ABSTRACT:

Objective:

To analyze the trend of standardized cancer mortality rate in the state of Mato Grosso according to health regions, from 2000 to 2015.

Methods:

Ecological time series study with data on deaths by cancer from the Mortality Information System. The rates were standardized using direct method and calculated by year and health regions. The annual percentage changes (APC) and respective confidence interval (95%CI) were obtained through simple linear regression. Thematic maps were built to show the spatial distribution of rates.

Results:

There were 28,525 deaths by cancer registered in Mato Grosso, with the main types being lung, prostate, stomach, breast and liver cancer. The highest mortality rates were found in regions Médio Norte, Baixada Cuiabana and Sul Mato-Grossense. From 2000 to 2015, an upward trend was seen in the mortality rate by cancer in Mato Grosso (APC=0.81%; 95%CI 0.38–1.26), and in four health regions, Garças Araguaia (APC=2.27%; 95%CI 1.46–3.08), Sul Mato-Grossense (APC=1.12%; 95%CI 0.28–1.97), Teles Pires (APC=1.93%; 95%CI 0,11–3,74) and Vale dos Arinos (APC=2.61%; 95%CI 1.10–4.70), while the other regions remained stable.

Conclusion:

In the state of Mato Grosso and in the four health regions, cancer mortality rate showed a growing trend. The results point to the need to consider regional differences when thinking about actions for cancer prevention, control and assistance.

Keywords:
Neoplasms; Mortality; Spatial analysis; Information systems; Time series studies

INTRODUCTION

In low- and middle-income countries, chronic non-communicable diseases such as cancer have grown considerably in recent years¹1 World Health Organization. Noncommunicable diseases. Progress monitor 2020. [cited on Jun 17, 2021]. Available at: https://www.who.int/publications/i/item/ncd-progress-monitor-2020
https://www.who.int/publications/i/item/... . In Brazil, 450 thousand new cases of cancer are estimated for each year of the triennium 2020-2022, excluding non-melanoma skin cancer²2 Brasil. Ministério da Saúde. Instituto Nacional de Câncer. Coordenação de Prevenção e Vigilância. Estimativa, 2020: incidência de câncer no Brasil. Rio de Janeiro: INCA; 2019. Available at: https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//estimativa-2020-incidencia-de-cancer-no-brasil.pdf
https://www.inca.gov.br/sites/ufu.sti.in... . Cancer is considered the second leading cause of death in the country, and in 2017 the most frequent types reported were breast, lung, colon and rectum, cervix and pancreas cancer among women and lung, prostate, colon and rectum, stomach and esophagus cancer among men²2 Brasil. Ministério da Saúde. Instituto Nacional de Câncer. Coordenação de Prevenção e Vigilância. Estimativa, 2020: incidência de câncer no Brasil. Rio de Janeiro: INCA; 2019. Available at: https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//estimativa-2020-incidencia-de-cancer-no-brasil.pdf
https://www.inca.gov.br/sites/ufu.sti.in... ^,33 Pan American Health Organization. NCDs at a glance. Noncommunicable disease mortality and risk factor prevalence in the Americas [Internet]. Washington: Pan American Health Organization; 2019. [cited on Jun 18, 2021]. Available at: https://iris.paho.org/handle/10665.2/51696
https://iris.paho.org/handle/10665.2/516... .

In Brazil, the analysis of trend in mortality by type of cancer from 1996 to 2010 showed a significant trend of increase and differences in relation to sex and between regions of the country. Up to 2030, an increase in rates is estimated for the North and Northeast regions and stability or decrease in the other regions⁴4 Barbosa IR, Souza DLB, Bernal MM, Costa ICC. Cancer mortality in Brazil: temporal trends and predictions for the year 2030. Medicine (Baltimore) 2015; 94(16): e746. https://doi.org/10.1097/MD.0000000000000746
https://doi.org/10.1097/MD.0000000000000... ; however, another study that covered a longer and more recent period (1990 to 2015) showed that mortality by type of cancer in Brazil remains stable⁵5 Guerra MR, Bustamante-Teixeira MT, Corrêa CSL, Abreu DMX, Curado MP, Mooney M, et al. Magnitude e variação da carga da mortalidade por câncer no Brasil e Unidades da Federação, 1990 e 2015. Rev Bras Epidemiol 2017; 20(Supl. 1): 102-17. https://doi.org/10.1590/1980-5497201700050009
https://doi.org/10.1590/1980-54972017000... .

These mortality rates deserve a regionalized analysis that is able to associate a broader and integrated perspective of changes in socioeconomic, demographic, epidemiological dimensions and in the availability of health services in each health region⁶6 Lima LD, Viana ALD, Machado CV. A regionalização da saúde no Brasil: condicionantes e desafios. In: Scatena JHG, Kehrig RT, Spinelli MAS, eds. Regiões de saúde: diversidade e processo de regionalização em Mato Grosso. São Paulo: Hucitec; 2014. p. 21-46., since health regions in Mato Grosso are spatially heterogeneous, with very evident inequalities⁷7 Scatena JHG, Oliveira LR, Galvão ND, das Neves MAB. O uso de indicadores compostos para classificação das regiões de saúde de Mato Grosso. In: Scatena JHG, Kehrig RT, Spinelli MAS. Regiões de saúde: diversidade e processo de regionalização em Mato Grosso. São Paulo: Hucitec; 2014. p. 169-92..

This study is remarkably relevant because the space, that is, the health regions, can present unique carcinogenic agents⁸8 Instituto Nacional de Câncer José Alencar Gomes da Silva. Ambiente, trabalho e câncer: aspectos epidemiológicos, toxicológicos e regulatórios. In: Instituto Nacional de Câncer José Alencar Gomes da Silva: Agrotóxicos. Rio de Janeiro: INCA; 2021. p. 241-260. Available at: https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//ambiente_trabalho_e_cancer_-_aspectos_epidemiologicos_toxicologicos_e_regulatorios.pdf
https://www.inca.gov.br/sites/ufu.sti.in... that, combined with genetics, behavioral factors and the aging process of the population possibly interfered in the carcinogenesis processes. In addition, the scientific production on cancer, using the health regions of Mato Grosso as a research variable, is still little explored, which further emphasizes the importance of this investigation.

The objective of this study was to analyze the temporal trend of standardized cancer mortality rates in the state of Mato Grosso according to health regions from 2000 to 2015.

METHODS

This is an ecological time series study in which the trend of standardized cancer mortality rate in the state of Mato Grosso from 2000 to 2015 was analyzed. Deaths with codes of the underlying cause of death were selected, such as malignant neoplasms (tumors) in Chapter II (codes C00 to C97)⁹9 Organização Mundial da Saúde. Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde – CID-10. 10ᵃ edição. São Paulo: Edusp; 2007.. Data were obtained from the Mortality Information System (SIM) and made available by the Mato Grosso State Health Department, grouped by state and by health regions. Census and intercensal population estimates were obtained with the Department of Informatics of the Unified Health System (SUS)¹⁰10 Brasil. Ministério da Saúde. DATASUS [Internet]. Estatísticas vitais. Sistema de Informação sobre mortalidade. [cited on Jun 21, 2021]. Available at: http://www2.datasus.gov.br
http://www2.datasus.gov.br... .

The state of Mato Grosso is part of the Mid-West Region of Brazil and in 2021 had an estimated population of 3,567,234 inhabitants. It is made up of 141 municipalities, organized into 16 health regions¹¹11 Brasil. Instituto Brasileiro de Geografia e Estatística. Cidades. Mato Grosso. População. [Internet]. [cited on Jul 12, 2021]. Available at: https://cidades.ibge.gov.br/brasil/mt/panorama
https://cidades.ibge.gov.br/brasil/mt/pa... : Alto Tapajós, Araguaia Xingu, Baixada Cuiabana, Centro Norte, Garças Araguaia, Médio Araguaia, Médio Norte Mato-Grossense, Noroeste Mato-Grossense, Norte Araguaia Karajá, Oeste Mato-Grossense, Oeste Mato-Grossense, Sudoeste Mato-Grossense, Sul-Mato-Grossense, Teles Pires, Vale do Peixoto and Vale dos Arinos.

Health regions have heterogeneous sociodemographic and health characteristics. According to the Mato Grosso index, which evaluated six dimensions of development (socioeconomic; epidemiological; availability of health services; appreciation of primary care; health expenditures; and public-private mix), only two health regions— Teles Pires and Norte Araguaia Karajá—are part of the upper quartile, while four are in the lower quartile (Oeste Mato-Grossense, Sudoeste Mato-Grossense, Noroeste Mato-Grossense and Médio Norte Mato-Grossense)⁷7 Scatena JHG, Oliveira LR, Galvão ND, das Neves MAB. O uso de indicadores compostos para classificação das regiões de saúde de Mato Grosso. In: Scatena JHG, Kehrig RT, Spinelli MAS. Regiões de saúde: diversidade e processo de regionalização em Mato Grosso. São Paulo: Hucitec; 2014. p. 169-92..

Cancer mortality rates were calculated for 100,000 inhabitants and standardized by the direct method, using the distribution of the world population as a standard¹²12 Segi M. Cancer mortality for selected sites in 24 countries (1950-1957). Sendai: Tohoku University School of Medicine; 1960.^,1313 Doll R, Payne P, Waterhouse JAH. Cancer incidence in five continents vol. I. Berlin: Springer-Verlag; 1966.. Rates were estimated for each year of the study period, for the state, and for health regions.

Absolute and relative frequencies of variables sex, age group, underlying cause of death and health regions were calculated. To estimate the time trend of the standardized cancer mortality rate from 2000 to 2015, a linear regression model was used, and the annual percentage change (APC) (ratio of the regression coefficient in relation to the mortality rate at the beginning of the analyzed period) and respective 95% confidence intervals (95%CI) were calculated. The trend was considered stable when the regression coefficient did not differ from zero (p>0.05), increasing when APC was positive, and decreasing when APC was negative. A significance level of 5% was adopted. Data analysis was performed using Stata, version 16.

In order to show the progression of cancer mortality in each health region, thematic maps were built using ESRI's ArcGis 10.5 software. The digital mesh of municipalities in the state of Mato Grosso was obtained from the Brazilian Institute of Geography and Statistics (IBGE) (https://cidades.ibge.gov.br, accessed on 05/26/2021). To generate a digital mesh of the 16 health regions, the municipalities were united through command "dissolve". The study was approved by the Research Ethics Committee of Hospital Universitário Júlio Müller (Certificate of Presentation of Ethical Appreciation: 98150718.1.40.8124).

RESULTS

From 2000 to 2015, 28,520 deaths from cancer occurred, which represented 12.8% of the total deaths in the state of Mato Grosso: 58% of cases being among males, 59.1% being among the aged 30 to 69 years old and 36.5% aged 70 years or older. The main types of cancer with the highest mortality in the state were lung, prostate, stomach, breast, and liver. The Baixada Cuiabana (37.3%), Sul Mato-Grossense (17.1%), Teles Pires (8.6%), Oeste Mato-Grossense (6.7%) and Médio Norte Mato-Grossense (5.8%) were equivalent to 75.5% of all cancer deaths and were the most affected regions in the state (Table 1).

The standardized cancer mortality rate in Mato Grosso went from 74.3 per 100,000 inhabitants in 2000 to 82 per 100,000 inhabitants in 2015 (Table 2). In 2000, three health regions had mortality rates higher than 80/100,000 inhabitants (Médio Norte, Baixada Cuiabana and Sul Mato-Grossense), while in 2015, in addition to these, three other had rates above this value (Alto Tapajós, Teles Pires and Arinos Valley). On the other hand, regions Araguaia Xingu, Norte Araguaia Karajá and Médio Araguaia maintained the lowest rates between 2000 and 2015 (Figure 1).

Figure 2 shows the historical series of the standardized cancer mortality rate for the health regions. Baixada Cuiabana, Teles Pires and Sul-Mato-Grossense had the highest mortality rates over the period, while Norte Araguaia Karajá had the lowest rates. A general upward trend was observed in the state of Mato Grosso (APC=0.81%; 95%CI 0.38–1.26) and in the following regions: Garças Araguaia (APC=2.27%; 95%CI 1.46–3.08), which maintained rates, per 100,000 inhabitants, between 40.1 and 60 until 2010 and between 60.1 and 80 in 2015; Sul-Mato-Grossense (APC=1.12%; 95%CI 0.28–1.97), which always reached values above 80 in the period; Teles Pires (APC=1.93%; 95%CI 0.11–3.74), which presented values between 60.1 and 80 at the beginning of the series and above 80 after 2005; and Vale dos Arinos (APC=2.61%; 95%CI 1.10–4.70), with rates between 40.1 and 60 in 2000, between 60.1 and 80 until 2010, and above 80 in 2015. The remaining regions showed a trend towards stability (Table 3).

DISCUSSION

Since 2000, cancer has been the third leading cause of death in the state of Mato Grosso and, in 2015, it accounted for 14.7% of all deaths in the state. In the period analyzed, most deaths were among males and aged 60 years or older. The five most frequent types of cancer in the state were lung, prostate, stomach, breast, and liver. This result is similar to that observed in a study on mortality by main types of cancer in the world, being the most frequent, for men, lung, liver, stomach, colorectal, and prostate; and, for women, breast, lung, colorectal, cervical uterus, and stomach¹⁴14 Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, et al. Global cancer observatory: cancer today. Lyon: International Agency for Research on Cancer; 2018. [cited on May 30, 2021]. Available at: https://gco.iarc.fr/today
https://gco.iarc.fr/today... .

Cancer has a multifactorial nature and depends on intrinsic factors such as age, gender, ethnicity/race and genetic inheritance or heredity, as well as modifiable factors such as tobacco use and alcohol consumption, physical inactivity, overweight and obesity, inadequate diet, socioeconomic status, and chemical, physical and biological agents¹⁵15 Behrend SJ, Giotopoulou GA, Spella M, Stathopoulos GT. A role for club cells in smoking-associated lung adenocarcinoma. Eur Respir Rev 2021; 30(162): 210122. https://doi.org/10.1183/16000617.0122-2021
https://doi.org/10.1183/16000617.0122-20... ^,1616 Instituto Nacional de Câncer José Alencar Gomes da Silva. ABC do câncer: abordagens básicas para o controle do câncer. Rio de Janeiro: Inca; 2020. Available at: https://www.inca.gov.br/sites/ufu.sti.inca.local/files/media/document/livro-abc-6-edicao-2020.pdf
https://www.inca.gov.br/sites/ufu.sti.in... . Cancer deaths, in turn, are associated with the time between diagnosis and start of treatment, access to health services and preventive actions, which represents a substantial challenge for health systems in all regions of the world. This setting demands investments in prevention and care policies, especially considering long-term exposure to occupational, environmental and individual risk factors⁸8 Instituto Nacional de Câncer José Alencar Gomes da Silva. Ambiente, trabalho e câncer: aspectos epidemiológicos, toxicológicos e regulatórios. In: Instituto Nacional de Câncer José Alencar Gomes da Silva: Agrotóxicos. Rio de Janeiro: INCA; 2021. p. 241-260. Available at: https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//ambiente_trabalho_e_cancer_-_aspectos_epidemiologicos_toxicologicos_e_regulatorios.pdf
https://www.inca.gov.br/sites/ufu.sti.in... ^,1414 Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, et al. Global cancer observatory: cancer today. Lyon: International Agency for Research on Cancer; 2018. [cited on May 30, 2021]. Available at: https://gco.iarc.fr/today
https://gco.iarc.fr/today... .

Cancer mortality rate in the whole Mato Grosso at the end of the study period (81.7/100,000 inhabitants) was lower than in the Midwest Region (86.1/100,000 inhabitants) and in Brazil (87.6/100,000 inhabitants),²2 Brasil. Ministério da Saúde. Instituto Nacional de Câncer. Coordenação de Prevenção e Vigilância. Estimativa, 2020: incidência de câncer no Brasil. Rio de Janeiro: INCA; 2019. Available at: https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//estimativa-2020-incidencia-de-cancer-no-brasil.pdf
https://www.inca.gov.br/sites/ufu.sti.in... as well as in developed countries such as the United States of America (91.0/100,000 inhabitants), Canada (92.8/100,000 inhabitants), United Kingdom (102.6/100,000 inhabitants) and Japan (85.2/100,000 inhabitants)¹⁴14 Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, et al. Global cancer observatory: cancer today. Lyon: International Agency for Research on Cancer; 2018. [cited on May 30, 2021]. Available at: https://gco.iarc.fr/today
https://gco.iarc.fr/today... .

The highest cancer mortality rates in the period were found in Baixada Cuiabana, Teles Pires and Sul-Mato-Grossense regions. Health regions are in different stages of demographic and epidemiological transition¹⁷17 Scatena JHG, Oliveira LR, Galvão ND, Neves MAB. Caracterização das regiões de saúde de Mato Grosso. In: Scatena JHG, Kehrig RT, Spinelli MAS, eds. Regiões de saúde: diversidade e processo de regionalização em Mato Grosso. São Paulo: Hucitec; 2014. p. 135-67., and this may be one of the explanations for the higher incidence of cancer and, consequently, higher mortality in some of them¹⁸18 Governo de Mato Grosso. Secretaria de Estado de Saúde de Mato Grosso. Plano Estadual de Saúde – PES MT 2016-2019. [Internet]. Relatório. Cuiabá: SES-MT; 2017. [cited on 15 mai. 2021]. Available at: https://www.conass.org.br/pdf/planos-estaduais-de-saude/MT_Plano-estadual-de-saude-2016-2019-[579-140617-SES-MT]%20(1).pdf
https://www.conass.org.br/pdf/planos-est... ^,1919 Governo do Estado de Mato Grosso. Secretaria de Estado de Saúde de Mato Grosso. Caderno de indicadores demográficos Mato Grosso. Mato Grosso: SES-MT [Internet]. 2018 [cited on May 15, 2021]. Available at: http://www.seplan.mt.gov.br/documents/363424/0/Caderno+de+Indicadores+Demogr%C3%A1ficos+de+2018_atualizado+26.11.2018.pdf/702891e0-990c-e293-cf43-1fea25dd74a2
http://www.seplan.mt.gov.br/documents/36... .

The state of Mato Grosso showed an increasing trend in cancer mortality rates, as did the health regions Garças Araguaia, Sul-Mato-Grossense, Teles Pires and Vale dos Arinos, whose populations represented about one third of the state inhabitants. This growth contrasts with that observed in Brazil as a whole, which was stable between 1990 and 2015¹⁵15 Behrend SJ, Giotopoulou GA, Spella M, Stathopoulos GT. A role for club cells in smoking-associated lung adenocarcinoma. Eur Respir Rev 2021; 30(162): 210122. https://doi.org/10.1183/16000617.0122-2021
https://doi.org/10.1183/16000617.0122-20... ^,2020 Malta DC, França E, Abreu DMX, Perillo RD, Salmen MC, Teixeira RA, et al. Mortality due to noncommunicable diseases in Brazil, 1990 to 2015, according to estimates from the Global Burden of Disease study. Sao Paulo Med J 2017; 135(3): 213-21. https://doi.org/10.1590/1516-3180.2016.0330050117
https://doi.org/10.1590/1516-3180.2016.0... , and with that observed in the Midwest Region in a more recent period (1999 to 2017)—also stable²¹21 Silva GA, Jardim BC, Ferreira VM, Junger WL, Girianelli VR. Mortalidade por câncer nas capitais e no interior do Brasil: uma análise de quatro década. Rev Saúde Pública 2020; 54(126): 126. https://doi.org/10.11606/s1518-8787.2020054002255
https://doi.org/10.11606/s1518-8787.2020... .

The growth in the mortality rate in the state and in some of its health regions may reflect population growth¹⁹19 Governo do Estado de Mato Grosso. Secretaria de Estado de Saúde de Mato Grosso. Caderno de indicadores demográficos Mato Grosso. Mato Grosso: SES-MT [Internet]. 2018 [cited on May 15, 2021]. Available at: http://www.seplan.mt.gov.br/documents/363424/0/Caderno+de+Indicadores+Demogr%C3%A1ficos+de+2018_atualizado+26.11.2018.pdf/702891e0-990c-e293-cf43-1fea25dd74a2
http://www.seplan.mt.gov.br/documents/36... , partially attributed to the intense migratory flow motivated by agribusiness²²22 Carmo RL, Vazquez FF, Camargo K. Agronegócio e dinâmica populacional: a soja e os frigoríficos em Mato Grosso. Boletim Regional, Urbano e Ambiental 2017; 17: 99-109. Available at: https://www.ipea.gov.br/portal/images/stories/PDFs/boletim_regional/171110_brua_17_Ensaio10.pdf
https://www.ipea.gov.br/portal/images/st... , as well as changes in the frequency and distribution of the main cancer risk factors, some of which are related to socioeconomic development¹⁴14 Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, et al. Global cancer observatory: cancer today. Lyon: International Agency for Research on Cancer; 2018. [cited on May 30, 2021]. Available at: https://gco.iarc.fr/today
https://gco.iarc.fr/today... and increased environmental and occupational exposure to chemical agents such as pesticides, heavy metals and benzene²³23 Curvo HRM, Pignati WA, Pignatti MG. Morbimortalidade por câncer infantojuvenil associada ao uso agrícola de agrotóxicos no Estado de Mato Grosso, Brasil. Cad Saúde Colet 2013; 21(1): 10-7.^–2626 Moura LTR, Bedor CNG, Lopez RVM, Santana VS, Rocha TMBS, Wünsch Filho V, et al. Exposição ocupacional a agrotóxicos organofosforados e neoplasias hematológicas: uma revisão sistemática. Rev Bras Epidemiol 2020; 23: E200022. https://doi.org/10.1590/1980-549720200022
https://doi.org/10.1590/1980-54972020002... .

Mato Grosso is known as the barn of Brazil for being the leader in production of agricultural commodities (soybean, corn, cotton) and cattle, whose agribusiness represents 50.5% of its gross domestic product (GDP)²⁷27 Mato Grosso. Instituto Mato-Grossense de Economia Agropecuária. Mapa das macrorregiões do IMEA. 2017 [cited on Jul 20, 2021]. Available at: https://www.imea.com.br/imea-site/view/uploads/metodologia/justificativamapa.pdf
https://www.imea.com.br/imea-site/view/u... . The state is one of the largest consumers of pesticides in the country²⁸28 Valadares A, Alves F, Galiza M. O crescimento do uso de agrotóxicos: uma análise descritiva dos resultados do Censo Agropecuário 2017. Nota técnica nº 65. Instituto de Pesquisa Econômica Aplicada; 2020. [cited on Ago 20, 2021]. Available at: https://www.ipea.gov.br/portal/images/stories/PDFs/nota_tecnica/200429_nt_disoc_n65.pdf
https://www.ipea.gov.br/portal/images/st... . Thus, it is important to discuss environmental exposure as a contributing factor to cancer incidence and mortality, namely to pesticides. Despite the biological and epidemiological plausibility²⁵25 Pluth TB, Zanini LAG, Battisti IDE. Pesticide exposure and cancer: an integrative literature review. Saúde Debate 2019; 43(122): 906-24. https://doi.org/10.1590/0103-1104201912220
https://doi.org/10.1590/0103-11042019122... ^,2626 Moura LTR, Bedor CNG, Lopez RVM, Santana VS, Rocha TMBS, Wünsch Filho V, et al. Exposição ocupacional a agrotóxicos organofosforados e neoplasias hematológicas: uma revisão sistemática. Rev Bras Epidemiol 2020; 23: E200022. https://doi.org/10.1590/1980-549720200022
https://doi.org/10.1590/1980-54972020002... ^,2929 Weichenthal S, Moase C, Chan P. A review of pesticide exposure and cancer incidence in the agricultural health study cohort. Cien Saude Colet 2012; 17(1): 255-70. http://doi.org/10.1590/s1413-81232012000100028
http://doi.org/10.1590/s1413-81232012000... ^,3030 Ellis L, Woods LM, Estève J, Eloranta S, Coleman MP, Rachet B. Cancer incidence, survival and mortality: explaining the concepts. Int J Cancer 2014; 135(8): 1774-82. http://doi.org/10.1002/ijc.28990
http://doi.org/10.1002/ijc.28990... , assessment of the carcinogenic potential of pesticides is complex, requiring new methodological approaches and the disaggregation of analyzes by type of cancer, so that this relationship can be examined with more clarity and caution.

Studies have pointed the relationship between exposure to pesticides and cancer morbidity and mortality in Brazil and in the state of Mato Grosso²³23 Curvo HRM, Pignati WA, Pignatti MG. Morbimortalidade por câncer infantojuvenil associada ao uso agrícola de agrotóxicos no Estado de Mato Grosso, Brasil. Cad Saúde Colet 2013; 21(1): 10-7.^,3131 Pignati WA, Lima FANS, Lara SS, Correa MLM, Barbosa JR, Leão LHC, et al. Distribuição espacial do uso de agrotóxicos no Brasil: uma ferramenta para a vigilância em saúde. Ciênc Saúde Colet 2017; 22(10): 3281-93. https://doi.org/10.1590/1413-812320172210.17742017
https://doi.org/10.1590/1413-81232017221... ^–3535 Dutra LS, Ferreira AP, Horta MAP, Palhares PR. Uso de agrotóxicos e mortalidade por câncer em regiões de monocultura. Saúde Debate 2020;44(127):1018-35. https://doi.org/10.1590/0103-1104202012706
https://doi.org/10.1590/0103-11042020127... . Research that evaluated the use of pesticides and cancer mortality in monoculture regions in Brazil put Mato Grosso as a high concentration spot of mortality rates for breast, uterus and prostate cancer in the south of the state and surroundings of the municipalities with the highest estimated use of pesticides²³23 Curvo HRM, Pignati WA, Pignatti MG. Morbimortalidade por câncer infantojuvenil associada ao uso agrícola de agrotóxicos no Estado de Mato Grosso, Brasil. Cad Saúde Colet 2013; 21(1): 10-7..

The growth in cancer mortality rates in some regions of the state may also result from inequality in access to health services. In Mato Grosso, long distances separate the municipalities from their regional headquarters, where there is greater service installed capacity, as well as from large centers of cancer care³⁶36 Fernandes NFF. Processo de organização e desenvolvimento de estratégias para divulgação e implantação do pacto pela saúde em Mato Grosso: relato de experiência. In: Scatena JHG, Kehrig RT, Spinelli MAS, eds. Regiões de saúde: diversidade e processo de regionalização em Mato Grosso. São Paulo: Hucitec; 2014. p. 239-63., making early diagnosis and timely treatment difficult. For example, the actions and services of oncology specialized care are distributed in five care macro-regions, and their offer is concentrated in the center-north macro-region, which includes health regions Baixada Cuiabana (where the state capital is located), Centro Norte, Médio Norte Mato-Grossense and Noroeste Mato-Grossense¹⁸18 Governo de Mato Grosso. Secretaria de Estado de Saúde de Mato Grosso. Plano Estadual de Saúde – PES MT 2016-2019. [Internet]. Relatório. Cuiabá: SES-MT; 2017. [cited on 15 mai. 2021]. Available at: https://www.conass.org.br/pdf/planos-estaduais-de-saude/MT_Plano-estadual-de-saude-2016-2019-[579-140617-SES-MT]%20(1).pdf
https://www.conass.org.br/pdf/planos-est... ^,1919 Governo do Estado de Mato Grosso. Secretaria de Estado de Saúde de Mato Grosso. Caderno de indicadores demográficos Mato Grosso. Mato Grosso: SES-MT [Internet]. 2018 [cited on May 15, 2021]. Available at: http://www.seplan.mt.gov.br/documents/363424/0/Caderno+de+Indicadores+Demogr%C3%A1ficos+de+2018_atualizado+26.11.2018.pdf/702891e0-990c-e293-cf43-1fea25dd74a2
http://www.seplan.mt.gov.br/documents/36... .

In addition, Mato Grosso did not implement the state plan to combat chronic non-communicable diseases (NCDs), whose strategies involve surveillance actions, health promotion and a comprehensive care network. Little has been invested in health care networks, whose primary care is the organizer and coordinator of care³⁷37 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Análise em Saúde e Vigilância de Doenças Não Transmissíveis. Plano de ações estratégicas para o enfrentamento das doenças crônicas e agravos não transmissíveis no Brasil 2021-2030. Brasília: Ministério da Saúde; 2021 [Internet]. [cited on Dec 21, 2021] Available at: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/publicacoes-svs/doencas-cronicas-nao-transmissiveis-dcnt/09-plano-de-dant-2022_2030.pdf/
https://www.gov.br/saude/pt-br/centrais-... . Specific cancer surveillance actions, which include the construction and permanent improvement of a specialized oncology information system and dissemination of information generated on it, are essential for strategic decisions at all management levels²2 Brasil. Ministério da Saúde. Instituto Nacional de Câncer. Coordenação de Prevenção e Vigilância. Estimativa, 2020: incidência de câncer no Brasil. Rio de Janeiro: INCA; 2019. Available at: https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//estimativa-2020-incidencia-de-cancer-no-brasil.pdf
https://www.inca.gov.br/sites/ufu.sti.in... ^,2020 Malta DC, França E, Abreu DMX, Perillo RD, Salmen MC, Teixeira RA, et al. Mortality due to noncommunicable diseases in Brazil, 1990 to 2015, according to estimates from the Global Burden of Disease study. Sao Paulo Med J 2017; 135(3): 213-21. https://doi.org/10.1590/1516-3180.2016.0330050117
https://doi.org/10.1590/1516-3180.2016.0... ^,3838 Instituto Nacional de Câncer José Alencar Gomes da Silva. Coordenação de Prevenção e Vigilância. Estimativa, 2016: incidência de câncer no Brasil. Rio de Janeiro: INCA; 2015. Available at: https://santacasadermatoazulay.com.br/wp-content/uploads/2017/06/estimativa-2016-v11.pdf
https://santacasadermatoazulay.com.br/wp... . The same goes for health promotion actions and prevention of the main risk factors for cancer, considering the long period of exposure to occupational, environmental and individual risk factors⁸8 Instituto Nacional de Câncer José Alencar Gomes da Silva. Ambiente, trabalho e câncer: aspectos epidemiológicos, toxicológicos e regulatórios. In: Instituto Nacional de Câncer José Alencar Gomes da Silva: Agrotóxicos. Rio de Janeiro: INCA; 2021. p. 241-260. Available at: https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//ambiente_trabalho_e_cancer_-_aspectos_epidemiologicos_toxicologicos_e_regulatorios.pdf
https://www.inca.gov.br/sites/ufu.sti.in... ^,1414 Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, et al. Global cancer observatory: cancer today. Lyon: International Agency for Research on Cancer; 2018. [cited on May 30, 2021]. Available at: https://gco.iarc.fr/today
https://gco.iarc.fr/today... , and access to cancer diagnosis and care through the strengthening and expansion of cancer treatment network within SUS³⁹39 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde. Saúde Brasil estados 2018: uma análise de situação de saúde segundo o perfil de mortalidade dos estados brasileiros e do Distrito Federal. Brasília: Ministério da Saúde; 2018. Available at: https://bvsms.saude.gov.br/bvs/publicacoes/saude_brasil_estados_2018_analise_situacao_saude_mortalidade.pdf
https://bvsms.saude.gov.br/bvs/publicaco... .

This study used secondary data obtained from SIM, and its results depend on the quality of records, especially considering under-registration and identification of underlying cause of death. In Brazil, there was an improvement in the quality of vital statistics with the active search for deaths and high coverage of the information system⁴⁰40 Szwarcwald CL, Morais-Neto OL, Frias PG, Souza-Júnior PRB, Escalante JJC, Lima RB, et al. Busca ativa de óbitos e nascimentos no Nordeste e na Amazônia Legal: estimação das coberturas do SIM e do SINASC nos municípios brasileiros. In: Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília: Ministério da Saúde; 2011. p. 79-98., which for the year 2015 was 94.3%⁴¹41 Oliveira ATR. Panorama das estatísticas vitais no Brasil. In: Oliveira ATR, org. Sistemas de estatísticas vitais no Brasil: avanços, perspectivas e desafios. Rio de Janeiro: IBGE; 2018. p. 9-25. Available at: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101575.pdf
https://biblioteca.ibge.gov.br/visualiza... . In the state of Mato Grosso, the percentage of ill-defined death causes (chapter XVIII of the ICD-10) represented 6.01% of all deaths and increased from 7.9% in 2000 to 6.6% in 2015. However, a difference was acknowledged in the proportion of ill-defined causes between regions, being higher from 2000 to 2015 in Norte Araguaia Karajá (23.1%), Norte Mato-Grossense (13.3%), Araguaia Xingu (11.2%) and Centro Norte (10.7%)¹⁰10 Brasil. Ministério da Saúde. DATASUS [Internet]. Estatísticas vitais. Sistema de Informação sobre mortalidade. [cited on Jun 21, 2021]. Available at: http://www2.datasus.gov.br
http://www2.datasus.gov.br... , which may have interfered with the findings.

Additionally, this study did not include incidence or survival rates, which provide more accurate information on the impact of cancer on the population when analyzed in conjunction with mortality rates⁴²42 Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68(6):394-424. https://doi.org/10.3322/caac.21492
https://doi.org/10.3322/caac.21492... . Comparison with other studies was also difficult, as most studies assess specific types of cancer.

On the other hand, the present study advances by disaggregating the mortality rates by health region, which allows one to understand local reality and the differences within the state, raising hypotheses regarding socio-environmental factors health services of Mato Grosso territory that are associated with cancer mortality.

The results point to the need for specific prevention, assistance and control actions related to cancer throughout the state of Mato Grosso and, particularly, in the health regions Garças Araguaia, Sul-Mato-Grossense, Teles Pires and Vale dos Arinos, which presented an upward trend in mortality rates.

Furthermore, this study contributes by broadening the debate on regionalization as a fruitful space for organizational arrangements of health actions and services for the development of policies and programs that strengthen universal and integral access to health policies in the state, taking into account the marked regional inequalities.

ACKNOWLEDGEMENTS

We thank the Coordination for the Improvement of Higher Education Personnel, the master's scholarship granted to Flávio de Macêdo Evangelista and Viviane Cardozo Modesto; the Mato Grosso State Health Department (SES-MT) and the Labor Public Ministry of the 23rd Region for the financial support for the project; and the José National Cancer Institute (INCA) Alencar Gomes da Silva, for the contribution to the training of cancer registrars.

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