Influence of Race/Skin Color on Delays in Care for Oral Cavity Cancer in Brazil: The Mediating Role of Geography and Clinical Severity

Lisboa, Lidiane de Jesus; Contreras, Jean Carlos Zambrano; Freitas, Valéria Souza

doi:10.32635/2176-9745.RBC.2026v72n3.5630

Original Article • Rev. Bras. Cancerol. 72 (3) • 2026 • https://doi.org/10.32635/2176-9745.RBC.2026v72n3.5630EN linkcopy

Influence of Race/Skin Color on Delays in Care for Oral Cavity Cancer in Brazil: The Mediating Role of Geography and Clinical Severity

Authorship SCIMAGO INSTITUTIONS RANKINGS

Introduction: The social, economic, cultural, and ethnic-racial disparities in Brazil may be related to the time it takes for healthcare services to diagnose and treat oral cavity cancer.

Objective: To analyze the relationship between race/skin color and different time intervals for the diagnosis and treatment of oral cavity cancer in Brazilian health services.

Method: Observational, hospital-based study with 12,421 cases retrieved from the Brazilian Hospital Cancer Registries. Ethnic-racial classification was based on the combination of color and race categories used by the Brazilian Institute of Geography and Statistics. The Wilcoxon rank-sum test, Poisson regression model, and causal mediation analysis were applied.

Results: The retrieved records represented 6,523 (53%) white individuals and 5,898 (47%) non-white individuals. The groups showed heterogeneity in sociodemographic, clinical, and therapeutic variables, but were homogeneous regarding the main risk factors for the disease. Significant differences were observed in all key points analyzed (p<0.001). Non-white individuals have a longer health services interval than white individuals (median of 71 vs. 57 days, respectively), with the direct effect of race/skin color being significant (p<0.001) even when mediated by region of residence or clinical stage of the disease.

Conclusion: Race/skin color has a decisive impact on waiting times in Brazilian healthcare services, where non-white individuals wait, on average, 16.2 days longer than white individuals.

Key words:
Mouth Neoplasms; Racial Groups; Diagnosis; Time-to-Treatment; Squamous Cell Carcinoma of the Head and Neck

Variables	White N = 6,523		Non-white N = 5,898*		p §
Sex					<0.001
Male	5,041	77%	4,383	74%
Female	1,482	23%	1,515	26%
Age					0.009
19-39 years old	284	4.4%	210	3.6%
40-59 years old	2,951	45%	2,685	46%
60-79 years old	2,807	43%	2,494	42%
≥80 years old	481	7.4%	509	8.6%
Marital status					<0.001
Has a spouse	3,410	54%	2,805	48.3%
No spouse	2,914	46%	3,002	51.7%
Education					<0.001
Illiterate	94	17%	1,379	27.6%
Elementary	3,713	67.2%	3,089	62%
High school	666	12.1%	444	9%
Higher education	206	3.7%	68	1.4%
Grouped occupation					<0.001
Agricultural, forestry, fishery	1,099	28%	1,666	44.2%
Officers	22	0.6%	18	0.5%
Public sector chiefs	48	1.2%	19	0.5%
Science and liberal arts professionals	166	4.2%	85	2.2%
Technicians with high school diploma	84	2.1%	48	1.3%
Administrative services	90	2.3%	63	1.7%
Services and sales	949	24.1%	708	18.8%
Extractive, construction, textile and other industries	1,221	31.1%	942	25%
Chemical, steel, food industries	39	1.0%	56	1.5%
Repair and maintenance	212	5.4%	163	4.3%
Region of residence					<0.001
Southeast	2,213	34%	1,406	23.9%
Northeast	1,208	18.6%	3,659	62.2%
South	2,771	42.8%	243	4.1%
Central-West	195	3%	217	3.7%
North	107	1.6%	359	6.1%
History of tobacco intake				0.057	0.057
Yes	3,627	70.6%	3,252	69%
No	1,504	29.4%	1,466	31%
History of alcohol intake				0.078	0.078
Yes	2,641	54.2%	2,316	53%
No	2,180	45.8%	2,058	47%
Family history of cancer					0.003
Yes	1,443	41%	1,180	37.4%
No	2,071	59%	1,971	62.6%

Variables	White N = 6,523		Non-white N = 5,898		p §
Tumor location					<0.001
Tongue	2,000	30.7%	2,135	36.2%
Lip	1,022	15.6%	499	8.5%
Gum	215	3.3%	221	3.7%
Floor of mouth	1,041	16%	915	15.5%
Palate	1,020	15.6%	1,057	18%
Other parts of mouth	1,225	18.8%	1,071	18.1%
Grouped staging					<0.001
Advanced staging	2,918	69.7%	3,150	74%
Initial stage	1,268	30.3%	1,110	26%
Origin of referral					0.811
SUS	4,660	83%	4,509	83%
Not SUS	953	17%	911	17%
Displacement					<0.001
No	2,662	41%	1,858	31.5%
Yes	3,861	59%	4,040	68.5%
First treatment					<0.001
Surgery	3,918	60.1%	2,859	48.5%
Radiotherapy	1,598	24.5%	1,978	33.6%
Chemotherapy	955	14.7%	993	16.8%
Others	39	0.6%	54	1%
None	8	0.1%	8	0.1%
Reason for not undergoing the first treatment					<0.001
Lack of clinical condition	84	1.3%	27	0.4%
Refusal / Drop out	33	0.5%	45	0.8%
Treatment performed elsewhere	6	0.1%	10	0.2%
Death	81	1.3%	204	3.5%
Other reasons	47	0.8%	65	1.1%
Underwent treatment	6,060	96%	5,424	94%
Disease status at the end of the first treatment					<0.001
Complete remission	1,944	39.3%	1,094	24.6%
Partial remission	400	8.1%	267	6%
Stable disease	922	18.7%	1,047	23.5%
Disease in progression	849	17.2%	984	22.1%
Death	826	16.7%	1,057	23.6%

Intervals	White N = 6,523*	Non-white N = 5,898*	p §
From admittance to oncology service to first consultation (days)	0 (0-0)	0 (0-1)	<0.001
From first consultation do diagnosis (days)	9 (4-25)	12 (5-29)	<0.001
From diagnosis to treatment start (days)	35 (0-71)	47 (9-85)	<0.001
Health services interval✝ (days)	57 (27 - 97)	71 (40 - 112)	<0.001

Model	PR	95% CI	global p
Model 1 a	1.28	1.21-1.36	<0.001
Model 2 b	1.25	1.17-1.32	<0.001
Model 3 c	1.24	1.16-1.31	<0.001
Model 4 d	1.02	0.97-1.07	<0.001

Mediation model	Direct Effect (ADE)	Indirect Affect (ACME)	Total Effect	Mediated Proportion
Mediator: Staging	7.48*	-0.31*	7.17*	-4.30%
Mediator: Region (N/NE) a	16.24*	0.70*	16.94*	4.10%

location_on

Instituto Nacional de Câncer Rua Marquês de Pombal, 125 - 2º andar, Centro , CEP 20230-240, Tel.: +55 21 3207-6132 - Rio de Janeiro - RJ - Brazil
E-mail: rbc@inca.gov.br

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[1] Captions:

[TFN19] ^*
Yellow = 77 records, Indigenous = 13 records, Brown = 5,082 records, Black = 725 records;

[TFN20] ^§
Pearson's Chi-square test.

[4] Source: Brazil¹⁸.