Colorectal cancer spatial pattern in the northeast region of São Paulo, Brazil.

Background: This study examined the spatial pattern of the colorectal cancer (CRC) in the 18 municipalities that compose the Regional Health Department of Barretos (RHD-V), which is in the northeast of the state of São Paulo, Brazil. Methods: All incident cases and deaths from CRC between 2002 and 2016 were included. Age-standardized rates (ASR) for incidence and mortality per 100,000 person-years were used to evaluate the spatial distribution for the total and five-year periods. The lethality rates were also assessed. Excess risk maps compared the observed and expected events. Age-standardized net survival was used to evaluate CRC survival. Results: For CRC incidence, the ASR value for the general population over the entire period (2002-2016) was 17.7 (95% CI: 16.7, 18.6), ranging from 16.7 (95% CI: 14.9, 18.4) (2002-2006) to 20.0 (95% CI: 18.3, 21.7) (2012-2016) per 100,000. When males and females were compared, the ASR was 20.1 (95% CI: 18.6, 21.6) and 15.7 (95% CI: 14.5, 17.0) per 100,000, respectively. For CRC mortality (2002-2016), the ASR was 8.2 (95% CI: 7.6, 8.9), ranging from 9.0 (95% CI: 7.8, 10.3) (2002-2006) to 8.2 (95% CI: 7.2, 9.3) (2012-2016) per 100,000. Overall, the excess risk up to 2.0 was more frequent. In terms of survival, municipalities with large port populations had lower survival in comparison with medium port. Conclusions: This study showed a variation in CRC incidence and mortality, with differences considering five-year periods and gender, being the incidence higher in males than females in the entire period, with mortality equivalent to half the incidence. The survival was lower in municipalities with large port populations in comparison with medium port. Knowing spatial patterns of incidence, mortality, lethality, and survival can be necessary to support policymakers to advance or implement effective cancer control programs.

Thyroid Cancer Incidence and Mortality by Socioeconomic Level in the State of São Paulo, Brazil 2001-2017.

OBJECTIVE: Thyroid cancer is rising largely due to greater detection of indolent or slow-growing tumors; we sought to compare the incidence and mortality profiles of thyroid cancer in the State of São Paulo by socioeconomic status (SES). METHODS: Data on thyroid cancer cases diagnosed from 2003 to 2017 in the Barretos Region and from 2001 to 2015 in the municipality of São Paulo were obtained from the respective cancer registries. Corresponding death data were obtained from a Brazilian public government database. Age-standardized rates were calculated and presented as thematic maps. The rates were also calculated by SES and spatial autocorrelation was assessed by global and local indices. RESULTS: There were 419 cases of thyroid cancer and 21 deaths in Barretos, contrasting with the highly populated São Paulo, with 30 489 cases and 673 deaths. The overall incidence rates in São Paulo (15.9) were three times higher than in Barretos (5.7), while incidence rates in women were close to five times higher in Barretos and four times higher in São Paulo than in men. Mortality rates were, in relative terms, very low in both regions. A clear stepwise gradient of increasing thyroid cancer incidence with increasing SES was observed in São Paulo, with rates in very high SES districts four times those of low SES (31.6 vs 8.1). In contrast, the incidence rates in Barretos presented little variation across SES levels. CONCLUSION: Thyroid cancer incidence varied markedly by SES in São Paulo, with incidence rates rising with increasing socioeconomic index. Overdiagnosis is likely to account for a large proportion of the thyroid cancer burden in the capital.

Cancer inequalities in incidence and mortality in the State of São Paulo, Brazil 2001-17.

BACKGROUND: Cancer disparities exist between and within countries; we sought to compare cancer-specific incidence and mortality according to area-level socioeconomic status (SES) in the State of São Paulo, Brazil. METHODS: Cancer cases diagnosed 2003-2017 in the Barretos region and 2001-2015 in the municipality of São Paulo were obtained from the respective cancer registries. Corresponding cancer deaths were obtained from a Brazilian public government database. Age-standardized rates for all cancer combined and the six most common cancers were calculated by SES quartiles. RESULTS: There were 14,628 cancer cases and 7513 cancer deaths in Barretos, and 472,712 corresponding cases and 194,705 deaths in São Paulo. A clear SES-cancer gradient was seen in São Paulo, with rates varying from 188.4 to 333.1 in low to high SES areas, respectively. There was a lesser social gradient for mortality, with rates in low to high SES areas ranging from 86.4 to 98.0 in Barretos, and from 99.2 to 100.1 in São Paulo. The magnitude of the incidence rates rose markedly with increasing SES in São Paulo city for colorectal, lung, female breast, and prostate cancer. Conversely, both cervical cancer incidence and mortality rose with lower levels of SES in both regions. CONCLUSIONS: A clear SES association was seen for cancers of the prostate, female breast, colorectum, and lung for São Paulo. This study offers a better understanding of the cancer incidence and mortality profile according to SES within a highly populated Brazilian state.

Intra-urban spatial variability of breast and cervical cancer mortality in the city of São Paulo: analysis of associated factors. / Variabilidade espacial intraurbana da mortalidade por câncer de mama e do colo do útero no município de São Paulo: análise dos fatores associados.

OBJECTIVE: To identify spatial variability of mortality from breast and cervical cancer and to assess factors associated in the city of São Paulo. METHODS: Between 2009 and 2016, 10,124 deaths from breast cancer and 2,116 deaths from cervical cancer were recorded in the Mortality Information System among women aged 20 years and over. The records were geocoded by address of residence and grouped according to Primary Health Care coverage areas. A spatial regression modeling was put together using the Bayesian approach with a Besag-York-Mollié structure to verify the association of deaths with selected indicators. RESULTS: Mortality rates from these types of cancer showed inverse spatial patterns. These variables were associated with breast cancer mortality: travel time between one and two hours to work (RR - relative risk: 0.97; 95%CI - credible interval: 0.93-1.00); women being the head of the household (RR 0.97; 95%CI 0.94-0.99) and deaths from breast cancer in private health institutions (RR 1.04; 95%CI 1.00-1.07). The following variables were associated with mortality from cervical cancer: travel time to work between half an hour and one hour (RR 0.92; 95%CI 0.87-0.98); per capita household income of up to 3 minimum wages (RR 1.27; 95%CI 1.18-1.37) and ratio of children under one year of age related to the female population aged 15 to 49 years (RR 1.09; 95%CI 1.01-1.18). CONCLUSION: The predicted RR for mortality from these cancers were calculated and associated with the socioeconomic conditions of the areas covered.

OBJETIVO: Identificar a variabilidade espacial da mortalidade por câncer de mama e colo do útero e avaliar fatores associados à mortalidade por esses cânceres no município de São Paulo. MÉTODOS: Entre 2009 e 2016 foram registrados, no Sistema de Informações sobre Mortalidade, 10.124 óbitos por câncer de mama e 2.116 óbitos por câncer do colo do útero em mulheres com 20 anos e mais. Os registros foram geocodificados por endereço de residência e agregados segundo território adstrito. Foram realizadas modelagens de regressão espacial utilizando-se a abordagem bayesiana com estrutura de Besag-York-Mollié para verificar a associação dos óbitos com indicadores selecionados. RESULTADOS: As taxas de mortalidade por esses cânceres apresentaram padrões espaciais inversos. As variáveis associadas à mortalidade por câncer de mama foram: tempo de deslocamento para o trabalho entre uma e duas horas (risco relativo ­ RR 0,97; intervalo de credibilidade ­ IC95% 0,93­1,00); mulheres responsáveis pelo domicílio (RR 0,97; IC95% 0,94­0,99) e óbitos por câncer de mama ocorridos em estabelecimentos privados (RR 1,04; IC95% 1,00­1,07). À mortalidade por câncer do colo do útero, estiveram associados: tempo de deslocamento para o trabalho entre meia e uma hora (RR 0,92; IC95% 0,87­0,98); rendimento domiciliar até três salários-mínimos (RR 1,27; IC95% 1,18­1,37); e razão de menores de um ano em relação à população feminina de 15 a 49 anos (RR 1,09; IC95% 1,01­1,18). CONCLUSÃO: Foram calculados os RR preditos para a mortalidade por esses cânceres, que estiveram associados às condições socioeconômicas das áreas de abrangência.

Variabilidade espacial intraurbana da mortalidade por câncer de mama e do colo do útero no município de São Paulo: análise dos fatores associados / Intra-urban spatial variability of breast and cervical cancer mortality in the city of São Paulo: analysis of associated factors

RESUMO Objetivo: Identificar a variabilidade espacial da mortalidade por câncer de mama e colo do útero e avaliar fatores associados à mortalidade por esses cânceres no município de São Paulo. Métodos: Entre 2009 e 2016 foram registrados, no Sistema de Informações sobre Mortalidade, 10.124 óbitos por câncer de mama e 2.116 óbitos por câncer do colo do útero em mulheres com 20 anos e mais. Os registros foram geocodificados por endereço de residência e agregados segundo território adstrito. Foram realizadas modelagens de regressão espacial utilizando-se a abordagem bayesiana com estrutura de Besag-York-Mollié para verificar a associação dos óbitos com indicadores selecionados. Resultados: As taxas de mortalidade por esses cânceres apresentaram padrões espaciais inversos. As variáveis associadas à mortalidade por câncer de mama foram: tempo de deslocamento para o trabalho entre uma e duas horas (risco relativo — RR 0,97; intervalo de credibilidade — IC95% 0,93-1,00); mulheres responsáveis pelo domicílio (RR 0,97; IC95% 0,94-0,99) e óbitos por câncer de mama ocorridos em estabelecimentos privados (RR 1,04; IC95% 1,00-1,07). À mortalidade por câncer do colo do útero, estiveram associados: tempo de deslocamento para o trabalho entre meia e uma hora (RR 0,92; IC95% 0,87-0,98); rendimento domiciliar até três salários-mínimos (RR 1,27; IC95% 1,18-1,37); e razão de menores de um ano em relação à população feminina de 15 a 49 anos (RR 1,09; IC95% 1,01-1,18). Conclusão: Foram calculados os RR preditos para a mortalidade por esses cânceres, que estiveram associados às condições socioeconômicas das áreas de abrangência.

ABSTRACT Objective: To identify spatial variability of mortality from breast and cervical cancer and to assess factors associated in the city of São Paulo. Methods: Between 2009 and 2016, 10,124 deaths from breast cancer and 2,116 deaths from cervical cancer were recorded in the Mortality Information System among women aged 20 years and over. The records were geocoded by address of residence and grouped according to Primary Health Care coverage areas. A spatial regression modeling was put together using the Bayesian approach with a Besag-York-Mollié structure to verify the association of deaths with selected indicators. Results: Mortality rates from these types of cancer showed inverse spatial patterns. These variables were associated with breast cancer mortality: travel time between one and two hours to work (RR - relative risk: 0.97; 95%CI - credible interval: 0.93-1.00); women being the head of the household (RR 0.97; 95%CI 0.94-0.99) and deaths from breast cancer in private health institutions (RR 1.04; 95%CI 1.00-1.07). The following variables were associated with mortality from cervical cancer: travel time to work between half an hour and one hour (RR 0.92; 95%CI 0.87-0.98); per capita household income of up to 3 minimum wages (RR 1.27; 95%CI 1.18-1.37) and ratio of children under one year of age related to the female population aged 15 to 49 years (RR 1.09; 95%CI 1.01-1.18). Conclusion: The predicted RR for mortality from these cancers were calculated and associated with the socioeconomic conditions of the areas covered.

The biobank of barretos cancer hospital: 14 years of experience in cancer research.

Despite the developments in cancer research over years, cancer is still one of the leading causes of death worldwide. In Brazil, the number of cancer cases for the several next years (2020-2022) is expected to increase up to 625,000. Thus, translational research has been vital to determine the potential risk, prognostic, and predictive biomarkers in cancer. Therefore, Barretos Cancer Hospital implemented a biobank (BB-BCH) in 2006, which is responsible for processing, storage, and provision of biological materials from cancer and non-cancer participants. Hence, this article aimed to describe BB-BCH's history, experiences, and outcomes and explore its impact on Brazilian translational oncology research scenario. BB-BCH has a multidisciplinary team who are responsible for guaranteeing the quality of all processes as recommended by international guidelines for biobanks. Furthermore, BB-BCH has ample equipment to ensure the quality of all material requested by researchers as genetic material (DNA and RNA) and/or entire biospecimens. From 2006 to 2019, BB-BCH contained 252,069 samples from 44,933 participants, the whole collection is represented by 15 different types of biospecimens collected from them. According to our data, the most collected and stored topography in men is head and neck (29%); in women is breast (28%); and in children is torso and limb (27%) samples. Finally, we supported national and international consortia and projects such as The Cancer Genome Atlas. BB-BCH is a vital knowledge source for scientific community, enabling the development of high-quality studies, with a wide variety of tumor categories and high national representativeness of Brazilian population.

Pink October and mammograms: when health communication misses the target. / Outubro Rosa e mamografias: quando a comunicação em saúde erra o alvo.

Breast cancer is the most frequently diagnosed type of cancer and is the leading cause of death from cancer in the female population. Screening mammograms and early treatment are the most frequently used means to attempt to reduce this mortality and are promoted during Pink October, an annual awareness-raising campaign. However, recent studies have correlated the increase in screening with higher morbidity and mortality, due to overdiagnosis and overtreatment. The current study assessed searches related to breast cancer and mammogram in Google Trends from 2004 to 2019 in terms of trend, seasonality, and distribution in Brazilian states. The study also evaluatedH the correlation between the number of searches in Google Trends and the number of screening mammograms. The two series showed a seasonal pattern with peaks in October, and there was an excess in tests performed outside the recommended age bracket. Pink October transmitted and popularized health information and induced behaviors related to this information, which are three desirable aspects in health communication and education. However, the campaign also generated an excess in screening mammograms and did not encourage autonomy and free and informed consent. Pink October revealed both the potential of mass communication in health and the need for messages to be aligned with the best available scientific evidence.

O câncer de mama é o tipo de câncer mais diagnosticado e a principal causa de morte por câncer na população feminina. As mamografias de rastreamento e o tratamento precoce são geralmente os meios mais utilizados na tentativa de reduzir essa mortalidade e são incentivados no Outubro Rosa, uma campanha de divulgação anual. Contudo, estudos recentes têm relacionado o aumento do rastreamento com uma maior morbimortalidade em razão do sobrediagnóstico e do sobretratamento. No presente estudo, avaliaram-se as buscas relativas ao câncer de mama e à mamografia no Google Trends, entre 2004 e 2019, em termos da tendência, da sazonalidade e da distribuição nas Unidades Federativas brasileiras. Avaliou-se também a correlação entre a quantidade de buscas no Google Trends e a quantidade de exames de rastreamento mamográfico. As duas séries tiveram um padrão sazonal com picos em outubro, e houve excesso de exames realizados fora da faixa etária recomendada. O Outubro Rosa transmitiu informações de saúde, as popularizou e induziu comportamentos relativos a informações transmitidas; três aspectos desejáveis na comunicação e na educação em saúde. Porém, gerou um excesso de mamografias de rastreamento e não incentivou a autonomia e o consentimento livre e esclarecido. O Outubro Rosa mostrou o potencial da comunicação em saúde para massas e a necessidade de que as mensagens sejam alinhadas com as melhores evidências científicas.

El cáncer de mama es el tipo de cáncer más diagnosticado y la principal causa de muerte por cáncer en la población femenina. Las mamografías de rastreo y el tratamiento precoz son generalmente los medios más utilizados en la tentativa de reducir esa mortalidad, y son incentivados en el Octubre Rosa, una campaña de divulgación anual. No obstante, estudios recientes han relacionado el aumento del rastreo con una mayor morbimortalidad, debido al sobrediagnóstico y al sobretratamiento. En el presente estudio se evaluaron las búsquedas relativas al cáncer de mama, y a la mamografía en Google Trends entre 2004 y 2019, en términos de tendencia, de estacionalidad y de su distribución en las Unidades Federativas brasileñas. Se evaluó también la correlación entre la cantidad de búsquedas en Google Trends y la cantidad de exámenes de rastreo mamográfico. Las dos series tuvieron un patrón estacional con picos en octubre, y hubo un exceso de exámenes realizados fuera de la franja etaria recomendada. Octubre Rosa transmitió información de salud, la popularizó e indujo a comportamientos relacionados con la información transmitida; tres aspectos deseables en la comunicación y educación en salud. Sin embargo, generó un exceso de mamografías de rastreo y no incentivó la autonomía y el consentimiento libre e informado. Octubre Rosa mostró el potencial de la comunicación en salud para las masas y la necesidad de que los mensajes estén alineados con mejores evidencias científicas.

Oncology palliative care: access barriers: bibliometric study.

OBJECTIVE: To perform a bibliometric analysis of studies that evaluated the barriers to access to cancer palliative care (PC). METHODS: This was a bibliometric review using MEDLINE; EMBASE; Web Of Science; LILACS and the Cochrane Library. A search was conducted with the terms Barriers, Palliative Care and Cancer. Articles whose objectives targeted barriers to access to PC were considered, regardless of the year of publication. The setting is articles published from 1987 to 2020. RESULTS: A total of 6158 articles were identified, of which 217 were eligible for analysis. The USA and UK being the countries with the largest number of articles on the subject (n=101, n=18, respectively). After expert analysis, the barriers were grouped into nine categories. CONCLUSIONS: Barriers related to symptom control were identified in 19% of the eligible articles, along with barriers related to health, which with 24% of occurrence in the articles, were the most frequently cited barriers. Countries which have implemented PC for some time were those with the greatest number of publications and in journals with the highest impact factors. Cross-sectional study design continues to be the most frequently used in publications.

Residential traffic exposure and lymphohematopoietic malignancies among children in the city of São Paulo, Brazil: An ecological study.

BACKGROUND: Despite widespread evidence that air pollution is carcinogenic, there is little evidence from low-middle income countries, especially related to childhood malignancies. We examined the role of traffic related pollution on lymphohematopoietic malignancies among under-14 s in Sao Paulo. METHODS: All incident cases between 2002 and 2011 were collected from a population-based registry. Exposures were assigned on residential address at diagnosis via traffic density database (for the year 2008) and a satellite derived NO2 land use regression model (averaged between 1997 and 2011). Incidence rate ratios (IRRs) were calculated via Poisson Regression adjusted by age, gender and socioeconomic status (SES), with additional stratification by SES. RESULTS: A positive association between traffic and NO2 with some lymphohematopoietic malignancies was observed with the degree of effect differing by SES. For example, lymphoid leukemia IRRs in the lower SES group were 1.21 (95 % CI: 1.06, 1.39) for traffic density and 1.38 (95 % CI: 1.13, 1.68) for NO2. In the higher group they were 1.06 (95 % CI: 1.00, 1.14) and 1.37 (95 % CI: 1.16, 1.62). CONCLUSION: NO2 and traffic density were associated with Hodgkin lymphoma and lymphoid leukemia among children in São Paulo. Differing IRRs by gender and SES group indicate differences in underlying risk and/or exposure profiles.

Outubro Rosa e mamografias: quando a comunicação em saúde erra o alvo / Octubre Rosa y mamografías: cuando la comunicación en salud confunde el objetivo / Pink October and mammograms: when health communication misses the target

O câncer de mama é o tipo de câncer mais diagnosticado e a principal causa de morte por câncer na população feminina. As mamografias de rastreamento e o tratamento precoce são geralmente os meios mais utilizados na tentativa de reduzir essa mortalidade e são incentivados no Outubro Rosa, uma campanha de divulgação anual. Contudo, estudos recentes têm relacionado o aumento do rastreamento com uma maior morbimortalidade em razão do sobrediagnóstico e do sobretratamento. No presente estudo, avaliaram-se as buscas relativas ao câncer de mama e à mamografia no Google Trends, entre 2004 e 2019, em termos da tendência, da sazonalidade e da distribuição nas Unidades Federativas brasileiras. Avaliou-se também a correlação entre a quantidade de buscas no Google Trends e a quantidade de exames de rastreamento mamográfico. As duas séries tiveram um padrão sazonal com picos em outubro, e houve excesso de exames realizados fora da faixa etária recomendada. O Outubro Rosa transmitiu informações de saúde, as popularizou e induziu comportamentos relativos a informações transmitidas; três aspectos desejáveis na comunicação e na educação em saúde. Porém, gerou um excesso de mamografias de rastreamento e não incentivou a autonomia e o consentimento livre e esclarecido. O Outubro Rosa mostrou o potencial da comunicação em saúde para massas e a necessidade de que as mensagens sejam alinhadas com as melhores evidências científicas.

El cáncer de mama es el tipo de cáncer más diagnosticado y la principal causa de muerte por cáncer en la población femenina. Las mamografías de rastreo y el tratamiento precoz son generalmente los medios más utilizados en la tentativa de reducir esa mortalidad, y son incentivados en el Octubre Rosa, una campaña de divulgación anual. No obstante, estudios recientes han relacionado el aumento del rastreo con una mayor morbimortalidad, debido al sobrediagnóstico y al sobretratamiento. En el presente estudio se evaluaron las búsquedas relativas al cáncer de mama, y a la mamografía en Google Trends entre 2004 y 2019, en términos de tendencia, de estacionalidad y de su distribución en las Unidades Federativas brasileñas. Se evaluó también la correlación entre la cantidad de búsquedas en Google Trends y la cantidad de exámenes de rastreo mamográfico. Las dos series tuvieron un patrón estacional con picos en octubre, y hubo un exceso de exámenes realizados fuera de la franja etaria recomendada. Octubre Rosa transmitió información de salud, la popularizó e indujo a comportamientos relacionados con la información transmitida; tres aspectos deseables en la comunicación y educación en salud. Sin embargo, generó un exceso de mamografías de rastreo y no incentivó la autonomía y el consentimiento libre e informado. Octubre Rosa mostró el potencial de la comunicación en salud para las masas y la necesidad de que los mensajes estén alineados con mejores evidencias científicas.

Breast cancer is the most frequently diagnosed type of cancer and is the leading cause of death from cancer in the female population. Screening mammograms and early treatment are the most frequently used means to attempt to reduce this mortality and are promoted during Pink October, an annual awareness-raising campaign. However, recent studies have correlated the increase in screening with higher morbidity and mortality, due to overdiagnosis and overtreatment. The current study assessed searches related to breast cancer and mammogram in Google Trends from 2004 to 2019 in terms of trend, seasonality, and distribution in Brazilian states. The study also evaluatedH the correlation between the number of searches in Google Trends and the number of screening mammograms. The two series showed a seasonal pattern with peaks in October, and there was an excess in tests performed outside the recommended age bracket. Pink October transmitted and popularized health information and induced behaviors related to this information, which are three desirable aspects in health communication and education. However, the campaign also generated an excess in screening mammograms and did not encourage autonomy and free and informed consent. Pink October revealed both the potential of mass communication in health and the need for messages to be aligned with the best available scientific evidence.

Spatial pattern of mortality from breast and cervical cancer in the city of São Paulo.

OBJECTIVE: To verify the spatial pattern of mortality from breast and cervical cancer in areas of primary health care, considering socioeconomic conditions. METHODS: This is an ecological study, from January 2000 to December 2016. The study area is the municipality of São Paulo, Brazil, and its 456 coverage areas of primary health units. Information on deaths of women aged 20 years or over were geocoded according to residence address. We calculated mortality rates, standardized by age, and smoothed by the local empirical Bayesian method, and grouped into three or two years to reduce the random fluctuation of the data. In addition, bivariate global and local Moran indexes were calculated to verify the existence of spatial agglomeration of standardized mortality rates with a domain of socioeconomic condition, elaborated based on the Índice Paulista de Vulnerabilidade Social (IPVS - São Paulo Index of Social Vulnerability). RESULTS: The success rate of geocoding was 98.9%. Mortality from breast cancer, without stratification by time, showed a pattern with higher rates located in central regions with better socioeconomic conditions. It showed a decrease at the end of the period and a change in spatial pattern, with increased mortality in peripheral regions. On the other hand, mortality from cervical cancer remained with the highest rates in peripheral regions with worse socioeconomic conditions, despite being reduced over time. CONCLUSION: The spatial pattern of mortality from the studied cancers, over time, suggests association with the best socioeconomic conditions of the municipality, either as protection (cervical) or risk (breast). This knowledge may direct resources to prevent and promote health in the territories.

Bayesian modeling of hematologic cancer and vehicular air pollution among young people in the city of São Paulo, Brazil.

Traffic-related air pollution is being associated with hematologic cancer in young individuals. This study performed a spatial analysis of the hematologic cancer incidence and mortality among younger people, using a Bayesian approach, to associate with traffic density in the city of São Paulo, Brazil. Two databases were employed: incidence (2002-2011) and mortality (2002-2013). The relationships between the cases of hematologic cancer and the covariates - traffic density, the Municipal Human Development Index (MHDI), and population density - were evaluated using a Besag-York-Mollié ecological model with relative risks (RRs) estimates. Per 1-unit standard-deviation increase in traffic density, in the MHDI, and in population density, the RR for the incidence was 1.06 (95% CI: 0.97-1.14), 1.28 (95% CI: 1.16-1.42), and 1.01 (95% CI: 0.94-1.08), respectively. For mortality, no covariates were considered risk factors. Our findings suggest significant association between living in regions with better socioeconomic conditions, where traffic density is usually higher, and risk of hematologic cancer in younger people.

Spatial pattern of mortality from breast and cervical cancer in the city of São Paulo / Padrão espacial da mortalidade por câncer de mama e colo do útero na cidade de São Paulo

ABSTRACT OBJECTIVE To verify the spatial pattern of mortality from breast and cervical cancer in areas of primary health care, considering socioeconomic conditions. METHODS This is an ecological study, from January 2000 to December 2016. The study area is the municipality of São Paulo, Brazil, and its 456 coverage areas of primary health units. Information on deaths of women aged 20 years or over were geocoded according to residence address. We calculated mortality rates, standardized by age, and smoothed by the local empirical Bayesian method, and grouped into three or two years to reduce the random fluctuation of the data. In addition, bivariate global and local Moran indexes were calculated to verify the existence of spatial agglomeration of standardized mortality rates with a domain of socioeconomic condition, elaborated based on the Índice Paulista de Vulnerabilidade Social (IPVS - São Paulo Index of Social Vulnerability). RESULTS The success rate of geocoding was 98.9%. Mortality from breast cancer, without stratification by time, showed a pattern with higher rates located in central regions with better socioeconomic conditions. It showed a decrease at the end of the period and a change in spatial pattern, with increased mortality in peripheral regions. On the other hand, mortality from cervical cancer remained with the highest rates in peripheral regions with worse socioeconomic conditions, despite being reduced over time. CONCLUSION The spatial pattern of mortality from the studied cancers, over time, suggests association with the best socioeconomic conditions of the municipality, either as protection (cervical) or risk (breast). This knowledge may direct resources to prevent and promote health in the territories.

RESUMO OBJETIVOS Verificar o padrão espacial da mortalidade pelos cânceres de mama e do colo do útero, em áreas da atenção primária à saúde, levando em consideração as condições socioeconômicas. MÉTODOS O estudo é ecológico, de janeiro de 2000 a dezembro de 2016. A área de estudo é o município de São Paulo, Brasil, e suas 456 áreas de abrangência das unidades básicas de saúde. As informações sobre óbitos de mulheres com 20 anos ou mais de idade foram geocodificadas segundo endereço de residência. Foram calculadas as taxas de mortalidade, padronizadas por idade, e suavizadas pelo método bayesiano empírico local, além de agrupadas em três ou dois anos para reduzir a flutuação aleatória dos dados. Além disso, foram calculados os índices de Moran global e local bivariados, para verificar a existência de aglomeração espacial das taxas de mortalidade padronizadas com um domínio de condição socioeconômica, elaborado a partir do Índice Paulista de Vulnerabilidade Social. RESULTADOS A taxa de sucesso da geocodificação foi de 98,9%. A mortalidade por câncer de mama, sem estratificação por tempo, apresentou um padrão com maiores taxas localizadas nas regiões centrais e com melhores condições socioeconômicas. Apresentou queda ao final do período e mudança de padrão espacial, com aumento da mortalidade nas regiões periféricas. Já a mortalidade por câncer do colo do útero manteve-se com as maiores taxas nas regiões periféricas e com piores condições socioeconômicas, apesar de apresentar redução ao longo do tempo. CONCLUSÃO O padrão espacial da mortalidade pelos cânceres do estudo, ao longo do tempo, sugere associação com as melhores condições socioeconômicas do município, seja como proteção (colo) ou risco (mama). Esse conhecimento pode direcionar recursos para a prevenção e a promoção da saúde nos territórios.

[Influence of vehicular traffic density on hospital admissions due to respiratory tract cancer in the city of São Paulo, Brazil]. / Influência da densidade de tráfego veicular na internação por câncer do aparelho respiratório no Município de São Paulo, Brasil.

Pollution related to traffic is a major problem in urban centers and a large portion of the population is vulnerable to its health effects. This study sought to identify a potential association between hospital admissions due to respiratory tract cancer and vehicular traffic density in the city of São Paulo, Brazil. It is an ecological study of the public (Hospital Inpatient Authorization - AIH, in Portuguese) and private (Hospital Inpatient Communication - CIH, in Portuguese) health care systems, from 2004 to 2006, geocoded by individuals' residential addresses. Using a Besag-York-Mollié ecological model, we initially evaluated the relationship between number of cases of hospital admission due to respiratory tract cancer in each weighting area and the standardized co-variables: traffic density and Municipal Human Development Index (MHDI) as indicator of socioeconomic status. Using a classic Poisson model, we then evaluated the risk associated with growing traffic density categories. The Besag-York-Mollié model estimated a RR = 1.09 (95%CI: 1.02-1.15) and RR = 1.19 (95%CI: 1.10-1.29) of admission due to respiratory tract cancer for each increase of one standard deviation of traffic and MHDI, respectively. The Poisson model also showed a clear exposure-response gradient for admission due to respiratory tract cancer (IRR = 1.11; 95%CI: 1.07-1.15, for each 10 units of added traffic density). This study suggests that there is an association between residing in areas with high traffic density and hospital admissions due to respiratory tract cancer in the city of São Paulo.

A poluição relacionada ao tráfego é um grande problema nos centros urbanos, e uma grande parcela da população fica vulnerável aos seus efeitos à saúde. Este trabalho teve como objetivo identificar potencial associação entre as internações hospitalares por câncer do aparelho respiratório com a densidade de tráfego veicular no Município de São Paulo, Brasil. É um estudo ecológico com dados de internações hospitalares por câncer dos sistemas público (Autorização de Internação Hospitalar - AIH) e particular (Comunicação de Internação Hospitalar - CIH), de 2004 a 2006, geocodificados por endereço de residência do indivíduo. Mediante um modelo ecológico de Besag-York-Mollié foi avaliada inicialmente a relação entre o número de casos de internação por câncer do aparelho respiratório em cada área de ponderação e as covariáveis padronizadas: densidade de tráfego e Índice de Desenvolvimento Humano Municipal (IDHM) como indicador de status socioeconômico. Sequencialmente, com um modelo clássico de Poisson, procedeu-se uma avaliação do risco associado às categorias crescentes de densidade de tráfego. O modelo de Besag-York-Mollié estimou um RR = 1,09 (IC95%: 1,02-1,15) e RR = 1,19 (IC95%: 1,10-1,29) de internação por câncer do aparelho respiratório, para cada aumento de um desvio padrão da densidade de tráfego e IDHM, respectivamente. Foi também evidenciado pelo modelo de Poisson um claro gradiente de exposição-resposta para internação por câncer respiratório (IRR = 1,11; IC95%: 1,07-1,15, para cada dez unidades de acréscimo da densidade de tráfego). Este trabalho sugere que há associação entre residir em áreas com alta densidade de tráfego e internação por câncer do aparelho respiratório no Município de São Paulo.

La contaminación relacionada con el tráfico es un gran problema en los centros urbanos, y una gran parte de la población es vulnerable a sus efectos para la salud. El objetivo de este trabajo fue identificar la potencial asociación entre los internamientos hospitalarios por cáncer del aparato respiratorio con la densidad del tráfico vehicular en el Municipio de São Paulo, Brasil. Es un estudio ecológico con datos de internamientos hospitalarios por cáncer de los sistemas público (Autorización de Internación Hospitalaria - AIH) y particular (Comunicación de Internación Hospitalaria - CIH), de 2004 a 2006, geocodificados por dirección de residencia del individuo. Mediante el modelo ecológico de Besag-York-Mollié se evaluó inicialmente la relación entre el número de casos de internamiento por cáncer del aparato respiratorio en cada área de ponderación y covariables estandarizadas: densidad de tráfico e Índice de Desarrollo Humano Municipal (IDHM), como indicador de estatus socioeconómico. Secuencialmente, con un modelo clásico de Poisson, se procedió a una evaluación del riesgo asociado a las categorías crecientes de densidad de tráfico. El modelo de Besag-York-Mollié estimó un RR = 1,09 (IC95%: 1,02-1,15) y RR = 1,19 (IC95%: 1,10-1,29) de internamiento por cáncer del aparato respiratorio, para cada aumento de un desvío estándar de la densidad de tráfico e IDHM, respectivamente. Se evidenció también, a través del modelo de Poisson, un claro gradiente de exposición-respuesta para el internamiento por cáncer respiratorio (IRR = 1,11; IC95%: 1,07-1,15, para cada 10 unidades de incremento de la densidad de tráfico). Este trabajo sugiere que existe una asociación entre residir en áreas con alta densidad de tráfico y el internamiento por cáncer del aparato respiratorio en el Municipio de São Paulo.

Incidence and mortality for respiratory cancer and traffic-related air pollution in São Paulo, Brazil.

BACKGROUND: Multiple lines of evidence have associated exposure to ambient air pollution with an increased risk of respiratory malignancies. However, there is a dearth of evidence from low-middle income countries, including those within South America, where the social inequalities are more marked. OBJECTIVES: To quantify the association between exposures to traffic related air pollution and respiratory cancer incidence and mortality within São Paulo, Brazil. Further, we aim to investigate the role of socioeconomic status (SES) upon these outcomes. METHODS: Cancer incidence between 2002 and 2011 was derived from the population-based cancer registry. Mortality data (between 2002 and 2013) was derived from the Municipal Health Department. A traffic density database and an annual nitrogen dioxide (NO2) land use regression model were used as markers of exposure. Age-adjusted Binomial Negative Regression models were developed, stratifying by SES and gender. RESULTS: We observed an increased rate of respiratory cancer incidence and mortality in association with increased traffic density and NO2 concentrations, which was higher among those regions with the lowest SES. For cancer mortality and traffic exposure, those in the most deprived region, had an incidence rate ratio (IRR) of 2.19 (95% CI: 1.70, 2.82) when comparing the highest exposure centile (top 90%) to the lowest (lowest 25%). By contrast, in the least deprived area, the IRR for the same exposure contrast was.1.07 (95% CI: 0.95, 1.20). For NO2 in the most deprived regions, the IRR for cancer mortality in the highest exposed group was 1.44 (95% CI: 1.10, 1.88) while in the least deprived area, the IRR for the highest exposed group was 1.11 (95% CI: 1.01, 1.23). CONCLUSIONS: Traffic density and NO2 were associated with an increased rate of respiratory cancer incidence and mortality in São Paulo. Residents from poor regions may suffer more from the impact of traffic air pollution.

Influência da densidade de tráfego veicular na internação por câncer do aparelho respiratório no Município de São Paulo, Brasil / Influence of vehicular traffic density on hospital admissions due to respiratory tract cancer in the city of São Paulo, Brazil / Influencia de la densidad de tráfico vehicular en el internamiento por cáncer del aparato respiratorio en el Municipio de São Paulo, Brasil

A poluição relacionada ao tráfego é um grande problema nos centros urbanos, e uma grande parcela da população fica vulnerável aos seus efeitos à saúde. Este trabalho teve como objetivo identificar potencial associação entre as internações hospitalares por câncer do aparelho respiratório com a densidade de tráfego veicular no Município de São Paulo, Brasil. É um estudo ecológico com dados de internações hospitalares por câncer dos sistemas público (Autorização de Internação Hospitalar - AIH) e particular (Comunicação de Internação Hospitalar - CIH), de 2004 a 2006, geocodificados por endereço de residência do indivíduo. Mediante um modelo ecológico de Besag-York-Mollié foi avaliada inicialmente a relação entre o número de casos de internação por câncer do aparelho respiratório em cada área de ponderação e as covariáveis padronizadas: densidade de tráfego e Índice de Desenvolvimento Humano Municipal (IDHM) como indicador de status socioeconômico. Sequencialmente, com um modelo clássico de Poisson, procedeu-se uma avaliação do risco associado às categorias crescentes de densidade de tráfego. O modelo de Besag-York-Mollié estimou um RR = 1,09 (IC95%: 1,02-1,15) e RR = 1,19 (IC95%: 1,10-1,29) de internação por câncer do aparelho respiratório, para cada aumento de um desvio padrão da densidade de tráfego e IDHM, respectivamente. Foi também evidenciado pelo modelo de Poisson um claro gradiente de exposição-resposta para internação por câncer respiratório (IRR = 1,11; IC95%: 1,07-1,15, para cada dez unidades de acréscimo da densidade de tráfego). Este trabalho sugere que há associação entre residir em áreas com alta densidade de tráfego e internação por câncer do aparelho respiratório no Município de São Paulo.

Pollution related to traffic is a major problem in urban centers and a large portion of the population is vulnerable to its health effects. This study sought to identify a potential association between hospital admissions due to respiratory tract cancer and vehicular traffic density in the city of São Paulo, Brazil. It is an ecological study of the public (Hospital Inpatient Authorization - AIH, in Portuguese) and private (Hospital Inpatient Communication - CIH, in Portuguese) health care systems, from 2004 to 2006, geocoded by individuals' residential addresses. Using a Besag-York-Mollié ecological model, we initially evaluated the relationship between number of cases of hospital admission due to respiratory tract cancer in each weighting area and the standardized co-variables: traffic density and Municipal Human Development Index (MHDI) as indicator of socioeconomic status. Using a classic Poisson model, we then evaluated the risk associated with growing traffic density categories. The Besag-York-Mollié model estimated a RR = 1.09 (95%CI: 1.02-1.15) and RR = 1.19 (95%CI: 1.10-1.29) of admission due to respiratory tract cancer for each increase of one standard deviation of traffic and MHDI, respectively. The Poisson model also showed a clear exposure-response gradient for admission due to respiratory tract cancer (IRR = 1.11; 95%CI: 1.07-1.15, for each 10 units of added traffic density). This study suggests that there is an association between residing in areas with high traffic density and hospital admissions due to respiratory tract cancer in the city of São Paulo.

La contaminación relacionada con el tráfico es un gran problema en los centros urbanos, y una gran parte de la población es vulnerable a sus efectos para la salud. El objetivo de este trabajo fue identificar la potencial asociación entre los internamientos hospitalarios por cáncer del aparato respiratorio con la densidad del tráfico vehicular en el Municipio de São Paulo, Brasil. Es un estudio ecológico con datos de internamientos hospitalarios por cáncer de los sistemas público (Autorización de Internación Hospitalaria - AIH) y particular (Comunicación de Internación Hospitalaria - CIH), de 2004 a 2006, geocodificados por dirección de residencia del individuo. Mediante el modelo ecológico de Besag-York-Mollié se evaluó inicialmente la relación entre el número de casos de internamiento por cáncer del aparato respiratorio en cada área de ponderación y covariables estandarizadas: densidad de tráfico e Índice de Desarrollo Humano Municipal (IDHM), como indicador de estatus socioeconómico. Secuencialmente, con un modelo clásico de Poisson, se procedió a una evaluación del riesgo asociado a las categorías crecientes de densidad de tráfico. El modelo de Besag-York-Mollié estimó un RR = 1,09 (IC95%: 1,02-1,15) y RR = 1,19 (IC95%: 1,10-1,29) de internamiento por cáncer del aparato respiratorio, para cada aumento de un desvío estándar de la densidad de tráfico e IDHM, respectivamente. Se evidenció también, a través del modelo de Poisson, un claro gradiente de exposición-respuesta para el internamiento por cáncer respiratorio (IRR = 1,11; IC95%: 1,07-1,15, para cada 10 unidades de incremento de la densidad de tráfico). Este trabajo sugiere que existe una asociación entre residir en áreas con alta densidad de tráfico y el internamiento por cáncer del aparato respiratorio en el Municipio de São Paulo.

Geography of Microcephaly in the Zika Era: A Study of Newborn Distribution and Socio-environmental Indicators in Recife, Brazil, 2015-2016.

OBJECTIVES: We assessed sociodemographic and health care factors of mothers and newborns during a 2015-2016 outbreak of microcephaly in Recife, Brazil, and we analyzed the spatial distribution and incidence risk of newborns with microcephaly in relation to socio-environmental indicators. METHODS: We collected data from August 2015 through May 2016 from Brazil's Live Birth Information System and Bulletin of Microcephaly Notification, and we geocoded the data by maternal residence. We constructed thematic maps of districts, according to socio-environmental and vector indicators. We identified spatial aggregates of newborns with microcephaly by using the Bernoulli model. We performed logistic regression analyses to compare the incidence risk of microcephaly within socio-environmental indicator groups. RESULTS: We geocoded 17 990 of 19 554 (92.0%) live births in Recife, of which 202 (1.1%) newborns were classified as having microcephaly, based on a head circumference of ≥2 standard deviations below the mean. Larger proportions of newborns with microcephaly (compared with newborns without microcephaly) were born to mothers who delivered in a public hospital, did not attend college, were aged ≤19, or were black or mixed race. A higher risk of microcephaly (incidence rate ratio [IRR] = 3.90; 95% confidence interval [CI], 1.88-8.06) occurred in districts with the lowest (vs highest) Municipal Human Development Index (ie, an index that assesses longevity, education, and income). The risk of microcephaly was significantly higher where rates of larvae density (IRR = 2.31; 95% CI, 1.19-4.50) and larvae detection (IRR = 2.04; 95% CI, 1.05-4.00) were higher and rates of sewage system (IRR = 2.20; 95% CI, 1.16-4.18) and garbage collection (IRR = 1.96; 95% CI, 0.99-3.88) were lower. Newborns with microcephaly lived predominantly in the poorest areas and in a high-risk cluster (relative risk = 1.89, P = .01) in the north. CONCLUSIONS: The disproportionate incidence of microcephaly in newborns in poor areas of Recife reinforces the need for government and public health authorities to formulate policies that promote social equity and support for families and their children with microcephaly.

Câncer e poluição do ar relacionada ao tráfego veicular no município de São Paulo: análise espacial em pequenas áreas / Cancer and traffic-related air pollution in São Paulo spatial analysis in small areas units

Introdução: A poluição do ar relacionada ao tráfego veicular é um grave problema nos centros urbanos, expondo parcela considerável da população ao risco de efeitos adversos à saúde. Estudos epidemiológicos e toxicológicos têm encontrado evidências que associam a exposição aos poluentes do tráfego veicular e a incidência de câncer. Objetivo: Realizar uma análise espacial dos casos de cânceres do trato respiratório e hematológico e de sua relação com a densidade de tráfego veicular no município de São Paulo. Métodos: Foram utilizados os dados de três bases distintas: dados de incidência de câncer do Registro de Câncer de Base Populacional do Município de São Paulo (RCBP) de 2002 a 2011; dados de internações hospitalares por câncer do sistema público e particular de 2004 a 2006; dados de mortalidade por neoplasias do Sistema de Informação de Mortalidade de 2002 a 2013, da Secretaria Municipal de Saúde. Para a avaliação da exposição foi utilizada a densidade de tráfego veicular e, como indicador de status socioeconômico, o Índice de Desenvolvimento Humano Municipal (IDHM). Foram utilizadas como unidade espacial as áreas de ponderação do Censo 2010 e uma grade de 500m x 500m. Mediante um modelo ecológico de Besag-York-Mollié foi avaliada a variabilidade espacial do risco de incidência, internação hospitalar e mortalidade por câncer do aparelho respiratório e hematológico, sendo os resultados expressos em termos de risco relativo (RR). Utilizou-se também um modelo de regressão Binomial Negativo e Poisson para quantificar a associação do desfecho estudado às categorias crescentes de exposição à densidade de tráfego obtendo-se estimativas da razão da taxa de incidência (IRR). Resultados: A variabilidade espacial do risco foi influenciada pelas covariáveis padronizadas: densidade de tráfego veicular e IDHM. Para cada aumento de um desvio padrão da densidade de tráfego obteve-se um RR= 1,07 (IC 95%: 1,02-1,13), RR= 1,09 (CI 95%: 1,02-1,15) e RR= 1,04 (CI 95%: 0,99-1,09), para incidência, internação hospitalar e mortalidade por câncer do aparelho respiratório para indivíduos > 20 anos de idade, respectivamente. Para a incidência de câncer hematológico em jovens obteve-se um RR= 1,09 (IC 95%: 1,00-1,18) para este mesmo aumento da densidade de tráfego. A avaliação da exposição por categorias crescentes de densidade de tráfego evidenciou um claro e significante gradiente de exposição-resposta para incidência e mortalidade por câncer respiratório em regiões com baixo IDHM, independente do sexo analisado. Na categoria mais alta de densidade de tráfego, homens de regiões com baixo IDHM apresentaram IRR= 3,29 (IC 95%: 2.34-4,64) comparado a IRR= 1,18 (IC 95%: 1,03-1,36) referente aos homens de regiões com alto IDHM. Conclusões: Os resultados mostraram uma associação positiva significante entre residir em áreas com alta densidade de tráfego e incidência, internação hospitalar e mortalidade por câncer respiratório em > 20 anos e incidência de câncer hematológico em indivíduos jovens. As pessoas de baixo status socioeconômico, embora não residam em áreas de maior exposição aos poluentes do tráfego, sofreram mais os efeitos da poluição do ar, provavelmente devido a fatores de vulnerabilidade

Introduction: Traffic-related air pollution is a serious problem in urban centers, exposing a considerable part of the population to the risk of adverse health effects. Epidemiological and toxicological studies have found evidence associating exposure to traffic pollutants and the incidence of cancer. Objective: To perform a spatial analysis of cases of respiratory and hematological cancers and its relation with traffic density in the city of São Paulo. Methods: Data from three different databases were used: cancer incidence data from the Population- Based Cancer Registry of the Municipality of São Paulo (RCBP) from 2002 to 2011; data from hospital admissions for cancer of the public and private system from 2004 to 2006; mortality data from the Mortality Information System (SIM) from 2002 to 2013, from the Municipal Health Department. The traffic density was used for exposure assessment, and the Municipal Human Development Index (MHDI) as an indicator of socioeconomic status. As a spatial unit, the weighting areas of the 2010 Census and a grid of 500 m x 500 m were used. The spatial variability of risk for incidence, hospital admission and mortality from respiratory and hematological cancers was assessed using an ecological model from Besag-York-Mollie. The results were expressed in terms of relative risk (RR). A Negative Binomial and Poisson regression model was used to quantify the association of the endpoint studied with the increasing categories of exposure to traffic density, obtaining estimates of the incidence rate ratio (IRR). Results: The spatial variability of the risk was influenced by the standardized covariates: traffic density and MHDI. For each increase of a standard deviation of the traffic density was obtained an RR = 1.07 (95% CI: 1.02-1.13), RR = 1.09 (95% CI: 1.02-1, 15) and RR = 1.04 (CI 95%: 0.99-1.09), for incidence, hospital admission and mortality from respiratory cancer, respectively, among individuals over 20 years of age. The RR = 1.09 (95% CI: 1.00-1.18) for this same increase in traffic density was obtained for the incidence of hematological cancer in youngsters. The exposure assessment by increasing categories of traffic density evidenced a clear and significant exposure-response gradient for incidence and mortality from respiratory cancer in regions with low MHDI, regardless of the sex analyzed. In the highest category of traffic density, men from regions with low MHDI regions presented IRR = 3.29 (95% CI: 2.34-4.64) compared to IRR = 1.18 (95% CI: 1.03-1, 36) for men from regions with high MHDI. Conclusions: The results showed a significant positive association between residing in areas with high traffic density and incidence, hospital admission and mortality from respiratory cancers in individuals over 20 years, and the incidence of hematological cancer in young individuals. People with low socioeconomic status, although not residing in areas of greater exposure to traffic pollutants, have been more affected by air pollution, probably due to vulnerability factors

Breast cancer mortality and associated factors in São Paulo State, Brazil: an ecological analysis.

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.