Disparidade racial na sobrevivência em 10 anos para o câncer de mama: uma análise de mediação usando abordagem de respostas potenciais

Guideline-concordant breast cancer care by patient race and ethnicity accounting for individual-, facility- and area-level characteristics: a SEER-Medicare study

PURPOSE

To examine racial-ethnic variation in adherence to established quality metrics (NCCN guidelines and ASCO quality metrics) for breast cancer, accounting for individual-, facility-, and area-level factors.

METHODS

Data from women diagnosed with invasive breast cancer at 66+ years of age from 2000 to 2017 were examined using SEER-Medicare. Associations between race and ethnicity and guideline-concordant diagnostics, locoregional treatment, systemic therapy, documented stage, and oncologist encounters were estimated using multilevel logistic regression models to account for clustering within facilities or counties.

RESULTS

Black and American Indian/Alaska Native (AIAN) women had consistently lower odds of guideline-recommended care than non-Hispanic White (NHW) women (Diagnostic workup: ORBlack 0.83 (0.79-0.88), ORAIAN 0.66 (0.54-0.81); known stage: ORBlack 0.87 (0.80-0.94), ORAIAN 0.63 (0.47-0.85); seeing an oncologist: ORBlack 0.75 (0.71-0.79), ORAIAN 0.60 (0.47-0.72); locoregional treatment: ORBlack 0.80 (0.76-0.84), ORAIAN 0.84 (0.68-1.02); systemic therapies: ORBlack 0.90 (0.83-0.98), ORAIAN 0.66 (0.48-0.91)). Commission on Cancer accreditation and facility volume were significantly associated with higher odds of guideline-concordant diagnostics, stage, oncologist visits, and systemic therapy. Black residential segregation was associated with significantly lower odds of guideline-concordant locoregional treatment and systemic therapy. Rurality and area SES were associated with significantly lower odds of guideline-concordant diagnostics and oncologist visits.

CONCLUSIONS

This is the first study to examine guideline-concordance across the continuum of breast cancer care from diagnosis to treatment initiation. Disparities were present from the diagnostic phase and persisted throughout the clinical course. Facility and area characteristics may facilitate or pose barriers to guideline-adherent treatment and warrant future investigation as mediators of racial-ethnic disparities in breast cancer care.

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.

Impacts of Sociodemographic Factors, Screening, and Organization of Health Services on Breast Cancer Mortality in Brazil: An Ecological Study of 20 Years

Background

Breast cancer mortality is increasing in Brazil. This study examines the impact of sociodemographic factors, screening procedures, and primary healthcare (PHC) on breast cancer mortality.

Methods

An ecological study analyzed secondary data of women diagnosed with breast cancer who died between 2000 and 2019. Sociodemographic factors, screening procedures, and PHC were examined in relation to breast cancer mortality. Statistical analyses included normality tests, Kruskal-Wallis and one-way ANOVA tests with post hoc comparisons, Pearson and Spearman correlation tests, age-period-cohort analysis, Kaplan-Meier analysis, and Cox regression analysis. Significance was set at p < 0.05.

Results

Mortality rates were higher in the southeast (15.77) and south (15.97) regions compared to the north (5.07) (p < 0.0001). Survival rates were longer in the southeast (70.3 ± 0.05) and south (70.6 ± 0.09) than in the north (63.98 ± 0.053) (p ≤ 0.001). Mortality increased with age after 32 years (p ≤ 0.001). Brown and indigenous women had lower mortality and survival rates. Increased coverage of PHC, ultrasound, and biopsy did not reduce mortality. However, improved cytopathologic analysis led to a decrease in mortality.

Conclusions

Sociodemographic factors, screening procedures, and PHC are specific predictors of breast cancer mortality in Brazil.

Factors associated with time-to-treatment initiation of breast cancer

The present retrospective study investigated factors associated with time-to-treatment initiation of breast cancer of a cohort of 12,100 cases of health facilities qualified for high complexity in oncology within the scope of the Brazilian Public Health System (SUS) of Rio de Janeiro between 2013 and 2019. Multivariate logistic regression was used to estimate odds ratios and 95% confidence intervals. Of all cases, 82.1% were submitted to the first treatment >60 days. Patients without previous diagnosis history, higher education and in stages III and IV were less likely to have their first treatment >60 days, while treatment at a health facility outside the capital showed a higher probability. Patients with a previous diagnosis history, aged ≥50, non-white race/skin color and in stage I were more likely to be submitted to their first treatment >60 days, while subjects with higher education, treated in a health facility outside the capital and in stage IV showed a lower probability. To summarize, sociodemographic, clinical and health facility-related factors are associated with time-to-treatment initiation of breast cancer.

Breast cancer survival and the health system in Brazil: an analysis of public and private healthcare

Background

The incidence of breast cancer is increasing globally; however, survival outcomes vary and are lower in developing countries.

Methods

We analyzed the 5- and 10-year survival rates for breast cancer according to the type of healthcare insurance (public vs. private) in a referral center for cancer care in the Brazilian southeast region. This hospital-based cohort study included 517 women diagnosed with invasive breast cancer between 2003 and 2005. The Kaplan-Meier method was used to estimate the probability of survival, and the Cox proportional hazards regression model was used to assess prognostic factors.

Results

The 5- and 10-year breast cancer survival rates were as follows: private healthcare service survival rate of 80.6% (95% CI 75.0-85.0) and 71.5% (95% CI 65.4-77.1), respectively, and public healthcare service survival rate of 68.5% (95% CI 62.5-73.8) and 58.5% (95% CI 52.1-64.4), respectively. The main factors associated with the worst prognosis were lymph node involvement in both healthcare services and tumor size >2 cm only in public health services. The use of hormone therapy (private) and radiotherapy (public) was associated with the best survival rates.

Conclusions

The survival discrepancies found between health services can be explained mainly by the difference in the stage of the disease at the time of diagnosis, indicating inequalities in access to the early detection of breast cancer.

Ways and detours in guarantee of health for the black population and the confrontation of racism in Brazil

Institutional racism is prevalent in the health services in Brazil and is based on concrete power relations that subjugate, dominate and exclude blacks from having adequate access to health care and health institutions. This critical essay analyzes the importance of expanding the debate, and the production of knowledge about the health of the black population (HBP), focusing on two points: the role of the National Policy for the Integral Health of the Black Population (PNSIPN) and the importance of including the skin color item in the health information systems; and the need for a process of permanent training of professionals, including contents related to the understanding of racism as an element of the social determination of health/disease and heir effects. To demonstrate how structural and institutional racism have affected the black population, we bring also examples of the quilombola populations in the context of the Covid-19 pandemic in the country since 2020. It is concluded that the promotion of care, the reduction of inequities and the quality of health care need to undergo changes in several dimensions, such as the strengthening of the SUS, the daily fight against structural and institutional racism, among others.

Ways and detours in guarantee of health for the black population and the confrontation of racism in Brazil

Abstract Institutional racism is prevalent in the health services in Brazil and is based on concrete power relations that subjugate, dominate and exclude blacks from having adequate access to health care and health institutions. This critical essay analyzes the importance of expanding the debate, and the production of knowledge about the health of the black population (HBP), focusing on two points: the role of the National Policy for the Integral Health of the Black Population (PNSIPN) and the importance of including the skin color item in the health information systems; and the need for a process of permanent training of professionals, including contents related to the understanding of racism as an element of the social determination of health/disease and heir effects. To demonstrate how structural and institutional racism have affected the black population, we bring also examples of the quilombola populations in the context of the Covid-19 pandemic in the country since 2020. It is concluded that the promotion of care, the reduction of inequities and the quality of health care need to undergo changes in several dimensions, such as the strengthening of the SUS, the daily fight against structural and institutional racism, among others.

Influence of high altitude on the expression of HIF-1 and on the prognosis of Ecuadorian patients with gastric adenocarcinoma

Since the incidence of gastric adenocarcinoma (GA) is high in populations living at high altitudes, we evaluated the influence of altitude on the expression of HIF-1 and survival of Ecuadorian GA patients. Method: 155 GA cases were studied: 56 from coastal (GAC) and 99 from mountainous regions (GAM), and 74 non-GA controls (25 coast and 49 mountain). The expression of HIF-1/HER2 was analyzed by immunohistochemistry. Analyses were performed using Fisher's exact and Breslow-Day tests for homogeneity and Kaplan-Meier curves and restricted median survival time ΔRMST. Results: HIF-1 was overexpressed in normal/inflamed gastric mucosa, especially in mountainous non-GA patients (p = 0.001). There was no difference between GAC and GAM in terms of age/gender, HIF-1/HER2 expression, stage/tumor location. Median survival at 120 months was significantly higher among GAC, with a difference (ΔRMST) of 43.7 months (95% CI 29.5, 57.8) (p < 0.001) and those with positive HIF-1 expression: ΔRMST 26.6 months (95% CI 11.0, 42.1) (p < 0.001). Positive HIF-1 expression was associated with better GAM survival, with ΔRMST 33.6 months (95% CI 14.2, 52.9) (p < 0.001). Conclusion: Despite the limitations of this retrospective study, GA patients in the coastal region and those who expressed HIF-1 exhibited a better prognosis, but this factor was associated with better survival only in the mountain region.

Racial inequalities in multimorbidity: baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

BACKGROUND

Evidence of multimorbidity has come mainly from high-income regions, while disparities among racial groups have been less explored. This study examined racial differences in multimorbidity in the multiracial cohort of the Longitudinal Study of Adult Health (Estudo Longitudinal de Saúde do Adulto), ELSA-Brasil.

METHODS

The study examined baseline (2008-2010) data for 14 099 ELSA-Brasil participants who self-reported being white, mixed-race, or black. A list of 16 morbidities was used to evaluate multimorbidity, operationalised by simple count into ≥ 2, ≥ 3, ≥ 4, ≥ 5 and ≥ 6 morbidities, in addition to evaluating the number of coexisting conditions. Prevalence ratios (PR) were estimated from logistic models and a quantile model was used to examine racial differences graphically in the distribution quantiles for the number of morbidities.

RESULTS

Overall prevalence of multimorbidity (≥ 2 morbidities) was 70% and, after controlling for age and sex, was greater among mixed-race and black participants - by 6% (PR: 1.06; 95% CI: 1.03-1.08) and 9% (PR: 1.09; 95% CI: 1.06-1.12), respectively - than among white participants. As the cutoff value for defining multimorbidity was raised, so the strength of the association increased, especially among blacks: if set at ≥ 6 morbidities, the prevalence was 27% greater for those of mixed-race (PR: 1.27; 95% CI: 1.07-1.50) and 47% greater for blacks (PR: 1.47; 95% CI: 1.22-1.76) than for whites. The disparities were smaller in the lower morbidity distribution quantiles and larger in the upper quantiles, indicating a heavier burden of disease, particularly on blacks.

CONCLUSIONS

Multimorbidity was common among adults and older adults in a Brazilian cohort, but important racial inequalities were found. Raising the cutoff point for defining multimorbidity revealed stronger associations between race/skin colour and multimorbidity, indicating a higher prevalence of multimorbidity among mixed-race and black individuals than among whites and that the former groups coexisted more often with more complex health situations (with more coexisting morbidities). Interventions to prevent and manage the condition of multimorbidity that consider the social determinants of health and historically discriminated populations in low- and middle-income regions are necessary.

Prevalência e fatores associados ao diagnóstico de câncer de mama em estágio avançado

Resumo Este estudo transversal investigou a prevalência e os fatores associados ao diagnóstico de câncer de mama em estágio avançado entre 18.890 mulheres assistidas em hospital especializado da capital do Rio de Janeiro, Brasil, entre os anos 1999 e 2016. Utilizou-se regressão de Poisson com variância robusta para estimar razões de prevalência e respectivos intervalos de 95% de confiança. Apresentaram maiores prevalências de diagnóstico nessa condição mulheres com idade entre 20-39 e 40-49 anos, de raça/cor da pele preta e parda, que viviam sem companheiro(a), procedentes de outros municípios do estado do Rio de Janeiro, que tiveram o Sistema Único de Saúde como origem do encaminhamento e que foram diagnosticadas nos sexênios 1999-2004 e 2005-2010. Em contrapartida, mulheres com idade entre 60-69 e 70-99 anos, que cursaram algum nível de escolaridade, com histórico familiar de câncer e que chegaram ao hospital com diagnóstico e sem tratamento apresentaram menores prevalências de diagnóstico em estágio avançado. Esses resultados podem ser considerados no planejamento de ações de prevenção secundária, a fim de antecipar o diagnóstico de câncer de mama dos grupos mais vulneráveis e assim colaborar para a redução da prevalência do diagnóstico em estágio avançado.

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 survival in Great Cuiaba, Brazil: a population-based study

OBJECTIVE

To analyze ten-year specific survival of women with breast cancer in Great Cuiaba, Mato Grosso, Brazil.

METHODS

A population-based cohort of 61 women diagnosed with breast cancer in 2008 and 2009, in Great Cuiabá, Mato Grosso, followed by 2018 in the regional mortality database. Specific survival was analyzed through the Kaplan-Meier curve, with adjustment of the Weibull model and Log-Weibull Regression. The survival curves of the variables were compared using the log-rank test which were statistically significance (p<0.05).

RESULTS

The mean time to death is approximately 51.1 months. Women aged ≤ 50 years and of white race/color presented the worst survival.

CONCLUSION

We found out that age, race/color affect specific survival and there is a need for reviewing the control plan for breast cancer in order to increase the survival of women diagnosed with this pathology.

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.