ABSTRACT

In the world, colorectal cancer presents high rates of incidence and mortality, with differences according to the level of sociodemographic development. The objective of this study was to analyze the sociodemographic disparities of colorectal cancer in the Brazilian population aged 30 and older. This is a time series study of incidence, mortality, disability-adjusted life years (DALY), and prevalence, by sex, in Brazil and its Federal Units (FU) states from 1990 to 2019. The trend was estimated using Joinpoint regression analysis, and the Socio-Demographic Index (SDI) was used in the correlation analysis. The data analyzed were estimated by the Global Burden of Diseases Study 19. In Brazil and its states, the highest rates of these indicators were observed in males, with an increasing trend in both sexes. There was a positive association between SDI and all the analyzed indicators except for DALY in men. The differences in rates and trends between the states reflect the country’s development processes, such as urbanization and industrialization. More developed states have high rates with stable trends, while less developed states exhibit the opposite behavior, suggesting improved access to healthcare services and diagnosis.

KEYWORDS
Colorectal neoplasms; Analytical epidemiology; Socioeconomic factors; Ecological studies; Global burden of disease

Introduction

Colorectal cancer (CRC) refers to any malignant cellular change that affects the colon, the rectum and the anal canal. It is considered a global public health problem¹1 Sung H, Ferlay J, Siegel RL, 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):209-249. DOI: https://doi.org/10.3322/caac.21660
https://doi.org/10.3322/caac.21660... , is the third most common cancer and the second leading cause of cancer death in the world, with 935,000 deaths estimated for 2020²2 Ferlay J, Colombet M, Soerjomatara I, et al. Cancer statistics for the year 2020: An overview. Int J Cancer. 2021;149(4)1:778-789. DOI: https://doi.org/10.1002/ijc.33588
https://doi.org/10.1002/ijc.33588... . In Brazil, around 45,500 new cases of colon cancer are estimated for the three-year period from 2023 to 2025, and CRC is already the second most common cancer and the third leading cause of cancer death in the country³3 Ministério da Saúde (BR), Coordenação de ensino. Estimativa 2020: incidência de câncer no Brasil [Internet]. Rio de Janeiro: Ministério da Saúde; 2020 [acesso em 2023 jan 5]. Disponível em: 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... ,⁴4 Instituto Nacional do Câncer. Câncer de cólon e reto [Internet]. Rio de Janeiro: INCA; 2023 [acesso em 2023 jan 5]. Disponível em: https://www.gov.br/inca/pt-br/assuntos/cancer/numeros/estimativa/sintese-de-resultados-e-comentarios/cancer-de-colon-e-reto
https://www.gov.br/inca/pt-br/assuntos/c... . There were 9,438 deaths from colon and rectal cancer in men (mortality rate of 10.3/100,000) and 9,767 in women (mortality rate of 7.9/100,000) in Brazil during 2020⁵5 Ferlay J. Global Cancer Observatory: cancer today [Internet]. Lion: International Agency for Research on Cancer; 2020 [acesso em 2023 jan 5]. Disponível em: https://gco.iarc.fr/today
https://gco.iarc.fr/today... .

Most cases of CRC (60-65%) occur sporadically, i.e. they affect individuals with no family history⁶6 Keum N, Giovannucci E. Global burden of colorectal cancer: emerging trends, risk factors and prevention strategies. Nat Rev Gastroenterol Hepatol. 2019;16(12):713-732. DOI: https://doi.org/10.1038/s41575-019-0189-8
https://doi.org/10.1038/s41575-019-0189-... ,⁷7 Jasperson KW, Tuohy TM. Neklason DW, et al. Hereditary and familial colon cancer. Gastroenterology. 2010;138(6):2044-2058. DOI: https://doi.org/10.1053/j.gastro.2010.01.054
https://doi.org/10.1053/j.gastro.2010.01... . The risk factors are age, male sex⁸8 Siegel RL, Miller KD, Fuchs HE, et al. Cancer statistics, 2021. CA Cancer J Clin. 2021;71(1):7-33. DOI: https://doi.org/10.3322/caac.21654
https://doi.org/10.3322/caac.21654... , westernised diet – including nitrates and nitrites consumption – physical inactivity, obesity, alcohol and tobacco consumption⁹9 Wu E, Ni JT, Chen X, et al. Genetic risk, incident colorectal cancer, and the benefits of adhering to a healthy lifestyle: A prospective study using data from UK Biobank and FinnGen. Front Oncol. 2022;12:894086. DOI: https://doi.org/10.3389/fonc.2022.894086
https://doi.org/10.3389/fonc.2022.894086... ,¹⁰10 Niklas AA, Borge GIA, Rødbotten R, et al. Levels of nitrate, nitrite and nitrosamines in model sausages during heat treatment and in vitro digestion – The impact of adding nitrite and spinach (Spinacia oleracea L.). Food Res Int. 2023;166:112595. DOI: https://doi.org/10.1016/j.foodres.2023.112595
https://doi.org/10.1016/j.foodres.2023.1... . In addition to environmental factors⁶6 Keum N, Giovannucci E. Global burden of colorectal cancer: emerging trends, risk factors and prevention strategies. Nat Rev Gastroenterol Hepatol. 2019;16(12):713-732. DOI: https://doi.org/10.1038/s41575-019-0189-8
https://doi.org/10.1038/s41575-019-0189-... , human papillomavirus (HPV) and human immunodeficiency virus (HIV) infection, together with sexual practices, are also risk factors for anal cancer¹¹11 Nahas CSR, Silva-filho EV, Pllara WM, et al. Rastreamento de lesões precursoras do carcinoma espino-celular anal em indivíduos portadores do HIV. ABCD, Arq Bras Cir Dig. 2011;24(2):168-172. DOI: https://doi.org/10.1590/S0102-67202011000200015
https://doi.org/10.1590/S0102-6720201100... ,¹²12 Ouhoummane N, Steben M, Coutlée F, et al. Squamous anal cancer: patient characteristics and HPV type distribution. Cancer Epidemiol. 2013;37(6):807-812. DOI: https://doi.org/10.1016/j.canep.2013.09.015
https://doi.org/10.1016/j.canep.2013.09.... .

Socio-economically disadvantaged areas have a worse prognosis, lower survival rates and a higher risk of death from cancer in general, as well as having the worst outcomes in relation to potentially curable cancers¹³13 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 Brasil, 2021-2030. Brasília, DF : Ministério da Saúde; 2021.,¹⁴14 Tron L, Belot A, Fauvernier M, et al. Socioeconomic environment and disparities in cancer survival for 19 solid tumor sites: An analysis of the French Network of Cancer Registries (FRANCIM) data. Int J Cancer. 2019;144(6):1262-1274. DOI: https://doi.org/10.1002/ijc.31951
https://doi.org/10.1002/ijc.31951... , including CRC. These situations could be avoided through strategic actions aimed at reducing social inequalities regarding access to healthcare services ¹⁵15 Viacava F, Bellido JG. Condições de saúde, acesso a serviços e fontes de pagamento, segundo inquéritos domiciliares. Ciênc saúde coletiva. 2016;21(2):351-370. DOI: https://doi.org/10.1590/1413-81232015212.19422015
https://doi.org/10.1590/1413-81232015212... and the control of risk factors¹³13 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 Brasil, 2021-2030. Brasília, DF : Ministério da Saúde; 2021.,¹⁶16 Cambota JN, Rocha FF. Determinantes das desigualdades na utilização de serviços de saúde: análise para o brasil e regiões. PPE [Internet]. 2015 [acesso em 2023 jan 10];45(2):219-243. Disponível em: https://repositorio.ipea.gov.br/bitstream/11058/6008/1/PPE_v45_n02_Determinantes.pdf
https://repositorio.ipea.gov.br/bitstrea... ,¹⁷17 Ribeiro AA, Nardocci AC. Desigualdades socioeconômicas na incidência e mortalidade por câncer: revisão de estudos ecológicos, 1998-2008. Saúde Soc. 2013;22(3):878-91. DOI: https://doi.org/10.1590/S0104-12902013000300020
https://doi.org/10.1590/S0104-1290201300... . Therefore, health promotion actions are aimed at halting or slowing down the course of the carcinogenic process¹⁸18 Roncucci L, Mariani F. Prevention of colorectal cancer: How many tools do we have in our basket? Eur J Intern Med. 2015;26(10):752-756. DOI: https://doi.org/10.1016/j.ejim.2015.08.019
https://doi.org/10.1016/j.ejim.2015.08.0... with the goal of cancer screening in its early stages, thereby increasing therapeutic efficacy and survival rates¹³13 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 Brasil, 2021-2030. Brasília, DF : Ministério da Saúde; 2021.,¹⁹19 Jansen L, Kanbach J, Finke I, et al. Estimation of the potentially avoidable excess deaths associated with socioeconomic inequalities in cancer survival in Germany. Cancers (Basel). 2021;13(2):357. DOI: https://doi.org/10.3390/cancers13020357
https://doi.org/10.3390/cancers13020357... . Socioeconomic inequalities have an important role in predicting morbidity and mortality of a disease among different populations. In people under the age of 30, CRC is a neoplasm associated with a genetic or hereditary mutation²⁰20 Willauer AN, Liu Y, Pereira AA, et al. Clinical and molecular characterization of early‐onset colorectal cancer. Cancer. 2019;125(12):2002-2010. DOI: https://doi.org/10.1002/cncr.31994
https://doi.org/10.1002/cncr.31994... . However, the prevalence of risk factors is higher from this age on, especially the modifiable ones²¹21 Stoffel EM, Murphy CC. Epidemiology and mechanisms of the increasing incidence of colon and rectal cancers in young adults. Gastroenterology. 2020;158(2):341-353. DOI: https://doi.org/10.1053/j.gastro.2019.07.055
https://doi.org/10.1053/j.gastro.2019.07... ,²²22 Jung YS, Ryu S, Chang Y, et al. Risk factors for colorectal neoplasia in persons aged 30 to 39 years and 40 to 49 years. Gastrointest Endosc. 2015;81(3):637-645.e7. DOI: https://doi.org/10.1016/j.gie.2014.09.031
https://doi.org/10.1016/j.gie.2014.09.03... , according to Federation Unit (FU)²³23 Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde: 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal [Internet]. Rio de Janeiro: IBGE; 2020 [acesso em 2023 jan 10]. Disponível em: https://www.pns.icict.fiocruz.br/wp-content/uploads/2021/02/liv101764.pdf
https://www.pns.icict.fiocruz.br/wp-cont... . The aim of this study is to analyse the sociodemographic disparities present in the lives of Brazilians who are 30 years old or more, and who are affected with colorectal cancer, from 1990 to 2019.

Material and methods

This is a time series analysis of the incidence, prevalence, mortality and Disability Adjusted Life Years (DALYs) of CRC in individuals aged 30 years and over²¹21 Stoffel EM, Murphy CC. Epidemiology and mechanisms of the increasing incidence of colon and rectal cancers in young adults. Gastroenterology. 2020;158(2):341-353. DOI: https://doi.org/10.1053/j.gastro.2019.07.055
https://doi.org/10.1053/j.gastro.2019.07... ,²²22 Jung YS, Ryu S, Chang Y, et al. Risk factors for colorectal neoplasia in persons aged 30 to 39 years and 40 to 49 years. Gastrointest Endosc. 2015;81(3):637-645.e7. DOI: https://doi.org/10.1016/j.gie.2014.09.031
https://doi.org/10.1016/j.gie.2014.09.03... .

We used estimated and available data from the Global Burden of Disease Study 19 (GBD19) (available at https://vizhub.healthdata.org/gbd-results)²⁴24 GBD-Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019). Socio-Demographic Index (SDI) 1950-2019, Quintiles [Internet]. Seattle, United States of America: Institute for Health Metrics and Evaluation (IHME); 2020 [acesso em 2023 jan 10]. Disponível em: https://ghdx.healthdata.org/sites/default/files/record-attached-files/IHME_GBD_2019_SDI_1950_2019_QUINTILES_Y2021M03D21.XLSX
https://ghdx.healthdata.org/sites/defaul... , broken down by Federation Unit (FU) and sex, for Brazil, from 1990 to 2019.

The GBD study uses national data collected from the Ministry of Health’s Mortality Information System (SIM)²⁵25 Ministério da Saúde (BR), Departamento de Informática do SUS. Sistema de Informação sobre Mortalidade [Internet]. Brasília, DF: Ministério da Saúde; 2023 [acesso em 2024 jun 20]. Disponível em: https://svs.aids.gov.br/daent/cgiae/sim/apresentacao/
https://svs.aids.gov.br/daent/cgiae/sim/... and, to improve the quality of the information, the GBD applies algorithms to correct the underreporting of deaths and to reallocate them according to rubbish codes among the deaths classified as underlying causes²⁶26 Malta DC, Teixeira R, Oliveira GMMD, et al. Mortalidade por doenças cardiovasculares segundo o sistema de informação sobre mortalidade e as estimativas do estudo carga global de doenças no Brasil, 2000-2017. Arq Bras Cardiol. 2020;115(2):152-60. DOI: https://doi.org/10.36660/abc.20190867
https://doi.org/10.36660/abc.20190867... ,²⁷27 Vos T, Lim SS, Abbafati C, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1204-1222. DOI: https://doi.org/10.1016/s0140-6736(20)30925-9
https://doi.org/10.1016/s0140-6736(20)30... . The data was also analysed according to the Socio-Demographic Index (SDI), a tool that measures indices such as per capita income, fertility and education²⁴24 GBD-Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019). Socio-Demographic Index (SDI) 1950-2019, Quintiles [Internet]. Seattle, United States of America: Institute for Health Metrics and Evaluation (IHME); 2020 [acesso em 2023 jan 10]. Disponível em: https://ghdx.healthdata.org/sites/default/files/record-attached-files/IHME_GBD_2019_SDI_1950_2019_QUINTILES_Y2021M03D21.XLSX
https://ghdx.healthdata.org/sites/defaul... . The SDI ranges from 0 (least developed) to 1 (most developed) enabling comparisons among Brazil’s different geographical realities according to their development. The SDI quintiles were calculated for each year from 1990 to 2019, considering the Federative Units, allowing them to be classified into five groups: Low (0.0–0.45), Medium Low (0.45–0.60), Medium (0.60–0.68), Medium High (0.68–0.80) and High (0.80–1.0). Standardization of all the indicators obtained was carried out by the direct method, using the GBD standard population per 100,000 inhabitants²⁸28 GBD-Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019). Socio-Demographic Index (SDI) 1950–2019, Quintiles [Internet]. Seattle, United States of America: Institute for Health Metrics and Evaluation (IHME); 2020 [acesso em 2023 jan 10]. Disponível em: https://ghdx.healthdata.org/sites/default/files/record-attached-files/IHME_GBD_2019_SDI_1950_2019_QUINTILES_Y2021M03D21.XLSX
https://ghdx.healthdata.org/sites/defaul... .

The Average Annual Percent Change (AAPC) and the respective 95% confidence intervals (95% CI) were calculated to identify trends in the mortality indicators studied. The AAPC is the weighted average of the angular coefficients of the regression line, given equal weight for each segment’s length over the entire interval. A significant increase or reduction in the trend occurs when it is different from zero (p<0.05). Joinpoint regression model was used to analyse the trend using Joinpoint software (version 4.9.1.0)²⁹29 National Cancer Institute, Joinpoint Regression Program – Surveillance Research Program. Joinpoint Trend Analysis Software [Internet]. Statistical methodology and applications branch, Surveillance Research Program. [local desconhecido]: NCI; 2019 [acesso em 2024 jun 16]. Disponível em: https://surveillance.cancer.gov/joinpoint/
https://surveillance.cancer.gov/joinpoin... .

Regarding the correlation between the SDI measures and AAPC, it was analysed from 1990 to 2019 using Pearson’s Correlation Test in the R software (version 4.2.2). In statistical analyses, correlation is a method used to assess a possible linear association between two continuous variables. In terms of the strength of relationship, the value of the correlation coefficient varies between +1 and -1. The closer to +1, the greater the strength of correlation and the closer to -1 the variables are inversely related, i.e., the higher one variable is, the lower the other is³⁰30 Hinkle DE, Wiersma W, Jurs SG. Applied statistics for the behavioral sciences. 5. ed. Boston: Houghton Mifflin; 2003..

The research respected all ethical precepts³¹31 Ministério da Saúde (BR); Conselho Nacional de Saúde. Resolução nº 466, de 12 de dezembro de 2012. Aprova as diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos e revoga as Resoluções CNS nos. 196/96, 303/2000 e 404/2008. Diário Oficial da União, Brasília, DF. 2013 jun 13; Seção I:549.,³²32 Ministério da Saúde (BR); Conselho Nacional de Saúde. Resolução nº 510, de 7 de abril de 2016. Dispõe sobre as normas aplicáveis a pesquisas em Ciências Humanas e Sociais cujos procedimentos metodológicos envolvam a utilização de dados diretamente obtidos com os participantes ou de informações identificáveis ou que possam acarretar riscos maiores do que os existentes na vida cotidiana. Diário Oficial da União, Brasília, DF. 2016 maio 24; Seção I:44. and was approved by the Research Ethics Committee of the Hospital das Clínicas of the Federal University of Goiás (UFG), under opinion no. 5.249.241.

Results

Analysing the entire period studied, men showed the highest incidence, prevalence, mortality and DALY rates in Brazil. There were significant annual increases in both sexes for all the parameters studied, although they were higher in men in the male group (figure 1 and tables 1 and 2).

Incidence rates in the Brazilian Federative Units were higher in men and showed upward trends in both sexes. Among males, the biggest increases were in Bahia (2.8% p.a.), Pernambuco (2.8% p.a.) and Rio Grande do Norte (2.6% p.a.); among females, in Maranhão (2.8% p.a.), Ceará (2.1% p.a.), Amapá and Acre (1.9% p.a.). Notably, the FU in the North and Northeast regions registered the highest annual percentage increases. The FU with the highest annual increases in male prevalence are Pernambuco (3.5% p.a.), Bahia and Ceará (3.4% p.a.) and for females Maranhão (3.3% p.a.), Ceará (2.7% p.a.) and Acre (2.6% p.a.), with upward trends in the North and Northeast macro regions (table 1).

Regarding men, mortality increased in 14 states, with higher percentiles in the North and Northeast regions; in the Federal District, there was a downward trend. Among the female population, mortality trends remained stable in 12 states and the only downward trend was observed in the Federal District (-0.3% p.a.). Comparatively, the Federal District’s women are the ones who suffer the least from CRC, with a downward trend in the quality-adjusted life years lost due to CRC (-0.4 percent p.a.). Increasing trends were observed mainly in the North and Northeast, with Maranhão showing the highest AAPC (1.9% p.a.), while in the male group there is no downward trend; Distrito Federal and Roraima are the only FU with stability, and the highest annual percentages are in Pernambuco and Bahia (2.1% p.a.) (table 2).

When analysing the indicators according to the levels of sociodemographic development divided into quintiles, in terms of rates, the highest quintile (SDI >0.80) shows the highest values in all indicators regardless of gender; as for the annual increase, this same sociodemographic level shows the lowest AAPC in all indicators, with a significant trend, except for mortality and DALY in females. In contrast, the rates are lower in the less developed regions (SDI <0.68) and the trends show increasing tendencies, except for the Middle quintile, which remains stable regarding female mortality (table 3).

The correlation between the incidence, prevalence and mortality rates with the Sociodemographic Indexes for colorectal cancer among men in 1990 was significant (p<0.05), with a 0.76, 0.8 and 0.78 coefficient, respectively. Significant correlations in 2019 (p<0.05) were 0.72 for incidence and 0.77 for prevalence. The patterns were similar for women in 1990; the correlation coefficients for incidence, prevalence and mortality were 0.85, 0.85 and 0.84, respectively, with p<0.05. In 2019, these scores were 0.79 for incidence, 0.81 for prevalence and 0.74 for mortality (p<0.05). The correlation between women and DALYs was significant, at 0.82 in 1990 and 0.79 in 2019 (p<0.05). Unlike men, for whom there was no difference. Finally, there was no statistically significant correlation between the differences in the SDIs in 2019 and 1990 and the indexes that were studied (figure 2).

Discussion

From 1990 to 2019, the epidemiological profile of colorectal cancer in Brazil and its Federated Units (FU) showed that men had the highest rates. In general, when analysed according to SDI quintiles, the least developed FU, especially those located in Brazil’s North and Northeast regions, showed the lowest rates of the indicators studied. Age is an important non-modifiable risk factor and may be associated with the annual increase in the incidence of CRC, primarily as observed in the North and Northeast regions, which have seen an increase in the ageing rate over the last 12 years when compared to Brazil’s South and Southeast regions, which had already shown older structures³³33 Gomes I, Britto V. Censo 2022: número de pessoas com 65 anos ou mais de idade cresceu 57,4% em 12 anos. Agência IBGE Notícias [Internet]. 2023 nov 1 [acesso em 2024 jun 20]. Disponível em: https://www.gov.br/inca/pt-br/assuntos/cancer/numeros/estimativa/sintese-de-resultados-e-comentarios/cancer-de-colon-e-reto
https://www.gov.br/inca/pt-br/assuntos/c... . The country has been experiencing a decline in mortality and fertility rates³⁴34 Cortez ACL, Silva CRL, Silva RCL, et al. Aspectos gerais sobre a transição demográfica e epidemiológica da população brasileira. Enferm Brasil. 2019;18(5):700. DOI: https://doi.org/10.33233/eb.v18i5.2785
https://doi.org/10.33233/eb.v18i5.2785... , resulting in a change of structure in the age pyramid, which in turn reflects in a population ageing similarly to the ones present in developed countries, and increases the burden of NCDs³⁴34 Cortez ACL, Silva CRL, Silva RCL, et al. Aspectos gerais sobre a transição demográfica e epidemiológica da população brasileira. Enferm Brasil. 2019;18(5):700. DOI: https://doi.org/10.33233/eb.v18i5.2785
https://doi.org/10.33233/eb.v18i5.2785... ,³⁵35 Reis Perreira B, Jesus IMO, Martins MMF. Perfil sociodemográfico da mortalidade da população idosa no nordeste brasileiro. Rev Atenção Saúde. 2020;18(64):9-21. DOI: https://doi.org/10.13037/ras.vol18n64.6273
https://doi.org/10.13037/ras.vol18n64.62... ,³⁶36 Oliveira AS. Transição demográfica, transição epidemiológica e envelhecimento populacional no Brasil. Hygeia. 2019;15(32):69-79. DOI: https://doi.org/10.14393/Hygeia153248614
https://doi.org/10.14393/Hygeia153248614... .

Even though it is the main modifiable risk factor for CRC, inadequate diet has become increasingly frequent in the eating routine of Brazilians³⁷37 Mondini L, Monteiro CA. Mudanças no padrão de alimentação da população urbana brasileira (1962-1988). Rev Saúde Pública. 1994;28(6):433-439. DOI: https://doi.org/10.1590/S0034-89101994000600007
https://doi.org/10.1590/S0034-8910199400... ,³⁸38 Santos AMSP. Política urbana no Brasil: a difícil regulação de uma urbanização periférica. Geo UERJ 2020;(36):47269. DOI: https://doi.org/10.12957/geouerj.2020.47268
https://doi.org/10.12957/geouerj.2020.47... . This increases the chances of people developing NCDs, such as CRC. In Brazil, in natura or minimally processed foods have been intensely replaced by ultraprocessed foods³⁷37 Mondini L, Monteiro CA. Mudanças no padrão de alimentação da população urbana brasileira (1962-1988). Rev Saúde Pública. 1994;28(6):433-439. DOI: https://doi.org/10.1590/S0034-89101994000600007
https://doi.org/10.1590/S0034-8910199400... ,³⁹39 Malta DC, Gomes CS, Prates EJS, et al. Analysis of demand and access to services in the last two weeks previous to the National Health Survey 2013 and 2019. Rev Bras Epidemiol. 2021;24(supl2). DOI: https://doi.org/10.1590/1980-549720210002.supl.2
https://doi.org/10.1590/1980-54972021000... ,⁴⁰40 Costa CDS, Sattamini IF, Steele EM. Consumo de alimentos ultraprocessados e associação com fatores sociodemográficos na população adulta das 27 capitais brasileiras (2019). Rev Saúde Pública. 2021;55:47. DOI: https://doi.org/10.11606/s1518-8787.2021055002833
https://doi.org/10.11606/s1518-8787.2021... ,⁴¹41 Carrera-Bastos P, Fontes-Villalba M, O’Keefe JH, et al. The western diet and lifestyle and diseases of civilization. Res Rep Clin Cardiol. 2011;2:15-35. DOI: https://doi.org/10.2147/RRCC.S16919
https://doi.org/10.2147/RRCC.S16919... ,⁴²42 Barros MBA, Lima MG, Medina LP, et al. Social inequalities in health behaviors among Brazilian adults: National Health Survey, 2013. Int J Equity Health. 2016;15(1):148. DOI: https://doi.org/10.1186/s12939-016-0439-0
https://doi.org/10.1186/s12939-016-0439-... along with physical inactivity and sedentary behaviour, which have been following increasing trends over time⁴¹41 Carrera-Bastos P, Fontes-Villalba M, O’Keefe JH, et al. The western diet and lifestyle and diseases of civilization. Res Rep Clin Cardiol. 2011;2:15-35. DOI: https://doi.org/10.2147/RRCC.S16919
https://doi.org/10.2147/RRCC.S16919... and contributing to the rise in obesity³⁹39 Malta DC, Gomes CS, Prates EJS, et al. Analysis of demand and access to services in the last two weeks previous to the National Health Survey 2013 and 2019. Rev Bras Epidemiol. 2021;24(supl2). DOI: https://doi.org/10.1590/1980-549720210002.supl.2
https://doi.org/10.1590/1980-54972021000... . Obesity, alcohol and tobacco consumption, as well as the intake of ultra-processed foods are more prevalent in men⁴⁴44 Fundação Oswaldo Cruz. III Levantamento Nacional sobre o uso de drogas pela população brasileira [Internet]. Rio de Janeiro: Fiocruz; 2017 [acesso em 2023 ago 29]. Disponível em: https://www.arca.fiocruz.br/bitstream/icict/34614/1/III%20LNUD_PORTUGU%c3%8aS.pdf
https://www.arca.fiocruz.br/bitstream/ic... ,⁴⁵45 Instituto Brasileiro de Geografia e Estatística. Pesquisa de orçamentos familiares: 2017-2018POF: avaliação nutricional da disponibilidade domiciliar de alimentos no Brasil [Internet]. Rio de Janeiro: IBGE; 2020 [acesso em 2023 ago 29]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101704.pdf
https://biblioteca.ibge.gov.br/visualiza... , supporting the findings in the male group of this study and the differences observed between the units of analysis.

Expanding the healthcare services allows access to diagnosis and treatment, as seen in the Northeast region, where Primary Care coverage was 60.65% in 2007 and rose to 81.74% in 2019⁴⁶46 Viacava F, Oliveira RAD, Carvalho CC, et al. SUS: supply, access to and use of health services over the last 30 years. Ciênc saúde coletiva. 2018;23(6):1751-1762. DOI: https://doi.org/10.1590/1413-81232018236.06022018
https://doi.org/10.1590/1413-81232018236... ,⁴⁷47 Ministério da Saúde (BR), Coordenação Geral de Informação da Atenção Primária, Departamento de Saúde da Família, Secretaria de Atenção Primária à Saúde. e-Gestor AB. Relatórios Públicos. Histórico de Cobertura da Atenção Primária: Histórico-AB-BRASIL-2007-202012. Brasília, DF: 2021., according to the quality of the data⁴⁸48 Sales OP, Vieira AFB, Martins AM, et al. O Sistema Único de Saúde: desafios, avanços e debates em 30 anos de história. Rev Humanid Inov [Internet]. 2019 [acesso em 2023 ago 29];6(17):54-65. Disponível em: https://revista.unitins.br/index.php/humanidadeseinovacao/article/view/1045
https://revista.unitins.br/index.php/hum... . However, there was a high mortality rate among males, which suggests delayed access to healthcare services. Low demand for health promotion and prevention services was observed in this group, which can result in late diagnosis and untreated health problems, something that has already been identified in other research studies⁴⁹49 Separavich MA, Canesqui AM. Saúde do homem e masculinidades na Política Nacional de Atenção Integral à Saúde do Homem: uma revisão bibliográfica. Saude soc. 2013;22(2):415-428. DOI: https://doi.org/10.1590/S0104-12902013000200013
https://doi.org/10.1590/S0104-1290201300... ,⁵⁰50 Vieira KLD, Gomes VLDO, Borba MR, et al. Atendimento da população masculina em unidade básica saúde da família: motivos para a (não) procura. Esc Anna Nery. 2013;17(1):120-127. DOI: https://doi.org/10.1590/S1414-81452013000100017
https://doi.org/10.1590/S1414-8145201300... ,⁵¹51 Malta DC, Bernal RTI, Gomes CS, et al. Desigualdades na utilização de serviços de saúde por adultos e idosos com e sem doenças crônicas no Brasil, Pesquisa Nacional de Saúde 2019. Rev Bras Epidemiol. 2021;24(supl2):e210003. DOI: https://doi.org/10.1590/1980-549720210003.supl.2
https://doi.org/10.1590/1980-54972021000... .

By analysing the indicators with the Sociodemographic Index, it can be seen that the more developed FU have the highest incidence and prevalence rates, which can be explained by the better socioeconomic conditions of these groups⁵²52 Instituto Brasileiro de Geografia e Estatística. Banco de Tabelas. Padrão de vida e distribuição de rendimentos [Internet]. Rio de Janeiro: IBGE; 2022 [acesso em 2023 ago 29]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/populacao/9221-sintese-de-indicadores-sociais.html
https://www.ibge.gov.br/estatisticas/soc... , Analysis of the indicators with the sociodemographic index shows that the more developed FU have the highest incidence and prevalence rates, which can be explained by the better socioeconomic conditions of these groups, such as easier access to industrialized foods due to higher local development and purchasing power, longer life expectancy which implies greater exposure to risk factors for NCDs, including CRC, and access to quality health services⁴⁴44 Fundação Oswaldo Cruz. III Levantamento Nacional sobre o uso de drogas pela população brasileira [Internet]. Rio de Janeiro: Fiocruz; 2017 [acesso em 2023 ago 29]. Disponível em: https://www.arca.fiocruz.br/bitstream/icict/34614/1/III%20LNUD_PORTUGU%c3%8aS.pdf
https://www.arca.fiocruz.br/bitstream/ic... ,⁴⁵45 Instituto Brasileiro de Geografia e Estatística. Pesquisa de orçamentos familiares: 2017-2018POF: avaliação nutricional da disponibilidade domiciliar de alimentos no Brasil [Internet]. Rio de Janeiro: IBGE; 2020 [acesso em 2023 ago 29]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101704.pdf
https://biblioteca.ibge.gov.br/visualiza... . Despite improvements in these conditions, the challenge remains to adhere to sustainable diets by integrating nutritional, cultural, economic and environmental aspects to guarantee food security, which will also make it possible to reduce NCDs⁵³53 Triches RM. Dietas saudáveis e sustentáveis no âmbito do sistema alimentar no século XXI. Saúde debate [Internet]. 2020;44(126):881-894. DOI: https://doi.org/10.1590/0103-1104202012622
https://doi.org/10.1590/0103-11042020126... .

Observed correlations can also be attributed to the country’s social and regional discrepancies. According to the Brazilian Institute of Geography and Statistics (IBGE), the lowest average household incomes per capita in the country’s main regions in 2019 were in the North (R$955.00) and the Northeast (R$945.00)⁵²52 Instituto Brasileiro de Geografia e Estatística. Banco de Tabelas. Padrão de vida e distribuição de rendimentos [Internet]. Rio de Janeiro: IBGE; 2022 [acesso em 2023 ago 29]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/populacao/9221-sintese-de-indicadores-sociais.html
https://www.ibge.gov.br/estatisticas/soc... as well as low incomes and low levels of education⁵⁴54 Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios Continua [Internet]. Educação 2022. Rio de Janeiro: IBGE; 2023 [acesso em 2023 mar 20]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv102002_informativo.pdf
https://biblioteca.ibge.gov.br/visualiza... , which increase the vulnerability of this group to CRC.

In both the 1990s and 2019, there was a strong correlation between rates and SDI in women, and those with higher income and schooling, as well as low fertility rates, showed better indicators compared to men, since they did not show an association between SDI and DALYs and mortality. Research shows that white women with higher incomes and more schooling tend to lead healthier lifestyles (diet, less tobacco and alcohol consumption and physical activity)⁴⁴44 Fundação Oswaldo Cruz. III Levantamento Nacional sobre o uso de drogas pela população brasileira [Internet]. Rio de Janeiro: Fiocruz; 2017 [acesso em 2023 ago 29]. Disponível em: https://www.arca.fiocruz.br/bitstream/icict/34614/1/III%20LNUD_PORTUGU%c3%8aS.pdf
https://www.arca.fiocruz.br/bitstream/ic... ,⁴⁵45 Instituto Brasileiro de Geografia e Estatística. Pesquisa de orçamentos familiares: 2017-2018POF: avaliação nutricional da disponibilidade domiciliar de alimentos no Brasil [Internet]. Rio de Janeiro: IBGE; 2020 [acesso em 2023 ago 29]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101704.pdf
https://biblioteca.ibge.gov.br/visualiza... have a greater perception of risk and, as a result, have a higher incidence of preventive medical consultations, which allows for the timely diagnosis and treatment of diseases³⁹39 Malta DC, Gomes CS, Prates EJS, et al. Analysis of demand and access to services in the last two weeks previous to the National Health Survey 2013 and 2019. Rev Bras Epidemiol. 2021;24(supl2). DOI: https://doi.org/10.1590/1980-549720210002.supl.2
https://doi.org/10.1590/1980-54972021000... that influence the reduction of mortality and morbidity.

A comparison of trends between Brazilian localities showed a different behaviour in the Federal District (DF), with a decreasing trend in mortality and DALYs for females and a stable trend for males. It should be noted that household income in the Federal District is the highest in the whole of Brazil (average per capita income of R$2,765.00)⁵²52 Instituto Brasileiro de Geografia e Estatística. Banco de Tabelas. Padrão de vida e distribuição de rendimentos [Internet]. Rio de Janeiro: IBGE; 2022 [acesso em 2023 ago 29]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/populacao/9221-sintese-de-indicadores-sociais.html
https://www.ibge.gov.br/estatisticas/soc... , which suggests greater access to health services and less dependence on public services. These findings are in line with previous studies which show that income has a negative correlation with the number of deaths from the disease, i.e., the higher the income, the lower the risk of dying and the less time lost due to death or disability⁵⁵55 Guimarães RM, Rocha PGM, Muzi CD, et al. Increase income and mortality of colorrectal cancer in Brazil, 2001-2009. Arq Gastroenterol. 2013;50(1):64-69. DOI: https://doi.org/10.1590/S0004-28032013000100012
https://doi.org/10.1590/S0004-2803201300... ,⁵⁶56 Vineis P, Wild CP. Global cancer patterns: causes and prevention. Lancet. 2014;383(9916):549-557. DOI: https://doi.org/10.1016/s0140-6736(13)62224-2
https://doi.org/10.1016/s0140-6736(13)62... .

Brazil is one of the few countries that offers a universal public health service for the entire population, whereby the Basic Health Units (UBS) and Family Health Units (USF) are responsible for prevention and promotion actions⁵⁷57 Paula Pires ME, Mezzomo DS, Leite FMM, et al. Rastreamento do câncer colorretal: revisão de literatura. Braz J Hea Rev. 2021;4(2):6866-6881. DOI: https://doi.org/10.34119/bjhrv4n2-233
https://doi.org/10.34119/bjhrv4n2-233... . There is currently no standardized, universal colorectal cancer (CRC) screening programme in the country. Screening approaches for CRC are selected based on criteria such as financial viability and patient suitability. So, access to CRC screening depends on the geographical region and the financial capacity of the local health system and the decision to carry out screening, as well as the patient’s individual medical history (risk of developing the disease)⁵⁷57 Paula Pires ME, Mezzomo DS, Leite FMM, et al. Rastreamento do câncer colorretal: revisão de literatura. Braz J Hea Rev. 2021;4(2):6866-6881. DOI: https://doi.org/10.34119/bjhrv4n2-233
https://doi.org/10.34119/bjhrv4n2-233... . There are initiatives to organize the healthcare network in terms of cancer prevention, diagnosis and timely treatment, with the aim of improving the cancer survival rate in the country, in line with the law that guarantees early treatment within 60 days after diagnosis⁵⁸58 Ministério da Saúde (BR), Gabinete do Ministro. Portaria nº 1.220, de 3 de junho de 2014. Altera o art. 3º da Portaria nº 876/GM/MS, de 16 de maio de 2013, que dispõe sobre a aplicação da Lei nº 12.732, de 22 de novembro de 2012, que versa a respeito do primeiro tratamento do paciente com neoplasia maligna comprovada, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União, Brasília, DF. 2014 jun 4; Edição 105; Seção I:91..

As this is a study using secondary data, it has limited accuracy of the indicators used. The Global Burden of Disease (GBD) statistically treats the data from the systems to obtain better quality data, such as corrections for underreporting of deaths and redistribution of unspecified causes, such as mortality. The methodology for these corrections and estimates includes many modelling stages, which consider data from the National Civil Registration Systems and other sources of information, as well as the redistribution of ill-defined codes. These estimates provide an overview of the epidemiology of RCC by comparing indicators between different states.

Conclusions

According to gender and state, the differences observed in colorectal cancer rates and their temporal evolution may be related to the various risk factors, as well as the lack of equitable access to healthcare services for timely diagnosis and treatment. The findings may reflect socioeconomic inequalities in Brazil and show a predominant increase in these trends in regions considered underdeveloped, regardless of gender, whereas the more developed regions show indicators with more stable trends, especially in the female group.

It is therefore essential that health policymakers adopt preventive policies against colorectal cancer. This entails investing in and prioritizing intersectoral public policies and surveillance programmes, which have a direct impact on life expectancy and morbidity and mortality rates in this population. Therefore, it must be emphasized that early detection of cancer is crucial for the success of treatment and to improve the chances of a cure.

References

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