Abstract
Reports of uterine cancer deaths that do not specify the subsite of the tumor threaten the quality of the epidemiologic appraisal of corpus and cervix uteri cancer mortality. The present study assessed the impact of correcting the estimated corpus and cervix uteri cancer mortality in the city of São Paulo, Brazil. The epidemiologic assessment of death rates comprised the estimation of magnitudes, trends (1980-2003), and area-level distribution based on three strategies: i) using uncorrected death certificate information; ii) correcting estimates of corpus and cervix uteri mortality by fully reallocating unspecified deaths to either one of these categories, and iii) partially correcting specified estimates by maintaining as unspecified a fraction of deaths certified as due to cancer of "uterus not otherwise specified". The proportion of uterine cancer deaths without subsite specification decreased from 42.9% in 1984 to 20.8% in 2003. Partial and full corrections resulted in considerable increases of cervix (31.3 and 48.8%, respectively) and corpus uteri (34.4 and 55.2%) cancer mortality. Partial correction did not change trends for subsite-specific uterine cancer mortality, whereas full correction did, thus representing an early indication of decrease for cervical neoplasms and stability for tumors of the corpus uteri in this population. Ecologic correlations between mortality and socioeconomic indices were unchanged for both strategies of correcting estimates. Reallocating unspecified uterine cancer mortality in contexts with a high proportion of these deaths has a considerable impact on the epidemiologic profile of mortality and provides more reliable estimates of cervix and corpus uteri cancer death rates and trends.
Highlights
Different histological, etiologic and epidemiologic features of uterine cancer require the anatomic specification of the tumor, which can originate in the corpus or in the cervix uteri
Time-series analysis for cervical cancer mortality indicated a stationary trend at nearly 6 deaths per year for each 100,000 women in the city (Figure 2, Table 1)
Both the partial and the full correction resulted in a significant increase in the magnitude of cervical cancer mortality: the partial correction indicated a stationary 31.3% higher trend, and the full correction indicated a decreasing trend at a rate of 8.62‰ per year, though maintaining, on average, a 48.8% higher magnitude
Summary
Etiologic and epidemiologic features of uterine cancer require the anatomic specification of the tumor, which can originate in the corpus or in the cervix uteri. Erroneous estimates of mortality rates are a long-standing concern affecting the epidemiologic assessment of uterine cancer in areas presenting a high percentage of uterine cancer deaths which are not specified as to the subsite where the tumor originated [1]. Cervix uteri tumors are mainly of squamous cell histological type, a category of carcinomas whose etiology is considered to be one of the best known [4,5], and a smaller proportion of cervical neoplasms refers to adenocarcinomas, with etiologic features analogous to those of corpus uteri cancer. Death certificates commonly classify as cancer of uterus NOS (not otherwise specified) cases lacking the identification of the subsite of the tumor. The topographic misclassification of cancer of the uterus indicates insufficient training of physicians filling out death certificates [6], in addition to possibly reflecting the high probability of delayed diagnosis and insufficient or inadequate medical assistance
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