ABSTRACT

OBJECTIVE

To analyze inequalities in incidence, mortality, and estimated survival for neoplasms in men according to social vulnerability.

METHODS

Analysis of cases and deaths of all neoplasms and the five most common in men aged 30 years or older in the city of Campinas (SP), between 2010 and 2014, using data from the Population-Based Cancer Registry (RCBP) and the Mortality Information System (SIM). The areas of residence were grouped into five social vulnerability strata (SVS) using São Paulo Social Vulnerability Index. For each SVS, age-standardized incidence and mortality rates were calculated. A five-year survival proxy was calculated by complementing the ratio of the mortality rate to the incidence rate. Inequalities between strata were measured by the ratios between rates, the relative inequality index (RII) and the angular inequality index (AII).

RESULTS

RII revealed that the incidence of all neoplasms (0.66, 95%CI 0.62–0.69) and colorectal and lung cancers were lower among the most socially vulnerable, who presented a higher incidence of stomach and oral cavity cancer. Mortality rates for stomach, oral cavity, prostate and all types of cancer were higher in the most vulnerable segments, with no differences in mortality for colorectal and lung cancer. Survival was lower in the most social vulnerable stratum for all types of cancer studied. AII showed excess cases in the least vulnerable and deaths in the most vulnerable. Social inequalities were different depending on the tumor location and the indicator analyzed.

CONCLUSION

There is a trend of reversal of inequalities between incidence-mortality and incidence-survival, and the most social vulnerable segment presents lower survival rates for the types of cancer, pointing to the existence of inequality in access to early diagnosis and effective and timely treatment.

Men; Neoplasms, epidemiology; Survival; Mortality; Health Status Disparities; Socioeconomic Factors

INTRODUCTION

Neoplasms are one of the main causes of morbidity and mortality worldwide and the first cause of premature death in most developed countries¹1. Wild CP, Weiderpass E, Stewart BW, editors. World Cancer Report 2020: cancer research for cancer prevention. Lyon (FR): IARC; WHO; 2020. 630 p. . In Brazil, prostate cancer is the most frequent in men, followed by colorectal, lung, stomach, and oral cavity cancer. In terms of mortality, the main causes of death from cancer in men are, in descending order, lung, prostate, colorectal, and stomach cancer²2. Instituto Nacional de Câncer José Alencar Gomes da Silva. Estimativa 2020 : incidência de câncer no Brasil. Rio de Janeiro : INCA, 2019. 120 p. .

Socioeconomic differences are found in incidence, mortality and survival for cancer between countries and between social strata within countries, resulting from different exposures to risk factors and unequal access to health services¹1. Wild CP, Weiderpass E, Stewart BW, editors. World Cancer Report 2020: cancer research for cancer prevention. Lyon (FR): IARC; WHO; 2020. 630 p. , ³3. 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(3):209-49. https://doi.org/10.3322/caac.21660
https://doi.org/10.3322/caac.21660... .

The direction and magnitude of social inequalities in incidence and mortality from neoplasms differ according to the tumor location⁴4. Vries E, Arroyave I, Pardo C. Time trends in educational inequalities in cancer mortality in Colombia, 1998 - 2012. BMJ Open. 2016;6(4):e008985. https://doi.org/10.1136/bmjopen-2015-00898
https://doi.org/10.1136/bmjopen-2015-008... , and have changed over time in several countries⁸8. Elstad JI, Torstensrud R, Lyngstad TH, Kravdal Ø. Trends in educational inequalities in mortality, seven types of cancers, Norway 1971-2002. Eur J Public Health. 2012;22(6):771-6. https://doi.org/https://doi.org/10.1093/eurpub/ckr181
https://doi.org/https://doi.org/10.1093/... , ⁹9. Enewold L, Horner MJ, Shriver CD, Zhu K. Socioeconomic disparities in colorectal cancer mortality in the United States, 1990-2007. J Community Health. 2014;39(4):760-6. https://doi.org/10.1007/s10900-014-9824-z
https://doi.org/10.1007/s10900-014-9824-... .

With regard to prostate cancer, in some countries there is no evidence of inequalities in incidence and mortality⁶6. Mackillop WJ, Zhang-Salomons J, Boyd CJ, Groome PA. Associations between community income and cancer incidence in Canada and the United States. Cancer. 2000;89(4):901-12. https://doi.org/10.1002/1097-0142(20000815)89:4<901::aid-cncr25>3.0.co;2-i
https://doi.org/10.1002/1097-0142(200008... , ⁷7. Hoebel J, Kroll LE, Fiebig J, Lampert T, Katalinic A, Barnes B, et al. Socioeconomic inequalities in total and site-specific cancer incidence in Germany: a population-based registry study. Front Oncol. 2018;8:402. https://doi.org/10.3389/fonc.2018.00402
https://doi.org/10.3389/fonc.2018.00402... . In others countries, such as Costa Rica, the highest incidence and mortality rates are observed in the best socioeconomic level stratum¹⁰10. Fantin R, Ulloa CS, Barboza-Solís C. Social gradient in cancer incidence in Costa Rica: findings from a national population-based cancer registry. Cancer Epidemiol. 2020;68:101789. https://doi.org/10.1016/j.canep.2020.101789
https://doi.org/10.1016/j.canep.2020.101... , ¹¹11. Fantin R, Santamaría-Ulloa C, Barboza-Solís C. Socioeconomic inequalities in cancer mortality: is Costa Rica an exception to the rule? Int J Cancer. 2020;147(5):1286-93. https://doi.org/10.1002/ijc.32883
https://doi.org/10.1002/ijc.32883... . There are countries where inequality is reversed and the incidence and mortality are higher in worst economic level strata⁵5. Kim CW, Lee SY, Moon OR. Inequalities in cancer incidence and mortality across income groups and policy implications in South Korea. Public Health. 2008;122(3):229-36. https://doi.org/10.1016/j.puhe.2007.07.003
https://doi.org/10.1016/j.puhe.2007.07.0... , ⁶6. Mackillop WJ, Zhang-Salomons J, Boyd CJ, Groome PA. Associations between community income and cancer incidence in Canada and the United States. Cancer. 2000;89(4):901-12. https://doi.org/10.1002/1097-0142(20000815)89:4<901::aid-cncr25>3.0.co;2-i
https://doi.org/10.1002/1097-0142(200008... . Regarding stomach and oral cavity cancer, studies in general indicate that, in most countries, both incidence and mortality rates are higher in the most socially vulnerable segments⁶6. Mackillop WJ, Zhang-Salomons J, Boyd CJ, Groome PA. Associations between community income and cancer incidence in Canada and the United States. Cancer. 2000;89(4):901-12. https://doi.org/10.1002/1097-0142(20000815)89:4<901::aid-cncr25>3.0.co;2-i
https://doi.org/10.1002/1097-0142(200008... .

In the past, in Western European countries and in the United States, higher incidence and mortality rates for lung and colorectal cancer were observed in the population with better socioeconomic status; in recent decades, however, this situation has been reversed and the highest incidences are observed in the worst socioeconomic condition strata⁶6. Mackillop WJ, Zhang-Salomons J, Boyd CJ, Groome PA. Associations between community income and cancer incidence in Canada and the United States. Cancer. 2000;89(4):901-12. https://doi.org/10.1002/1097-0142(20000815)89:4<901::aid-cncr25>3.0.co;2-i
https://doi.org/10.1002/1097-0142(200008... .

Research shows the increase in survival rates that have occurred in recent decades for various types of cancer, but inequalities persist between countries and between social segments and, in some cases, there is an increase in inequality, unfavorable for the population with lower socioeconomic status¹⁵15. Allemani C, Matsuda T, Di Carlo V, Harewood R, Matz M, Nikšić M, et al. Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries. Lancet. 2018;391(10125):1023-75. https://doi.org/10.1016/S0140-6736(17)33326-3
https://doi.org/10.1016/S0140-6736... .

In Brazil, there are few studies that analyze social inequalities in cancer, which are almost always focused on mortality or on a specific type of cancer. Studies that analyze inequalities in incidence, mortality, and estimated survival for a set of neoplasms are rare worldwide. Aiming to contribute to a better understanding of this topic, this study aims to analyze inequalities, according to social vulnerability, in incidence, mortality, and estimated survival for all malignant neoplasms and the five most common types in men in a large municipality in the Southeast region of Brazil.

METHODS

This is an ecological study on incidence, mortality, and survival for all neoplasms and the five most common types of cancer in men. The study was carried out in the city of Campinas, with information about cases and deaths from 2010 to 2014. Campinas is a metropolis in the Southeast region of Brazil, located 99 km north of the capital of the state of São Paulo, with a population of 1,213,792 inhabitants in the year 2020. In 2018, it was the 14^th most populous city and the 11^th largest economy in the country¹⁹19. Instituto Brasileiro de Geografia e Estatística. Cidades e Estados: Campinas -SP. Rio de Janeiro: IBGE; 2010 [citado 15 dez 2020]. Disponível em: https://www.ibge.gov.br/cidades-e-estados/sp/campinas.html
https://www.ibge.gov.br/cidades-e-estado... .

Information about cancer cases was obtained from the Population-Based Cancer Registry (RCBP), and about deaths from the Mortality Information System (SIM), both made available by the Municipal Health Secretariat of Campinas. The neoplasms studied were: prostate (C61), colorectal (C18_20), lung (C33_34), stomach (C16), oral cavity (C00_14), and the total number of neoplasms, excluding those of non-melanoma skin (C00_97, excluding C44).

Population data were obtained from population estimates of the areas covered by the basic health units (UBS), provided by the Municipal Health Secretariat of Campinas, and made from data from the demographic census of the Brazilian Institute of Geography and Statistics (IBGE) from 2010²⁰20. Secretaria Municipal de Saúde de Campinas, Coordenadoria de Informação e Informática. Sistema de Informação -TabNet. População por faixa etária e sexo das áreas de abrangências dos CS e Distritos de Saúde, 2000 a 2018. Campinas; s.d [citado 15 ago 2020]. Disponível em: http://tabnet.campinas.sp.gov.br/dh?populacao/pop3.def
http://tabnet.campinas.sp.gov.br/dh?popu... .

For the construction of the strata according to the social vulnerability of the area of residence, the 2010 São Paulo Social Vulnerability Index (IPVS-2010) was used, prepared by the State Data Analysis System Foundation (Seade) of the state of São Paulo, which is an institution of national reference in performing and disseminating analysis and socioeconomic and demographic statistics²¹21. Fundação Sistema Estadual de Análise de Dados. Índice Paulista de Vulnerabilidade Social - IPVS versão 2010: São Paulo: SEADE; 2013 [citado 15 dez 2020]. Disponível em: http://indices-ilp.al.sp.gov.br/view/pdf/ipvs/metodologia.pdf
http://indices-ilp.al.sp.gov.br/view/pdf... . This index is available for all census tracts in the municipalities of São Paulo and has been used in research on social inequalities.

IPVS is composed of socioeconomic and demographic variables. The index classifies the sectors into seven groups according to the vulnerability level, classifying IPVS 1 as the least socially vulnerable and IPVS 6 and IPVS 7 as the most vulnerable for the urban and rural areas, respectively. The social vulnerability strata (SVS) for this study were constructed from the coverage areas of the municipality’s UBS, which received a score according to the proportion of sectors classified in each IPVS level. The areas were ordered from lowest to highest score, and grouped into population quintiles, generating five SVSs, with SVS 1 being the least socially vulnerable and SVS 5 the most vulnerable, with approximately 20% population in each SVS ( Figure 1 ).

Mean incidence and mortality rates were calculated for the period from 2010 to 2014 per 100,000 men aged 30 years or older for each type of cancer, for all neoplasms, and for each SVS. The choice of age group for the study was made according to the types of cancer studied, which are rare in men under 30 years old. Rates were age-standardized, at five-year intervals, by the direct method, using the 1960 world population as standard, modified by Doll et al. in 1966²²22. Doll R, Payne P, Waterhouse J, editors. Cancer incidence in five continents: a technical report. International Union Against Cancer. Berlin (DE); Springer; International Union Against Cancer; 1966. .

To measure the inequalities between the extreme strata, the ratios between the rates (RR) of SVS 5 in relation to SVS 1 and respective 95% confidence intervals (95%CI)²²22. Doll R, Payne P, Waterhouse J, editors. Cancer incidence in five continents: a technical report. International Union Against Cancer. Berlin (DE); Springer; International Union Against Cancer; 1966. were estimated.

The survival estimate was calculated by adding the ratio of the mortality rate to the incidence rate (MIR – mortality-to-incidence ratio), a validated method that has been used by several authors as a survival proxy²³23. Agência Internacional para Pesquisa sobre o Câncer; Associação Internacional de Registros de Câncer. Registro de Câncer: princípios e métodos. Rio de Janeiro: 1995. (IARC Publicações Científicas; nº 95). 304 p. , and shown values similar to those obtained with measured survival²⁶26. Kamangar F, Dores GM, Anderson WF. Patterns of cancer incidence, mortality, and prevalence across five continents: defining priorities to reduce cancer disparities in different geographic regions of the world. J Clin Oncol. 2006;24(14):2137-50. https://doi.org/10.1200/JCO.2005.05.2308
https://doi.org/10.1200/JCO.2005.05.2308... , ²⁷27. Hébert JR, Daguise VG, Hurley DM, Wilkerson RC, Mosley CM, Adams SA, et al. Mapping cancer mortality-to-incidence ratios to illustrate racial and sex disparities in a high-risk population. Cancer. 2009;115(11):2539-52. https://doi.org/10.1002/cncr.24270
https://doi.org/10.1002/cncr.24270... . The validity of using this estimate depends on the quality of mortality information and the stability of incidence and survival rates.

To measure inequalities in incidence and mortality for all neoplasms and the five types of cancer studied, the relative inequality index (RII) and the angular inequality index (AII)²⁸28. Schneider MC, Castillo-Salgado C, Bacallao J, Loyola E, Mujica OJ, Vidaurre M, et al. Métodos de mensuração das desigualdades em saúde. Rev Panam Salud Publica. 2002 [citado 15 dez 2020];12(6):1-17. Disponível em: https://www.scielosp.org/pdf/rpsp/v12n6/pt_a08v12n6.pdf
https://www.scielosp.org/pdf/rpsp/v12n6/... were calculated.

To calculate AII and RII values, one used RIIGEN, module of Stata 15.0 StataCorp LLC), to generate a rank variable considering all socioeconomic strata, ordered from the lowest to the highest social vulnerability level and classified with a score from 0 to 1 based on the accumulated relative population position. After analyzing the linearity between the health indicators of each stratum (dependent variable) and the rank (independent variable), Poisson regression was performed to estimate RII value, which shows the relative difference between the strata and makes it possible, from linear regression, to estimate AII value, which measures the absolute difference of the analyzed indicators from the highest to the lowest social vulnerability level ²⁸28. Schneider MC, Castillo-Salgado C, Bacallao J, Loyola E, Mujica OJ, Vidaurre M, et al. Métodos de mensuração das desigualdades em saúde. Rev Panam Salud Publica. 2002 [citado 15 dez 2020];12(6):1-17. Disponível em: https://www.scielosp.org/pdf/rpsp/v12n6/pt_a08v12n6.pdf
https://www.scielosp.org/pdf/rpsp/v12n6/... .

RII values greater than 1 indicate a greater risk for more social vulnerable segments, and values lower than 1 indicate greater risk for reduced vulnerability segments. AII values can be negative or positive, where the positive ones indicate excess occurrences (per 100 thousand inhabitants) in the most socially vulnerable stratum, and the negative ones indicate excess occurrences in the least vulnerable.

Statistical analyzes were performed using Microsoft Excel 2016® and Stata 15.0 software (StataCorp LLC, College Station, USA). The figure of the areas according to social vulnerability was made using TabWin software, version 4.1.5.

The research project that resulted in this article was approved by the Ethics Committee of the School of Medical Sciences of the University of Campinas (Unicamp) under the Certificate of Presentation for Ethical Appreciation (CAAE) No. 09217719.9.0000.5404.

RESULTS

Age-adjusted rates, presented in Table 1 , reveal that incidence of colorectal cancer and all neoplasms decreases with increased social vulnerability, while the reverse occurs with incidence of stomach cancer. In relation to the other locations studied, the differences between the strata are not statistically significant. Mortality rates show a clear growth level with increased social vulnerability for stomach cancer and a trend towards higher rates in the most vulnerable strata for oral cavity and prostate cancer, in addition to higher values for colorectal cancer in the least vulnerable segment ( Table 1 ).

Table 2 shows that the highest five-year survival percentages are observed for prostate cancer, followed by oral cavity and colorectal neoplasms, and that the lowest survival is observed for lung cancer, followed by stomach cancer. It is also observed that survival for all types of cancer studied tends to decrease with increased social vulnerability.

The assessment of the magnitude of inequalities in incidence and mortality using RR between the extreme strata (SVS 5 and SVS 1) and RII reveals similar results, with some differences regarding statistical significance. Incidence of total neoplasms and colorectal cancer, according to the two measures, and lung cancer, according to RII, are significantly lower among the most vulnerable. There is a higher incidence of stomach cancer, according to both indicators, and oral cavity cancer, according to RII, in men from the most socially vulnerable stratum. For prostate cancer, no inequality in incidence was detected by the two indicators.

Regarding mortality, the rates for stomach and oral cavity cancer in the most socially vulnerable stratum are more than double those observed in the least vulnerable. Deaths from prostate cancer and the total number of neoplasms are also higher among more socially vulnerable men. For lung and colorectal cancer, the inequalities detected in mortality did not reach statistical significance in the indicators evaluated ( Table 3 ).

For the total number of neoplasms and for the types of cancer studied, the five-year survival estimate proxy was lower for men in the most socially vulnerable stratum compared to the least vulnerable; the smallest difference observed was six percentage points for prostate cancer, and the greatest one was 23 percentage points for colorectal cancer ( Table 3 ). While 73% men with colorectal cancer from the least vulnerable stratum survive five years after diagnosis, only 50% survive if they belong to the most social vulnerable segment.

Figure 2 shows the excess incidence of cancer, mainly due to colorectal cancer, and lung and prostate cancer in the least socially vulnerable segment compared to the most vulnerable. Regarding mortality, the situation is reversed and excess mortality from cancer is observed in the most socially vulnerable stratum, except for the colorectal cancer ( Figure 2 ).

DISCUSSION

The results of this study show, in Campinas’ male population, social inequalities of different magnitudes and directions depending on the type of neoplasm and the measure used, whether incidence, mortality, or survival. Men from the most socially vulnerable stratum had higher incidence rates of stomach cancer and lower rates of colorectal cancer and total neoplasms, compared to the least socially vulnerable segment, according to the ratios between SVS 5 rates and SVS 1 rates.

RII analysis also detects a higher incidence of lung cancer in the least vulnerable segment and oral cavity cancer in the most vulnerable ones. The situation was reversed in relation to mortality, in which men in situations of greater social vulnerability had higher mortality rates for all neoplasms and for prostate, stomach, and oral cavity cancer, and no differences for colorectal and lung neoplasms, considering both RR and RII. The proxy used to estimate survival was lower in men with greater social vulnerability for all neoplasms and for the five types of cancer analyzed.

Regarding prostate cancer, the lack of social inequality in incidence verified in this study is similar to the results found in studies carried out in Canada⁶6. Mackillop WJ, Zhang-Salomons J, Boyd CJ, Groome PA. Associations between community income and cancer incidence in Canada and the United States. Cancer. 2000;89(4):901-12. https://doi.org/10.1002/1097-0142(20000815)89:4<901::aid-cncr25>3.0.co;2-i
https://doi.org/10.1002/1097-0142(200008... and Germany⁷7. Hoebel J, Kroll LE, Fiebig J, Lampert T, Katalinic A, Barnes B, et al. Socioeconomic inequalities in total and site-specific cancer incidence in Germany: a population-based registry study. Front Oncol. 2018;8:402. https://doi.org/10.3389/fonc.2018.00402
https://doi.org/10.3389/fonc.2018.00402... . However, research carried out in the United States and South Korea detected a higher incidence of prostate cancer among men of lower socioeconomic status⁵5. Kim CW, Lee SY, Moon OR. Inequalities in cancer incidence and mortality across income groups and policy implications in South Korea. Public Health. 2008;122(3):229-36. https://doi.org/10.1016/j.puhe.2007.07.003
https://doi.org/10.1016/j.puhe.2007.07.0... , ⁶6. Mackillop WJ, Zhang-Salomons J, Boyd CJ, Groome PA. Associations between community income and cancer incidence in Canada and the United States. Cancer. 2000;89(4):901-12. https://doi.org/10.1002/1097-0142(20000815)89:4<901::aid-cncr25>3.0.co;2-i
https://doi.org/10.1002/1097-0142(200008... . Many cases of prostate carcinoma are detected only by screening through the measurement of prostate-specific antigen (PSA) and the inequalities in access to the screening program can explain partially the inequalities found in the incidence¹1. Wild CP, Weiderpass E, Stewart BW, editors. World Cancer Report 2020: cancer research for cancer prevention. Lyon (FR): IARC; WHO; 2020. 630 p. , ³3. 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(3):209-49. https://doi.org/10.3322/caac.21660
https://doi.org/10.3322/caac.21660... , ¹²12. Boing AF, Antunes JLF. Condições socioeconômicas e câncer de cabeça e pescoço: uma revisão sistemática de literatura. Cienc Saude Colet. 2011;16(2):615-22. https://doi.org/10.1590/S1413-81232011000200025
https://doi.org/10.1590/S1413-8123201100... . Other factors related to lifestyle, such as obesity, smoking, alcohol consumption, and physical inactivity have not been proven to be risk factors for this type of cancer¹²12. Boing AF, Antunes JLF. Condições socioeconômicas e câncer de cabeça e pescoço: uma revisão sistemática de literatura. Cienc Saude Colet. 2011;16(2):615-22. https://doi.org/10.1590/S1413-81232011000200025
https://doi.org/10.1590/S1413-8123201100... . Higher mortality from prostate cancer in the greatest social vulnerability segment found in this study is similar to the results of research carried out in South Korea⁵5. Kim CW, Lee SY, Moon OR. Inequalities in cancer incidence and mortality across income groups and policy implications in South Korea. Public Health. 2008;122(3):229-36. https://doi.org/10.1016/j.puhe.2007.07.003
https://doi.org/10.1016/j.puhe.2007.07.0... .

Studies carried out in Norway, France, Spain, and Colombia did not find social inequalities in mortality from prostate cancer⁸8. Elstad JI, Torstensrud R, Lyngstad TH, Kravdal Ø. Trends in educational inequalities in mortality, seven types of cancers, Norway 1971-2002. Eur J Public Health. 2012;22(6):771-6. https://doi.org/https://doi.org/10.1093/eurpub/ckr181
https://doi.org/https://doi.org/10.1093/... , ²⁹29. Menvielle G, Rey G, Jougla E, Luce D. Diverging trends in educational inequalities in cancer mortality between men and women in the 2000s in France. BMC Public Health. 2013;13:823. https://doi.org/10.1186/1471-2458-13-823
https://doi.org/10.1186/1471-2458-13-823... , and analysis carried out in Costa Rica showed higher mortality in men with better socioeconomic status¹¹11. Fantin R, Santamaría-Ulloa C, Barboza-Solís C. Socioeconomic inequalities in cancer mortality: is Costa Rica an exception to the rule? Int J Cancer. 2020;147(5):1286-93. https://doi.org/10.1002/ijc.32883
https://doi.org/10.1002/ijc.32883... . Lower survival of men with prostate cancer belonging to the most socially vulnerable stratum, as found in this study, was also reported in surveys carried out in Colombia and Germany³²32. Arias-Ortiz NE, Vries E. Health inequities and cancer survival in Manizales, Colombia: a population-based study. Colomb Med (Cali). 2018;49(1):63-72. https://doi.org/ 10.25100/cm.v49i1.3629
https://doi.org/ 10.25100/cm.v49i1.3629... , ³³33. Jansen L, Eberle A, Emrich K, Gondos A, Holleczek B, Kajüter H, et al. Socioeconomic deprivation and cancer survival in Germany: an ecological analysis in 200 districts in Germany. Int J Cancer. 2014;134(12):2951-60. https://doi.org/10.1002/ijc.28624
https://doi.org/10.1002/ijc.28624... . Inequalities found in mortality and survival in Campinas indicate diagnosis in advanced stages and delay in starting treatment¹1. Wild CP, Weiderpass E, Stewart BW, editors. World Cancer Report 2020: cancer research for cancer prevention. Lyon (FR): IARC; WHO; 2020. 630 p. , ¹³13. Mihor A, Tomsic S, Zagar T, Lokar K, Zadnik V. Socioeconomic inequalities in cancer incidence in Europe: a comprehensive review of population-based epidemiological studies. Radiol Oncol. 2020;54(1):1-13. https://doi.org/10.2478/raon-2020-0008
https://doi.org/10.2478/raon-2020-0008... .

With regard to colorectal cancer, men from the lowest socially vulnerable stratum had a higher incidence rate than those from the most vulnerable stratum, as observed in research conducted in Costa Rica¹⁰10. Fantin R, Ulloa CS, Barboza-Solís C. Social gradient in cancer incidence in Costa Rica: findings from a national population-based cancer registry. Cancer Epidemiol. 2020;68:101789. https://doi.org/10.1016/j.canep.2020.101789
https://doi.org/10.1016/j.canep.2020.101... . This pattern of inequality was found in European countries until 1990, but it was reversed at the beginning of the twenty-first century and the highest incidence rates began to occur in individuals of lower socioeconomic status¹⁴14. Kogevinas EM, Pearce N, Susser M, Boffetta I, editors. Social inequalities and cancer. Lyon (FR): International Agency for Reserch on Cancer; 1997. (IARC Scientific Publications; nº 138). , ³⁴34. Loon AJM, Brandt PA, Golbohm RA. Socioeconomic status and colon cancer incidence: a prospective cohort study. Br J Cancer. 1995;71(4):882-7. https://doi.org/10.1038/bjc.1995.170
https://doi.org/10.1038/bjc.1995.170... , ³⁵35. Redondo-Sánchez D, Marcos-Gragera R, Carulla M, Lopez de Munain A, Gregori CS, Jiménez Chillarón R, et al. Lung, breast and colorectal cancer incidence by socioeconomic status in Spain: a population-based multilevel study. Cancers (Basel). 2021;13(11):2820. https://doi.org/10.3390/cancers13112820
https://doi.org/10.3390/cancers13112820... , a pattern that persists in these countries⁶6. Mackillop WJ, Zhang-Salomons J, Boyd CJ, Groome PA. Associations between community income and cancer incidence in Canada and the United States. Cancer. 2000;89(4):901-12. https://doi.org/10.1002/1097-0142(20000815)89:4<901::aid-cncr25>3.0.co;2-i
https://doi.org/10.1002/1097-0142(200008... , ⁷7. Hoebel J, Kroll LE, Fiebig J, Lampert T, Katalinic A, Barnes B, et al. Socioeconomic inequalities in total and site-specific cancer incidence in Germany: a population-based registry study. Front Oncol. 2018;8:402. https://doi.org/10.3389/fonc.2018.00402
https://doi.org/10.3389/fonc.2018.00402... to date. The differences in incidence found in Campinas and Costa Rica in relation to the results of research conducted in developed countries may be due to inequalities in access to diagnosis and changes in exposure to risk factors, many of them related to lifestyle, which, at first, affect the population with better socioeconomic status the most¹⁴14. Kogevinas EM, Pearce N, Susser M, Boffetta I, editors. Social inequalities and cancer. Lyon (FR): International Agency for Reserch on Cancer; 1997. (IARC Scientific Publications; nº 138). , ³⁴34. Loon AJM, Brandt PA, Golbohm RA. Socioeconomic status and colon cancer incidence: a prospective cohort study. Br J Cancer. 1995;71(4):882-7. https://doi.org/10.1038/bjc.1995.170
https://doi.org/10.1038/bjc.1995.170... .

In this study, no differences were detected in mortality from colorectal cancer between socially vulnerable strata, results similar to those found in analyzes carried out in France²⁹29. Menvielle G, Rey G, Jougla E, Luce D. Diverging trends in educational inequalities in cancer mortality between men and women in the 2000s in France. BMC Public Health. 2013;13:823. https://doi.org/10.1186/1471-2458-13-823
https://doi.org/10.1186/1471-2458-13-823... , Colombia⁴4. Vries E, Arroyave I, Pardo C. Time trends in educational inequalities in cancer mortality in Colombia, 1998 - 2012. BMJ Open. 2016;6(4):e008985. https://doi.org/10.1136/bmjopen-2015-00898
https://doi.org/10.1136/bmjopen-2015-008... and Spain³¹31. Santos-Sánchez V, Córdoba-Doña JA, Viciana F, Escolar-Pujolar A, Pozzi L, Ramis R. Geographical variations in cancer mortality and social inequalities in southern Spain (Andalusia). 2002-2013. PLoS One. 2020;15(5):e0233397. https://doi.org/10.1371/journal.pone.0233397
https://doi.org/10.1371/journal.pone.023... . Unlike these results, a study carried out in Costa Rica found higher mortality from colorectal cancer in men of better socioeconomic status and the opposite was found in research conducted in South Korea, where the mortality rate was higher in men of lower socioeconomic status⁵5. Kim CW, Lee SY, Moon OR. Inequalities in cancer incidence and mortality across income groups and policy implications in South Korea. Public Health. 2008;122(3):229-36. https://doi.org/10.1016/j.puhe.2007.07.003
https://doi.org/10.1016/j.puhe.2007.07.0... , ¹¹11. Fantin R, Santamaría-Ulloa C, Barboza-Solís C. Socioeconomic inequalities in cancer mortality: is Costa Rica an exception to the rule? Int J Cancer. 2020;147(5):1286-93. https://doi.org/10.1002/ijc.32883
https://doi.org/10.1002/ijc.32883... . The lowest five-year survival estimate in men from the most socially vulnerable stratum was found in Campinas, Germany³³33. Jansen L, Eberle A, Emrich K, Gondos A, Holleczek B, Kajüter H, et al. Socioeconomic deprivation and cancer survival in Germany: an ecological analysis in 200 districts in Germany. Int J Cancer. 2014;134(12):2951-60. https://doi.org/10.1002/ijc.28624
https://doi.org/10.1002/ijc.28624... , and the United States³⁶36. White A, Joseph D, Rim SH, Johnson CJ, Coleman MP, Allemani C. Colon cancer survival in the United States by race and stage (2001-2009): findings from the CONCORD-2 study. Cancer. 2017;123 Suppl 24:5014-36. https://doi.org/ 10.1002/cncr.31076
https://doi.org/... . The absence of inequality in mortality from colorectal cancer found in this study, despite the higher incidence in men from the least socially vulnerable stratum, and the lower survival rate in the most vulnerable segment, indicate difficulties in accessing early diagnosis and delay in starting and quality of colorectal cancer treatment with regard to the population in a situation of greater social vulnerability¹1. Wild CP, Weiderpass E, Stewart BW, editors. World Cancer Report 2020: cancer research for cancer prevention. Lyon (FR): IARC; WHO; 2020. 630 p. , ¹⁴14. Kogevinas EM, Pearce N, Susser M, Boffetta I, editors. Social inequalities and cancer. Lyon (FR): International Agency for Reserch on Cancer; 1997. (IARC Scientific Publications; nº 138). , ³⁷37. Vaccarella S, Lortet-Tieulent J, Saracci R, Fidler MM, Conway DI, Vilahur N, et al. Reducing social inequalities in cancer: setting priorities for research. CA Cancer J Clin. 2018;68(5):324-6. https://doi.org/10.3322/caac.21463
https://doi.org/10.3322/caac.21463... .

Higher incidence and mortality rates for stomach cancer in the most socially vulnerable segment observed in this study are generally reported in other studies⁵5. Kim CW, Lee SY, Moon OR. Inequalities in cancer incidence and mortality across income groups and policy implications in South Korea. Public Health. 2008;122(3):229-36. https://doi.org/10.1016/j.puhe.2007.07.003
https://doi.org/10.1016/j.puhe.2007.07.0... . Higher incidence of this cancer in strata with the worst socioeconomic status is probably due to infection by Helicobacter pylori (H. pylori), which is the main risk factor and is related to poorer living conditions and lack of basic sanitation. The lowest five-year survival estimate for men with stomach cancer in situations of greatest social vulnerability in relation to those in the least vulnerable stratum was also verified in research conducted in Colombia and Germany³²32. Arias-Ortiz NE, Vries E. Health inequities and cancer survival in Manizales, Colombia: a population-based study. Colomb Med (Cali). 2018;49(1):63-72. https://doi.org/ 10.25100/cm.v49i1.3629
https://doi.org/ 10.25100/cm.v49i1.3629... , ³³33. Jansen L, Eberle A, Emrich K, Gondos A, Holleczek B, Kajüter H, et al. Socioeconomic deprivation and cancer survival in Germany: an ecological analysis in 200 districts in Germany. Int J Cancer. 2014;134(12):2951-60. https://doi.org/10.1002/ijc.28624
https://doi.org/10.1002/ijc.28624... .

Higher incidence of oral cavity cancer, according to RII, found in this study in men in situations of greatest social vulnerability, was also detected in studies carried out in the United States and Germany and also reported in other studies⁶6. Mackillop WJ, Zhang-Salomons J, Boyd CJ, Groome PA. Associations between community income and cancer incidence in Canada and the United States. Cancer. 2000;89(4):901-12. https://doi.org/10.1002/1097-0142(20000815)89:4<901::aid-cncr25>3.0.co;2-i
https://doi.org/10.1002/1097-0142(200008... , ⁷7. Hoebel J, Kroll LE, Fiebig J, Lampert T, Katalinic A, Barnes B, et al. Socioeconomic inequalities in total and site-specific cancer incidence in Germany: a population-based registry study. Front Oncol. 2018;8:402. https://doi.org/10.3389/fonc.2018.00402
https://doi.org/10.3389/fonc.2018.00402... , ¹²12. Boing AF, Antunes JLF. Condições socioeconômicas e câncer de cabeça e pescoço: uma revisão sistemática de literatura. Cienc Saude Colet. 2011;16(2):615-22. https://doi.org/10.1590/S1413-81232011000200025
https://doi.org/10.1590/S1413-8123201100... . Research conducted in the city of São Paulo that analyzed inequalities in incidence and mortality from oral cavity cancer in the period from 2008 to 2013 did not detect inequalities in incidence, but higher mortality rates in districts with low Human Development Index (HDI)³⁸38. Ferreira MAF, Gomes MN, Michels FAS, Dantas AA, Latorre MRDO. Desigualdade social no adoecimento e morte por câncer de boca e orofaríngeo no município de São Paulo, Brasil: 1997 a 2008. Cad Saude Publica. 2012;28(9):1663-73. https://doi.org/10.1590/S0102-311X2012000900006
https://doi.org/10.1590/S0102-311X201200... . Higher incidence of oral cavity cancer in more socially vulnerable men may be related to higher prevalence of smoking, alcohol abuse, and human papillomavirus (HPV) infection in men of lower socioeconomic status¹⁴14. Kogevinas EM, Pearce N, Susser M, Boffetta I, editors. Social inequalities and cancer. Lyon (FR): International Agency for Reserch on Cancer; 1997. (IARC Scientific Publications; nº 138). , ³⁹39. Danaei G, Vander Hoorn S, Lopez AD, Murray CJL, Ezzati M; Comparative Risk Assessment collaborating group (Cancers). Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. Lancet. 2005;366(9499):1784-93. https://doi.org/10.1016/S0140-6736(05)67725-2
https://doi.org/10.1016/S0140-6736(05)67... , ⁴⁰40. Stewart BW, Wild CP. World cancer report 2014. Geneva (CH): WHO; 2014. . Higher mortality and lower survival estimate in men from the most socially vulnerable stratum found in Campinas has also been reported in other studies¹¹11. Fantin R, Santamaría-Ulloa C, Barboza-Solís C. Socioeconomic inequalities in cancer mortality: is Costa Rica an exception to the rule? Int J Cancer. 2020;147(5):1286-93. https://doi.org/10.1002/ijc.32883
https://doi.org/10.1002/ijc.32883... , ¹²12. Boing AF, Antunes JLF. Condições socioeconômicas e câncer de cabeça e pescoço: uma revisão sistemática de literatura. Cienc Saude Colet. 2011;16(2):615-22. https://doi.org/10.1590/S1413-81232011000200025
https://doi.org/10.1590/S1413-8123201100... , ³²32. Arias-Ortiz NE, Vries E. Health inequities and cancer survival in Manizales, Colombia: a population-based study. Colomb Med (Cali). 2018;49(1):63-72. https://doi.org/ 10.25100/cm.v49i1.3629
https://doi.org/ 10.25100/cm.v49i1.3629... , ³³33. Jansen L, Eberle A, Emrich K, Gondos A, Holleczek B, Kajüter H, et al. Socioeconomic deprivation and cancer survival in Germany: an ecological analysis in 200 districts in Germany. Int J Cancer. 2014;134(12):2951-60. https://doi.org/10.1002/ijc.28624
https://doi.org/10.1002/ijc.28624... .

The absence of inequality in incidence of lung cancer found in this study is different from the results of other studies carried out in the United States⁶6. Mackillop WJ, Zhang-Salomons J, Boyd CJ, Groome PA. Associations between community income and cancer incidence in Canada and the United States. Cancer. 2000;89(4):901-12. https://doi.org/10.1002/1097-0142(20000815)89:4<901::aid-cncr25>3.0.co;2-i
https://doi.org/10.1002/1097-0142(200008... , Canada⁶6. Mackillop WJ, Zhang-Salomons J, Boyd CJ, Groome PA. Associations between community income and cancer incidence in Canada and the United States. Cancer. 2000;89(4):901-12. https://doi.org/10.1002/1097-0142(20000815)89:4<901::aid-cncr25>3.0.co;2-i
https://doi.org/10.1002/1097-0142(200008... and Germany⁷7. Hoebel J, Kroll LE, Fiebig J, Lampert T, Katalinic A, Barnes B, et al. Socioeconomic inequalities in total and site-specific cancer incidence in Germany: a population-based registry study. Front Oncol. 2018;8:402. https://doi.org/10.3389/fonc.2018.00402
https://doi.org/10.3389/fonc.2018.00402... , where results showed a higher incidence in men from lower socioeconomic strata. With regard to mortality, analyzes carried out in Colombia³⁰30. Vries E, Arroyave I, Pardo C, Wiesner C, Murillo R, Forman D, et al. Trends in inequalities in premature cancer mortality by educational level in Colombia, 1998-2007. J Epidemiol Community Health. 2015;69(5):408-15. https://doi.org/10.1136/jech-2014-204650
https://doi.org/10.1136/jech-2014-204650... , France²⁹29. Menvielle G, Rey G, Jougla E, Luce D. Diverging trends in educational inequalities in cancer mortality between men and women in the 2000s in France. BMC Public Health. 2013;13:823. https://doi.org/10.1186/1471-2458-13-823
https://doi.org/10.1186/1471-2458-13-823... and Norway⁸8. Elstad JI, Torstensrud R, Lyngstad TH, Kravdal Ø. Trends in educational inequalities in mortality, seven types of cancers, Norway 1971-2002. Eur J Public Health. 2012;22(6):771-6. https://doi.org/https://doi.org/10.1093/eurpub/ckr181
https://doi.org/https://doi.org/10.1093/... detected higher mortality in men with the lowest socioeconomic status. These differences in the results found in Campinas are due to changes in the prevalence of smoking over time, which in the past was more common in better socioeconomic status segments and is currently more prevalent in more socially vulnerable segments¹⁴14. Kogevinas EM, Pearce N, Susser M, Boffetta I, editors. Social inequalities and cancer. Lyon (FR): International Agency for Reserch on Cancer; 1997. (IARC Scientific Publications; nº 138). .

The social inequalities observed in incidence of neoplasms differ according to the type of cancer, countries, and the periods analyzed. Higher incidences of stomach and oral cavity cancer have been observed over time in lower socioeconomic status segments in most countries studied⁶6. Mackillop WJ, Zhang-Salomons J, Boyd CJ, Groome PA. Associations between community income and cancer incidence in Canada and the United States. Cancer. 2000;89(4):901-12. https://doi.org/10.1002/1097-0142(20000815)89:4<901::aid-cncr25>3.0.co;2-i
https://doi.org/10.1002/1097-0142(200008... . However, the finding in Campinas – higher incidence of colorectal and lung cancers in the least socially vulnerable stratum – is similar to the situation observed in the past in other countries⁸8. Elstad JI, Torstensrud R, Lyngstad TH, Kravdal Ø. Trends in educational inequalities in mortality, seven types of cancers, Norway 1971-2002. Eur J Public Health. 2012;22(6):771-6. https://doi.org/https://doi.org/10.1093/eurpub/ckr181
https://doi.org/https://doi.org/10.1093/... , ⁹9. Enewold L, Horner MJ, Shriver CD, Zhu K. Socioeconomic disparities in colorectal cancer mortality in the United States, 1990-2007. J Community Health. 2014;39(4):760-6. https://doi.org/10.1007/s10900-014-9824-z
https://doi.org/10.1007/s10900-014-9824-... and may indicate that the trend in Brazil is that these neoplasms will affect the poorest population segments more intensively, as already seen in the United States, Canada, and in some European countries⁶6. Mackillop WJ, Zhang-Salomons J, Boyd CJ, Groome PA. Associations between community income and cancer incidence in Canada and the United States. Cancer. 2000;89(4):901-12. https://doi.org/10.1002/1097-0142(20000815)89:4<901::aid-cncr25>3.0.co;2-i
https://doi.org/10.1002/1097-0142(200008... .

Differences in incidence result from the degree of exposure to risk factors, some of which are related to production processes, advances in industrialization, and type of consumption and lifestyle, such as inadequate diet, physical inactivity, obesity, smoking, and excessive alcohol consumption³⁹39. Danaei G, Vander Hoorn S, Lopez AD, Murray CJL, Ezzati M; Comparative Risk Assessment collaborating group (Cancers). Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. Lancet. 2005;366(9499):1784-93. https://doi.org/10.1016/S0140-6736(05)67725-2
https://doi.org/10.1016/S0140-6736(05)67... , ⁴⁰40. Stewart BW, Wild CP. World cancer report 2014. Geneva (CH): WHO; 2014. . In addition to environmental and genetic factors, incidence of some cancers is related to the prevalence of infectious agents, such as H. pylori in stomach cancer (except cardia), and HPV in oropharyngeal cancer³⁹39. Danaei G, Vander Hoorn S, Lopez AD, Murray CJL, Ezzati M; Comparative Risk Assessment collaborating group (Cancers). Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. Lancet. 2005;366(9499):1784-93. https://doi.org/10.1016/S0140-6736(05)67725-2
https://doi.org/10.1016/S0140-6736(05)67... .

Access to diagnosis influences incidence rates in a strong manner, due to the coverage of health services, also made possible by screening programs. Lifestyle-related risk factors are modifiable over time, and the advancement of knowledge of these factors and adoption of healthier lifestyles tend to reach social strata with better education and income levels first³⁷37. Vaccarella S, Lortet-Tieulent J, Saracci R, Fidler MM, Conway DI, Vilahur N, et al. Reducing social inequalities in cancer: setting priorities for research. CA Cancer J Clin. 2018;68(5):324-6. https://doi.org/10.3322/caac.21463
https://doi.org/10.3322/caac.21463... .

In this study, none of the types of cancer studied had a significantly higher mortality rate in the best socioeconomic status segment, and the survival estimate, for all of them, was lower among the most socially vulnerable. These results point to inequalities in access to diagnosis in the early stages of the disease, delay in starting treatment, and lower adherence to and quality of treatments for strata with worse socioeconomic status¹⁴14. Kogevinas EM, Pearce N, Susser M, Boffetta I, editors. Social inequalities and cancer. Lyon (FR): International Agency for Reserch on Cancer; 1997. (IARC Scientific Publications; nº 138). .

In recent decades in Brazil, the Ministry of Health has developed programs and actions for cancer control, ranging from health promotion, prevention, and early diagnosis to the expansion of treatment centers⁴²42. Migowski A, Atty ATM, Tomazelli JG, Kneipp Dias MB, Jardim BC. Atenção Oncológica e os 30 Anos do Sistema Unico de Saúde. Rev Bras Cancerol. 2018;64(2):247-50. https://doi.org/10.32635/2176-9745.RBC.2018v64n2.84
https://doi.org/10.32635/2176-9745.RBC.2... .

Since the 2000s, monitoring of risk factors for chronic diseases – such as smoking, alcohol consumption, obesity, physical inactivity and dietary patterns – has been carried out periodically⁴³43. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Análise de Situação de Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Basil : 2011-2022. Brasília, DF; 2011. (Série B. (Textos Básicos de Saúde). . Research conducted in state capitals show a trend towards a reduction in smoking⁴⁴44. Malta DC, Silva AG, Sá ACMGN, Santos FM, Prates EJS, Cristo EB. Trends in smoking prevalence in all Brazilian capitals between 2006 and 2017. J Bras Pneumol. 2019;45(5):e20180384. https://doi.org/ 10.1590/1806-3713/e20180384
https://doi.org/... , stability in alcohol consumption⁴⁵45. Munhoz TN, Santos IS, Nunes BP, Mola CL, Silva ICM, Matisajevich A. Tendências de consumo abusivo de álcool nas capitais brasileiras entre os anos de 2006 a 2013: análise das informações do VIGITEL. Cad Saude Publica. 2017;33(7):e00104516. https://doi.org/10.1590/0102-311X00104516
https://doi.org/10.1590/0102-311X0010451... , and an increase in overweight and obesity in the population aged 18 years and over⁴⁶46. Malta DC, Santos MAS, Andrade SSCA, Oliveira T, Stopa SR, Oliveira MM, et al. Tendência temporal dos indicadores de excesso de peso em adultos nas capitais brasileiras, 2006-2013. Cienc Saude Colet. 2016;21(4):1061-9. https://doi.org/10.1590/1413-81232015214.12292015
https://doi.org/10.1590/1413-81232015214... . Changes in prevalence of the population behaviors and health conditions influence changes in incidence of neoplasms in different social groups. In addition to the programs and actions to combat non-communicable chronic diseases, the Ministry of Health launched, in 2008, the National Policy for Comprehensive Attention to Men’s Health, with a specific focus on the male population health ⁴⁷47. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde do Homem: princípios e diretrizes. Brasília, DF; 2008. .

One of the limitations of this study is that the socially vulnerable strata were constructed from information on the area of residence and not from individual information. Another limitation is that the five-year survival estimate was not directly measured, but estimated by complementing the ratio of mortality to incidence, which, however, has been considered an adequate proxy of five-year survival²⁴24. Ferlay J, Colombet M, Soerjomataram I, Mathers C, Parkin DM, Piñeros M, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer. 2019;144(8):1941-53. https://doi.org/10.1002/ijc.31937
https://doi.org/10.1002/ijc.31937... , ²⁵25. Asadzadeh Vostakolaei F, Karim-Kos HE, Janssen-Heijnen MLG, Visser O, Verbeek ALM, Kiemeney LALM. The validity of the mortality to incidence ratio as a proxy for site-specific cancer survival. Eur J Public Health. 2011;21(5):573-7. https://doi.org/10.1093/eurpub/ckq120
https://doi.org/10.1093/eurpub/ckq120... . The quality of mortality information and the instability of incidence and mortality rates for some types of cancer have been the main arguments of authors who criticize the use of this ratio as a survival proxy⁴⁸48. Ellis L, Belot A, Rachet B, Coleman MP. The mortality-to-incidence ratio is not a valid proxy for cancer survival. J Glob Oncol. 2019;5:1-9. https://doi.org/ 10.1200/JGO.19.00038
https://doi.org/... . Due to dependence on the information quality, it is recommended that the analyzes should be carried out with information from the same location or from the same data source, as performed in this study⁴⁹49. Parkin DM, Bray F. Evaluation of data quality in the cancer registry: principles and methods Part II. Completeness. Eur J Pediatr. 2009;45(5):756-64. https://doi.org/10.1016/j.ejca.2008.11.033
https://doi.org/10.1016/j.ejca.2008.11.0... .

The study results show the importance of considering social inequalities in incidence, mortality, and survival rates, as the direction and magnitude of inequalities differ. Results, by revealing the loss in mortality and in the estimated survival of the most socially vulnerable segments – which are those that depend on the public health sector performance –, emphasize the need for advances by the Unified Health System (SUS) in the implementation of actions of promotion, prevention, early detection, and access to quality treatment in a timely manner. These advances may lead to a reduction in mortality rates due to neoplasms and an increase in survival, especially in the poorest segments, reducing the prevailing inequity.

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