Inequities in access to mammographic screening in Brazil

Inequality by Skin Color in Breast Cancer Screening in Brazil: a Differences-in-Differences Analysis of the COVID-19 Pandemic

Breast cancer is the second most common cancer type and the first in mortality among Brazilian women. Mammograms are one of the main early diagnosis strategies. National breast cancer screening coverage is still low. Brazil's low screening coverage is due to high mammography access inequality. Skin color defines healthcare access differences. Our article explores the natural event of the COVID-19 pandemic to analyze differences in screening rates between two racial groups of women through the application of the differences in differences (DiD) estimator. The results indicate that BBI women (Black, Brown, and Indigenous Brazilian) have lower screening rates than WY women (White and Yellow) and that the pandemic reduced the difference between these two groups due to the lower number of mammograms performed by WY women. It is believed that the information channel can explain much of this result. The BA population, wealthier and more educated, may have had additional information about COVID-19 and its consequences, as well as an increased likelihood of working remotely and practicing social distance. Structural racism causes many social indicators to be correlated with inequality of access to mammography and negatively impacts health conditions for BBI women. Public policies are necessary for equal access to breast cancer screening for the most vulnerable women.

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.

Geographic variations in cancer incidence and mortality in the State of São Paulo, Brazil 2001-17

BACKGROUND

Cancer is a leading cause of morbidity and mortality in Brazil and the burden is rising. To better inform tailored cancer actions, we compare incidence and mortality profiles according to small areas in the capital and northeast region of the State of São Paulo for the leading cancer types.

METHODS

New cancer cases were obtained from cancer registries covering the department of Barretos (2003-2017) and the municipality of São Paulo (2001-2015). Cancer deaths for the same period were obtained from a Brazilian public government database. Age-standardized rates per 100,000 persons-years by cancer and sex are presented as thematic maps, by municipality for Barretos region, and by district for São Paulo.

RESULTS

Prostate and breast cancer were the leading forms of cancer incidence in Barretos, with lung cancer leading in terms of cancer mortality in both regions. The highest incidence and mortality rates were seen in municipalities from the northeast of Barretos region in both sexes, while elevated incidence rates were mainly found in São Paulo districts with high and very high socioeconomic status (SES), with mortality rates more dispersed. Breast cancer incidence rates in São Paulo were 30 % higher than Barretos, notably in high and very high SES districts, while corresponding rates of cervical cancer conveyed the opposite profile, with elevated rates in low and medium SES districts.

CONCLUSIONS

There is substantial diversity in the cancer profiles in the two regions, by cancer type and sex, with a clear relation between the cancer incidence and mortality patterns observed at the district level and corresponding SES in the capital.

Disparities in breast cancer mortality among Latin American women: trends and predictions for 2030

BACKGROUND

Breast cancer is among the leading cause of cancer-related mortality among Latin American and Caribbean (LAC) women, but a comprehensive and updated analysis of mortality trends is lacking. The objective of this study was to determine the breast cancer mortality rates between 1997 and 2017 for LAC countries and predict mortality until 2030.

METHODS

We retrieved breast cancer deaths across 17 LAC countries from the World Health Organization mortality database. Age-standardized mortality rates per 100,000 women-years were estimated. Mortality trends were evaluated with Joinpoint regression analyses by country and age group (all ages, < 50 years, and ≥ 50 years). By 2030, we predict number of deaths, mortality rates, changes in population structure and size, and the risk of death from breast cancer.

RESULTS

Argentina, Uruguay, and Venezuela reported the highest mortality rates throughout the study period. Guatemala, El Salvador, and Nicaragua reported the largest increases (from 2.4 to 2.8% annually), whereas Argentina, Chile, and Uruguay reported downward trends (from - 1.0 to - 1.6% annually). In women < 50y, six countries presented downward trends and five countries showed increasing trends. In women ≥ 50y, three countries had decreased trends and ten showed increased trends. In 2030, increases in mortality are expected in the LAC region, mainly in Guatemala (+ 63.0%), Nicaragua (+ 47.3), El Salvador (+ 46.2%), Ecuador (+ 38.5%) and Venezuela (+ 29.9%).

CONCLUSION

Our findings suggest considerable differences in breast cancer mortality across LAC countries by age group. To achieve the 2030 sustainable developmental goals, LAC countries should implement public health strategies to reduce mortality by breast cancer.

COVID-19 and Breast Cancer in Brazil

Objectives: This study aimed to evaluate COVID-19 effects on breast cancer screening and clinical stage at diagnosis in patients of 50-69 years of age receiving care within the public healthcare network (SUS) in 2013-2021 in Brazil and its macro-regions. Methods: This ecological study used Poisson regression to analyze trends in screening and staging. A secondary database was formed using SUS sources: outpatient data system of the SUS network and Oncology-Brazil Panel. Results: There was a reduction in screening, with an annual percent change of -5.9 (p < 0.022). The number of notified cases fell by 31.5% in 2020-2021 compared to 2018-2019. There was a 10.7% increase in the proportion of stage III/IV cases (p < 0.001) in 2020-2021 compared to 2013-2019, now surpassing the number of cases of early stage breast cancer. Conclusion: COVID-19 led to a reduction in breast cancer screening and an expressive increase in advanced tumors in users of the public healthcare network. Urgent interventions in public policies are required as the negative effects of the pandemic on the diagnosis/treatment of breast cancer are becoming apparent even earlier than expected.

Tendência Temporal da Cobertura de Mamografias no Sistema Único de Saúde, Brasil, 2010-2019

Introdução: O câncer de mama no Brasil apresenta elevadas taxas de incidência e mortalidade apesar da tendência de redução da mortalidade em algumas Regiões. Objetivo: Descrever a tendência da cobertura de mamografias de rastreamento nas Macrorregiões e Estados brasileiros e identificar a influência de Políticas Nacionais voltadas ao controle do câncer de mama entre 2010-2019. Método: Foi calculada a razão entre mamografias de rastreamento na faixa etária de 50-69 anos por local de residência e subtraída a população das residentes com plano de saúde na faixa etária e no período referidos. A tendência foi avaliada pelo modelo de regressão Joinpoint. Resultados: A cobertura aumentou no Brasil de 2010-2014 e apresentou queda de 2014-2019, com aumento na proporção de exames realizados na população-alvo. Esse padrão foi observado nas demais Regiões, exceto na Centro-Oeste, porém com ano de mudança da tendência diferente. Foram identificados dois pontos de mudança no país: de 2010-2014, com tendência crescente (APC 8,7, IC 95% 6,2; 11,3), e de 2014-2019, com tendência decrescente (APC -4,2, IC 95% -5,7; -2,7), ambos significantes. A Região Nordeste foi a única com três pontos de mudança de tendência: 2010-2012 (APC 30,3, IC 95% 22,9; 38,2), 2012-2017 (APC 4,7, IC 95% 3,0; 6,4) e 2017-2019 (APC -14,9, IC 95% -19,7; - 9,8). Não foi identificada tendência para a Região Centro-Oeste. Conclusão: Houve crescimento na proporção de mamografias de rastreamento realizadas na população-alvo no período, para Brasil e Regiões, e tendência de redução na cobertura da mamografia a partir de 2014. Esses resultados indicam priorização da população-alvo do programa nas ações de rastreamento.

Impact of educational level and travel burden on breast cancer stage at diagnosis in the state of Sao Paulo, Brazil

We describe the characteristics of cases of breast cancer among women assisted at hospitals affiliated to the public health system in the state of São Paulo (Brazil), analysing the effects of level of education and travel burden to point of treatment. We conducted a retrospective analysis of invasive breast cancer among women diagnosed between 2000 and 2015. Data were extracted from the hospital-based cancer registries of Fundação Oncocentro de São Paulo—FOSP. The outcome was clinical stage at diagnosis (stage III–IV versus I–II). The explanatory variables were educational level and travel burden. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated. Multiple imputations were used for missing educational level (31%). The study included 81,669 women with invasive breast cancer diagnosed between 2000 and 2015. The mean age of patients at diagnosis was 56.8 years (standard deviation 13.6 years). 38% of patients were at an advanced stage at diagnosis (stage III–IV). Women with lower levels of education and those who received cancer care in municipalities other than where they lived were more likely to be diagnosed at an advanced stage. In conclusion, promotion of breast cancer awareness and improving pathways to expedite breast cancer diagnosis and treatment could help identify breast tumors at earlier stages.

Regional and social inequalities in mammography and Papanicolaou tests in Brazilian state capitals in 2019: a cross-sectional study

OBJECTIVE

To assess regional and social inequalities in mammography and Papanicolaou tests.

METHODS

This was a cross-sectional study with data from the 2019 Chronic Disease Risk and Protective Factors Surveillance Telephone Survey (Vigitel). The outcome variables were mammography and cytopathology test. The exposure variables were race/skin color, schooling and region of residence in Brazil. Absolute inequality measurements were presented using the slope index of inequality (SII) and equiplots.

RESULTS

23,339 women were included in this study. Having a mammography was 5.2 percentage points higher in women with higher levels of education, while having a cytopathology test was 5.3 percentage points lower in women of Black race/skin color.Having mammography and cytopathology tests was 3.9 and 11.2 percentage points higher, respectively, in the Southern region.

CONCLUSION

Social and regional inequalities persist in Brazil and affect mainly women of Black race/skin color, with low education levels and living in the Northeast region of the country.

Changes in the pattern of health services use in Brazil between 2013 and 2019

This study aimed to investigate changes in the health service use pattern based on information from the 2013 and 2019 National Health Surveys (PNS). The two outcomes, "Seeking health-related care in the past two weeks" and "Medical visit in the last twelve months", were analyzed according to socioeconomic, geographic and health conditions characteristics. Multivariate Poisson regression models were used to investigate the factors associated with seeking care due to a health problem or prevention. The prevalence of chronic diseases increased from 15.0% to 22.5% between 2013 and 2019. The proportion of seeking care increased from 15.3 to 18.6%, and medical visits from 71.2% to 76.2%, ranging from 61.4 to 75.8% and 68.0 to 80.6% between the North and Southeast regions. There was no significant association of seeking care due to a health problem with per capita income, after controlling for the other covariates. We conclude by saying that, despite the expanded coverage of health service use, the persistent regional inequalities indicate unmet health needs among residents of the less developed regions. Health care models focused on prevention and health promotion are required.

Cancer care in Brazil: structure and geographical distribution

Background

The organisation and systematisation of health actions and services are essential to ensure patient safety and the effectiveness and efficiency of cancer care. The objective of this study was to analyse the structure of cancer care envisaged in Brazilian norms, describe the types of accreditations of cancer services and their geographic distribution, and determine the planning and evaluation parameters used to qualify the health units that provide cancer care in Brazil.

Methods

This observational study identified the current organisation of cancer care and other health services that are accredited by Brazil’s national health system (SUS) for cancer treatment as of February 2017. The following information was collected from the current norms and the National Registry of Health Establishments: geographic location, type of accreditation, type of care, and hospital classification according to annual data of the number of cancer surgeries. The adequacy of the number of licensed units relative to population size was assessed. The analysis considered the facilitative or restrictive nature of policies based on the available rules and resources.

Results

The analysis of the norms indicated that these documents serve as structuring rules and resources for developing and implementing cancer care policies in Brazil. A total of 299 high-complexity oncology services were identified in facilities located in 173 (3.1%) municipalities. In some states, there were no authorised services in radiotherapy, paediatric oncology and/or haematology-oncology. There was a significant deficit in accredited oncology services.

Conclusions

The parameters that have been used to assess the need for accredited cancer services in Brazil are widely questioned because the best basis of calculation is the incidence of cancer or disease burden rather than population size. The results indicate that the availability of cancer services is insufficient and the organisation of the cancer care network needs to be improved in Brazil.