Diagnóstico em estádio avançado do câncer de mama na América Latina e Caribe e sobrevida de mulheres tratadas para essa doença pelo Sistema Único de Saúde segundo raça/cor

Abstract

Breast cancer is the most common cancer in women in the world. The incidence is higher in developed countries; however, the incidence/mortality ratio is higher in developing countries probably due to the high proportion of advanced stage diagnosis. In Brazil, black women have less access to the actions of the breast cancer control plan than white women. In this thesis, we conducted a systematic review with meta-analysis to assess the proportion of advanced stage diagnosis (pas) in Latin America and the Caribbean (LAC) and a nation-wide non-concurrent cohort study to assess the five-year survival of women treated by SUS for breast cancer according to race/skin color. For the systematic review, we searched the MEDLINE, Embase and LILACS databases to identify studies, in any language, indexed before 11/05/2018. pea was summarized with meta-analysis using the random effects model and meta-regression was performed to identify sources of variation. We included 63 studies, 13 of which population-based, from 22 countries comprising 221,255 women diagnosed from 1966 to 2017. The distribution of patients by stage varied greatly in LAC (pas 40.8%, 95%CI 37.0% to 44.6%; I2 = 99%; p<0.0001). The heterogeneity was not explained by any variable included in the meta-regression. There was no difference in pas among the Caribbean (pas 43.0%, 95%CI 33.1% to 53.6%), Central America (pas 47.0%, 95%CI 40.4% to 53.8%) and South America (pas 37.7%, 95%CI 33.1% to 42.5%) regions. In Brazil, the pas showed a downward trend, but it is still high, of more than 40% in the most recent study included in the systematic review that evaluated data from the Registros Hospitalares de Câncer of 2000-2011. For the survival study, we extracted a cohort from a database built through the deterministic-probabilistic records linkage from the Ambulatory Information System, Hospital Information System and the Mortality Information System. We included women who started treatment between 01/01/2008 and 11/30/2010 and followed them until 12/31/2015. 59,811 women diagnosed in stage I-IV were identified, with a mean age at the beginning of treatment of 54.6 years (standard deviation 12.8). Most women (62.4%) identified themselves as white, followed by brown (31.4%) and black (6.2%). The pas was 60.3% for black, 55.5% for brown and 48.6% for white (p-value <0.05). Specific five-year survival was lower for black women when compared to white women, and the difference between these groups increased the more advanced the disease at diagnosis. In the adjusted models, black women presented a higher risk of death than white women, regardless of the stage at diagnosis. For the subgroup of women in the southeast region, whose adjusted model included income, there was a difference in risk between races for stages III and IV. Adjusted analysis of survival-related factors for each race/skin color of the whole cohort revealed that conservative surgery combined with radiation therapy showed the greatest risk reduction for all skin color groups when compared to chemotherapy alone. Hormone therapy provided important reductions in the risk of death for all race/skin color groups. In the subgroup analysis, higher income was associated with lower risk of death for all skin color groups. Breast cancer is a public health problem that must be taken seriously by governments. The results of this thesis support the review of the breast cancer control strategy in Brazil, in that it showed the high pas in the country, and demonstrate that if this issue is best addressed, racial inequity with respect to survival can be mitigated.