the Human DeveIopment and the variations in mortality rates in each state.

Results

Age-standardized mortality rates in Brazil were found to be stable (annual percent change [APC] = 0.3; 95% CI: −0.1 – 0.7) between 1994 and 2011. Considering the Brazilian states, significant decreases in mortality rates were found in Rio Grande do Sul, Rio de Janeiro and São Paulo. Increases in mortality rates were most notable in the states of Maranhão (APC = 11.2; 95 %CI: 5.8 – 16.9), Piauí (APC = 9.8; 95% CI: 7.6 – 12.1) and Paraíba (APC = 9.3; 95% CI: 6.0 – 12.8). There was a statistically significant correlation between Social Exclusion Index and a change in female breast cancer mortality rates in the Brazilian states between 1990 and 2011 and between Human Development Index and mortality between 2001 and 2011.

Conclusions

Female breast cancer mortality rates are stable in Brazil. Reductions in these rates were found in the more developed states, possibly reflecting better healthcare.

Molecular breast cancer subtypes and therapies in a public hospital of northeastern Brazil

BACKGROUND

The frequencies of molecular breast cancer subtypes vary among different human populations. The Northeastern region of Brazil has a mixed population of African, Indigenous and European ancestry. This retrospective study investigated breast cancer subtypes and applied therapies in a public hospital of Northeastern Brazil.

METHODS

Data of 633 patients with invasive breast cancer from 2005 to 2011 were obtained from medical records. Status of hormone receptor (HR), HER2 and Ki67 expression index of 269 out of 633 patients were used to define subtypes of Luminal A and B, HER2 and triple negative (TN) breast cancer. Expression index of Ki67 ≥ 14% was applied to distinguish Luminal A from Luminal B subtypes.

RESULTS

Overall, 185 (68.77%) and 132 (49.07%) patients showed positive hormone receptor (HR+) and positive HER2 (HER2+) tumors. The mean age ranged from 53.33 to 58.25 years for patients with tumors of Luminal B and Luminal A subtypes, respectively (p = 0.0182). In general, 67.39% of patients with TN tumors aged over 50 and 19.57% aged between 31 and 40 years (p = 0.0046). The rate of small tumors (T1: ≤ 2.0 cm) varied from 22.73% to 52.46% for TN and Luminal A subtypes (p = 0.0088). The rate of high graded (G3) tumors was increased for HER2 and TN subtypes (35.29% and 34.28%) compared to Luminal A and Luminal B subtypes (3.92% and 12.62%), respectively (p < 0.0001). The five-year survival rate ranged from 92.86% to 75.00%, for Luminal A, HER2 and TN subtypes, respectively (HR: 0.260 to 1.015; 95% CI: 0.043 to 3.594; p = 0.2589). Patients with HER2 positive (HER2+) breast tumors did not receive immunotherapy and chemotherapy application varied from 54.84% to 86.49% for Luminal A and HER2 subtypes, respectively (p = 0.0131).

CONCLUSIONS

The results of this study revealed a high percentage of HER2+ breast tumors and an increased rate of patients with TN tumors aged over 50 years. This emphasizes the need for establishing immunotherapy as an additional therapeutic option to improve clinical outcomes for patients with HER2+ tumors and to investigate the risk factors of TN breast cancer.

Cervical and female breast cancers in the Americas: current situation and opportunities for action

OBJECTIVE

To understand better the current regional situation and public health response to cervical cancer and female breast cancer in the Americas.

METHODS

Data on cervical cancer and female breast cancers in 33 countries, for the period from 2000 to the last year with available data, were extracted from the Pan American Health Organization (PAHO) Regional Mortality Database and analysed. Changes in mortality rates over the study period - in all countries except those with small populations and large fluctuations in time-series mortality data - were calculated using Poisson regression models. Information from the PAHO Country Capacity Survey on noncommunicable diseases was also analysed.

FINDINGS

The Bahamas, Trinidad and Tobago and Uruguay showed relatively high rates of death from breast cancer, whereas the three highest rates of death from cervical cancer were observed in El Salvador, Nicaragua and Paraguay. Several countries - particularly Paraguay and Venezuela - have high rates of death from both types of cancer. Although mortality from cervical cancer has generally been decreasing in the Americas, decreases in mortality from breast cancer have only been observed in a few countries in the Region of the Americas. All but one of the 25 countries in the Americas included in the PAHO Country Capacity Survey reported having public health services for the screening and treatment of breast and cervical cancers.

CONCLUSION

Most countries in the Americas have the public health capacity needed to screen for - and treat - breast and cervical cancers and, therefore, the potential to reduce the burden posed by these cancers.

Disparities in female breast cancer mortality rates between urban centers and rural areas of Brazil: ecological time-series study

OBJECTIVES

To evaluate trends in breast cancer mortality in urban centers and rural areas of Brazil.

METHODS

Ecological time-series study using data on breast cancer deaths and census. Mortality trends were analyzed using change-point regression: 1980-2010.

RESULTS

A declining trend was found in five urban centers: São Paulo (APC = -1.7%), Porto Alegre (APC = -1.6%), Belo Horizonte (APC = -1.2%), Rio de Janeiro and Recife (APC = -0.9%). An increasing was found in: Porto Velho (APC = 9.0%), Teresina (APC = 4.6%), João Pessoa (APC = 1.6%), Belém (APC = 0.8%) and Fortaleza (APC = 0.5%). In the majority of rural areas, mortality continues to rise, with the exception of some areas in the southern.

CONCLUSION

Disparities in breast cancer mortality were found across the country, with increasing trends occurring predominantly in the north and northeastern regions. One of the reasons for this disparity may be that access to treatment is more difficult for patients living in rural areas and in the north of Brazil.

Planning cancer control in Latin America and the Caribbean

Non-communicable diseases, including cancer, are overtaking infectious disease as the leading health-care threat in middle-income and low-income countries. Latin American and Caribbean countries are struggling to respond to increasing morbidity and death from advanced disease. Health ministries and health-care systems in these countries face many challenges caring for patients with advanced cancer: inadequate funding; inequitable distribution of resources and services; inadequate numbers, training, and distribution of health-care personnel and equipment; lack of adequate care for many populations based on socioeconomic, geographic, ethnic, and other factors; and current systems geared toward the needs of wealthy, urban minorities at a cost to the entire population. This burgeoning cancer problem threatens to cause widespread suffering and economic peril to the countries of Latin America. Prompt and deliberate actions must be taken to avoid this scenario. Increasing efforts towards prevention of cancer and avoidance of advanced, stage IV disease will reduce suffering and mortality and will make overall cancer care more affordable. We hope the findings of our Commission and our recommendations will inspire Latin American stakeholders to redouble their efforts to address this increasing cancer burden and to prevent it from worsening and threatening their societies.