Abstract

The objective of this study was to identify indicators of social inequalities associated with mortality from neoplasms in the Brazilian adult population. A scoping review method was used, establishing the guiding question: What is the effect of social inequalities on mortality from neoplasms in the Brazilian adult population? A total of 567 papers were identified, 22 of which were considered eligible. A variety of indicators were identified, such as the Human Development Index and the Gini Index, which primarily assessed differences in income, schooling, human development and vulnerability. A single pattern of association between the indicators and the different neoplasms was not established, nor was a single indicator capable of explaining the effect of social inequality at all levels of territorial area and by deaths from all types of neoplasms identified. It is known that mortality is influenced by social inequalities and that the study of indicators provides an opportunity to define which best explains deaths. This review highlights important gaps regarding the use of non-modifiable social indicators, analysis of small geographical areas, and limited use of multidimensional indicators.

Key words:
Mortality; Neoplasms; Social differences; Health inequality; Brazil

Introduction

In 2022, it was estimated that Brazil had a population of 212 million. Projections for 2040 indicate a population increase of 9.5%, with a reduction of 32% in the population under 15 and an increase of 138% in those 65 or over¹1 Bonifácio G, Guimarães R. Projeções populacionais por idade e sexo para o Brasil até 2100. Rio de Janeiro: Ipea; 2021.. Brazilian demographic adjustment tends to align with the epidemiological and health adjustment, whose mortality has been more frequent in more advanced age strata for non-communicable chronic diseases (NCCD), requiring an organized social response for their control²2 Souza MFM, Malta DC, França EB, Barreto ML. Transição da saúde e da doença no Brasil e nas Unidades Federadas durante os 30 anos do Sistema Único de Saúde. Cien Saude Colet 2018; 23(6):1737-1750.. Among the NCCD, neoplasms demand special attention, as the growth in mortality resulting from these conditions in Brazil is a consolidated fact, with a tendency to increase over time³3 Piñeros M, Laversanne M, Barrios E, Cancela MC, De Vries E, Pardo C, Bray F. An updated profile of the cancer burden, patterns and trends in Latin America and the Caribbean. Lancet Reg Health Am 2022; 13. DOI: 10.1016/j.lana.2022.100294
https://doi.org/10.1016/j.lana.2022.1002...

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Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 29 cancer groups, 1990 to 2017: a systematic analysis for the Global Burden of Disease Study. JAMA Oncol 2019; 5(12):1749-1768.^-55 GBD 2019 Cancer Risk Factors Collaborators. The global burden of cancer attributable to risk factors, 2010-19: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2022; 400(10352):563-591.. By 2020, the neoplastic mortality rate in Brazil was 122.7/100,000 inhabitants and, by 2040, it could reach 222/100,000, a rise of 80.9%⁶6 International Agency for Research on Cancer. Cancer tomorrow [Internet]. [cited 2022 ago 11]. Available from: https://gco.iarc.fr/tomorrow/en/dataviz/bars?types=1&single_unit=100000&populations=76&group_populations=1&multiple_populations=1&age_start=4&mode=population&bar_mode=stacked&key=total&show_bar_mode_prop=1
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Neoplasms are considered different diseases not only in molecular aspect, but also in the social, due to regional variability in the incidence and mortality profile, which are, in turn, influenced by different levels of socioeconomic development⁷7 Vale DB, Sauvaget C, Murillo R, Muwonge R, Zeferino LC, Sankaranarayanan R. Correlation of cervical cancer mortality with fertility, access to health care and socioeconomic indicators. Rev Bras Ginecol Obstet 2019; 41(4):249-255.. Socioeconomic development, which unfolds into different axes, such as income inequalities, schooling, geographical location, degree of urbanization, life expectancy, race/ethnicity and housing conditions, is considered a fundamental cause of mortality disparities, which affects the whole continuum of neoplasms⁸8 Vaccarella S, Lortet-Tieulent J, Saracci R, Conway DI, Straif K, Wild CP, editors. Reducing social inequalities in cancer: evidence and priorities for research [Internet]. Lyon: International Agency for Research on Cancer; 2019. [cited 2022 ago 12]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK566181/

9 Lortet-Tieulent J, Georges D, Bray F, Vaccarella S. Profiling global cancer incidence and mortality by socioeconomic development. Int J Cancer 2020; 147(11):3029-3036.

10 Lima KYN, Cancela MC, Souza DLB. Spatial assessment of advanced-stage diagnosis and lung cancer mortality in Brazil. PloS One 2022; 17(3):e0265321.^-1111 Oliveira NPD, Siqueira CAS, Lima KYN, Cancela MC, Souza DLB. Association of cervical and breast cancer mortality with socioeconomic indicators and availability of health services. Cancer Epidemiol 2020; 64:101660..

Modifiable risk factors for occurrence and mortality by neoplasms are subdivided into conventional and unconventional, the former being related to behavioral¹²12 Rezende LFM, Garcia LMT, Mielke GI, Lee DH, Giovannucci E, Eluf-Neto J. Physical activity and preventable premature deaths from non-communicable diseases in Brazil. J Public Health 2019; 41(3):e253-e60.^,1313 Torres-Domínguez JA, Betancourt AM, Mejía LSP, Noverón NR. Lung cancer mortality trends in Mexico, 1998-2018: the impact of the General Law on Tobacco Control. Rev Bras Epidemiol 2022; 25:e220003., food¹⁴14 Keum N, Giovannucci E. Global burden of colorectal cancer: emerging trends, risk factors and prevention strategies. Nat Rev Gastroenterol Hepatol 2019; 16(12):713-732., environmental¹⁵15 Yin J, Wu X, Li S, Li C, Guo Z. Impact of environmental factors on gastric cancer: A review of the scientific evidence, human prevention and adaptation. J Environ Sci (China) 2020; 89:65-79.^,1616 Ribeiro AG, Baquero OS, Freitas CU, Neto FC, Cardoso MRA, Latorre MRDO, Nardocci AC. Bayesian modeling of hematologic cancer and vehicular air pollution among young people in the city of São Paulo, Brazil. Int J Environ Health Res 2020; 30(5):504-514. and biological¹⁷17 Martel C, Georges D, Bray F, Ferlay J, Clifford GM. Global burden of cancer attributable to infections in 2018: a worldwide incidence analysis. Lancet Glob Health 2020; 8(2):e180-e190. factors, and the latter to social risk factors, whose magnitude of association may be greater than the association with conventional risk factors¹⁸18 Teng AM, Atkinson J, Disney G, Wilson N, Sarfati D, McLeod M, Blakely T. Ethnic inequalities in cancer incidence and mortality: census-linked cohort studies with 87 million years of person-time follow-up. BMC Cancer 2016; 16(1):755.

19 Zhao J, Miller KD, Islami F, Zheng Z, Han X, Ma J, Jemal A, Yabroff KR. Racial/ethnic disparities in lost earnings from cancer deaths in the United States. JNCI Cancer Spectr 2020; 4(5):pkaa038.^-2020 Bryere J, Tron L, Menvielle G, Launoy G; French Network of Cancer Registries (FRANCIM). The respective parts of incidence and lethality in socioeconomic differences in cancer mortality. An analysis of the French network Cancer registries (FRANCIM) data. Int J Equity Health 2019; 18(1):189.. Given this, different research aims at evaluation of the impacts of social inequalities on mortality by neoplasms, and seek to understand how they affect mortality, what indicators are involved, and how they are associated with the outcome.

The use of indicators is relevant to observe and describe the health condition of a population, boosting decision-making that impacts health improvement and reducing avoidable inequalities²¹21 Organização Pan-Americana da Saúde (Opas). Indicadores de saúde. Elementos conceituais e práticos [Internet]. 2018. [acessado 2022 ago 14]. Disponível em: https://iris.paho.org/handle/10665.2/49057?show=full
https://iris.paho.org/handle/10665.2/490... . Understanding the indicators that relate to mortality by neoplasms contributes to identification of vulnerable groups and to the debate on which measures should be adopted to control it, especially in cases of deaths from avoidable and preventable neoplasms⁹9 Lortet-Tieulent J, Georges D, Bray F, Vaccarella S. Profiling global cancer incidence and mortality by socioeconomic development. Int J Cancer 2020; 147(11):3029-3036.

10 Lima KYN, Cancela MC, Souza DLB. Spatial assessment of advanced-stage diagnosis and lung cancer mortality in Brazil. PloS One 2022; 17(3):e0265321.^-1111 Oliveira NPD, Siqueira CAS, Lima KYN, Cancela MC, Souza DLB. Association of cervical and breast cancer mortality with socioeconomic indicators and availability of health services. Cancer Epidemiol 2020; 64:101660.. It is important to highlight that mortality is also considered a potent indicator of the population’s health condition, and, like others, enables situation analysis, planning, assessment of actions and programs, reflecting not only the current situation, but the health changes of population groups, since mortality data is linked to demographic, geographical and cause of death information²¹21 Organização Pan-Americana da Saúde (Opas). Indicadores de saúde. Elementos conceituais e práticos [Internet]. 2018. [acessado 2022 ago 14]. Disponível em: https://iris.paho.org/handle/10665.2/49057?show=full
https://iris.paho.org/handle/10665.2/490... ^,2222 Brasil. Ministério da Saúde (MS). Asis - Análise de Situação de Saúde [Internet]. 2015. [acessado 2022 ago 3]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/asis_analise_situacao_saude_volume_1.pdf
https://bvsms.saude.gov.br/bvs/publicaco... .

The increase in the number of deaths from neoplasms, which is linked to age and the effect of social inequalities, arouses researchers’ interest in this health condition and how the relationship between death and socioeconomic contexts occurs. The research that describes this relationship present different methodologies, producing diversity in the correlations and associations found. Part of this is due to the very diversity of the causes of death by neoplasms and the different mechanisms of carcinogenesis²³23 Ferreira MC, Sarti FM, Barros MBA. Social inequalities in the incidence, mortality, and survival of neoplasms in women from a municipality in Southeastern Brazil. Cad Saude Publica 2022; 38(2):e00107521., which make the mapping of existing information complex, but also serious gaps in the literature have been identified that make understanding of where we have reached unfeasible, and how much must be done to elucidate the relationship between social inequality and neoplasm mortality²⁴24 Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol 2018; 18(1):143.. Thus, the aim of this study was to identify scientific evidence via the indicators of social inequalities associated with the outcome of neoplasms in the Brazilian adult population.

Methodology

This is a scope review developed from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews, whose recommended use is to assist with preparation of a report that contributes to the extension examination, range and nature of the available evidence²⁵25 Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L, Hempel S, Akl EA, Chang C, McGowan J, Stewart L, Hartling L, Aldcroft A, Wilson MG, Garritty C, Lewin S, Godfrey CM, Macdonald MT, Langlois EV, Soares-Weiser K, Moriarty J, Clifford T, Tunçalp Ö, Straus SE. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med 2018; 169(7):467-473.^,2626 McGowan J, Straus S, Moher D, Langlois EV, O'Brien KK, Horsley T, Aldcroft A, Zarin W, Garitty CM, Hempel S, Lillie E, Tunçalp ?, Tricco AC. Reporting scoping reviews - PRISMA ScR extension. J Clin Epidemiol 2020; 123:177-179.. This report was registered with the Open Science Framework (DOI 10.17605/OSF.io/C8UEX). The Population, Concept and Context strategy was applied, the Population being the mortality from neoplasms; the Concept, the relationship between mortality from neoplasms and social inequality; and the Context, Brazil. This review aimed to understand the differences in neoplasm mortality rate in socioeconomically distinct groups, starting from the following guiding question: “What is the effect of social inequalities on neoplasms in the Brazilian adult population?”.

Considered eligible for this review were articles in periodicals reviewed by peers, without initial date restriction, which were published until May 2022, written in Portuguese, English and Spanish, and analyzed the effect of different socioeconomic conditions on deaths caused by one or more causes defined in Chapter II - Neoplasias (tumors) - from the International Classification of Diseases, 2010 (ICD-10), which occurred in the Brazilian adult population (aged 19 year or over), of both sexes.

The exclusion criteria were articles that did not contemplate the age group in focus, review articles, meta-analyses and meta-syntheses; even so, their references were analyzed to verify the existence of some publication that had not been found in the search, experimental studies, conferences, abstracts, editorials, reports, comments, theses and dissertations.

The documents were extracted from the bases, Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed, in the Portal of the Biblioteca Virtual em Saúde (BVS), Scopus and Web of Science. These bases were chosen in terms of the benefits offered by each: Scopus provides a range of academic information, allowing a broader view of the research area; MEDLINE is the world’s most accessed international database, contemplating millions of quality references; Web of Science is a site that provides access to various databases, enabling simultaneous exploration; and BVS focuses on information and knowledge production for the Latin America and Caribbean region²⁵25 Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L, Hempel S, Akl EA, Chang C, McGowan J, Stewart L, Hartling L, Aldcroft A, Wilson MG, Garritty C, Lewin S, Godfrey CM, Macdonald MT, Langlois EV, Soares-Weiser K, Moriarty J, Clifford T, Tunçalp Ö, Straus SE. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med 2018; 169(7):467-473..

The search was conducted from March to May 2022. The descriptors and terms were extracted from the descriptors in Ciências da Saúde (DeCS) and Medical Subject Headings (MeSH), respectively. Data management was performed with the aid of Zotero and Microsoft Excel 2010 softwares. The search strategy used (Chart 1) was planned to retrieve studies that contained at least one of the terms of each concept (neoplasms; mortality; socioeconomic factors; Brazil). The first stage of evidence selection was independent and sequential from the title, followed by the abstract. Once elements corresponding to the guiding question were identified, the document was considered potentially relevant. The second stage involved complete reading of the publication and whether or not its inclusion in the review would be granted.

Results

The search covered 567 works, 284 of which were duplicates; after reading the titles and abstracts, 236 were removed because they did not comply with the inclusion criteria. In the end, 47 articles were read in full; of these, 22 were considered eligible (Figure 1). The studies included in this review were published between 2008 and 2022, 16 (72.7 %) in the last five years. 10 (45.5 %) assessed the Breast Neoplasia Mortality outcome and only one approached all the neoplasms. Regarding the type of study, 17 were described as ecological, three as temporal series, one as observational and one as ecological and temporal series combined.

Different demographic profiles were addressed in the studies. 54.5% of the work assessed mortality only among women, 45.5% for both sexes and only 1 exclusively assessed the elderly. The levels of territorial area covered in the studies were municipality (27%), state (45.5%), region (22%) and intermediate regions of urban articulation (13.6%) exceeding 100%, as some analyzed more than one area level. Chart 2 includes a summary of the studies included.

Social inequality indicators

In all the articles selected, unidimensional indicators were identified that proposed measurement of the effect of income on neoplasm mortality. They were: income per capita⁷7 Vale DB, Sauvaget C, Murillo R, Muwonge R, Zeferino LC, Sankaranarayanan R. Correlation of cervical cancer mortality with fertility, access to health care and socioeconomic indicators. Rev Bras Ginecol Obstet 2019; 41(4):249-255.^,1010 Lima KYN, Cancela MC, Souza DLB. Spatial assessment of advanced-stage diagnosis and lung cancer mortality in Brazil. PloS One 2022; 17(3):e0265321.^,1111 Oliveira NPD, Siqueira CAS, Lima KYN, Cancela MC, Souza DLB. Association of cervical and breast cancer mortality with socioeconomic indicators and availability of health services. Cancer Epidemiol 2020; 64:101660.^,2727 Ramos JLS, Figueiredo FWDS, Zuchelo LTS, Purcino FAC, Adami F, Goncalves R, Ruiz CA, Baracat EC, Soares Junior JM, Sorpreso ICE. Health services, socioeconomic indicators, and primary care coverage in mortality by lower genital tract and breast neoplasias in Brazilian women during reproductive and non-reproductive periods. Int J Environ Res Public Health 2020; 17(16):5804.

28 Sakamoto AJ, Brizon VSC, Bulgareli JV, Ambrosano GMB, Hebling E. Influence of municipal socioeconomic indices on mortality rates for oral and oropharyngeal cancer in older adults in the State of São Paulo, Brazil. Rev Bras Epidemiol 2019; 22:e190013.

29 Moi GP, Silva AMC, Galvão ND, Meneghim MC, Pereira AC. Spatial analysis of the death associated factors due oral cancer in Brazil: an ecological study. BMC Oral Health 2018; 18(1):14.

30 Rocha-Brischiliari SC, Andrade L, Nihei OK, Brischiliari A, Hortelan MDS, Carvalho MDB, Pelloso SM. Spatial distribution of breast cancer mortality: socioeconomic disparities and access to treatment in the state of Parana, Brazil. PloS One 2018; 13(10):e0205253.

31 Oliveira MM, Latorre MRDO, Tanaka LF, Rossi BM, Curado MP. Disparities in colorectal cancer mortality across Brazilian states. Rev Bras Epidemiol 2018; 21:e180012.

32 Barbosa IR, Costa ICC, Pérez MMB, Souza DLB. Desigualdades socioeconômicas e mortalidade por câncer: um estudo ecológico no Brasil. Rev Bras Prom Saude 2016; 29(3):350-356.^-3333 Duarte DAP, Nogueira MC, Magalhães MC, Bustamante-Teixeira MT. Iniquidade social e câncer de mama feminino: análise da mortalidade. Cad Saude Colet 2020; 28(4):465-476., poverty percentage¹¹11 Oliveira NPD, Siqueira CAS, Lima KYN, Cancela MC, Souza DLB. Association of cervical and breast cancer mortality with socioeconomic indicators and availability of health services. Cancer Epidemiol 2020; 64:101660.^,3434 Carvalho JB, Paes NA. Socioeconomic inequalities in breast cancer mortality in microregions of the Brazilian Northeast. Rev Bras Saude Materno Infant 2019; 19(2):391-400., income quintile³⁵35 Figueiredo FWDS, Adami F. Income inequality and mortality owing to breast cancer: evidence from Brazil. Clin Breast Cancer 2018; 18(4):e651--e658., average household income³⁶36 Müller EV, Biazevic MGH, Antunes JLF, Crosato EM. Socioeconomic trends and differentials in mortality due to cervical cancer in the State of Paraná (Brazil), 1980-2000. Cien Saude Colet 2011; 16(5):2495-2500., Palma Index³⁵35 Figueiredo FWDS, Adami F. Income inequality and mortality owing to breast cancer: evidence from Brazil. Clin Breast Cancer 2018; 18(4):e651--e658., Theil-L Index³⁵35 Figueiredo FWDS, Adami F. Income inequality and mortality owing to breast cancer: evidence from Brazil. Clin Breast Cancer 2018; 18(4):e651--e658., Gini Index¹⁰10 Lima KYN, Cancela MC, Souza DLB. Spatial assessment of advanced-stage diagnosis and lung cancer mortality in Brazil. PloS One 2022; 17(3):e0265321.^,1111 Oliveira NPD, Siqueira CAS, Lima KYN, Cancela MC, Souza DLB. Association of cervical and breast cancer mortality with socioeconomic indicators and availability of health services. Cancer Epidemiol 2020; 64:101660.^,2727 Ramos JLS, Figueiredo FWDS, Zuchelo LTS, Purcino FAC, Adami F, Goncalves R, Ruiz CA, Baracat EC, Soares Junior JM, Sorpreso ICE. Health services, socioeconomic indicators, and primary care coverage in mortality by lower genital tract and breast neoplasias in Brazilian women during reproductive and non-reproductive periods. Int J Environ Res Public Health 2020; 17(16):5804.^,3131 Oliveira MM, Latorre MRDO, Tanaka LF, Rossi BM, Curado MP. Disparities in colorectal cancer mortality across Brazilian states. Rev Bras Epidemiol 2018; 21:e180012.^,3232 Barbosa IR, Costa ICC, Pérez MMB, Souza DLB. Desigualdades socioeconômicas e mortalidade por câncer: um estudo ecológico no Brasil. Rev Bras Prom Saude 2016; 29(3):350-356.^,3535 Figueiredo FWDS, Adami F. Income inequality and mortality owing to breast cancer: evidence from Brazil. Clin Breast Cancer 2018; 18(4):e651--e658.

36 Müller EV, Biazevic MGH, Antunes JLF, Crosato EM. Socioeconomic trends and differentials in mortality due to cervical cancer in the State of Paraná (Brazil), 1980-2000. Cien Saude Colet 2011; 16(5):2495-2500.

37 Oliveira NPD, Cancela MC, Martins LFL, Souza DLB. Spatial distribution of advanced stage diagnosis and mortality of breast cancer: socioeconomic and health service offer inequalities in Brazil. PloS One 2021; 16(2):e0246333.

38 Freire AR, Freire DEWG, Araújo ECF, Lucena EHG, Cavalcanti YW. Influence of public oral health services and socioeconomic indicators on the frequency of hospitalization and deaths due to oral cancer in Brazil, between 2002-2017. Int J Environ Res Public Health 2020; 18(1):e238.

39 Figueiredo FWS, Adami F. Effects of the high-inequality of income on the breast cancer mortality in Brazil. Sci Rep 2019; 9(1):4173.

40 Ferreira MAF, Gomes MN, Michels FAS, Dantas AA, Latorre MRDO. Social inequality in morbidity and mortality from oral and oropharyngeal cancer in the city of São Paulo, Brazil: 1997-2008. Cad Saude Publica 2012; 28(9):1663-1673.^-4141 Borges DML, Sena MF, Ferreira MAF, Roncalli AG. Mortality for oral cancer and socioeconomic status in Brazil. Cad Saude Publica 2009; 25(2):321-327. and percentage of household heads who declared absence of a formal income⁴²42 Antunes JLF, Borrell C, Rodríguez-Sanz M, Pérez G, Biazevic MGH, Wünsch-Filho V. Sex and socioeconomic inequalities of lung cancer mortality in Barcelona, Spain and São Paulo, Brazil. Eur J Cancer Prev 2008; 17(5):399-405..

Following the income indicators, those of schooling were the most outstanding, present in 45.5% of the studies, measured through: the population’s average number of years of study²⁷27 Ramos JLS, Figueiredo FWDS, Zuchelo LTS, Purcino FAC, Adami F, Goncalves R, Ruiz CA, Baracat EC, Soares Junior JM, Sorpreso ICE. Health services, socioeconomic indicators, and primary care coverage in mortality by lower genital tract and breast neoplasias in Brazilian women during reproductive and non-reproductive periods. Int J Environ Res Public Health 2020; 17(16):5804., percentage of individuals aged ≤ 25 years with over 11 years of schooling⁴³43 Girianelli VR, Gamarra CJ, Silva GA. Disparities in cervical and breast cancer mortality in Brazil. Rev Saude Publica 2014; 48(3):459-467., educational level³⁶36 Müller EV, Biazevic MGH, Antunes JLF, Crosato EM. Socioeconomic trends and differentials in mortality due to cervical cancer in the State of Paraná (Brazil), 1980-2000. Cien Saude Colet 2011; 16(5):2495-2500., percentage of household heads with less than 4 years of schooling⁴²42 Antunes JLF, Borrell C, Rodríguez-Sanz M, Pérez G, Biazevic MGH, Wünsch-Filho V. Sex and socioeconomic inequalities of lung cancer mortality in Barcelona, Spain and São Paulo, Brazil. Eur J Cancer Prev 2008; 17(5):399-405., percentage of household heads who had completed a university course⁴²42 Antunes JLF, Borrell C, Rodríguez-Sanz M, Pérez G, Biazevic MGH, Wünsch-Filho V. Sex and socioeconomic inequalities of lung cancer mortality in Barcelona, Spain and São Paulo, Brazil. Eur J Cancer Prev 2008; 17(5):399-405., female illiteracy rate¹¹11 Oliveira NPD, Siqueira CAS, Lima KYN, Cancela MC, Souza DLB. Association of cervical and breast cancer mortality with socioeconomic indicators and availability of health services. Cancer Epidemiol 2020; 64:101660.^,2727 Ramos JLS, Figueiredo FWDS, Zuchelo LTS, Purcino FAC, Adami F, Goncalves R, Ruiz CA, Baracat EC, Soares Junior JM, Sorpreso ICE. Health services, socioeconomic indicators, and primary care coverage in mortality by lower genital tract and breast neoplasias in Brazilian women during reproductive and non-reproductive periods. Int J Environ Res Public Health 2020; 17(16):5804. and general illiteracy rate⁷7 Vale DB, Sauvaget C, Murillo R, Muwonge R, Zeferino LC, Sankaranarayanan R. Correlation of cervical cancer mortality with fertility, access to health care and socioeconomic indicators. Rev Bras Ginecol Obstet 2019; 41(4):249-255.^,2929 Moi GP, Silva AMC, Galvão ND, Meneghim MC, Pereira AC. Spatial analysis of the death associated factors due oral cancer in Brazil: an ecological study. BMC Oral Health 2018; 18(1):14.^,3030 Rocha-Brischiliari SC, Andrade L, Nihei OK, Brischiliari A, Hortelan MDS, Carvalho MDB, Pelloso SM. Spatial distribution of breast cancer mortality: socioeconomic disparities and access to treatment in the state of Parana, Brazil. PloS One 2018; 13(10):e0205253.^,3232 Barbosa IR, Costa ICC, Pérez MMB, Souza DLB. Desigualdades socioeconômicas e mortalidade por câncer: um estudo ecológico no Brasil. Rev Bras Prom Saude 2016; 29(3):350-356.^,3434 Carvalho JB, Paes NA. Socioeconomic inequalities in breast cancer mortality in microregions of the Brazilian Northeast. Rev Bras Saude Materno Infant 2019; 19(2):391-400.^,3636 Müller EV, Biazevic MGH, Antunes JLF, Crosato EM. Socioeconomic trends and differentials in mortality due to cervical cancer in the State of Paraná (Brazil), 1980-2000. Cien Saude Colet 2011; 16(5):2495-2500.^,4343 Girianelli VR, Gamarra CJ, Silva GA. Disparities in cervical and breast cancer mortality in Brazil. Rev Saude Publica 2014; 48(3):459-467..

Other unidimensional indicators were identified, namely: fertility rate⁷7 Vale DB, Sauvaget C, Murillo R, Muwonge R, Zeferino LC, Sankaranarayanan R. Correlation of cervical cancer mortality with fertility, access to health care and socioeconomic indicators. Rev Bras Ginecol Obstet 2019; 41(4):249-255., unemployment rate³⁶36 Müller EV, Biazevic MGH, Antunes JLF, Crosato EM. Socioeconomic trends and differentials in mortality due to cervical cancer in the State of Paraná (Brazil), 1980-2000. Cien Saude Colet 2011; 16(5):2495-2500., aging rate¹⁰10 Lima KYN, Cancela MC, Souza DLB. Spatial assessment of advanced-stage diagnosis and lung cancer mortality in Brazil. PloS One 2022; 17(3):e0265321., life expectancy³²32 Barbosa IR, Costa ICC, Pérez MMB, Souza DLB. Desigualdades socioeconômicas e mortalidade por câncer: um estudo ecológico no Brasil. Rev Bras Prom Saude 2016; 29(3):350-356., percentage of economically active women³⁴34 Carvalho JB, Paes NA. Socioeconomic inequalities in breast cancer mortality in microregions of the Brazilian Northeast. Rev Bras Saude Materno Infant 2019; 19(2):391-400., live alone³⁴34 Carvalho JB, Paes NA. Socioeconomic inequalities in breast cancer mortality in microregions of the Brazilian Northeast. Rev Bras Saude Materno Infant 2019; 19(2):391-400., percentage of female family heads, single and with children ≤ 15⁴³43 Girianelli VR, Gamarra CJ, Silva GA. Disparities in cervical and breast cancer mortality in Brazil. Rev Saude Publica 2014; 48(3):459-467., percentage of heads of household who declared absence of formal income⁴²42 Antunes JLF, Borrell C, Rodríguez-Sanz M, Pérez G, Biazevic MGH, Wünsch-Filho V. Sex and socioeconomic inequalities of lung cancer mortality in Barcelona, Spain and São Paulo, Brazil. Eur J Cancer Prev 2008; 17(5):399-405., degree of urbanization¹⁰10 Lima KYN, Cancela MC, Souza DLB. Spatial assessment of advanced-stage diagnosis and lung cancer mortality in Brazil. PloS One 2022; 17(3):e0265321.^,3030 Rocha-Brischiliari SC, Andrade L, Nihei OK, Brischiliari A, Hortelan MDS, Carvalho MDB, Pelloso SM. Spatial distribution of breast cancer mortality: socioeconomic disparities and access to treatment in the state of Parana, Brazil. PloS One 2018; 13(10):e0205253.^,3333 Duarte DAP, Nogueira MC, Magalhães MC, Bustamante-Teixeira MT. Iniquidade social e câncer de mama feminino: análise da mortalidade. Cad Saude Colet 2020; 28(4):465-476., Gross Domestic Product⁷7 Vale DB, Sauvaget C, Murillo R, Muwonge R, Zeferino LC, Sankaranarayanan R. Correlation of cervical cancer mortality with fertility, access to health care and socioeconomic indicators. Rev Bras Ginecol Obstet 2019; 41(4):249-255.^,3131 Oliveira MM, Latorre MRDO, Tanaka LF, Rossi BM, Curado MP. Disparities in colorectal cancer mortality across Brazilian states. Rev Bras Epidemiol 2018; 21:e180012., infant mortality rate⁴¹41 Borges DML, Sena MF, Ferreira MAF, Roncalli AG. Mortality for oral cancer and socioeconomic status in Brazil. Cad Saude Publica 2009; 25(2):321-327.^,4343 Girianelli VR, Gamarra CJ, Silva GA. Disparities in cervical and breast cancer mortality in Brazil. Rev Saude Publica 2014; 48(3):459-467., and housing conditions³⁴34 Carvalho JB, Paes NA. Socioeconomic inequalities in breast cancer mortality in microregions of the Brazilian Northeast. Rev Bras Saude Materno Infant 2019; 19(2):391-400.^,4343 Girianelli VR, Gamarra CJ, Silva GA. Disparities in cervical and breast cancer mortality in Brazil. Rev Saude Publica 2014; 48(3):459-467..

The multidimensional indicator, Human Development Index was what stood out, found in 63.7% of the studies⁷7 Vale DB, Sauvaget C, Murillo R, Muwonge R, Zeferino LC, Sankaranarayanan R. Correlation of cervical cancer mortality with fertility, access to health care and socioeconomic indicators. Rev Bras Ginecol Obstet 2019; 41(4):249-255.^,1111 Oliveira NPD, Siqueira CAS, Lima KYN, Cancela MC, Souza DLB. Association of cervical and breast cancer mortality with socioeconomic indicators and availability of health services. Cancer Epidemiol 2020; 64:101660.^,2828 Sakamoto AJ, Brizon VSC, Bulgareli JV, Ambrosano GMB, Hebling E. Influence of municipal socioeconomic indices on mortality rates for oral and oropharyngeal cancer in older adults in the State of São Paulo, Brazil. Rev Bras Epidemiol 2019; 22:e190013.

29 Moi GP, Silva AMC, Galvão ND, Meneghim MC, Pereira AC. Spatial analysis of the death associated factors due oral cancer in Brazil: an ecological study. BMC Oral Health 2018; 18(1):14.^-3030 Rocha-Brischiliari SC, Andrade L, Nihei OK, Brischiliari A, Hortelan MDS, Carvalho MDB, Pelloso SM. Spatial distribution of breast cancer mortality: socioeconomic disparities and access to treatment in the state of Parana, Brazil. PloS One 2018; 13(10):e0205253.^,3333 Duarte DAP, Nogueira MC, Magalhães MC, Bustamante-Teixeira MT. Iniquidade social e câncer de mama feminino: análise da mortalidade. Cad Saude Colet 2020; 28(4):465-476.^,3636 Müller EV, Biazevic MGH, Antunes JLF, Crosato EM. Socioeconomic trends and differentials in mortality due to cervical cancer in the State of Paraná (Brazil), 1980-2000. Cien Saude Colet 2011; 16(5):2495-2500.

37 Oliveira NPD, Cancela MC, Martins LFL, Souza DLB. Spatial distribution of advanced stage diagnosis and mortality of breast cancer: socioeconomic and health service offer inequalities in Brazil. PloS One 2021; 16(2):e0246333.^-3838 Freire AR, Freire DEWG, Araújo ECF, Lucena EHG, Cavalcanti YW. Influence of public oral health services and socioeconomic indicators on the frequency of hospitalization and deaths due to oral cancer in Brazil, between 2002-2017. Int J Environ Res Public Health 2020; 18(1):e238.^,4040 Ferreira MAF, Gomes MN, Michels FAS, Dantas AA, Latorre MRDO. Social inequality in morbidity and mortality from oral and oropharyngeal cancer in the city of São Paulo, Brazil: 1997-2008. Cad Saude Publica 2012; 28(9):1663-1673.^,4141 Borges DML, Sena MF, Ferreira MAF, Roncalli AG. Mortality for oral cancer and socioeconomic status in Brazil. Cad Saude Publica 2009; 25(2):321-327.^,4343 Girianelli VR, Gamarra CJ, Silva GA. Disparities in cervical and breast cancer mortality in Brazil. Rev Saude Publica 2014; 48(3):459-467.^,4444 Fernandes GA, Menezes FDS, Silva LF, Antunes JLF, Toporcov TN. Inequalities in lung cancer mortality trends in Brazil, 2000-2015. Sci Rep 2020; 10(1):19164.. Other less frequently used multidimensional indicators were the Health Vulnerability Index³³33 Duarte DAP, Nogueira MC, Magalhães MC, Bustamante-Teixeira MT. Iniquidade social e câncer de mama feminino: análise da mortalidade. Cad Saude Colet 2020; 28(4):465-476. and the Social Vulnerability Index²³23 Ferreira MC, Sarti FM, Barros MBA. Social inequalities in the incidence, mortality, and survival of neoplasms in women from a municipality in Southeastern Brazil. Cad Saude Publica 2022; 38(2):e00107521., which appeared once each.

Discussion

The majority of the studies were ecological, but it is important to consider their limitations. In this design, exposure measurements are a proxy based on the population average, and require care when extrapolating the findings to the individual level. Another limiting factor is the information quality, as there may be systematic differences in the recording of disease frequency and the completeness of the data, as well as the availability of information about confusing factors⁴⁵45 Neumark Y. What can ecological studies tell us about death? Isr J Health Policy Res 2017; 6(1):52. Costa ACO, Ferreira BH, Souza MR, Costa Filho AM, Souza AA. Análise da qualidade da informação sobre óbitos por neoplasias no Brasil, entre 2009 e 2019. Rev Bras Epidemiol 2022; 25:e220022.^,4646 Batista HR, Mollo MLR. A questão da desigualdade multidimensional: discutindo a construção de um indicador. Rev Econ Contemp 2021; 25(1):e212516..

In this review, the use of unidimensional indicators was identified, which refer to a single dimension of inequalities, and for this reason they are not able to contextualize the complexity of the disparities between groups. Multidimensional indicators were also observed, which seek to unify the individual, home and social dimensions of the inequalities, thus offering a more realistic response to health conditions⁴⁷47 Rezende LFM, Lee DH, Louzada MLC, Song M, Giovannucci E, Eluf-Neto J. Proportion of cancer cases and deaths attributable to lifestyle risk factors in Brazil. Cancer Epidemiol 2019; 59:148-157..

The existence of multiple social indicators provides an opportunity to study neoplasm mortality, enabling observation of the difference in the association patterns with the various types of neoplasms, and how social factors, information quality and geographical area level impact outcomes. According to CID-10, there are approximately 852 neoplastic conditions whose carcinogenesis processes are influenced by behavioral⁴⁸48 Wray AJD, Minaker LM. Is cancer prevention influenced by the built environment? A multidisciplinary scoping review. Cancer 2019; 125(19):3299-3311., environmental⁴⁹49 Arbyn M, Weiderpass E, Bruni L, Sanjosé S, Saraiya M, Ferlay J, Bray F. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. Lancet Glob Health 2020; 8(2):e191-e203., social²⁰20 Bryere J, Tron L, Menvielle G, Launoy G; French Network of Cancer Registries (FRANCIM). The respective parts of incidence and lethality in socioeconomic differences in cancer mortality. An analysis of the French network Cancer registries (FRANCIM) data. Int J Equity Health 2019; 18(1):189., biological⁵⁰50 Brand NR, Qu LG, Chao A, Ilbawi AM. Delays and barriers to cancer care in low- and middle-income countries: a systematic review. Oncologist 2019; 24(12):e1371-e1380. factors and access to health services¹¹11 Oliveira NPD, Siqueira CAS, Lima KYN, Cancela MC, Souza DLB. Association of cervical and breast cancer mortality with socioeconomic indicators and availability of health services. Cancer Epidemiol 2020; 64:101660.^,5151 Dean LT, Gehlert S, Neuhouser ML, Oh A, Zanetti K, Goodman M, Thompson B, Visvanathan K, Schmitz KH. Social factors matter in cancer risk and survivorship. Cancer Causes Control 2018; 29(7):611-618., all these, in turn, influenced by social inequalities³⁰30 Rocha-Brischiliari SC, Andrade L, Nihei OK, Brischiliari A, Hortelan MDS, Carvalho MDB, Pelloso SM. Spatial distribution of breast cancer mortality: socioeconomic disparities and access to treatment in the state of Parana, Brazil. PloS One 2018; 13(10):e0205253.^,3333 Duarte DAP, Nogueira MC, Magalhães MC, Bustamante-Teixeira MT. Iniquidade social e câncer de mama feminino: análise da mortalidade. Cad Saude Colet 2020; 28(4):465-476.^,3535 Figueiredo FWDS, Adami F. Income inequality and mortality owing to breast cancer: evidence from Brazil. Clin Breast Cancer 2018; 18(4):e651--e658.^,3636 Müller EV, Biazevic MGH, Antunes JLF, Crosato EM. Socioeconomic trends and differentials in mortality due to cervical cancer in the State of Paraná (Brazil), 1980-2000. Cien Saude Colet 2011; 16(5):2495-2500.^,4040 Ferreira MAF, Gomes MN, Michels FAS, Dantas AA, Latorre MRDO. Social inequality in morbidity and mortality from oral and oropharyngeal cancer in the city of São Paulo, Brazil: 1997-2008. Cad Saude Publica 2012; 28(9):1663-1673.^,4343 Girianelli VR, Gamarra CJ, Silva GA. Disparities in cervical and breast cancer mortality in Brazil. Rev Saude Publica 2014; 48(3):459-467..

Regarding social factors whose exposure increases the mortality risk, they are considered heterogeneous, reflecting differences in human development, exposure to carcinogens and availability of health resources in different areas of the country¹⁰10 Lima KYN, Cancela MC, Souza DLB. Spatial assessment of advanced-stage diagnosis and lung cancer mortality in Brazil. PloS One 2022; 17(3):e0265321.^,2727 Ramos JLS, Figueiredo FWDS, Zuchelo LTS, Purcino FAC, Adami F, Goncalves R, Ruiz CA, Baracat EC, Soares Junior JM, Sorpreso ICE. Health services, socioeconomic indicators, and primary care coverage in mortality by lower genital tract and breast neoplasias in Brazilian women during reproductive and non-reproductive periods. Int J Environ Res Public Health 2020; 17(16):5804.^,2929 Moi GP, Silva AMC, Galvão ND, Meneghim MC, Pereira AC. Spatial analysis of the death associated factors due oral cancer in Brazil: an ecological study. BMC Oral Health 2018; 18(1):14.^,3434 Carvalho JB, Paes NA. Socioeconomic inequalities in breast cancer mortality in microregions of the Brazilian Northeast. Rev Bras Saude Materno Infant 2019; 19(2):391-400.^,3535 Figueiredo FWDS, Adami F. Income inequality and mortality owing to breast cancer: evidence from Brazil. Clin Breast Cancer 2018; 18(4):e651--e658.^,3838 Freire AR, Freire DEWG, Araújo ECF, Lucena EHG, Cavalcanti YW. Influence of public oral health services and socioeconomic indicators on the frequency of hospitalization and deaths due to oral cancer in Brazil, between 2002-2017. Int J Environ Res Public Health 2020; 18(1):e238.^,4444 Fernandes GA, Menezes FDS, Silva LF, Antunes JLF, Toporcov TN. Inequalities in lung cancer mortality trends in Brazil, 2000-2015. Sci Rep 2020; 10(1):19164.. According to Dean et al. (2018)⁵²52 Queiroz BL, Freire FHMA, Gonzaga MR, Lima EEC. Estimativas do grau de cobertura e da mortalidade adulta (45q15) para as unidades da federação no Brasil entre 1980 e 2010. Rev Bras Epidemiol 2017; 20(Supl. 1):21-33., socioeconomic position influences the incidence and mortality from neoplasms, and needs to be considered in the research, as lack of understanding of this factor is what sustains the disparities in incidence and mortality.

The outstanding social indicators were the Human Development Index (HDI) and income measurements, which, when associated with neoplasm mortality from different causes, did not have a single associative pattern. In the research by Oliveira et al. (2020)¹¹11 Oliveira NPD, Siqueira CAS, Lima KYN, Cancela MC, Souza DLB. Association of cervical and breast cancer mortality with socioeconomic indicators and availability of health services. Cancer Epidemiol 2020; 64:101660.. standardized cervical neoplasm mortality rates were negatively associated with regions presenting lower HDI levels, while the opposite was verified for standardized breast neoplasm mortality rates. In this same research, the authors demonstrate that the effect of inequality on uterine neoplasm mortality demands action to reduce exposure to risk factors and expand access to prevention, diagnosis and treatment services, especially among socioeconomically disadvantaged women resident in regions with the highest levels of social inequality and the lowest levels of human development. Regarding Breast Neoplasia Mortality, Oliveira et al. (2020)¹¹11 Oliveira NPD, Siqueira CAS, Lima KYN, Cancela MC, Souza DLB. Association of cervical and breast cancer mortality with socioeconomic indicators and availability of health services. Cancer Epidemiol 2020; 64:101660. suggest reverse causality, that is, areas with greater development and greater provision of licensed oncology services have more diagnoses and, consequently, higher mortality.

In the work by Lima et al. (2022)¹⁰10 Lima KYN, Cancela MC, Souza DLB. Spatial assessment of advanced-stage diagnosis and lung cancer mortality in Brazil. PloS One 2022; 17(3):e0265321., which assessed, among other indicators, the effect of income per capita on lung neoplasm mortality, it was evidenced that the highest mortality rates according to age were verified in regions with higher income per capita, and regions with lower income concentrated lower rates. The authors believe that this effect is due to factors such as high exposure to risk agents, the highest aging rates in regions with better demographic and socioeconomic indicators, plus the effect of reverse causality¹⁰10 Lima KYN, Cancela MC, Souza DLB. Spatial assessment of advanced-stage diagnosis and lung cancer mortality in Brazil. PloS One 2022; 17(3):e0265321..

For Sakamoto et al. (2019)²⁸28 Sakamoto AJ, Brizon VSC, Bulgareli JV, Ambrosano GMB, Hebling E. Influence of municipal socioeconomic indices on mortality rates for oral and oropharyngeal cancer in older adults in the State of São Paulo, Brazil. Rev Bras Epidemiol 2019; 22:e190013., who assessed the effect of mean income per capita on oral and oropharynx neoplasms among the elderly, the association was negative: with increase in income there was a reduction in the mortality rate. The authors emphasize that the findings diverge from those of other previously published studies, whose associations with socioeconomic conditions are positive, due to the longer life expectancy in these locations and the death records system of better quality. Thus, they believe that the inverse effect is due to the use of a sample more vulnerable to the occurrence of the disease, as well as the increased exposure to risk factors in socioeconomically disadvantaged groups²⁸28 Sakamoto AJ, Brizon VSC, Bulgareli JV, Ambrosano GMB, Hebling E. Influence of municipal socioeconomic indices on mortality rates for oral and oropharyngeal cancer in older adults in the State of São Paulo, Brazil. Rev Bras Epidemiol 2019; 22:e190013..

The quality of information, necessary to reflect the health condition of the population, is not homogeneous throughout the country⁴⁶46 Batista HR, Mollo MLR. A questão da desigualdade multidimensional: discutindo a construção de um indicador. Rev Econ Contemp 2021; 25(1):e212516.. Less developed regions are those with worse data quality indicators, a fact that impacts the mortality rate by neoplasms and the possibility of knowing the real trend of this event³3 Piñeros M, Laversanne M, Barrios E, Cancela MC, De Vries E, Pardo C, Bray F. An updated profile of the cancer burden, patterns and trends in Latin America and the Caribbean. Lancet Reg Health Am 2022; 13. DOI: 10.1016/j.lana.2022.100294
https://doi.org/10.1016/j.lana.2022.1002... ^,3131 Oliveira MM, Latorre MRDO, Tanaka LF, Rossi BM, Curado MP. Disparities in colorectal cancer mortality across Brazilian states. Rev Bras Epidemiol 2018; 21:e180012.^,3737 Oliveira NPD, Cancela MC, Martins LFL, Souza DLB. Spatial distribution of advanced stage diagnosis and mortality of breast cancer: socioeconomic and health service offer inequalities in Brazil. PloS One 2021; 16(2):e0246333.^,4141 Borges DML, Sena MF, Ferreira MAF, Roncalli AG. Mortality for oral cancer and socioeconomic status in Brazil. Cad Saude Publica 2009; 25(2):321-327.^,4242 Antunes JLF, Borrell C, Rodríguez-Sanz M, Pérez G, Biazevic MGH, Wünsch-Filho V. Sex and socioeconomic inequalities of lung cancer mortality in Barcelona, Spain and São Paulo, Brazil. Eur J Cancer Prev 2008; 17(5):399-405.^,5353 Bigoni A, Ferreira Antunes JL, Weiderpass E, Kjærheim K. Describing mortality trends for major cancer sites in 133 intermediate regions of Brazil and an ecological study of its causes. BMC Cancer 2019; 19(1):940.. For this reason, correction of deaths from ill-defined causes is essential, especially in regions where data quality is considered regular or poor⁵⁴54 Dantas de Araújo Santos Camargo J, Dos Santos J, Simões TC, Carvalho JBL, Silva GWDS, Dantas ESO, Rodrigues WTDS, Freire FHMA, Meira KC. Mortality due to breast cancer in a region of high socioeconomic vulnerability in Brazil: analysis of the effect of age-period and cohort. PLoS One 2021; 16(8):e0255935.^,5555 Bilal U, Alazraqui M, Caiaffa WT, Lopez-Olmedo N, Martinez-Folgar K, Miranda JJ, Rodriguez DA, Vives A, Diez-Roux AV. Inequalities in life expectancy in six large Latin American cities from the SALURBAL study: an ecological analysis. Lancet Planet Health 2019; 3(12):e503-e510.. A study by Oliveira et al. (2018)³¹31 Oliveira MM, Latorre MRDO, Tanaka LF, Rossi BM, Curado MP. Disparities in colorectal cancer mortality across Brazilian states. Rev Bras Epidemiol 2018; 21:e180012., whose principal objective was to assess mortality from colorectal neoplasia, showed that mortality rates increased from 1996 to 2012 in all the states for males, but the majority were females. By adjusting the statistical model due to poorly defined causes, the tendency to increase remained in 20 states for males and 10 for females, highlighting the influence of information quality on the analysis of trends. The authors also pointed out that the highest average mean mortality rates due to poorly defined causes were observed in states in the North and Northeast, which are considered less developed³¹31 Oliveira MM, Latorre MRDO, Tanaka LF, Rossi BM, Curado MP. Disparities in colorectal cancer mortality across Brazilian states. Rev Bras Epidemiol 2018; 21:e180012..

For research on health outcomes, such as neoplasm mortality, to achieve more reliable results matching the Brazilian reality, it is recommended that the impact of social inequalities be placed at the center of discussion and verified in the spatial sphere, taking into account the country’s different regional scenarios³⁰30 Rocha-Brischiliari SC, Andrade L, Nihei OK, Brischiliari A, Hortelan MDS, Carvalho MDB, Pelloso SM. Spatial distribution of breast cancer mortality: socioeconomic disparities and access to treatment in the state of Parana, Brazil. PloS One 2018; 13(10):e0205253.^,5656 Marcelino AC, Gozzi B, Cardoso-Filho C, Machado H, Zeferino LC, Vale DB. Race disparities in mortality by breast cancer from 2000 to 2017 in São Paulo, Brazil: a population-based retrospective study. BMC Cancer 2021; 21(1):998.. In this review, different levels of geographical area were addressed, and the similarity between neoplastic site and inequality indicators did not confer equivalence to the findings.

The research conducted by Freire et al. (2020)³⁸38 Freire AR, Freire DEWG, Araújo ECF, Lucena EHG, Cavalcanti YW. Influence of public oral health services and socioeconomic indicators on the frequency of hospitalization and deaths due to oral cancer in Brazil, between 2002-2017. Int J Environ Res Public Health 2020; 18(1):e238. and Borges et al. (2009)⁴¹41 Borges DML, Sena MF, Ferreira MAF, Roncalli AG. Mortality for oral cancer and socioeconomic status in Brazil. Cad Saude Publica 2009; 25(2):321-327. described that Brazilian municipalities and regions with high HDI had high rates of mortality from oral neoplasia in comparison to less developed municipalities and regions. For Sakamoto et al. (2019), however, the effect was the opposite, that is, lower rates of oral neoplasia mortality in the municipalities of São Paulo state with high HDI. It is necessary to stress that the studies are methodologically distinct, and that the territorial area used can have influence on the difference between the findings, since regions, states and municipalities are very comprehensive geographical areas and that, within these spaces, there are great socioeconomic differences. Thus, when analyzing the results and extrapolating them, it is necessary to consider that this factor can produce different results from what is experienced by the population. In this sense, the recommendation is that the lowest possible territorial ​​area be used to approximate individual reality.

This review summarizes part of the efforts made in Brazil to determine which social inequality indicators affect neoplasm mortality in the country. This effort is necessary, as it is long known that the continuum of neoplasms and persistent mortality disparity cannot be explained only biologically and genetically⁵²52 Queiroz BL, Freire FHMA, Gonzaga MR, Lima EEC. Estimativas do grau de cobertura e da mortalidade adulta (45q15) para as unidades da federação no Brasil entre 1980 e 2010. Rev Bras Epidemiol 2017; 20(Supl. 1):21-33..

This study concluded that it was not possible to identify a single indicator that can explain this effect on all levels of geographical area and for deaths by all types of neoplasms in the Brazilian adult population. However, it was possible to list a diversity of income, education and human development indicators and their associations, as well as identify the demand for inclusion of other indicators and other levels of geographical area as a census sector.

The limitations of this study corroborate those that permeate literature reviews, such as, possibility of heterogeneity of selected studies, publication biases and constant need for updating. However, it made it possible to understand which gaps still remain and how the indicators are used in the face of the neoplasm mortality outcome.

This review highlights three gaps, which will need to be filled by other reviews and future research on neoplasms in the Brazilian adult population. One is the absence of non-modifiable social indicators, such as race/ethnicity, considered an indicator of accessibility to oncological care, especially early detection, as well as being a complex inequality indicator due to its intersectional effect⁵⁷57 Allik M, Ramos D, Agranonik M, Júnior EPP, Ichihara MY, Barreto ML, Leyland AH, Dundas R. Small-area deprivation measure for Brazil: data documentation [Internet]. 2020. [cited 2022 ago 3]. Available from: https://researchdata.gla.ac.uk/980/2/DataDocumentation.pdf
https://researchdata.gla.ac.uk/980/2/Dat... . The second gap is the demand for studies that analyze small territorial areas, which would minimize ecological fallacies and better describe the social reality in which individuals are placed³⁹39 Figueiredo FWS, Adami F. Effects of the high-inequality of income on the breast cancer mortality in Brazil. Sci Rep 2019; 9(1):4173.. The third gap is the limited use of multidimensional indicators compared to the extensive use of unidimensional ones, especially income. Income alone is not able to convey the different experiences of inequality. In this sense, the debate on the need for the use of multidimensional measurements has grown, ones which consider what the inequality is, who experiences it, when and where it occurs, thus enabling improved definition of its effects⁴⁷47 Rezende LFM, Lee DH, Louzada MLC, Song M, Giovannucci E, Eluf-Neto J. Proportion of cancer cases and deaths attributable to lifestyle risk factors in Brazil. Cancer Epidemiol 2019; 59:148-157..

The second and third gaps may be filled in the near future by research involving the use of composite measurement to assess material deprivation in census sectors; this measure has already been implemented to monitor health inequalities and to estimate the effect of deprivation on the mortality outcome, thus following the experience of other countries⁵⁸.

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