Social inequalities in access to cancer screening and early detection: A population-based study in the city of São Paulo, Brazil

Santos, Edige Felipe de Sousa; Monteiro, Camila Nascimento; Vale, Diama Bhadra; Louvison, Marília; Goldbaum, Moisés; Cesar, Chester Luiz Galvão; Barros, Marilisa Berti de Azevedo

doi:10.1016/j.clinsp.2022.100160

Brasil

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Original articles • Clinics 78 • 2023 • https://doi.org/10.1016/j.clinsp.2022.100160 linkcopy

Social inequalities in access to cancer screening and early detection: A population-based study in the city of São Paulo, Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective: This study monitors trends in access to cancer screening, focusing on mammography, Papanicolaou (Pap smear), and Prostate-Specific Antigen (PSA), assessing the magnitude of inequality in the city of São Paulo from 2003 to 2015 according to education level.

Method: This is a cross-sectional population-based study conducted with data from the 2003, 2008, and 2015 editions of the Health Survey of the City of São Paulo (ISA-Capital). Outcome variables were the proportion of mammography, Papanicolaou (Pap smear), and Prostate-Specific Antigen (PSA) tests according to the protocols. Inequality was measured by education level according to years of study. For static analysis, Poisson regression was used to estimate proportion ratios.

Results: The proportion of Pap smears remained stationary at a high level (>89%) throughout the study period, while access to mammography and PSA tests significantly increased in the 2003–2015 period. The present results indicate inequalities in access to cancer screening due to education, and being more expressive for mammography and PSA tests. However, this inequality significantly decreased over the period analyzed comparing the most educated individuals with those with the lowest educational level. In addition, an increase in the proportion of tests performed in the Brazilian Unified Health System was identified, especially for mammography and PSA tests, in the period 2003–2015.

Conclusions: The inequalities observed in the access to preventive exams were influenced by the level of education. The offer of exams was expanded, more significantly for mammography and PSA, especially among the less educated group.

Keywords: Socioeconomic inequalities; Secondary prevention; Mass screening; Early detection of cancer; Uterine cervical neoplasms; Breast neoplasms; Prostatic neoplasms

HIGHLIGHTS

The proportion of Pap smears remained at a high level (>89%) from 2003 to 2015 in Sao Paulo.

The offer of exams was expanded, more significantly for mammography and PSA, especially among the less educated group.

Were identified inequalities in access to cancer screening due to education, being more expressive for mammography and PSA tests.

Women
	2003		2008		2015
Variables	n^a a Number of individuals in the unweighted sample. (563)	%^b b Proportions calculated under weighting.	n (836)	%	n (1412)	%
Age Group
25 to 39 years	181	46.7	278	42.9	507	41.8
40 to 59 years	152	41.9	299	46.3	555	44.1
60 to 69 years	230	11.5	259	10.8	350	14.1
Years of study ^c c 11 (1.9%) missing (2003), 1 (0.1%) missing (2008), 10 (0.7%) missing (2015).
Less than 8 years	327	43.0	360	28.9	412	23.2
8 to 11 years	146	33.5	338	47.1	613	43.9
More than 11 years	79	23.5	137	24.1	377	32.9
Private healthcare
No	-	-	470	50.8	825	54.9
Yes	-	-	366	49.2	587	45.1

Men
	2003		2008		2015
Variables	n (562)	%	n (574)	%	n (822)	%
Age Group
40 to 49 years	73	36.2	131	43.8	235	38.5
50 to 59 years	68	33.7	87	27.9	200	30.1
60 years or older	421	30.1	356	28.3	387	31.3
Years of study ^d d 10 (1.8%) missing (2003), 1 (0.2%) missing (2008), 3 (0.4%) missing (2015).
Less than 8 years	361	45.9	320	38.5	359	36.2
8 to 11 years	116	27.0	179	39.4	297	38.2
More than 11 years	75	27.0	74	22.0	163	25.6
Private healthcare ^e e – (2003), no missing (2008), 2 (0.4%) missing (2015).
No	-	-	318	52.4	508	56.3
Yes	-	-	256	47.6	312	43.7

	2003	2008	2015
Years of study	Proportion^a a Proportions (95% CI) calculated under weighting. % (95% CI)^b b 95% CI, 95% Confidence Interval.	Proportion^a a Proportions (95% CI) calculated under weighting. % (95% CI)^b b 95% CI, 95% Confidence Interval.	Proportion^a a Proportions (95% CI) calculated under weighting. % (95% CI)^b b 95% CI, 95% Confidence Interval.
Pap smear ^c c 4 (0.9%) missing (2003), 1 (0.1%) missing (2008), 7 (0.6%) missing (2015).
Less than 8 years	88.5 (82.8, 92.5)	83.1 (76.2, 88.4)	82.9 (77.6, 87.2)
8 to 11 years	92.7 (86.0, 96.3)	91.8 (87.5, 94.7)	89.5 (86.5, 91.9)
More than 11 years	99.1 (93.4, 99.9)	95.4 (88.9, 98.2)	93.9 (90.7, 96.0)
Total	92.4 (89.3, 94.6)	90.3 (87.5, 92.6)	89.6 (87.7, 91.3)
Mammography ^d d 6 (2.1%) missing (2003), no missing (2008), 2 (0.5%) missing (2015).
Less than 8 years	53.8 (42.9, 64.3)	60.3 (50.9, 68.9)	69.2 (62.9, 74.8)
8 to 11 years	45.9 (30.0, 62.8)	79.0 (69.1, 86.3)	73.8 (66.2, 80.2)
More than 11 years	90.4 (78.2, 96.1)	91.6 (76.2, 97.3)	80.1 (72.6, 85.9)
Total	55.6 (46.6, 64.2)	74.3 (68.0, 79.7)	73.8 (69.6, 77.7)
PSA ^e e 2 (1.1%) missing (2003), no missing (2008), 3 (0.6%) missing (2015).
Less than 8 years	20.5 (14.8, 27.6)	39.5 (31.8, 47.8)	56.4 (50.4, 62.3)
8 to 11 years	24.8 (16.4, 35.7)	45.1 (36.9, 53.5)	58.2 (51.7, 64.5)
More than 11 years	67.4 (51.8, 79.9)	64.8 (48.5, 78.4)	80.1 (72.4, 86.1)
Total	34.6 (28.2, 41.6)	47.3 (41.1, 53.7)	63.2 (59.3, 67.0)

	2003	2008	2015
Years of study	PRa ^a a PRa (95% CI), Adjusted Prevalece Ratio (95% Confidence Interval) calculated under weighting. (95% CI)^b b 95% CI, 95% Confidence Interval.	PRa ^a a PRa (95% CI), Adjusted Prevalece Ratio (95% Confidence Interval) calculated under weighting. (95% CI)^b b 95% CI, 95% Confidence Interval.	PRa ^a a PRa (95% CI), Adjusted Prevalece Ratio (95% Confidence Interval) calculated under weighting. (95% CI)^b b 95% CI, 95% Confidence Interval.
Pap smear
Less than 8 years	1	1	1
8 to 11 years	1.04 (0.96,1.12)	1.10 (1.01,1.19)	1.06 (0.99,1.14)
More than 11 years	1.11 (1.04,1.17)	1.14 (1.04,1.25)	1.12 (1.04,1.19)
Mammography
Less than 8 years	1	1	1
8 to 11 years	0.84 (0.55,1.27)	1.28 (1.04,1.56)	1.07 (0.92,1.23)
More than 11 years	1.66 (1.32,2.08)	1.47 (1.20,1.79)	1.16 (1.02,1.32)
PSA
Less than 8 years	1	1	1
8 to 11 years	1.40 (0.84,2.33)	1.40 (1.08,1.83)	1.17 (1.01,1.35)
More than 11 years	3.89 (2.72,5.57)	1.96 (1.48,2.60)	1.48 (1.29,1.69)

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Faculdade de Medicina / USP Rua Dr Ovídio Pires de Campos, 225 - 6 and., 05403-010 São Paulo SP - Brazil, Tel.: (55 11) 2661-6235 - São Paulo - SP - Brazil
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[TFN1] Source: ISA-Capital, 2003, 2008, 2015.

[TFN2] ^a
Number of individuals in the unweighted sample.

[TFN3] ^b
Proportions calculated under weighting.

[TFN4] ^c
11 (1.9%) missing (2003), 1 (0.1%) missing (2008), 10 (0.7%) missing (2015).

[TFN5] ^d
10 (1.8%) missing (2003), 1 (0.2%) missing (2008), 3 (0.4%) missing (2015).

[TFN6] ^e
– (2003), no missing (2008), 2 (0.4%) missing (2015).