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Breast cancer mortality and associated factors in São Paulo State, Brazil: an ecological analysis
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  • Published on:
    Reply to the letter by Camargo Jr on 27 October 2017
    • Carmen SG Diniz, Professor Faculdade de Saúde Pública da Universidade de São Paulo
    • Other Contributors:
      • Alessandra CG Pellini, Professor
      • Adeylson G Ribeiro, PhD Candidate
      • Marcello V Tedardi, PhD Candidate
      • Marina J Miranda, Consultora
      • Michelle M Touso, Researcher
      • Oswaldo S Baquero, Professor
      • Patricia C Santos, Technical staff
      • Francisco Chiaravalloti-Neto, Professor

    Dear Editor

    We thank Prof. Helio S. A. Camargo Jr, a respected author of a handbook on breast image exams, for his letter, which presents an opportunity to make our points clearer. We agree that “having a mammogram is not the same thing as being screened with mammography”. According to Tomazelli et al (2017), based on the National Breast Cancer Control Information System (Sismama), 96.2% of the mammograms in Brazil were for screening (performed in asymptomatic women) and 3.8% were diagnostic (in patients with suspicious breast cancer signs and/or symptoms), in the period they analyzed (2010-2011) (1).
    That means that less than 1 in 25 mammograms in Brazil were diagnostic, which must be one of the lowest rates in the world. The proportion of screening over diagnostic mammography must have further increased, with the expansion in coverage of breast screening in the last five years (2). The distribution of the mammographies for reasons other than screening are, therefore, diluted in the municipalities, without forming specific clusters.
    We also agree that “death certificates in Brazil do not always reflect the actual cause of death” and we recognized this limitation in our study. But is noteworthy the Brazilian health information system has improved dramatically in last decades since the creation of SUS (Public Health System) in 1988, in terms of quality and completeness. The analysis of data quality collected by the Mortality Information System indicates t...

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    Conflict of Interest:
    None declared.
  • Published on:
    Interpreting the carcinogenicity of social and medical development - Reply to the letter by Freitas-Junior et al. on 15 October 2017
    • Carmen Simone Grilo Diniz, Professor Departamento de Saúde, Ciclos de Vida e Sociedade da Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, Brazil
    • Other Contributors:
      • Alessandra Cristina Guedes Pellini, Professor
      • Oswaldo Santos Baquero, Professor
      • Francisco Chiaravalloti-Neto, Professor

    Dear Editor:

    We thank Freitas-Junior et al. for their detailed letter, which we read with great consideration, specially coming from leaders of the Brazilian Mastology Society.
    We will reply starting from the points that we believe that we all agree. First, that breast cancer mortality is linked to “social and medical developments”. Better health and higher life expectancy are associated with indicators of social development, such as Human development index (IDH), higher income and education. But better health is not necessarily associated to more health care (1). People of higher income may have more cancer not because of their wealth (which was expected to protect them), but because they are subjected to higher “observational intensity”, the combined effect of factors such as the frequency of screening and diagnostic exams, the ability of the exams to detect small irregularities, and the threshhold used to label results as abnormal, which can be an undesirable consequence (overdiagnosis) of medical development. As pointed by Welch and Fisher (2017), “Excessive testing of low-risk people produces real harm, leading to treatments that have no benefit (because there is nothing to fix) but can nonetheless result in medication side effects, surgical complications, and occasionally even death” (1).
    We also agree that radioprotection and radioinduced breast cancer are important issues to be addressed in a benefit-harm rationale, but we believe that the harm...

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    Conflict of Interest:
    None declared.
  • Published on:
    Breast cancer mortality and associated factors in São Paulo State, Brazil: two flaws need to be acknowledged

    Dear Editor:
    On reading the study conducted by Diniz et al. on the possible association between mammography and breast cancer-related mortality in the state of São Paulo, Brazil, I found two weaknesses that cannot go unnoticed. The authors have gathered information on mammography ratio and discussed the presumable effect on mortality of mammographic screening. These are two different situations. Having a mammogram is not the same thing as being screened with mammography. There are other reasons for having a mammogram, as having a palpable lump, being prepared for breast cancer surgery or systemic treatment, following up patients treated for breast cancer, orienting breast biopsies. When studying a population comprised of people who have actually died of breast cancer, one should expect to find a cluster of mammograms performed for non-screening purposes. And one should expect a higher mortality rate from breast cancer in this population.
    The other weakness is perhaps easier to understand for those familiar with health care in Brazil. It is very well known that death certificates in Brazil do not always reflect the actual cause of death. It is to be expected a serious under notification in the public health sector as compared to the private health sector. I do acknowledge that the mortality information system in Sao Paulo state is extensive in its coverage and that could be perceived as a strength of the article. However, one has to make sure that the rate of ad...

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    Conflict of Interest:
    None declared.
  • Published on:
    Breast cancer mortality is associated with factors linked to social and medical development in São Paulo State, Brazil
    • Ruffo Freitas-Junior, Professor & physician Rede Brasileira de Pesquisa em Mastologia. Faculdade de Medicina da Universidade Federal de Goiás - Goiânia, GO, Brasil.
    • Other Contributors:
      • Rosemar Macedo Sousa Rahal, Professor & physician
      • Rosangela da Silveira Correa, Researcher
      • Danielle Cristina Netto Rodrigues, Researcher
      • Nilson Clementino Ferreira, Professor & researcher
      • Noely Vicente Ribeiro, Professor & researcher
      • Leonardo Ribeiro Soares, Researcher & physician

    Dear Editor:
    We have read the study conducted by Diniz et al. on the possible association between mammography and breast cancer-related mortality in the state of São Paulo, Brazil with the greatest of care. Despite the detailed statistical analysis, the ecological study design implies limitations to the hypothesis generated, as pointed out by the authors themselves (1). In our opinion, both the authors’ main conclusion and the assumed association of cause and effect are inappropriate.

    The factors associated with the incidence of breast cancer in Brazil and its resulting mortality have recently been evaluated in different studies (2-4). Mortality rates have been found to vary as a function of geospatial location (rural areas versus urban centers)(4). In addition, the reduction encountered in mortality was associated with the regions in which the human development index (HDI) was higher. On the other hand, the highest mortality rates have been found to occur in the states with the highest HDI (5). Diniz et al. and many other investigators have mentioned that a higher incidence of breast cancer occurs among more affluent women living in urban areas and in large cities (1,5). In this respect, we are certain that mortality is also related to the incidence of the disease; hence, the higher the incidence, the greater the resulting mortality will be. Conversely, women who do not have breast cancer will obviously not die from the disease.

    Therefore, we believe t...

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    Conflict of Interest:
    None declared.