Gulnar Azevedo e Silva

Chronic non-communicable diseases in Brazil: burden and current challenges

Non-communicable diseases (NCDs) have become a major health priority in Brazil--72% of all deaths were attributable to NCDs in 2007. They are also the main source of disease burden, with neuropsychiatric disorders being the single largest contributor. Morbidity and mortality due to NCDs are greatest in the poor population. Although the crude NCD mortality increased 5% between 1996 and 2007, age-standardised mortality declined by 20%. Declines were primarily for cardiovascular and chronic respiratory diseases, in association with the successful implementation of health policies that lead to decreases in smoking and the expansion of access to primary health care. Of note, however, the prevalence of diabetes and hypertension is rising in parallel with that of excess weight; these increases are associated with unfavourable changes of diet and physical activity. Brazil has implemented major policies for the prevention of NCDs, and its age-adjusted NCD mortality is falling by 1·8% per year. However, the unfavourable trends for most major risk factors pose an enormous challenge and call for additional and timely action and policies, especially those of a legislative and regulatory nature and those providing cost-effective chronic care for individuals affected by NCDs.

Global surveillance of cancer survival 1995–2009: analysis of individual data for 25 676 887 patients from 279 population-based registries in 67 countries (CONCORD-2)

BACKGROUND Worldwide data for cancer survival are scarce. We aimed to initiate worldwide surveillance of cancer survival by central analysis of population-based registry data, as a metric of the effectiveness of health systems, and to inform global policy on cancer control. METHODS Individual tumour records were submitted by 279 population-based cancer registries in 67 countries for 25·7 million adults (age 15-99 years) and 75,000 children (age 0-14 years) diagnosed with cancer during 1995-2009 and followed up to Dec 31, 2009, or later. We looked at cancers of the stomach, colon, rectum, liver, lung, breast (women), cervix, ovary, and prostate in adults, and adult and childhood leukaemia. Standardised quality control procedures were applied; errors were corrected by the registry concerned. We estimated 5-year net survival, adjusted for background mortality in every country or region by age (single year), sex, and calendar year, and by race or ethnic origin in some countries. Estimates were age-standardised with the International Cancer Survival Standard weights. FINDINGS 5-year survival from colon, rectal, and breast cancers has increased steadily in most developed countries. For patients diagnosed during 2005-09, survival for colon and rectal cancer reached 60% or more in 22 countries around the world; for breast cancer, 5-year survival rose to 85% or higher in 17 countries worldwide. Liver and lung cancer remain lethal in all nations: for both cancers, 5-year survival is below 20% everywhere in Europe, in the range 15-19% in North America, and as low as 7-9% in Mongolia and Thailand. Striking rises in 5-year survival from prostate cancer have occurred in many countries: survival rose by 10-20% between 1995-99 and 2005-09 in 22 countries in South America, Asia, and Europe, but survival still varies widely around the world, from less than 60% in Bulgaria and Thailand to 95% or more in Brazil, Puerto Rico, and the USA. For cervical cancer, national estimates of 5-year survival range from less than 50% to more than 70%; regional variations are much wider, and improvements between 1995-99 and 2005-09 have generally been slight. For women diagnosed with ovarian cancer in 2005-09, 5-year survival was 40% or higher only in Ecuador, the USA, and 17 countries in Asia and Europe. 5-year survival for stomach cancer in 2005-09 was high (54-58%) in Japan and South Korea, compared with less than 40% in other countries. By contrast, 5-year survival from adult leukaemia in Japan and South Korea (18-23%) is lower than in most other countries. 5-year survival from childhood acute lymphoblastic leukaemia is less than 60% in several countries, but as high as 90% in Canada and four European countries, which suggests major deficiencies in the management of a largely curable disease. INTERPRETATION International comparison of survival trends reveals very wide differences that are likely to be attributable to differences in access to early diagnosis and optimum treatment. Continuous worldwide surveillance of cancer survival should become an indispensable source of information for cancer patients and researchers and a stimulus for politicians to improve health policy and health-care systems. FUNDING Canadian Partnership Against Cancer (Toronto, Canada), Cancer Focus Northern Ireland (Belfast, UK), Cancer Institute New South Wales (Sydney, Australia), Cancer Research UK (London, UK), Centers for Disease Control and Prevention (Atlanta, GA, USA), Swiss Re (London, UK), Swiss Cancer Research foundation (Bern, Switzerland), Swiss Cancer League (Bern, Switzerland), and University of Kentucky (Lexington, KY, USA).

Pesquisa Nacional de Saude no Brasil: concepcao e metodologia de aplicacao

The National Health Survey is a household-based nationwide survey carried out by the Ministry of Health in partnership with the Brazilian Institute of Geography and Statistics. The scope of the survey is to establish the health status and lifestyles of the population - as well as how they look after their health - with regard to access and use of services, preventive actions, continuity of care, and health care financing. The sample size is 80,000 households and enables the calculation of some indicators at different geographic levels, namely states, capitals, metropolitan and rural areas. The questionnaire is divided into three parts. The first two are answered by one resident and include questions on the household characteristics and on the social and economic level and health status of all inhabitants. The individual questionnaire is answered by an adult (aged 18 years or more), selected with equal probability among the adult residents, and focuses on morbidity and lifestyle. For this individual, measurements of weight, height, waist circumference and blood pressure are taken, as well as laboratory exams to characterize the lipid profile and blood glucose level, as well as determine the urine sodium content. The laboratory exams are taken in a subsample of 25% of the census sectors selected.

Invalidez por dor nas costas entre segurados da Previdência Social do Brasil

OBJECTIVE To describe disability pension from back pain. METHODS Descriptive study based on data from the Brazilian Social Security Beneficiary Database and the Social Security Statistics Annual Report in 2007. The incidence rate of disability pension from back pain was estimated according to gender and age by Brazilian states. There were also estimated working days lost due to back pain disability by occupation. RESULTS Idiopathic back pain was the most common cause of disability among social security pension and accidental retirement. Most pensioners were living in urban areas and were commercial workers. The rate of disability pension from back pain in Brazil was 29.96 per 100,000 beneficiaries. A higher rate was seen among males and older individuals. Rondônia showed the highest rate, four times as high as expected (RR= 4.05) followed by Bahia with a rate about twice as high as expected (RR=2.07). Commercial workers accounted for 96.9% of working days lost due to disability. CONCLUSIONS Back pain was a major cause of disability in 2007 mostly among commercial workers showing great differences between the Brazilian states.OBJETIVO: Descrever as aposentadorias por invalidez decorrente de dor nas costas. METODOS: Estudo descritivo com dados do Sistema Unico de Informacoes de Beneficios e dos Anuarios Estatisticos da Previdencia Social em 2007. A taxa de incidencia de dor nas costas como causa das aposentadorias por invalidez foi calculada segundo as variaveis idade e sexo, nos estados. Os dias de trabalho perdidos por invalidez decorrente de dor nas costas foram calculados segundo atividade profissional. RESULTADOS: A dor nas costas idiopatica foi a primeira causa de invalidez entre as aposentadorias previdenciarias e acidentarias. A maioria dos beneficiarios residia em area urbana e era comerciario. A taxa de incidencia de dor nas costas como causa das aposentadorias por invalidez no Brasil foi de 29,96 por 100.000 contribuintes. Esse valor foi mais elevado entre os homens e entre as pessoas mais velhas. Rondonia exibiu taxa quatro vezes superior ao esperado (RT = 4,05) e a segunda maior taxa, referente a Bahia, foi de aproximadamente duas vezes o esperado (RT = 2,07). Os comerciarios foram responsaveis por 96,9% dos dias perdidos por invalidez. CONCLUSOES: A dor nas costas foi uma importante causa de invalidez em 2007, sobretudo entre comerciarios, com grandes diferencas entre os estados.

Tendência da mortalidade por câncer nas capitais e interior do Brasil entre 1980 e 2006

OBJECTIVE To analyze the corrected trend of overall cancer mortality and leading sites in the state capitals and other municipalities of Brazil between 1980 and 2006. METHODS Data on deaths (n = 2,585,012) caused by cancer between 1980 and 2006 were obtained from Sistema de Informações sobre Mortalidade (Mortality Information System), and demographic data were provided by Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics). The rates of overall cancer mortality and major types were corrected by proportionally redistributing 50% of ill-defined causes of death and standardizing them by age according to the standard world population. Trend curves for Brazil and its major regions were calculated for state capitals and other municipalities according to sex, and were evaluated by means of simple linear regression. RESULTS Among men, ascending mortality rates were observed for lung, prostate and colorectal cancer; declining rates for stomach cancer; and stable rates for esophagus cancer. Among women, mortality from breast, lung and colorectal cancer increased, and the rates for cervical and stomach cancer declined. Mortality evolution varied across the regions of Brazil, with distinct patterns between state capitals and other municipalities. CONCLUSIONS The correction of mortality rates based on redistribution of ill-defined causes of death increased the magnitude of the overall cancer mortality in Brazil by approximately 10% in 1980 and 5% in 2006. In the inland municipalities no decrease or stability was identified, differently from what was observed in the state capitals. Limited scope of prevention actions and lower access to services of cancer diagnosis and treatment for the population living away from large urban centers may partly explain these differences.OBJETIVO: Analizar la tendencia corregida de la mortalidad general por cancer y principales tipos en las capitales y demas municipios de Brasil entre 1980 a 2006. METODOS: Los datos sobre obitos (n= 2.585.012) originados por cancer entre 1980 y 2006 fueron obtenidos en el Sistema de Informaciones sobre Mortalidad, y los demograficos, en el Instituto Brasileno de Geografia y Estadistica. Las tasas de mortalidad general por cancer y principales tipos fueron corregidas redistribuyendo proporcionalmente 50% de las muertes mal definidas y estandarizandolas por edad segun poblacion patron mundial. Las curvas de tendencia para Brasil y grandes regiones fueron calculadas para capitales y demas municipios segun sexo y evaluadas por medio de regresion linear simple. RESULTADOS: Entre los hombres, las tasas de mortalidad para los canceres de pulmon, prostata y colorrectal fueron ascendentes; declinantes para el de estomago y estables para el de esofago. Entre las mujeres, hubo aumento de la mortalidad por cancer de mama, pulmon y colorrectal; y disminucion de las tasas para los canceres de cuello uterino y de estomago. La evolucion de la mortalidad vario entre las regiones del Pais, con patrones distintos entre las capitales y demas municipios. CONCLUSIONES: La correccion de las tasas de mortalidad con redistribucion de los obitos mal definidos aumento la magnitud de la mortalidad general por cancer en Brasil en cerca de 10% en 1980 y 5% en 2006. En los municipios del interior no se observo tendencia de disminucion o estabilidad como en las capitales. Menor alcance de las acciones de prevencion y la dificultad de acceso a servicios diagnostico y tratamiento para cancer para la poblacion residente fuera de los grandes centros urbanos pueden explicar, en parte, estas diferencias.

Trends in smoking among the adult population in Brazilian capitals: a data analysis of telephone surveys from 2006 to 2009

The objective of this study was to analyze the trend of tobacco use and smoking cessation, and the intensity of cigarettes per day from 2006 to 2009 in the Brazilian state capitals. Data were analyzed for 18-year-old individuals or older who were interviewed by the Telephone-based Surveillance of Risk and Protective Factors for Chronic Diseases (VIGITEL), which was performed in the Brazilian State capitals and the Federal District in 2006, 2007, 2008, and 2009. For each year and large areas, age-adjusted prevalence and prevalence according to age groups (18 to 29, 30 to 59 and 60 and older) stratified by sex were calculated. Smoking cessation index was assessed and, for current smokers, the proportion of those who reported smoking 20 or more cigarettes a day was estimated according to gender and age group (18 to 39 and 40 and over). The results show a slight tendency to the reduction of tobacco use among men and stability for women, except for residents from the North and Northeast Regions. In general, the greatest prevalence among men is in younger groups; while amongst women, it is in the intermediary age group (30 to 59 years old). Smoking cessation seems to be slightly higher among men; there is a strong reverse relation between tobacco use and schooling. The proportion of 20 or more cigarettes per day is higher among older people and varies in Brazilian Regions. Results point out the need to prioritize strategies for tobacco control that can reach young individuals and women at low-education level.

Disparities in cervical and breast cancer mortality in Brazil

OBJECTIVE To analyze cervical and breast cancer mortality in Brazil according to socioeconomic and welfare indicators. METHODS Data on breast and cervical cancer mortality covering a 30-year period (1980-2010) were analyzed. The data were obtained from the National Mortality Database, population data from the Brazilian Institute of Geography and Statistics database, and socioeconomic and welfare information from the Institute of Applied Economic Research. Moving averages were calculated, disaggregated by capital city and municipality. The annual percent change in mortality rates was estimated by segmented linear regression using the joinpoint method. Pearson’s correlation coefficients were conducted between average mortality rate at the end of the three-year period and selected indicators in the state capital and each Brazilian state. RESULTS There was a decline in cervical cancer mortality rates throughout the period studied, except in municipalities outside of the capitals in the North and Northeast. There was a decrease in breast cancer mortality in the capitals from the end of the 1990s onwards. Favorable socioeconomic indicators were inversely correlated with cervical cancer mortality. A strong direct correlation was found with favorable indicators and an inverse correlation with fertility rate and breast cancer mortality in inner cities. CONCLUSIONS There is an ongoing dynamic process of increased risk of cervical and breast cancer and attenuation of mortality because of increased, albeit unequal, access to and provision of screening, diagnosis and treatment.

Tabagismo e escolaridade no Brasil, 2006

OBJETIVO: Analisar a prevalencia de tabagismo e uso acumulado de cigarro na vida e fatores associados. METODOS: Foram analisados dados referentes aos 54.369 individuos com idade >18 anos entrevistados pelo sistema de Vigilância de Fatores de Risco e Protecao para Doencas Cronicas por Inquerito Telefonico (VIGITEL), realizado nas capitais brasileiras e Distrito Federal em 2006. Foram calculadas as prevalencias de tabagismo estratificadas por escolaridade segundo sexo para as cidades de cada regiao e as razoes de prevalencia brutas e ajustadas por numero de pessoas e de comodos no domicilio. O consumo de cigarros na vida (macos-ano) foi analisado segundo escolaridade e sexo por regiao. RESULTADOS: No Brasil, a prevalencia de tabagismo foi significativamente maior entre homens e mulheres com baixa escolaridade (ate oito anos de estudo = 24,2% e nove ou mais = 15,5%). Esta diferenca diminuiu com a idade ou se inverteu entre os mais idosos. Observou-se diminuicao de risco de ser fumante para a populacao de maior escolaridade, independentemente do numero de pessoas e de comodos por domicilio. A prevalencia de fumantes com consumo intenso de cigarros foi maior entre os de escolaridade mais baixa, principalmente entre mulheres da regiao Norte. A excecao foram os homens da regiao Sul, onde esse percentual foi maior entre aqueles com maior escolaridade. CONCLUSOES: Confirmou-se haver maior concentracao de fumantes na populacao de menor escolaridade, principalmente entre homens mais jovens. E necessario compreender melhor a dinâmica da epidemia de tabagismo para adequar medidas preventivas especificas para individuos conforme idade e estrato social.OBJECTIVE To analyze smoking prevalence and cumulative cigarette consumption and factors associated. METHODS Data from 54,369 respondents aged > or = 18 years were analyzed. Data was collected through interviews using the Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (VIGITEL--Telephone-Based Surveillance of Risk and Protective Factors for Chronic Diseases) conducted in Brazilian state capitals and Federal District in 2006. Smoking prevalence rates were estimated stratified by level of education and gender in all cities studied and prevalence ratios, crude and adjusted for number of adults living in the same household and number of rooms per household, were also calculated. Lifetime cigarette consumption (pack-years) was analyzed by level of education and gender in all macroregions studied. RESULTS In Brazil, overall smoking prevalence was significantly higher among men and women with lower education (eight years of schooling = 24.2%; nine years and more = 15.5%). This difference tended to decrease with age and an inverse proportion was seen among the elderly. Reduced risk of smoking was found associated to higher education regardless of the number of adults living in the same household and the number of rooms per household. The prevalence of heavy smokers was higher among those with lower education, especially among women in the Northern region, except for the Southern region, where it was higher among men with higher education. CONCLUSIONS The study results confirmed higher smoking prevalence among those with lower education, especially among younger males. Further studies are needed to better understand the dynamics of tobacco epidemic for developing specific prevention actions targeting different age and social groups.

Correção da magnitude da mortalidade por câncer do colo do útero no Brasil, 1996-2005

OBJECTIVE To develop a methodology for correction of reported cervical cancer deaths in Brazil. METHODS Data on 9,607,177 cancer deaths were obtained from the Brazilian National Mortality Database for the period between 1996 and 2005. For correction of underreporting of deaths, factors generated by the Global Burden of Disease Study in Brazil-1998 were used. Proportional distribution was used in order to correct the categories of unknown, incomplete or ill-defined death diagnosis. The corrections were applied to each Brazilian state and the results were presented for Brazil nationwide, macroregions, and geographical areas (capital, other cities of metropolitan areas and interior cities) as percent variability of cervical mortality rates before and after correction. Corrections were analyzed by multivariate linear regression with interaction terms between macroregion and geographical area. RESULTS After correction, cervical cancer mortality rates showed an increment of 103% nationwide, ranging between 35% (Southern region capitals) and 339% (Northeastern region interior cities). The reallocation of cervical cancer deaths not otherwise specified resulted in greater mortality rate increments. The percent correction by year of death revealed steady trends nationwide. CONCLUSIONS The study results showed that the proposed methodology was appropriate for the correction of cervical cancer mortality rates in Brazil. It evidenced that cervical cancer mortality is even higher than that reported.OBJETIVO: Desenvolver uma metodologia para correcao da magnitude dos obitos por câncer do colo do utero no Brasil. METODOS: Os dados sobre os 9.607.177 obitos foram obtidos do Sistema de Informacao sobre Mortalidade, para o periodo de 1996 a 2005. Para a correcao do sub-registro, foram utilizados os fatores de expansao gerados pelo Projeto Carga Global de Doenca no Brasil - 1998. Para correcao das categorias de diagnosticos desconhecidos, incompletos ou mal definidos de obitos, foi aplicada redistribuicao proporcional. Os dados ausentes de idade foram corrigidos por imputacao. As correcoes foram aplicadas por Unidade Federativa e os resultados apresentados para o Brasil, regiao e areas geograficas (capital, demais municipios das regioes metropolitanas e interior) por meio do percentual de variabilidade da magnitude das taxas, antes e apos a correcao dos obitos. O comportamento das correcoes foi analisado por modelo de regressao linear multivariada com termos de interacao entre regiao do Pais e area geografica. RESULTADOS: As taxas corrigidas de mortalidade por câncer do colo do utero no Brasil mostraram um acrescimo de 103,4%, variando de 35% para as capitais da regiao Sul a 339% para o interior da regiao Nordeste. A redistribuicao dos obitos por câncer de utero sem especificacao de localizacao anatomica promoveu os maiores acrescimos na magnitude das taxas. Os percentuais de correcao, segundo ano de ocorrencia do obito, mostraram tendencia estacionaria no Brasil. CONCLUSOES: Os resultados permitem concluir que a metodologia proposta foi adequada para corrigir a magnitude das taxas de mortalidade por câncer do colo do utero no Pais, mostrando que a mortalidade por esse câncer e ainda maior do que o observado nos informes oficiais.

Acesso à detecção precoce do câncer de mama no Sistema Único de Saúde: uma análise a partir dos dados do Sistema de Informações em Saúde

A reducao recente na mortalidade por câncer de mama em paises de alta renda e atribuida a deteccao precoce e melhorias no tratamento. O câncer de mama e o tipo mais frequente de câncer feminino no Brasil, e, desde 2004, o governo recomenda o exame clinico anual das mamas para mulheres a partir dos 40 anos e rastreio mamografico bienal entre 50 e 69 anos. Este artigo investiga o nivel de implementacao dessas recomendacoes usando os dados dos sistemas de informacoes do SUS de 2010 por macrorregiao e grupo etario. Evidenciou-se uma cobertura baixa de mamografia entre a populacao alvo (32%: 50-59 anos; 25%: 60-69 anos). A proporcao de mulheres com achados radiologicos anormais submetidas a biopsia tambem foi baixa (27%: 50-59 anos; 63%: 60-69 anos). O numero de cirurgias para câncer de mama foi maior do que o numero de casos detectaveis pela mamografia, mas muito inferior ao numero estimado de casos incidentes para 2010. Existem marcadas desigualdades regionais no acesso a deteccao precoce e a cirurgia, sendo o acesso mais baixo na Regiao Norte e mais alto na Regiao Sul.The recent reduction in breast cancer mortality in high-income countries resulted from improvements in early detection and treatment. Breast cancer is the most common cancer in Brazilian women. Since 2004, the government has recommended annual clinical breast examination for women aged ≥ 40 years and biannual mammograms for those aged 50-69. This article investigates the degree of implementation of these guidelines using data from the Brazilian Unified National Health System for 2010 according to major geographic region and age group. The findings showed low national mammogram coverage in the target population (32% in the 50-59-year group; 25% from 60 to 69 years). The percentage of women with abnormal radiological findings who underwent biopsy was also low (27% for 50-59 years; 63% for 60-69 years). The number of breast cancer surgeries exceeded the number of cases detected by mammography but was well below the estimated number of incident breast cancer cases in 2010. There are striking regional inequalities in access to early detection and surgery, being the lowest access in the North Region and the highest in the South Region.