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Breast cancer mortality and associated factors in São Paulo State, Brazil: an ecological analysis
  1. Carmen Simone Grilo Diniz1,
  2. Alessandra Cristina Guedes Pellini2,
  3. Adeylson Guimarães Ribeiro3,
  4. Marcello Vannucci Tedardi4,
  5. Marina Jorge de Miranda1,
  6. Michelle Mosna Touso5,
  7. Oswaldo Santos Baquero6,
  8. Patrícia Carlos dos Santos7,
  9. Francisco Chiaravalloti-Neto8
  1. 1 Departamento de Saúde, Ciclos de Vida e Sociedade da Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, Brazil
  2. 2 Centro de Vigilância Epidemiológica “Prof. Alexandre Vranjac”, Secretaria de Estado da Saúde de São Paulo, São Paulo, Brazil
  3. 3 Departamento de Saúde Ambiental, Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, Brazil
  4. 4 Departamento de Patologia, Faculdade de Medicina Veterinária e Zootecnia, Universidade de São Paulo, São Paulo, Brazil
  5. 5 Departamento de Enfermagem Materno-Infantil e Saúde Pública, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, São Paulo, Brazil
  6. 6 Departamento de Medicina Veterinária Preventiva, Faculdade de Medicina Veterinária e Zootecnia, Universidade de São Paulo, São Paulo, Brazil
  7. 7 Secretaria Municipal de Saúde de São Paulo, Coordenação de Epidemiologia e Informação, São Paulo, Brazil
  8. 8 Departamento Epidemiologia, Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, Brazil
  1. Correspondence to Dr Francisco Chiaravalloti-Neto; franciscochiara{at}


Objective Identify the factors associated with the age-standardised breast cancer mortality rate in the municipalities of State of São Paulo (SSP), Brazil, in the period from 2006 to 2012.

Design Ecological study of the breast cancer mortality rate standardised by age, as the dependent variable, having each of the 645 municipalities in the SSP as the unit of analysis.

Settings The female resident population aged 15 years or older, by age group and municipality, in 2009 (mid-term), obtained from public dataset (Informatics Department of the Unified Health System).

Participants Women 15 years or older who died of breast cancer in the SSP were selected for the calculation of the breast cancer mortality rate, according to the municipality and age group, from 2006 to 2012.

Main outcome measures Mortality rates for each municipality calculated by the direct standardisation method, using the age structure of the population of SSP in 2009 as the standard.

Results In the final linear regression model, breast cancer mortality, in the municipal level, was directly associated with rates of nulliparity (p<0.0001), mammography (p<0.0001) and private healthcare (p=0.006).

Conclusions The findings that mammography ratio was associated, in the municipal level, with increased mortality add to the evidence of a probable overestimation of benefits and underestimation of risks associated with this form of screening. The same paradoxical trend of increased mortality with screening was found in recent individual-level studies, indicating the need to expand informed choice for patients, primary prevention actions and individualised screening. Additional studies should be conducted to explore if there is a causality link in this association.

  • breast tumours
  • epidemiology
  • public health

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  • Contributors Conception and design of study: CSGD, ACGP, MJM, OSB and FCN; acquisition of data: ACGP, MVT, MJM, MMT and PCS; analysis and/or interpretation of data: CSGD, ACGP, AGR, MVT, MJM, MMT, OSB, PCS and FCN; drafting the manuscript: CSGD, ACGP, AGR, OSB and FCN; revising the manuscript critically for important intellectual content: CSGD, ACGP, AGR, MMT, OSB and FCN. All authors approved of the version of the manuscript to be published.

  • Competing interests None declared.

  • Ethics approval The study did not obtain the approval of Ethics Committee because the used data (about the breast cancer mortality and about the covariates) were obtained from public datasets that are open for the access of everyone.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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