Trends in Female Breast Cancer Mortality in Urban Centers and Rural Regions of Brazil

Abstract

BACKGROUND: Social and regional inequalities in Brazil such as delayed diagnosis and a healthcare system with technological limitations hamper the access of socioeconomically deprived women with breast cancer to treatment. Women living in urban centers are known to have a more favorable socioeconomic status and better access to medical and hospital care compared to those living in rural areas. In addition, the coverage of death registration is wider in urban areas. Nevertheless, few studies have been conducted to compare breast cancer mortality in urban centers and rural regions of Brazil. AIMS: To provide a comprehensive picture of mortality trends in female breast cancer in urban centers and rural regions of Brazil. METHODS: This was an ecological study of a temporal series, using mortality database (SIM/WHO) and demographic database (IBGE/WHO). An analysis of the mortality trends between 1980 and 2010 was performed using Poisson regression model. RESULTS: Breast cancer mortality was found to be 3 times lower in rural areas compared to urban areas throughout the entire evaluation period. A declining trend in mortality was found in some urban centers: Porto Alegre (-1.6%; 95%CI: -2.4 to -0.7; p<0.01); Rio de Janeiro (-0.9%; -1.4 to -0.4; p<0.01); Sao Paulo (-1.7%; -2.6 to -0.9; p<0.01); Belo Horizonte (-1.2%; -2.0 to -0.4; p=0.01) and Recife (-0.9%; -1.7 to -0.1; p=0.03). However, increases were found in other urban centers: Fortaleza (0.5%; 95%CI: 0.1–0.9; p=0.02), Belem (0.8%; 0.2–1.5; p=0.01), Joao Pessoa (1.6%; 0.7–2.6; p<0.01), Teresina (4.6%; 1.2–8.2; p=0.01) and Porto Velho (9.0%; 3.8–14.6; p<0.01). A reduction occurred in rural areas of the state of Sao Paulo (-2.8%; 95%CI: -4.4 to -1.3; p<0.01). However, increases were found in most other rural areas in all the different states of the country, the worst being in Maranhao (17.6%; 95%CI: 9.2–26.7; p<0.01), Paraiba (14.5%; 10.0–19.2; p<0.01), Piaui (10.0%; 8.1–13.7; p<0.01) and Alagoas (10.8%; 7.1–14.6; p<0.01). DISCUSSION: In the period between 1980 and 2010, considerable differences were found in mortality from breast cancer in the urban and rural regions of Brazil. These findings coincide with the socioeconomic inequalities that are prevalent in this country. Mortality rates are higher in the urban centers despite the fact that this is exactly where specialized healthcare is more readily available. No conclusions can be reached concerning the access of these women to diagnosis and treatment, since the coverage of death registration is heterogeneous in the different areas of the country. CONCLUSION: Reductions were found in female breast cancer mortality in five urban centers in Brazil, while increases incurred in most rural areas with the exception of some regions in the south of the country. One of the reasons for this disparity may be the lower access to treatment among patients living in rural areas.