Abstract

Introdution

Cervical cancer occurs due to persistent lesions from cervical infection caused by oncogenic subtypes of the human papillomavirus (HPV) ¹1. Papanicolaou GN, Traut HF. Diagnosis of uterine cancer by the vaginal smear. Am J Clin Pathol 1944; 14:127.^,22. Hausen HZ. Human papillomaviruses and their possible role in squamous cell carcinomas. Curr Top Microbiol Immunol 1977; 78:1-30.. Even when such lesions are asymptomatic, they can be identified by cytopathological examination during the precursor stage of cancer, which increases the likelihood of cure if treatment is begun early ³3. Monsonego J, Bosch FX, Coursaget P, Cox JT, Franco E, Frazer I, et al. Cervical cancer control, priorities and new directions. Int J Cancer 2004; 108:329-33.. Based on this evidence, since 1984 Brazil has adopted the prevention strategy of cytopathology screening in women 25 to 64 years of age who are already sexually active ⁴4. Coordenação de Prevenção e Vigilância, Instituto Nacional de Câncer José Alencar Gomes da Silva. Diretrizes brasileiras para o rastreamento do câncer do colo do útero. Rio de Janeiro: Instituto Nacional de Câncer José Alencar Gomes da Silva; 2016..

Among the most important neoplasms in the world in women, cervical cancer has the fourth highest incidence and is the fourth leading cause of death. The rates are even higher in less developed countries, since the disease is intrinsically linked to unfavorable living and health conditions ⁵5. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015; 136:E359-86.^,66. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021; 71:209-49.^,77. World Health Organization. Human papillomavirus and cervical cancer. https://www.who.int/en/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer (acessado em 19/Jan/2021).
https://www.who.int/en/news-room/fact-sh... .

In Brazil, cervical cancer shows intermediate incidence and mortality rates when compared to the global scenario, as the third leading cause of cancer in women (except nonmelanoma skin cancer) and the fourth most lethal cause ⁸8. Instituto Nacional de Câncer José Alencar Gomes da Silva. Atlas on-line de mortalidade. https://mortalidade.inca.gov.br/MortalidadeWeb/ (acessado em 21/Dez/2020).
https://mortalidade.inca.gov.br/Mortalid... ^,99. Instituto Nacional de Câncer José Alencar Gomes da Silva. Conceito e magnitude. https://www.inca.gov.br/controle-do-cancer-do-colo-do-utero/conceito-e-magnitude (acessado em 21/Dez/2020).
https://www.inca.gov.br/controle-do-canc... . The mortality rate in Brazil in 2019 (adjusted for age and the world population), was 5.33 deaths per 100,000 women, and estimated incidence in 2020 was 12.60 cases per 100,000 women ⁸8. Instituto Nacional de Câncer José Alencar Gomes da Silva. Atlas on-line de mortalidade. https://mortalidade.inca.gov.br/MortalidadeWeb/ (acessado em 21/Dez/2020).
https://mortalidade.inca.gov.br/Mortalid... ^,1010. Coordenação de Prevenção e Vigilância, Instituto Nacional de Câncer José Alencar Gomes da Silva. Estimativa 2020: incidência de câncer no Brasil. Rio de Janeiro: Instituto Nacional de Câncer José Alencar Gomes da Silva; 2019..

Comparing Brazil’s five major geographic regions, the rates were highest in the North and Northeast, with 26.24 and 16.10 cases of cervical cancer per 100,000 women, respectively. In Bahia, the largest state in Northeast Brazil, cervical cancer was the second most common cancer in women (12.51 new cases per 100,000 women) ¹⁰10. Coordenação de Prevenção e Vigilância, Instituto Nacional de Câncer José Alencar Gomes da Silva. Estimativa 2020: incidência de câncer no Brasil. Rio de Janeiro: Instituto Nacional de Câncer José Alencar Gomes da Silva; 2019..

Although data from the World Health Organization (WHO) point to a reduction in the incidence of this neoplasm in Brazil, the rates are still far from reaching the levels in developed countries ⁹9. Instituto Nacional de Câncer José Alencar Gomes da Silva. Conceito e magnitude. https://www.inca.gov.br/controle-do-cancer-do-colo-do-utero/conceito-e-magnitude (acessado em 21/Dez/2020).
https://www.inca.gov.br/controle-do-canc... ^,1111. Kothari A. Human papilloma virus (HPV) and cervical cancer. Independent Nurse 2020; 10 fev. https://www.independentnurse.co.uk/clinical-article/human-papilloma-virus-hpv-and-cervical-cancer/223983/.
https://www.independentnurse.co.uk/clini... .

Given the issue’s social relevance, the Brazilian Congress passed Federal Law n. 12,732 in 2012 ¹²12. Brasil. Lei nº 12.732, de 22 de novembro de 2012. Dispõe sobre o primeiro tratamento de paciente com neoplasia maligna comprovada e estabelece prazo para seu início. Diário Oficial da União 2012; 23 nov., also known as the “60 Days Law”, which determines that all persons diagnosed with cancer should receive the first treatment within 60 days after the confirmed diagnosis. However, since there are still no mechanisms to ensure the law’s enforcement, persons with cancer, users of the Brazilian Unified National Health System (SUS), report long and difficult efforts to access timely oncological treatment ¹³13. Carvalho PG, O'Dwer G, Rodrigues NCP. Trajetórias assistenciais de mulheres entre diagnóstico e início de tratamento do câncer de colo uterino. Saúde Debate 2018; 42:687-701..

The current study thus aims to analyze factors associated with delay in specialized treatment after cervical cancer diagnosis in women recorded in the Hospital-Based Cancer Registry (HBCR) in Bahia State.

Methods

This retrospective cross-sectional observational hospital-based epidemiological study used the public domain secondary database of the HBCR in the State of Bahia ¹⁴14. Instituto Nacional de Câncer José Alencar Gomes da Silva. Integrador RHC. https://irhc.inca.gov.br/RHCNet//consultaInstituicaoPublico.action?busca=consulta&buscaMunicipio=false (acessado em 15/Jan/2021).
https://irhc.inca.gov.br/RHCNet//consult... .

Study subjects were women diagnosed with cervical cancer that received the first treatment in specialized cancer care centers accredited in the SUS and recorded in the HBCR in the state of Bahia, from 2008 to 2017 (Figure 1). The sample included all women with the primary tumor in the uterine cervix and classified in the system as “analytical cases” (n = 10,627), since “nonanalytical cases” refer to single consultations performed to complement follow-up already underway in other institutions (i.e., inclusion of these cases could generate duplicate information). Exclusion criteria were: (a) observations in persons less than 10 years old (n = 6); (b) cases in which it was not possible to determine whether the woman’s place of residence was in the State of Bahia (n = 11) and/or those belonging to other states (n = 182); (c) observations that were missing the date of diagnosis and/or date of start of first treatment for the cervical cancer (n = 763), since the absence of either would prevent the determination of the outcome variable (time-to-treatment); and (d) cases in which date of start of treatment preceded date of diagnosis (n = 481), since it was not possible to confirm whether the treatment was performed before the histopathological diagnosis or if it was a keying-in error. After application of these criteria (Figure 2), a dataset was obtained with 9,184 observations, exported to an Excel (https://products.office.com/) spreadsheet and categorized as dichotomous or polytomous variables. The included and excluded individuals’ basic characteristics were analyzed, and no major differences were observed between the groups.

The outcome variable was defined as delayed treatment, dichotomized as “yes” (> 60 days) and “no” (≤ 60 days). Independent variables were: age group (10-24, 25-34, 35-44, 45-54, 55-64, and 65 years or older); schooling (university, secondary, primary, none); race/skin color (nonblack versus black, the former consisting of white, Asian-descendant, and indigenous and the latter of black and brown); marital status (married versus unmarried, the first consisting of married or living with partner and the second single, widow, and separate); tumor stage (early versus advanced, the latter defined as cases with classification ≥ IIb); year of inclusion in the HBCR (variable dichotomized as 2008-2012 and 2013-2017, based on the 60-day parameter set by Federal Law n. 12,732/2012¹²12. Brasil. Lei nº 12.732, de 22 de novembro de 2012. Dispõe sobre o primeiro tratamento de paciente com neoplasia maligna comprovada e estabelece prazo para seu início. Diário Oficial da União 2012; 23 nov.). Among these variables, some data were excluded because they were classified as “missing” or “not applicable”, namely: race/skin color (6.4%), schooling (13.7%), marital status (6.9%), and tumor stage (13%).

Descriptive analysis identified absolute and relative frequencies for each of the variables. Bivariate analysis showed crude association between each of the independent variables and the outcome variable, using as measure of association the prevalence ratio (PR) in each stratum with the respective 95% confidence intervals (95%CI). Statistical significance was assessed with Pearson’s chi-square test, setting significance at p ≤ 0.05.

Multivariate analysis was performed using backward stepwise logistic regression and verification of likelihood ratio. Based on the saturated model, variables without statistical significance were removed from the final model. The final model’s goodness-of-fit was assessed with the Hosmer-Lemeshow test. Since this was a prevalence study, the odds ratios (OR) were converted to PR, using logistic regression for correction to PR as proposed by Norton et al. ¹⁵15. Norton EC, Miller MM, Kleinman LC. Computing adjusted risk ratios and risk differences in Stata. Stata J 2013; 13:492-509., a procedure to control the associations’ overestimation. All analyses were performed in Stata version 16.0 (https://www.stata.com).

The study was submitted to the State University of Bahia (UNEB) Institutional Review Board (CAAE n. 26815519.2.0000.0057), in compliance with Resolutions n. 466/2012 and n. 510/2016, and was approved under review (n. 3.786.718) on December 20, 2019.

Results

The 9,184 women with cervical cancer in the sample had the following characteristics: delayed treatment (65.1%), age 35 to 44 years (25.5%), primary schooling (53.1%), black race/skin color (87.4%), unmarried (67.4%), early-stage tumor (48.8%), and first specialized consultation from 2008 to 2012 (50.5%) (Table 1).

As for the relationship between accreditation of healthcare establishments and the percentage of delayed treatment, except for the year 2012, although accreditation of hospitals in the State of Bahia was increasing, the data showed no major change in the proportion of delayed treatment (Figure 1).

Bivariate analysis (Table 2) showed an increase in the prevalence of delayed treatment between age groups, with a gradual elevation of the prevalence ratio from 8% (95%CI: 0.99-1.17) in women 25-34 years of age to 19% (95%CI: 1.11-1.28) in those 35-44 years, 29% (95%CI: 1.21-1.38) from 45-54 years, 30% (95%CI: 1.22-1.38) from 55-64 years, and 31% (95%CI: 1.24-1.39) in women 65 or older, compared to females 10-24 years of age. Education showed an inverse association between more schooling (university level) and delayed treatment, or 13% (95%CI: 1.04-1.22) for women with secondary schooling, 28% (95%CI: 1.16-1.40) for primary, and 34% (95%CI: 1.26-1.42) for no schooling. As for marital status, unmarried women had 4% (95%CI: 1.01-1.08) higher prevalence of delayed treatment compared to married women. For staging, there was a 20% higher prevalence of delayed treatment (95%CI: 1.16-1.24) among women with advanced-stage tumor diagnosis, compared to early-stage diagnosis. The variables race/skin color and year of first consultation did not show statistically significant differences in the bivariate analysis, but we opted to include the variable “year of first consultation” in the adjusted model, considering its explanatory importance for the outcome (delayed treatment) following passage of the “60 Days Law” ¹²12. Brasil. Lei nº 12.732, de 22 de novembro de 2012. Dispõe sobre o primeiro tratamento de paciente com neoplasia maligna comprovada e estabelece prazo para seu início. Diário Oficial da União 2012; 23 nov..

The final model (Table 2) elaborated in the multivariate analysis showed the following prevalence rates for delayed treatment according to age group: 25-34, 35-44 years, 45-54, 55-64, and 65 years or older, respectively, 12% (95%CI: 1.02-1.22), 22% (95%CI: 1.13-1.38), 28% (95%CI: 1.18-1.38), 28% (95%CI: 1.19-1.38), and 30% (95%CI: 1.21-1.39) higher than females in the 10-24-year group, thus with a dose-response effect. The same effect was seen in schooling, as shown by confirmation of a direct association between delayed treatment and low schooling, with increases of 12% (95%CI: 1.03-1.22), 18% (95%CI: 1.07-1.30), and 24% (95%CI: 1.15-1.33) in women with secondary, primary, and no schooling, respectively, compared to those with university education. As for cancer staging, the prevalence of delayed treatment was 17% higher (95%CI: 1.13-1.21) among cases diagnosed in advanced stages compared to those diagnosed in early stages. As for marital status, unmarried women showed 4% higher prevalence of delayed treatment compared to married women. However, no statistically significant association was seen between this variable and delayed treatment after converting the measure of association from OR to PR. Although it was not possible to reach conclusions concerning this variable in the current study, we opted to maintain it in the adjusted analysis, since it improved the final model’s goodness-of-fit.

Discussion

This study showed that 65% of women in the sample began their cervical cancer treatment with delay. Prompt specialized treatment is considered a determinant factor for survival of cervical cancer patients, but there is no standardized international definition of “delayed treatment” ¹⁶16. Walter F, Webster A, Scott S, Emery J. The andersen model of total patient delay: a systematic review of its application in cancer diagnosis. J Health Ser Res Policy 2012; 17:110-8.^,1717. Weller D, Vedsted P, Rubin G, Walter FM, Emery J, Scott S, et al. The Aarhus statement: Improving design and reporting of studies on early cancer diagnosis. Br J Cancer 2012; 106:1262-7., which hinders the comparison of studies, especially in different countries. Most studies in Brazil use the 60-day parameter between diagnosis and treatment as the cutoff to assess results, which allows comparison of their findings with the current study ¹⁸18. Assenço KC, Kluthcovsky ACGC, Mansani F. Atraso no diagnóstico e tratamento de pacientes com câncer de colo de útero atendidas pelo Sistema Único de Saúde em um centro de referência do Sul do Brasil. Mundo Saúde 2017; 41:692-702.^,1919. Renna Junior NL, Silva GA. Tendências temporais e fatores associados ao diagnóstico em estágio avançado de câncer do colo uterino: análise dos dados dos registros hospitalares de câncer no Brasil, 2000-2012. Epidemiol Serv Saúde 2018; 27:e2017285.^,2020. Nascimento MI, Azevedo e Silva G. Efeito do tempo de espera para radioterapia na sobrevida geral em cinco anos de mulheres com câncer do colo do útero, 1995-2010. Cad Saúde Pública 2015; 31:2437-48.^,2121. Silva IF, Silva IF, Koifman RJ. Cervical cancer treatment delays and associated factors in a cohort of women from a developing country. J Glob Oncol 2019; 5:1-11.^,2222. Nascimento MI, Silva GA. Waiting time for radiotherapy in women with cervical cancer. Rev Saúde Pública 2015; 49:92.. Previous studies have found that time between diagnosis and first treatment of cervical cancer exceeded 60 days in most patients, corroborating our findings ¹⁸18. Assenço KC, Kluthcovsky ACGC, Mansani F. Atraso no diagnóstico e tratamento de pacientes com câncer de colo de útero atendidas pelo Sistema Único de Saúde em um centro de referência do Sul do Brasil. Mundo Saúde 2017; 41:692-702.^,2020. Nascimento MI, Azevedo e Silva G. Efeito do tempo de espera para radioterapia na sobrevida geral em cinco anos de mulheres com câncer do colo do útero, 1995-2010. Cad Saúde Pública 2015; 31:2437-48.^,2121. Silva IF, Silva IF, Koifman RJ. Cervical cancer treatment delays and associated factors in a cohort of women from a developing country. J Glob Oncol 2019; 5:1-11.^,2222. Nascimento MI, Silva GA. Waiting time for radiotherapy in women with cervical cancer. Rev Saúde Pública 2015; 49:92..

Another study on time trend and factors associated with advanced-stage diagnosis of cervical cancer showed that delayed treatment is a persistent problem throughout Brazil, since this unfavorable outcome was observed in roughly half of the cases analyzed ¹⁹19. Renna Junior NL, Silva GA. Tendências temporais e fatores associados ao diagnóstico em estágio avançado de câncer do colo uterino: análise dos dados dos registros hospitalares de câncer no Brasil, 2000-2012. Epidemiol Serv Saúde 2018; 27:e2017285.. Other authors also reported that delay in diagnosis and treatment of cervical cancer is a reality for users of the SUS, due to weaknesses in the cancer care network, a fact directly associated with higher case-fatality in this disease ¹⁸18. Assenço KC, Kluthcovsky ACGC, Mansani F. Atraso no diagnóstico e tratamento de pacientes com câncer de colo de útero atendidas pelo Sistema Único de Saúde em um centro de referência do Sul do Brasil. Mundo Saúde 2017; 41:692-702.^,2020. Nascimento MI, Azevedo e Silva G. Efeito do tempo de espera para radioterapia na sobrevida geral em cinco anos de mulheres com câncer do colo do útero, 1995-2010. Cad Saúde Pública 2015; 31:2437-48..

According to a meta-analysis with data from 34 articles (n = 1,272,681 patients), assessing the scenario for the world´s seven most prevalent types of cancer, including cervical cancer, for every four weeks of delay between diagnosis and first treatment, or between the conclusion of one treatment and the start of the next, there is a 6-8% increase in the odds of death, while a delay of eight or 12 weeks represented increases in case-fatality of 17% and 26%, respectively, thus having greater impact on the population ²³23. Hanna TP, King WD, Thibodeau S, Jalink M, Paulin GA, Jones EH, et al. Mortality due to cancer treatment delay: systematic review and meta-analysis. BMJ 2020; 371:m4087..

The current study’s results also showed that young women have lower prevalence of delayed treatment when compared to older women, with an upward trend according to increasing age. Still, in the adjusted analysis, the rates were slightly stationary among women over 45 years. In agreement with these findings, a study in Taiwan (China) and another in California (United States) found that older women had longer delays in accessing treatment for cervical cancer ²⁴24. Tabnak F, Müller HG, Wang JL, Zhang W, Howell LP. Timeliness and follow-up patterns of cervical cancer detection in a cohort of medically underserved California women. Cancer Causes Control 2010; 21:411-20.^,2525. Shen S-C, Hung YC, Kung PT, Yang WH, Wang YH, Tsai WC. Factors involved in the delay of treatment initiation for cervical cancer patients: a nationwide population-based study. Medicine (Baltimore) 2016; 95:e4568..

In Brazil, other studies have already reported an association between advanced age and late diagnosis and advanced clinical stages ¹⁸18. Assenço KC, Kluthcovsky ACGC, Mansani F. Atraso no diagnóstico e tratamento de pacientes com câncer de colo de útero atendidas pelo Sistema Único de Saúde em um centro de referência do Sul do Brasil. Mundo Saúde 2017; 41:692-702.^,1919. Renna Junior NL, Silva GA. Tendências temporais e fatores associados ao diagnóstico em estágio avançado de câncer do colo uterino: análise dos dados dos registros hospitalares de câncer no Brasil, 2000-2012. Epidemiol Serv Saúde 2018; 27:e2017285.^,2626. Thuler LCS, Aguiar SS, Bergmann A. Determinantes do diagnóstico em estadio avançado do câncer do colo do útero no Brasil. Rev Bras Ginecol Obstet 2014; 36:237-43.. These findings may be related to the low coverage of cervical cancer screening among older women, as indicated in previous studies ²⁷27. Andrade MS, Almeida MMG, Araújo TM, Santos KOB. Fatores associados a não adesão ao Papanicolau entre mulheres atendidas pela Estratégia Saúde da Família em Feira de Santana, Bahia, 2010. Epidemiol Serv Saúde 2014; 23:111-20.^,2828. Silva KB, Bezerra AFB, Chaves LDP, Tanaka OY. Integrality in cervical cancer care: evaluation of access. Rev Saúde Pública 2014; 48:240-8., culminating in diagnosis in more advanced stages and thus in delays in initiating treatment.

The analysis according to tumor stage showed that in Bahia state, the detection of cervical cancer was late in the period from 2008 to 2017, when approximately 38% of cases recorded in the HBCR were in advanced stages at diagnosis. The scenario was even more critical, since among these cases there was a higher prevalence of delayed treatment compared to those detected in the early stage. Other authors have reported similar results, for example in a hospital-based study in 2018 with 65,843 Brazilian women, showing that the proportion of advanced-stage diagnoses increased from 46.80% in 2000 to 53.53% in 2012 ¹⁹19. Renna Junior NL, Silva GA. Tendências temporais e fatores associados ao diagnóstico em estágio avançado de câncer do colo uterino: análise dos dados dos registros hospitalares de câncer no Brasil, 2000-2012. Epidemiol Serv Saúde 2018; 27:e2017285.. Another study reported that 44% of women were diagnosed in stage III, followed by 31.4% in stage II ²⁹29. Mascarello KC, Silva NF, Piske MT, Viana KCG, Zandonade E, Amorim MHC. Perfil sociodemográfico e clínico de mulheres com câncer do colo do útero associado ao estadiamento inicial. Rev Bras Cancerol 2012; 58:417-26.. Consistent with these studies, Nascimento & Silva ²⁰20. Nascimento MI, Azevedo e Silva G. Efeito do tempo de espera para radioterapia na sobrevida geral em cinco anos de mulheres com câncer do colo do útero, 1995-2010. Cad Saúde Pública 2015; 31:2437-48. emphasize that the risk of death increases more than threefold in advanced stages with indication of palliative radiotherapy ²³23. Hanna TP, King WD, Thibodeau S, Jalink M, Paulin GA, Jones EH, et al. Mortality due to cancer treatment delay: systematic review and meta-analysis. BMJ 2020; 371:m4087..

Although the subjective reasons for the high prevalence of delayed cervical cancer treatment and advanced stages of the disease were not the object of this study, one can assume a relationship between access to diagnosis and available treatment services in the state healthcare network, especially for women living in rural areas. However, further studies are necessary to elucidate this phenomenon.

Women with less schooling were more prone to delayed treatment when compared to those with more schooling. Other authors had already associated low schooling with advanced stages of cervical cancer ¹⁹19. Renna Junior NL, Silva GA. Tendências temporais e fatores associados ao diagnóstico em estágio avançado de câncer do colo uterino: análise dos dados dos registros hospitalares de câncer no Brasil, 2000-2012. Epidemiol Serv Saúde 2018; 27:e2017285.^,2626. Thuler LCS, Aguiar SS, Bergmann A. Determinantes do diagnóstico em estadio avançado do câncer do colo do útero no Brasil. Rev Bras Ginecol Obstet 2014; 36:237-43.^,3030. Ribeiro KG, Andrade LOM, Aguiar JB, Moreira AEMM, Frota AC. Educação e saúde em uma região em situação de vulnerabilidade social: avanços e desafios para as políticas públicas. Interface (Botucatu) 2018; 22 Suppl 1:1387-98.. However, our study also evidenced a dose-response effect between schooling and time from cancer diagnosis to first treatment, where the lower the schooling, the longer the time elapsed. This finding may be related to more proactive selfcare in persons with more schooling, better understanding of the health-disease process, knowledge of and access to the healthcare network, and better socioeconomic status, but other study designs are needed to explore and test these assumptions.

According to the WHO, HPV vaccination, screening, and management of care for the disease can help eliminate cervical cancer when applied strategically, but such strategic actions have not been implemented comprehensively, especially in low and middle-income countries. WHO thus launched a global strategy in 2020 to accelerate the elimination of cervical cancer as a public health problem, calling on nations to meet the 90-70-90 targets by the year 2030, according to which, 90% of girls vaccinated against HPV by 15 years of age, 70% of women screened by 35 years and again at 45 years, and treatment of 90% of women diagnosed with cervical cancer or precursor lesions ³¹31. World Health Organization. Global strategy to accelerate the elimination of cervical cancer as a public health problem. Geneva: World Health Organization; 2020.. However, in addition to the importance of reaching the proposed 90% treatment target for women diagnosed with cervical cancer, our results point to the need to ensure access to timely first treatment, since 65% of the women in our sample began treatment late. Corroborating this need, the delay in initiating treatment has been identified as a determinant factor in increased cancer mortality ²³23. Hanna TP, King WD, Thibodeau S, Jalink M, Paulin GA, Jones EH, et al. Mortality due to cancer treatment delay: systematic review and meta-analysis. BMJ 2020; 371:m4087..

In addition, our study found no statistically significant difference in the association between delayed treatment for cervical cancer when comparing the period prior to (2008-2012) and following (2013-2017) passage of the “60 Days Law” ¹²12. Brasil. Lei nº 12.732, de 22 de novembro de 2012. Dispõe sobre o primeiro tratamento de paciente com neoplasia maligna comprovada e estabelece prazo para seu início. Diário Oficial da União 2012; 23 nov., possibly because there was not enough time for any change to be observed. Since the analysis was performed since the first year after passage of the law, which limits the identification of its impact for reducing the time to access treatment, one can assume that the current study is not only pioneering but may serve as a reference for future analyses of the trend in delayed treatment in the State of Bahia. New studies are thus needed in subsequent periods to assess the adequacy of the healthcare network for cancer patients and possible impacts on access to first treatment after cervical cancer diagnosis.

The possibility of selection bias in this study needs to be addressed, since the dataset was from hospitals in the SUS, which are predominantly public units with a minimal share of private institutions (which complement the public system through public contracts or agreements with the SUS). Thus, the sample may not include an important share of high-income persons, who generally rely on private health services. Still, we believe that the study portrays the reality of the great majority of the female population in the state, since evidence shows that in Northeast Brazil, where the State of Bahia is located, 83.4% of the population lacks access to private care and only uses the SUS ³²32. Coordenação de Trabalho e Rendimento, Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2019: informações sobre domicílios, acesso e utilização dos serviços de saúde: Brasil, grandes regiões e Unidades da Federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020..

Since the study used a secondary database, it also had limitations related to incompleteness of data with random distribution among the variables, namely: race/skin color 6%; marital status 7%; schooling 14%; and tumor stage 13%. We opted to keep these variables in the study (especially schooling and staging, with incompleteness exceeding 10%) based on their importance for explaining the outcome variable. Considering that data in the HBCR are obtained from records of care in each accredited healthcare unit, we emphasize the importance of record completeness, not only for clinical practice, but also for developing research and public policies based on each location’s specificities.

Finally, we reiterate that treatment delays in cervical cancer are still a public health problem in the Bahia state, requiring increasing and on-going preventive measures and intensification of screening, as well as the supply of timely treatment, especially among women with low schooling, diagnosed in advanced stages of the disease, and with increasing age. We thus recommend the implementation of policies to ensure early treatment of the disease, in compliance with the Brazilian legislation.

Acknowledgments

The authors wish to thank Dr. Helena Maria Silveira Fraga Maia and Dr. Laio Magno Santos de Sousa for orientating the article’s entire production.

References

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History