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Revista Brasileira de Epidemiologia

Print version ISSN 1415-790XOn-line version ISSN 1980-5497

Rev. bras. epidemiol. vol.19 no.1 São Paulo Jan./Mar. 2016

http://dx.doi.org/10.1590/1980-5497201600010001 

Original Articles

Clinical breast examination and mammography: inequalities in Southern and Northeast Brazilian regions

Zaida da Silva BorgesI 

Fernando César WehrmeisterI 

Ana Paula GomesI 

Helen GonçalvesI 

IGraduate Program in Epidemiology , Universidade Federal de Pelotas - Pelotas (RS), Brazil.

ABSTRACT:

Objective:

To evaluate the prevalence and associated factors of doing clinical breast examinations (CBE) and mammogram (MMG) in the Southern and Northeast Brazilian regions, focusing on some social inequalities.

Methods:

This is a cross-sectional study using data from the 2008 National Household Sampling Survey (PNAD). We evaluated the prevalence of CBE during the last year and of the MMG in the last two years, which were analyzed based on demographic (age, skin color, and marital status) and socioeconomic (income and schooling) variables. Gross and adjusted prevalence ratios were obtained using Poisson regression models. All analyses were stratified by region.

Results:

The sample comprised 27,718 women aged 40 to 69 years. Less than a half of the women followed the recommendation of annual CBE performance in both the regions. The MMG prevalence during the last two years was 58.6 and 45.5% for the Southern and Northeast regions, respectively. More than a quarter of the women had never had a MMG (26.5% in the Southern and 40.6% in the Northeast regions). Not having performed both examinations was almost two times higher in the Northeast region (29.7%) when compared with the Southern (15.9%). The risk for not having performed both examinations was greater among nonwhite women, aged 60 to 69 years, with lower schooling level and family income.

Conclusion:

Important inequalities were seen between the Southern and Northeast regions for CBE and MMG. Health public policies should prioritize the most vulnerable groups to reduce these inequalities.

Keywords: Health inequalities; Mammogram; Breast neoplasms; Women's health; Neoplasms; Mass screening.

INTRODUCTION

The World Health Organization estimates that there will be, in 2030, 27 million cases of all kinds of cancer, 17 million deaths, and 75 million people living with this disease per year in all the world1. Breast cancer is a neoplasm with higher incidence and mortality rate among women in Brazil (with the exception of the Northern regions) and the second most common in the world2. Breast cancer issue has become important in the political and technical schedules in health, thus enabling that the recommendations for the identification of new cases and prevention are updated based on the magnitude and impact of such disease on the population1,3,4.

The Brazilian Department of Health develops the recommendations for early detection and monitoring of breast cancer3. Currently, a clinical breast examination (CBE) is an annual investigation recommended for women aged 40 to 49 years for an early detection. For 50 to69-year-old women, the CBE is still an annual recommendation, in addition to the mammogram (MMG) performance every 2 years. For women with high risk for breast cancer, the best management should be assessed by the doctor5. The strategies are simple and easy to perform; therefore, they should be a priority for the disease monitoring4. The early detection of breast cancer can avoid about 30% of the deaths owing to this condition6.

According to data from the 2003 National Household Sampling Survey (PNAD), almost a half of 50 to 69-year-old women (49.3%) have never had a MMG in life, and around 35% of women older than 40 years have never performed a CBE7,8. In 2008, about 40% of women aged 40 years or older performed a CBE in the last year, and 54% of 50 to 69-year-old women had a MMG in the last 2 years, as preconized by the Brazilian Department of Health3,9. With regard to the last examination, almost half of it was performed in women aged 50 to 69 years old9. Even though the percentages show an increase in the performance of preventive examinations by women, if we compare these data to those obtained in the 2003 PNAD10, the Brazilian reality is far from reaching most women who need monitoring, as preconized by the Brazilian Policy of Oncological Care11.

Population-based studies showed the existence of significant socioeconomic, racial, and regional inequalities, among other differences in the performance of preventive examinations12,13. In summary, they showed that the most privileged women in the performance of examinations are white women with higher acquisitive power, living in the wealthiest regions of the country, with a higher schooling level and who have a spouse. On the basis of these data, the less socioeconomically privileged population still remains an important focus for the Healthy Policy still current in the country10,14. The survival of a hearable cancer, such as breast cancer, is deeply and positively related to the country income, offer opportunity, monitoring effectiveness of this neoplasm and the socioeconomic development of these regions in the country15. Therefore, the evaluation of inequalities among the Brazilian regions, with regard to preventive examinations performance, such as the CBE and MMG, is a relevant datum for health institutions.

The Southern and Northeast regions are admittedly different in economic, social, and cultural terms. Thus, they are both the target for analysis of this study, whose objective is to evaluate the CBE and MMG prevalence and the factors associated with its performance in women aged 40 to 69 years living in such locations.

METHODS

This cross-sectional population study used secondary data from the PNAD conducted in the year of 2008 by the Brazilian Institute of Geography and Statistics (IBGE)9. In such year, additional information about the health characteristics of local residents was collected to identify possible regional inequalities, including data about the CBE and MMG performance.

The PNAD is carried out through a probabilistic sample of households obtained during three stages: municipalities, censor sectors, and house units. The sample is significant for Brazil, for great regions, for states and 10 metropolitan areas. In 2008, the survey included 150,591 households with 391,868 interviewed subjects9. This study, however, used information regarding the 40 to 69-year-old female population, from the Brazilian Southern and Northeast regions, in the referred survey year.

The evaluated outcomes were the CBE and MMG prevalence. For the CBE, answers to the question "When was the last time a doctor or a nurse performed the clinical breast exam of the <interviewed subject>?" were categorized in 1 year or less than a year (follows the recommendation), in more than a year (did it in less time), and never had it (never had it). The 2004 Consensus3 considers adequate breast cancer monitoring through CBE in a yearly basis after 40 years for women without risk and 35 years or older for those at risk of developing the disease. For the MMG, the question "When was the last time the <interviewed subject> had a mammogram?" generated answers that were categorized in: 2 or less years (follows the recommendation), more than 2 years (did it in less time), and never had it (never had it). If the examination was performed in a period of 2 or less years from age 50, it was adequate.

The demographic characteristics (age, skin color, marital status, socioeconomic level, and schooling) were independent variables. The age variable was grouped in three groups: 40 to 49; 50 to 59; and 60 to 69 years. Skin color - based on IBGE establishments and self-declared by the interviewed - was once more categorized as white and nonwhite owing to the low rates in the categories of yellow color and indigenous. Marital status was divided into with and without a spouse, being self-declared by the interviewed. The socioeconomic level was investigated following the score of the Classification from the Brazilian Association of Survey Companies (ABEP)16 and divided into quintiles. Schooling was categorized in complete years of study, such as: none; from 1 to 4; from 5 to 8; and 9 or more.

The statistical analyzes were conducted using the Stata 12.1 program (Statcorp, Texas), with description and prevalence of CBE and MMG divided by the Southern and Northeast regions. Bivariate analyzes were carried out using Pearson χ2 and lineal tendency tests (if needed) between exposures and outcomes. The gross and adjusted prevalence rates were obtained through Poisson regression. The adjusted analysis for each region (Southern and Northeast) and for every outcome (non-performance of CBE, of MMG or of both), separately, was done considering all independent variables at the same time in the model. Because this is a complex sample, sampling weights and study outline effect were considered in the analysis. The work was submitted to the Research Ethics Committee of the School of Medicine from Universidade Federal de Pelotas for knowledge and approved according to protocol number 467,419 from October 2013.

RESULTS

The sample comprised 27,718 women, and 10,037 of them lived in the Southern and 17,681 in the Northeast (Table 1) regions. In both regions, women aged 40 to 49 years showed a higher prevalence, and about one-third had 9 or more years of schooling level. While 80.5% of the sample in the Southern region referred being white, 69.2% of women from the Northeast called themselves as nonwhite. In addition, differences related to living with a spouse were seen: in the Southern, 55.0% of the women lived with a spouse, and less than a half of the women (48.4%) living in the Northeast showed the same characteristic.

Table 1: Distribution of the sample according to socioeconomic and demographic characteristics in the Brazilian Southern and Northeast regions. 2008 Brazilian Survey by House Sample. 

*Maximum number of ignored values: income variable (301 - Southern region and 440 - Northeast region)

Table 2 presents the CBE prevalence based on the recommendations of the Brazilian Department of Health. It was seen that less than a fifth (17.5%) of women from the Southern had never performed a CBE against 32.0% of those living in the Northeast. Furthermore, in both regions, women who had never had or had had and are below the recommendations for breast cancer prevention were aged between 60 and 69 years and showed a family income lower than those following the recommendations. The group below recommendations was very similar in both evaluated regions. In this Table, we can see that in the Northeast region, women living with a spouse were the group with the highest rate of having never performed a CBE, and the highest percentages for women who were below recommendations had more schooling and higher income levels.

Table 2: Description and prevalence of clinical breast examination (never performed it, performed it and is below the recommendations, and follows recommendations) per region and Southern/Northeast ratio. 2008 National Household Sampling Survey. 

Less than a half of the evaluated women and resident in the Northeast region (45.5%) followed the recommendations to have a MMG, while more than a half (58.6%) of the women from the Southern region performed these same procedures (Table 3). White women aged 50 to 59 years, richer, and with higher schooling level were the ones who most followed the recommendations for MMG. About 40.6% of the Northeast women who had never had a MMG was reported against 26.6% of those in the Southern region. By comparing the regions, women with higher schooling level from the Northeast presented more prevalence of being below the recommendations than those in the Southern. Women living with a spouse followed fewer recommendations than those without a spouse, and women living with a spouse had a higher percentage of having never had a MMG than their group of comparison.

Table 3: Description and prevalence of Mammogram (never had it, had it and is below recommendations, and follows recommendations) per region and Southern/Northeast ratio. 2008 National Household Sampling Survey. 

In addition, in the group of women who had never had a MMG and/or CBE (Table 4), the highest risk for nonperformance of these examinations in both regions was found among poorer and less-schooled women.

Table 4: Prevalence ratio for women who never had a mammogram, a clinical breast examination or both examinations. 2008 National Household Sampling Survey. 

MMG: mammogram; CBE: clinical breast examination; PR: prevalence ratio; 95%CI: 95% confidence interval.

In the evaluation of the rate of women from both regions that had never performed the analyzed examinations, those living in the Northeast region had the highest prevalence of never performing the CBE, MMG, or CBE and MMG. The prevalence of having never performed any examinations is almost the double in women from the Northeast (30%) than in the Southern (16%) (data are not presented).

DISCUSSION

Since 1998, the PNAD has regularly analyzed important health indicators of the Brazilian population. The use of secondary data sources provides accurate and representative estimations for the Brazilian macroregions, thus creating valuable information for planning actions in public health, such as data related to women's health.

Although the prevalence of MMG and CBE conduction has increased when compared with the estimative obtained by PNAD in 200310, this study showed that the most vulnerable groups still need more attention by health professionals and consequently of public actions directed to them. During the period from 2003 to 2008, there was a decrease of inequality in the performance of preventive examinations10. However, as seen in the demonstrated results, women who do not follow recommendations - never had or are below the recommendations - are still those presenting relevant characteristics to other health outcomes, such as nonwhite women aged 60 years or older, with the lowest income quintile. These findings are in agreement with the studies carried out with smaller samples and in different regions of the country8,17,18,19. Women with higher schooling and income levels, generally, have more access to information and health services, therefore resulting in the highest prevalence of performing examinations closer to the recommendations for prevention or treatment of diseases8,17,20. After comparing national data of 2003 and 2008 PNAD, we found an increase in the rate of women aged 50 to 69 years who had a MMG in their lives to be 54.6 and 71.5%, respectively21. Moreover, regarding the MMG, the study pointed out that young women, who are not in the age range recommended to perform the examination, represent a high percentage compared with those who should be the procedure target. Because the recommendation for performing the MMG involves 50-year-old women or older3,5, a lower prevalence would be expected in women aged younger than 50 years. Because data do not allow identifying women with high risk for breast cancer, there is the possibility that, among this group, there are some women with an indication to have the MMG. As to skin color, there are more inequalities in the Southern region than in the Northeast, mainly regarding the nonperformance of the MMG, which can more strongly mark the access differences and information from unequal situations from the race/skin color in both analyzed contexts. The investigations of Amorin et al.17 and Oliveira et al.10 also point out some differences regarding this subject, with the worst results found for nonwhite women.

As to the target regions of the study, we noticed that Southern women most refer performing CBE and MMG if compared with the Northeast region. This datum was also seen in the 2003 PNAD7, which shows the existence of a temporal trend to be combated. Because the goal established by Department of Health is of 60% to MMG performance in the target population22, we can see that the Southern region was close to reaching it (59.1%), while the Northeast region is still far (49.8%) from it. Studies that evaluated health iniquities and inequalities in the Brazilian regions also point out more unfavorable indicators for the Northeast compared with the Southern8,23. According to the authors, differences can be seen such as in the number of mammography units and treatments available and the distance to get to the examination location. More economically developed regions tend to detect more breast cancer cases12. Regions with lower poverty rate, such as the Brazilian Northeast, have a great contingent of health problems in all areas23. Historically, the absence of constant investments in public health services and skilled professionals that are able to care for and monitor diseases such as breast cancer in these regions might explain a great part of the differences24,25.

The opportunistic monitoring, therefore, keeps the inequalities of access and use of monitoring examinations. Although the Department of Health recommends an active search in the target population (who never had a MMG and need to have it)4, such acts are still not part of the Brazilian reality as a whole. It is seen that such kind of monitoring causes inequalities in the access and use of preventive examinations, thus causing the prioritization of MMG instead of CBE21, as showed. According to Silva and Hortale21, the organized monitoring programs could correct inequalities if the four main components (technical, economic, social, and ethical) were ensured. It is worth emphasizing that costs with preventive actions are smaller than with disease treatment26. Its direct and indirect costs are associated with breast stage during diagnosis moment. Costs to health system might increase if the municipalities do not have the preconized treatment.

Other associated reasons to not have the MMG pointed out in literature include: lack of medical requirement27,28,29,30, not knowing age range in which the examination must be taken27, obstacles related to public services27,28, fear of performing the examination27,28,30, pain, discomfort, and anxiety regarding the examination28,31,32, and lack of time28. In addition to them, sociocultural aspects are also believed to influence care practices and and ways of noticing health needs and comprehension of how to prevent diseases in both regions and of professionals towards them17. These aspects might also be quite related to the fact that women living with a spouse in the Northeast region are the group with the highest rate of having never performed the CBE and of them following fewer recommendations and corresponding to the highest percentage of having never had a MMG.

This study presents an important estimation regarding the performance of preventive examinations in women on the studied regions. However, it is important to mention some limitations. Owing to the use of secondary data obtained with specific questions on the theme, it was not possible to make new categorizations for comparative purposes with other studies. As it is a survey with an interview, the memory bias to talk about the period of the last examination and of information might have influenced the percentages for both examinations. Impossibility in inferring causality is another limitation of the study, although the associated factors evaluation, even noncasually, is an important tool to plan public policies.

The results from this study, based on 2008 PNAD, might provide grants to the managers for formulating public policies with the aim of an effective and efficient increase of CBE and MMG. Therefore, they should consider in their actuations the differences seen between the regions, such intensifying the MMG monitoring in the Northeast region, which is a place where less women have had it; strengthening this monitoring for the target population in both regions. In addition, new investigations are recommended in order to improve the understanding about factors associated with these examinations, promoting the comprehension and aiming to dissolve social inequalities associated with nonperformance of the analyzed examinations, and to promote health equities.

CONCLUSION

Important inequalities in the conduction of preventive examinations for breast cancer were seen between the Brazilian Southern and Northeast regions. Health public policies should give priority to the most vulnerable groups in order to reduce such inequalities.

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Financial support: none.

Received: November 15, 2014; Accepted: September 18, 2015

Corresponding author: Helen Gonçalves. Rua Marechal Deodoro, 1160, 3° andar, CEP: 96220-220, Pelotas, RS, Brasil. E-mail: hdgs.epi@gmail.com

Conflict of interests: nothing to declare

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