Aspectos Socio-Econômicos do Câncer no Brasil
Autor: Andre Cezar Medici | Publicado: 2016-10-03T09:40:00-06:00





André Medici

Kaizô Beltrão







Introdução



Este artigo é a revisão de parte de um&nbsp;documento&nbsp;mais amplo escrito no ano de 2013&nbsp;(Aspectos Demográficos e Socioeconômicos&nbsp;do Câncer no Brasil),&nbsp;que pode ser obtido no seguinte link: 



https://www.researchgate.net/publication/308512695_Aspectos_demograficos_e_socio-economicos_do_cancer_no_Brasil



A idéia deste artigo foi buscar evidências a partir dos dados das pesquisas domiciliares (1)&nbsp;de como a prevalência de câncer se comporta de acordo com o nível de renda das&nbsp;famílias, os grupos de idade e as características&nbsp;étnicas e raciais da população brasileira.



A&nbsp;prevalência de câncer, ao refletir os casos acumulados
existentes,&nbsp;é maior do que a indicência,&nbsp;dado que a última&nbsp;mede o número de novos casos
detectados no ano Os dados das Pesquisas Nacionais por Amostra de&nbsp;Domicílios (PNADS) de&nbsp;1998, 2003 e&nbsp;2008 foram utilizados nesta análise.



Estes dados&nbsp;revelam, para o ano de 2008, &nbsp;uma taxa de prevalência de
câncer sensivelmente maior do que a incidência registrada nas Projeções do Instituto Nacional do Câncer (INCA) para 2012. De
acordo com a PNAD, a prevalência chegaria a 453,3 por 100 mil para homens e
567,8 por 100 mil para as mulheres.&nbsp;Mas os&nbsp;dados mostram uma diferença de 81% e
118% acima das&nbsp;estimativas de incidência do INCA, para homens e
mulheres, em 2012, respectivamente. 






A diferença entre&nbsp;estimativas e projeções&nbsp;de incidência do INCA, baseadas em registros
administrativos, e os casos de prevalência levantados pelas PNADs pode ser
explicada pelo fato de que: (a)&nbsp;a&nbsp;prevalência&nbsp;representa&nbsp;o estoque&nbsp; de casos&nbsp;existentes&nbsp;no&nbsp;ano da medição e a&nbsp;incidência o número de novos casos ocorridos no mesmo ano; (b)&nbsp;as estimativas&nbsp;do INCA&nbsp;se baseiam em dados do&nbsp;DATASUS e dos Registros de Mortalidade,&nbsp;que não são capazes de captar a totalidade
dos casos, especialmente daqueles relacionados a pessoas que consultaram médicos
mais não se registraram no SUS ou nos planos de saúde&nbsp;(para efeitos de morbidade), ou&nbsp;que ao morrerem, não tiveram registrado em sua declaração de óbito o&nbsp;cancer como causa de morte. 



Já no caso das PNADS, a
informação&nbsp;poderá estar&nbsp;sujeita a&nbsp;flutuações amostrais
ou erros alheios a amostragem, dado que pesquisas por amostragem tem coeficientes de variação que aumentam de forma proporcional à redução do tamanho da amostra. Por este motivo, os dados aqui apresentados representam medias nacionais, dado que a amostra da PNAD não resistiria a análise dos dados&nbsp;a níveis mais desagregados, como&nbsp;Estados ou Municípios, onde o tamanho da amostra poderia fazer com que as estimativas não fossem estatisticamente confiáveis.



Prevalência de Câncer por Idade






Entre os dados investigados através da informação de morbidade
referida da PNAD,&nbsp;foram analisadas&nbsp;três variáveis: a) a distribuição etária
das estimativas de câncer; b) a prevalência de câncer por quintil de renda e c)
a prevalência de câncer por cor-raça. A primeira questão importante a destacar
é a evolução das taxas de prevalência de câncer no Brasil, de acordo com as
PNADS, entre 1998 e 2008, como pode ser visto no Gráfico No. 1.



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Entre 1998 e 2008, as taxas masculinas passaram de 224 para 456 por 100 mil&nbsp; habitantes, enquanto as
femininas, de 268 para 568, no mesmo período. Estes dados&nbsp;poderiam indicar que um&nbsp;acelerado processo de transição demográfica e epidemiológica no Brasil
influenciou o rápido crescimento na prevalência desta doença. Mas, como os
dados de morbidade referida se relacionam&nbsp;à percepção e informação do
indivíduo, esta rápida evolução também pode estar associada a um maior acesso dos
indivíduos a diagósticos, serviços de saúde ou a melhor informação sobre o seu
estado de saúde. 






No que diz respeito a evolução do cancer por idade, os dados da PNAD
2008, de acordo com o Gráfico 2, revelam que as taxas de prevalência de câncer são crescentes para ambos os
sexos, na medida em que avança a idade. No entanto, estas taxas, para ambos os&nbsp;sexos,&nbsp;avançam de forma similar até a idade de 25 anos. Entre os 25 e os 60
anos de idade, as taxas femininas de prevalência de câncer são&nbsp;bem superiores
as masculinas, provavelmente em função da prevalência de câncer cervico-uterino e posteriormente de câncer de mama,&nbsp;os quais costumam ser mais&nbsp;frequentes&nbsp;entre mulheres, em geral ao final da menopausa mas&nbsp;antes do ingresso&nbsp;na terceira idade. 





&nbsp;



Já a&nbsp;partir dos 60 anos, a prevalência de câncer entre os homens&nbsp;passa a ser&nbsp;muito
maior do que entre as mulheres, dada a alta participação de câncer de prostata, específico para os homens,
e de pulmão, traquéia e brônquios e outros que incidem mais pesadamente entre o sexo masculino.



Prevalência de Câncer por Nivel de Renda






Outro indicador importante do câncer no Brasil é sua prevalência por nível
de renda. Os gráficos&nbsp;3 e 4&nbsp;mostram a evolução da prevalência de câncer por
quintil de renda nas PNADs 1998, 2003 e 2008. Verifica-se que esta prevalência
tem aumentado ao longo dos anos, em todos os quintis de renda, tanto para
homens como para mulheres. 





&nbsp;



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Os dados mostram, por outro lado, que a&nbsp;prevalência de cancer&nbsp;aparenta ser&nbsp;crescente
de acordo com o&nbsp;nivel de renda&nbsp;no Brasil,&nbsp;mas esta realidade pode
estar refletindo diferente contextos regionais associados a&nbsp; transição demográfica e epidemiológica.
Assim, as pessoas que estão no primeiro quintil de renda estão distribuídas
desproporcionalmente nas regiões mais pobres do país (Norte e Nordeste, regiões
rurais, etc.) onde as principais causas de mortalidade ainda são as
materno-infantis ou transmissíveis. No entanto, pessoas que estão nos primeiros
quintis de renda da população nas regiões mais ricas (Estados do Sul e do
Sudeste) poderiam estar em quintis de renda superiores comparados com a média
nacional. Por fim, como o câncer e o nível de renda se associam positivamente
com a idade no Brasil, é de se esperar que a incidência de câncer seja mais
frequente em pessoas com nível de renda mais elevada em função de sua idade.
Uma análise mais explicativa sobre a distribuição da&nbsp;prevalência de câncer por
quintil de renda deveria ser feita no contexto de uma região mais desenvolvida
e de uma região menos desenvolvida separadamente.





Uma outra análise a ser realizada é a comparação das taxas padronizadas de
prevalência de câncer por idade, segundo o sexo e quintil de renda, considerando
a evolução do período 1998-2008, conforme pode ser visto no gráfico 5.

&nbsp;



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&nbsp;



Os dados demonstram que em 1998, havia uma maior prevalência de câncer
feminino no primeiro quintil em relação aos quintis 2, 3 e 4, provavelmente
pela maior exposição das mulheres de menor renda ao câncer cérvico-uterino,
pela baixa frequência de processos&nbsp;de detecção precoce através de exames de citologia e pela falta
de tratamento de infecções cervicais. No entanto, a partir de 1998, o Ministério
da Saúde passou a fazer uma campanha agressiva para a realização de exames
papa-nicoulau através do SUS, o que pode ter ajudado a reverter esta tendência.
Entre 1998&nbsp;de 2008, o crescimento da prevalência de câncer feminino passou a crescer
continuamente de acordo com os quintis de renda, refletindo a tendência natural ao
envelhecimento, dado que a esperança de vida é diretamente proporcional ao nível
de renda.






No que se refere ao câncer masculino, se pode dizer que em 1998, sua
prevalência&nbsp;era maior&nbsp;no quintil 4 e se reduzia no
quintil de renda mais elevada, tendência que se reverte em 2008, quando o
aumento da prevalência passa a ser contínua de acordo ao nível de renda,
provavelmente por estar associada também a uma maior expectativa de vida por
nível de renda.






Os gráficos&nbsp;6 e 7&nbsp;mostram as curvas de Lorenz da prevalência de câncer
padronizada por idade para os dois sexos para os anos 2003 e 2008.



&nbsp;

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&nbsp;

Observa-se que em 1998, a prevalência de câncer aparenta ser mais concentrada do que em 2008, tanto para homens como para mulheres, dado que&nbsp;entre estes dois anos, a Curva de Lorenz se
deslocou na direção da reta de equidade plena&nbsp;que corta em 45% os dois eixos do Gráfico representative desta curva. Dado que entre estes dois anos também ocorreu uma melhora na
distribuição de renda, pode-se dizer que a maiores oportunidades trazidas por
uma renda melhor distribuida tiveram como contra-partida maiores riscos de
prevalência do câncer na população de menor renda,&nbsp;que ao viver&nbsp;mais e morrer menos por doenças transmissíveis ou causas maternas e peri-natais, poderia estar mais exposta aos fatores de risco&nbsp;associados ao&nbsp;câncer. 






Mas, por outro lado, ao longo do tempo, com a melhoria da atenção
básica, passa a ocorrer também uma maior probabilidade de diagnosticar
precocemente o câncer em populações de mais baixa renda, contribuindo para
reduzir o hiato de desconhecimento da doença entre os mais ricos e os mais
pobres. Em outras palavras, mesmo com a padronização por idade, a evidência nas
pesquisas domiciliares de que pobres declaram que tem menos&nbsp; câncer do
que os mais ricos pode estar associada a falta de informação dos mais pobres
sobre se tem ou não a doença, o que tende a se reduzir quando melhora a
distribuição de renda e principalmente o acesso ao diagnóstico precoce através
da atenção básica. Os dados sobre a realização de exames de diagnóstico de
câncer por nível de renda poderiam contribuir para&nbsp;explicar melhor&nbsp;este tema.&nbsp;Mas o fato é que, na medida em que melhora o nivel de renda das pessoas e sua distribuição,&nbsp;o câncer deixa de&nbsp;apresentar-se nas estatísticas domiciliares como&nbsp;uma
doença de ricos para ser prevalente de forma mais homogênea em toda a&nbsp; população.






Diferenças Étnico-Raciais Associadas ao Cancer





 



 


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As diferenças étnico-raciais&nbsp;nas PNADS são pesquisadas através da
declaração de côr dos indivíduos. Neste sentido, pelo menos quatro grupos de
cor são pesquisados segundo esta declaração: brancos, pretos, pardos e
amarelos. Os dados de incidência de câncer de acôrdo com estas&nbsp;características podem
ser vistos no gráfico 8.



&nbsp;



Os dados relevam que a prevalência de câncer é maior
para as mulheres do que para os homens em todos os agrupamentos por côr. As prevalências entre brancos e amarelos são próximas e muito maiores
(quase o dobro) das prevalências entre pardos e negros. Como
brancos e amarelos, em função de seu nivel de renda, tem uma cobertura de
assistência médica maior que negros e pardos, é possível que estes últimos não
tenham as mesmas chances que os&nbsp; brancos
e amarelos de contar com um diagnóstico precoce quando são portadores de câncer.



Portanto, estes dados
podem estar relevando, além das&nbsp;diferenças entre a estrutura etária e os níveis de renda
dos distintos grupos populacionais segundo a cor (1), diferenças quanto ao acesso aos serviços e o auto-conhecimento do&nbsp; seus respectivos estados de saúde.&nbsp;Passaremos a analisar, portanto, como evolui a prevalência de câncer
segundo a côr e idade. Os gráficos&nbsp;9 e&nbsp;10 mostram essa evolução&nbsp;do câncer por idade para&nbsp;brancos,
pretos e pardos (2).








No caso dos homens, verifica-se que a prevalência de câncer é maior para os
brancos em todos os grupos etários, demonstrando que o câncer, neste caso se
associa mais com a idade. 





&nbsp;

No caso das mulheres, o comportamento é um pouco diferente dado que,
entre as idades de 5 a 35 anos,&nbsp;a prevalência de câncer entre as mulheres que
se declaram pretas é maior do que entre as mulheres brancas e pardas, indicando
que alguns tipos de cancer,&nbsp;associados à&nbsp;pobreza e que&nbsp;aparecem em idades mais jovens, como o câncer cérvico uterino, são mais prevalentes entre as mulheres
negras. 






Análise Combinada da Incidência de Câncer por Renda e Idade





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Vejamos agora como se configura a prevalência do câncer no Brasil,
segundo os quintis de renda e a idade para homens e mulheres. 





&nbsp;

Comecemos pela análise das taxas masculinas. Pode-se dizer que não
existe muita variação na prevalência nas idades mais jovens, embora se possa
notar uma preponderância da prevalência no quintil&nbsp;2, entre as idades de 5-9
anos e 25-34 anos. Mas é entre as idades de 60-65 anos que&nbsp;a prevalência de câncer do
quintil mais pobre atinge seu ponto mais elevado. Dada a falta de tratamento, a esperança de vida da população neste quintil de renda é mais baixa e&nbsp;a
incidência começa a declinar a partir desta idade, devido à&nbsp;&nbsp;redução desproporcionalmente maior&nbsp;do tamanho da população neste quintil de&nbsp;renda,&nbsp;na medida em que avança a idade.&nbsp;Por ter uma sobrevivência maior, as taxas de prevalência passam a ser mais elevadas&nbsp;no quintil mais rico a partir&nbsp;dos 70
anos de idade. 





&nbsp;

No caso das taxas femininas de câncer por idade e quintil de renda, os dados são mais difíceis de
interpretar, mas também se observa&nbsp;a hegemonia da prevalência dos quintis mais ricos (4º e 5º) nas idades
acima de 60 anos, com alguns picos de variação nos demais quintis em idades,
como é o caso do primeiro quintil. 



Os dados da amostra da PNAD 2008 podem não
ser muito sensíveis para alguns dos níveis de desagregação utilizados, como o
cruzamento de prevalencias de câncer para idades e&nbsp;quintis de renda, mas de
alguma forma, uma análise agregada permite mostrar a tendência geral de que as
taxas de prevalência de câncer tendem a ser maiores para os grupos de renda mais
elevada porque estes sobrevivem ao câncer e a outras doenças em idades mais avançadas do que os mais pobres, mas também porque os mais pobres tem menos informação e acesso ao diagnostico para responder positivamente quando perguntados se são portadores de câncer.







[1] Segundo a PNAD 2008, a renda
média entre os negros era de R$383,40 e R$583,30, enquanto que a dos brancos
era de R$742,10 e R$1181,10 para homens e mulheres, respectivamente. Portanto a
renda dos brancos era&nbsp; quase o dobro da dos negros



[2] Os dados relacionados as pessoas que se declaram como
amarelos não foram incorporados em função da baixa representatividade das
estimativas para este grupo de raça-cor por idade.

&nbsp;

&nbsp;



﻿