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Time trend and regional variability of mortality rate due to ovarian cancer in Brazil: a 15-year analysis

Time trend and regional variability of mortality rate due to ovarian cancer in Brazil: a 15-year... Abstract Introduction Ovarian cancer (OC) is the most lethal gynecological tumor. In Brazil, there are important regional differences regarding mortality rates for the same cancer type. Objectives To analyze the progression of OC mortality rates in Brazil and its regions, in age groups over 50 years, between 2000 and 2015. Methods Ecological longitudinal study carried out using secondary data from DATASUS (Brazil’s public health system database) regarding deaths due to OC in women living in Brazil between 2000 and 2015. We calculated gross and adjusted mortality, estimated the impact of death of OC and proportional mortality rate of all cancer types in women between the age of 50 and 79 years. Results There were 34.335 deaths due to OC in women in the referred age interval, with a 9% increase in mortality adjusted for age, a 0.05% (P = 0.012) trend and a 24.67% increase in the proportional mortality due to all causes with a 0.02% (P < 0.001) trend. There were statistically significant increases in mortality rates due to OC in the age groups of 50–54 (28,4%, P < 0,05) and 75–79 years (25,1%, P < 0,05). Conclusion Although there are oscillations in mortality rates of OC in Brazil and its regions over the period studied, this parameter has remained relatively stable. cancer, public health, women’s health Introduction Overall, ovarian cancer (OC) is the sixth most frequent neoplasm in women, being the most lethal gynecological tumor.1–3 Typically, the disease has a higher incidence in women around the age of 60, and when there is heredity, cases appear ~10 years earlier.4 According to estimates, 60% of patients diagnosed with new cases of OC in 2017 in the USA will die as a consequence of their condition.5 In Brazil, data from the National Cancer Institute (INCA) point to OC as the gynecological neoplasm with lowest chance of cure.6 In addition to the regional differences existent in the country—Brazil is a developing country of great territorial extension in which important social and income inequalities occur—there are disagreements on the number of expected cases and mortality from various types of cancer.7 These differences are evidenced by the existence of different mortality rates for the same type of cancer and administrative region.8–10 With respect to OC, in particular, it should be noted that the standardization of its diagnosis and treatment at the national level occurred only in 2012,11 which could have led to a consequent standardization of its mortality among the regions of the country after its implementation. Therefore, the aim of this study was to analyze the behavior of OC mortality rate in Brazil and its administrative regions, in the age groups above 50 years, between the years of 2000 and 2015. Methods Study design A longitudinal ecological study based on secondary data on OC mortality in Brazilian women between 2000 and 2015. Data source, coverage and collection The present study was performed using secondary data of women residing in Brazil between 2000 and 2015. The units of analysis were Brazil and its five administrative regions (North, Northeast, South, Southeast and Midwest). Data were obtained from the Department of Informatics of the Unified Health System (DATASUS), maintained by the Brazilian Ministry of Health. DATASUS provides for public access a database where there are several specific systems with information about hospitalizations, deaths and hospital services, e.g. all of which regarding the public health system. The Mortality Information System (SIM) is a database run by the Departments of State and Municipal Health, as well as by the Health Surveillance Department.12 The source document of the obtained data is the declaration of death, according to guidelines of the World Health Organization (WHO).12 According to data from the General Coordination of Information and Epidemiological Analysis (CGIAE) of the Ministry of Health, mortality data coverage has improved since the last decade, reaching 96.1% in 2011.13 However, in order to know the reliability of the data used in this study and to guarantee its internal validity, we estimated the coverage of the SIM for neoplasms in women throughout the study period. For this, we obtained the number of deaths reported in the SIM and the total number of deaths recorded by active search in registry offices in each administrative region. Since this information was only available until 2013 – and data presented a normal distribution (Shapiro–Wilk, P > 0.05)—we used a linear regression model to estimate coverage by 2015. In the Supplementary Material 1, we present the percentage variation in the coverage of data due to mortality by neoplasms in women aged 50–79 years in the available period, i.e. between 2000 and 2013. Study variables Number of deaths due to OC Two researchers independently collected data on OC deaths reported by the Mortality Information System (SIM) in women aged 50–79 between 2000 and 2015. Deaths have not been divided by cancer stage, due to the impossibility of the system from which they were collected. OC was defined according to the 10th revision of the International Classification of Diseases (ICD10) by code C.56.14 Disagreements on the number of deaths—when present—were resolved by consensus with a third researcher. Age-standardized mortality from OC To calculate the OC mortality, we used the number of deaths in women aged between 50 and 79 years and the resident female population. The resident female population was obtained from the Demographic and Socioeconomic Information of the Brazilian Institute of Geography and Statistics (IBGE), also accessible by DATASUS. Gross mortality was calculated from the ratio between the number of deaths and the resident population (per 100 000 women) of each administrative region of the country for each year between 2000 and 2015. Gross mortality rates for the 4-year intervals were also estimated. To allow comparison with other studies and across regions, gross rates of OC mortality in administrative regions were standardized by age. Standardization was performed by the direct method, based on the standard population of the World Health Organization (WHO).15 Proportional mortality from all causes and for all cancers The magnitude of OC deaths in relation to all defined causes of ICD-10 deaths and in relation to all deaths due to neoplasms was calculated from data from the SIM. For the calculation, deaths reported with ICD in the interval between R00 and R99 were not included because they do not present the defined cause of death. In turn, proportional mortality for all cancers in women in the age range studied was estimated by the ratio of the amount of OC deaths and all deaths from cancer (as defined in Chapter 2 of ICD-10). It should be noted that, for all calculations, the female population comprised between 50 and 79 years of age was the only one considered. Statistical analysis To describe OC mortality, descriptive statistics were performed. Linear regression was used to analyze the relationship between mortality and the administrative regions of Brazil, constituting a time trend. The dependent variable is the ‘mortality adjusted by the standard population’ and the independent variable, the ‘calendar years’ and the administrative regions. The percent change (PC) and the annual percentage change (APC) are the two trend measures in this analysis. Both are represented below16: PC=NumberofeventsinA−NumberofeventsinBNumberofeventsinB×100 APC = log β, where β is the slope of the linear regression. The level of confidence was 5%. The statistical program used was Stata® (Stata Corp., College Station, EUA) 11.0. Results Between 2000 and 2015, 34 335 deaths due to OC were registered in women aged 50–79 years in Brazil, representing a mortality rate of 10.5 per 100 000 women for the age group. In this period, OC deaths accounted for 4.4% of all deaths due to neoplasms, and 1% of deaths due to defined causes occurred in the country (Table 1). Table 1 Deaths, mortality and proportional mortality (for all types of neoplasms and all deaths) of ovarian cancer in Brazil between 2000 and 2015 Variables Deaths Mortalitya (95% CI) Proportional mortality (95% CI) All-neoplasms All-cause Brazil 34 335 10.5 (10.29; 10.69) 4.5 (4.42; 4.56) 1.1 (1.01; 1.09) Regions  North 1001 6.1 (5.42; 6.86) 3.1 (2.87; 3.42) 0.7 (0.64; 0.79)  Northeast 6344 7.6 (6.87; 8.27) 4.1 (3.91; 4.22) 0.8 (0.79; 0.90)  Southeast 18 302 11.8 (11.46; 12.17) 4.8 (4.65; 4.87) 1.1 (1.09; 1.17)  South 6684 12.5 (12.17; 12.85) 4.5 (4.36; 4.61) 1.2 (1.12; 1.24)  Midwest 2004 10.5 (9.65; 11.31) 4.4 (4.08; 4.70) 1.0 (0.89; 1.07) Age groups  50–54 years 4451 30.6 (29.45; 31.68) 4.3 (4.16; 4.43) 1.3 (1.28; 1.41)  55–59 years 5177 37.2 (35.94; 38.41) 4.3 (4.19; 4.46) 1.3 (1.24; 1.36)  60–64 years 5313 39.6 (38.47; 40.70) 4.1 (3.98; 4.19) 1.1 (1.07; 1.15)  65–69 years 5245 40.1 (38.59; 41.62) 3.8 (3.68; 3.98) 0.9 (0.88; 0.95)  70–74 years 4966 37.2 (36.29; 38.11) 3.6 (3.46; 3.66) 0.7 (0.70; 0.74)  75–79 years 4040 28.6 (27.01; 30.27) 3.0 (2.90; 3.17) 0.5 (0.48; 0.53) Variables Deaths Mortalitya (95% CI) Proportional mortality (95% CI) All-neoplasms All-cause Brazil 34 335 10.5 (10.29; 10.69) 4.5 (4.42; 4.56) 1.1 (1.01; 1.09) Regions  North 1001 6.1 (5.42; 6.86) 3.1 (2.87; 3.42) 0.7 (0.64; 0.79)  Northeast 6344 7.6 (6.87; 8.27) 4.1 (3.91; 4.22) 0.8 (0.79; 0.90)  Southeast 18 302 11.8 (11.46; 12.17) 4.8 (4.65; 4.87) 1.1 (1.09; 1.17)  South 6684 12.5 (12.17; 12.85) 4.5 (4.36; 4.61) 1.2 (1.12; 1.24)  Midwest 2004 10.5 (9.65; 11.31) 4.4 (4.08; 4.70) 1.0 (0.89; 1.07) Age groups  50–54 years 4451 30.6 (29.45; 31.68) 4.3 (4.16; 4.43) 1.3 (1.28; 1.41)  55–59 years 5177 37.2 (35.94; 38.41) 4.3 (4.19; 4.46) 1.3 (1.24; 1.36)  60–64 years 5313 39.6 (38.47; 40.70) 4.1 (3.98; 4.19) 1.1 (1.07; 1.15)  65–69 years 5245 40.1 (38.59; 41.62) 3.8 (3.68; 3.98) 0.9 (0.88; 0.95)  70–74 years 4966 37.2 (36.29; 38.11) 3.6 (3.46; 3.66) 0.7 (0.70; 0.74)  75–79 years 4040 28.6 (27.01; 30.27) 3.0 (2.90; 3.17) 0.5 (0.48; 0.53) aAge-standardized mortality per 100 000 inhabitants. 95% CI = 95% confidence Interval. Table 1 Deaths, mortality and proportional mortality (for all types of neoplasms and all deaths) of ovarian cancer in Brazil between 2000 and 2015 Variables Deaths Mortalitya (95% CI) Proportional mortality (95% CI) All-neoplasms All-cause Brazil 34 335 10.5 (10.29; 10.69) 4.5 (4.42; 4.56) 1.1 (1.01; 1.09) Regions  North 1001 6.1 (5.42; 6.86) 3.1 (2.87; 3.42) 0.7 (0.64; 0.79)  Northeast 6344 7.6 (6.87; 8.27) 4.1 (3.91; 4.22) 0.8 (0.79; 0.90)  Southeast 18 302 11.8 (11.46; 12.17) 4.8 (4.65; 4.87) 1.1 (1.09; 1.17)  South 6684 12.5 (12.17; 12.85) 4.5 (4.36; 4.61) 1.2 (1.12; 1.24)  Midwest 2004 10.5 (9.65; 11.31) 4.4 (4.08; 4.70) 1.0 (0.89; 1.07) Age groups  50–54 years 4451 30.6 (29.45; 31.68) 4.3 (4.16; 4.43) 1.3 (1.28; 1.41)  55–59 years 5177 37.2 (35.94; 38.41) 4.3 (4.19; 4.46) 1.3 (1.24; 1.36)  60–64 years 5313 39.6 (38.47; 40.70) 4.1 (3.98; 4.19) 1.1 (1.07; 1.15)  65–69 years 5245 40.1 (38.59; 41.62) 3.8 (3.68; 3.98) 0.9 (0.88; 0.95)  70–74 years 4966 37.2 (36.29; 38.11) 3.6 (3.46; 3.66) 0.7 (0.70; 0.74)  75–79 years 4040 28.6 (27.01; 30.27) 3.0 (2.90; 3.17) 0.5 (0.48; 0.53) Variables Deaths Mortalitya (95% CI) Proportional mortality (95% CI) All-neoplasms All-cause Brazil 34 335 10.5 (10.29; 10.69) 4.5 (4.42; 4.56) 1.1 (1.01; 1.09) Regions  North 1001 6.1 (5.42; 6.86) 3.1 (2.87; 3.42) 0.7 (0.64; 0.79)  Northeast 6344 7.6 (6.87; 8.27) 4.1 (3.91; 4.22) 0.8 (0.79; 0.90)  Southeast 18 302 11.8 (11.46; 12.17) 4.8 (4.65; 4.87) 1.1 (1.09; 1.17)  South 6684 12.5 (12.17; 12.85) 4.5 (4.36; 4.61) 1.2 (1.12; 1.24)  Midwest 2004 10.5 (9.65; 11.31) 4.4 (4.08; 4.70) 1.0 (0.89; 1.07) Age groups  50–54 years 4451 30.6 (29.45; 31.68) 4.3 (4.16; 4.43) 1.3 (1.28; 1.41)  55–59 years 5177 37.2 (35.94; 38.41) 4.3 (4.19; 4.46) 1.3 (1.24; 1.36)  60–64 years 5313 39.6 (38.47; 40.70) 4.1 (3.98; 4.19) 1.1 (1.07; 1.15)  65–69 years 5245 40.1 (38.59; 41.62) 3.8 (3.68; 3.98) 0.9 (0.88; 0.95)  70–74 years 4966 37.2 (36.29; 38.11) 3.6 (3.46; 3.66) 0.7 (0.70; 0.74)  75–79 years 4040 28.6 (27.01; 30.27) 3.0 (2.90; 3.17) 0.5 (0.48; 0.53) aAge-standardized mortality per 100 000 inhabitants. 95% CI = 95% confidence Interval. The Southeastern region had the highest number of deaths and mortality proportional to all neoplasms (18 302 deaths in total and 4.8%, respectively). The South region had the highest mortality rate (12.5 deaths per 100 women aged 50–79 years) and mortality proportional to all causes (1.2% of all deaths due to defined causes). The majority of deaths occurred in the age group of 60 to 64 years (5313 deaths) and the highest mortality was recorded in the age group of 65–69 years (40.1 deaths per 100 000 women). The highest mortality proportional to all neoplasms (4.3%) and the highest proportional mortality for all causes (1.3%) occurred in the age groups between 50 and 54 and between 55 and 59 years (Table 1). With regard to the behavior of OC rates between 2000 and 2015, there was a 9% increase in age-standardized mortality, with a trend of 0.05% (ranging from 0.01 to 0.08% per year, P = 0.012) and 24.67% in mortality proportional to all causes, with a trend of 0.02% (ranging from 0.01 to 0.02% per year, P < 0.001) (Table 2). Data behavior over time and be easily seen in Fig. 1. Table 2 Temporal trend of mortality and magnitude of ovarian cancer in Brazilian women aged 50–79 years between 2000 and 2015 Ovarian cancer Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya 9.9 10.9 9.01 0.05 (0.01; 0.08) 0.37 0.012 Proportional mortality  To all defined causes 0.9 1.1 24.67 0.02 (0.01; 0.02) 0.89 <0.001  To all neoplasms 4.3 4.5 5.75 0.01 (−0.00; 0.03) 0.24 0.056 Ovarian cancer Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya 9.9 10.9 9.01 0.05 (0.01; 0.08) 0.37 0.012 Proportional mortality  To all defined causes 0.9 1.1 24.67 0.02 (0.01; 0.02) 0.89 <0.001  To all neoplasms 4.3 4.5 5.75 0.01 (−0.00; 0.03) 0.24 0.056 *Linear regression. aAge-standardized mortality per 100 000 inhabitants PC = percent change; APC = annual percentage change; 95% CI = 95% confidence interval. Table 2 Temporal trend of mortality and magnitude of ovarian cancer in Brazilian women aged 50–79 years between 2000 and 2015 Ovarian cancer Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya 9.9 10.9 9.01 0.05 (0.01; 0.08) 0.37 0.012 Proportional mortality  To all defined causes 0.9 1.1 24.67 0.02 (0.01; 0.02) 0.89 <0.001  To all neoplasms 4.3 4.5 5.75 0.01 (−0.00; 0.03) 0.24 0.056 Ovarian cancer Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya 9.9 10.9 9.01 0.05 (0.01; 0.08) 0.37 0.012 Proportional mortality  To all defined causes 0.9 1.1 24.67 0.02 (0.01; 0.02) 0.89 <0.001  To all neoplasms 4.3 4.5 5.75 0.01 (−0.00; 0.03) 0.24 0.056 *Linear regression. aAge-standardized mortality per 100 000 inhabitants PC = percent change; APC = annual percentage change; 95% CI = 95% confidence interval. Fig. 1 View largeDownload slide Temporal trend of ovarian cancer mortality in Brazil between 2000 and 2015. Fig. 1 View largeDownload slide Temporal trend of ovarian cancer mortality in Brazil between 2000 and 2015. There was an increase in all indicators related to OC mortality in the North, Northeast and Midwest regions. In the Southeast region, although there was a reduction in mortality, there was an increase in mortality proportional to all causes and no significant changes were observed in mortality proportional to all neoplasms (P = 0.809). On the other hand, in the South region, although there were no significant changes in mortality (P = 0.741), there was an increase in mortality proportional to all causes and mortality proportional to all neoplasms (Table 3). Table 3 Temporal trend of mortality and magnitude of ovarian cancer in Brazilian women aged 50–79 years according to administrative regions Regions Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya  North 4.9 7.7 57.6 0.24 (0.15; 0.33) 0.71 <0.001  Northeast 5.6 8.3 48.4 0.24 (0.16; 0.32) 0.76 <0.001  Southeast 12.4 11.9 −4.44 −0.08 (−0.14; −0.02) 0.34 0.018  South 12 12.5 3.78 −0.01 (−0.09; 0.06) 0.01 0.741  Midwest 8.5 11.9 40.4 0.21 (0.07; 0.36) 0.42 0.007 Proportional mortality to all-causes  North 0.6 0.8 35.64 0.02 (0.01; 0.03) 0.61 <0.001  Northeast 0.7 0.9 20.86 0.02 (0.01; 0.02) 0.72 <0.001  Southeast 1.0 1.3 22.97 0.01 (0.01; 0.02) 0.54 0.001  South 0.9 1.3 41.31 0.02 (0.02; 0.03) 0.83 <0.001  Midwest 0.7 1.2 63.17 0.03 (0.02; 0.04) 0.70 <0.001 Proportional mortality to all-neoplasms  North 2.9 3.5 20.84 0.07 (0.03; 0.12) 0.47 0.004  Northeast 3.9 3.9 −0.43 0.03 (0.00; 0.06) 0.28 0.035  Southeast 4.7 4.9 5.62 −0.003 (-0.03; 0.02) 0.01 0.809  South 4.0 4.5 11.22 0.02 (0.00; 0.05) 0.25 0.049  Midwest 3.7 5 35.24 0.09 (0.04; 0.14) 0.49 0.003 Regions Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya  North 4.9 7.7 57.6 0.24 (0.15; 0.33) 0.71 <0.001  Northeast 5.6 8.3 48.4 0.24 (0.16; 0.32) 0.76 <0.001  Southeast 12.4 11.9 −4.44 −0.08 (−0.14; −0.02) 0.34 0.018  South 12 12.5 3.78 −0.01 (−0.09; 0.06) 0.01 0.741  Midwest 8.5 11.9 40.4 0.21 (0.07; 0.36) 0.42 0.007 Proportional mortality to all-causes  North 0.6 0.8 35.64 0.02 (0.01; 0.03) 0.61 <0.001  Northeast 0.7 0.9 20.86 0.02 (0.01; 0.02) 0.72 <0.001  Southeast 1.0 1.3 22.97 0.01 (0.01; 0.02) 0.54 0.001  South 0.9 1.3 41.31 0.02 (0.02; 0.03) 0.83 <0.001  Midwest 0.7 1.2 63.17 0.03 (0.02; 0.04) 0.70 <0.001 Proportional mortality to all-neoplasms  North 2.9 3.5 20.84 0.07 (0.03; 0.12) 0.47 0.004  Northeast 3.9 3.9 −0.43 0.03 (0.00; 0.06) 0.28 0.035  Southeast 4.7 4.9 5.62 −0.003 (-0.03; 0.02) 0.01 0.809  South 4.0 4.5 11.22 0.02 (0.00; 0.05) 0.25 0.049  Midwest 3.7 5 35.24 0.09 (0.04; 0.14) 0.49 0.003 *Linear regression. aAge-standardized mortality per 100 000 inhabitants. PC = percent change; APC = annual percentage change; 95% CI = 95% confidence interval. Table 3 Temporal trend of mortality and magnitude of ovarian cancer in Brazilian women aged 50–79 years according to administrative regions Regions Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya  North 4.9 7.7 57.6 0.24 (0.15; 0.33) 0.71 <0.001  Northeast 5.6 8.3 48.4 0.24 (0.16; 0.32) 0.76 <0.001  Southeast 12.4 11.9 −4.44 −0.08 (−0.14; −0.02) 0.34 0.018  South 12 12.5 3.78 −0.01 (−0.09; 0.06) 0.01 0.741  Midwest 8.5 11.9 40.4 0.21 (0.07; 0.36) 0.42 0.007 Proportional mortality to all-causes  North 0.6 0.8 35.64 0.02 (0.01; 0.03) 0.61 <0.001  Northeast 0.7 0.9 20.86 0.02 (0.01; 0.02) 0.72 <0.001  Southeast 1.0 1.3 22.97 0.01 (0.01; 0.02) 0.54 0.001  South 0.9 1.3 41.31 0.02 (0.02; 0.03) 0.83 <0.001  Midwest 0.7 1.2 63.17 0.03 (0.02; 0.04) 0.70 <0.001 Proportional mortality to all-neoplasms  North 2.9 3.5 20.84 0.07 (0.03; 0.12) 0.47 0.004  Northeast 3.9 3.9 −0.43 0.03 (0.00; 0.06) 0.28 0.035  Southeast 4.7 4.9 5.62 −0.003 (-0.03; 0.02) 0.01 0.809  South 4.0 4.5 11.22 0.02 (0.00; 0.05) 0.25 0.049  Midwest 3.7 5 35.24 0.09 (0.04; 0.14) 0.49 0.003 Regions Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya  North 4.9 7.7 57.6 0.24 (0.15; 0.33) 0.71 <0.001  Northeast 5.6 8.3 48.4 0.24 (0.16; 0.32) 0.76 <0.001  Southeast 12.4 11.9 −4.44 −0.08 (−0.14; −0.02) 0.34 0.018  South 12 12.5 3.78 −0.01 (−0.09; 0.06) 0.01 0.741  Midwest 8.5 11.9 40.4 0.21 (0.07; 0.36) 0.42 0.007 Proportional mortality to all-causes  North 0.6 0.8 35.64 0.02 (0.01; 0.03) 0.61 <0.001  Northeast 0.7 0.9 20.86 0.02 (0.01; 0.02) 0.72 <0.001  Southeast 1.0 1.3 22.97 0.01 (0.01; 0.02) 0.54 0.001  South 0.9 1.3 41.31 0.02 (0.02; 0.03) 0.83 <0.001  Midwest 0.7 1.2 63.17 0.03 (0.02; 0.04) 0.70 <0.001 Proportional mortality to all-neoplasms  North 2.9 3.5 20.84 0.07 (0.03; 0.12) 0.47 0.004  Northeast 3.9 3.9 −0.43 0.03 (0.00; 0.06) 0.28 0.035  Southeast 4.7 4.9 5.62 −0.003 (-0.03; 0.02) 0.01 0.809  South 4.0 4.5 11.22 0.02 (0.00; 0.05) 0.25 0.049  Midwest 3.7 5 35.24 0.09 (0.04; 0.14) 0.49 0.003 *Linear regression. aAge-standardized mortality per 100 000 inhabitants. PC = percent change; APC = annual percentage change; 95% CI = 95% confidence interval. In relation to the age groups, there was a 28.4% increase in OC mortality in the age group of 50–54 years, with an increasing trend of 0.24% per year (ranging from 0.03 to 0.45%, r2 = 0.29, P = 0.031), and an of 25.1% in the age group of 75–79 years, with an increasing trend of 0.43% per year (ranging from 0.15 to 0.70%; r2 = 0.44, P = 0.005). Additionally, in all age groups studied, there was an increase in mortality proportional to all causes (P < 0.05) and there were no differences in mortality proportional to all neoplasms (Table 4). Table 4 Time trend of mortality and magnitude of ovarian cancer in Brazilian women aged 50–79 according to age groups Age groups Year PC APC 2000 2015 β (95% CI) r2 P* Standardized mortalitya  50–54 years 27.1 34.7 28.4 0.24 (0.03; 0.45) 0.29 0.031  55–59 years 34.9 39.4 12.9 0.18 (−0.08; 0.44) 0.14 0.151  60–64 years 38.7 37.6 −2.8 0.07 (−0.18; 0.32) 0.02 0.559  65–69 years 42.9 38.6 −9.9 0.03 (−0.31; 0.37) 0.00 0.860  70–74 years 33.9 38.9 14.7 0.02 (−0.18; 0.23) 0.00 0.828  75–79 years 25.7 32.2 25.1 0.43 (0.15; 0.70) 0.44 0.005 Proportional mortality to all-causes  50–54 years 1.1 1.6 48.0 0.02 (0.01; 0.03) 0.62 <0.001  55–59 years 1.1 1.5 26.9 0.02 (0.01; 0.02) 0.47 0.003  60–64 years 1.0 1.1 13.2 0.01 (0.01; 0.02) 0.53 0.001  65–69 years 0.9 0.9 1.4 0.01 (0.00; 0.01) 0.26 0.043  70–74 years 0.6 0.8 24.4 0.00 (0.00; 0.01) 0.26 0.043  75–79 years 0.5 0.6 23.7 0.01 (0.00; 0.01) 0.50 0.002 Proportional mortality to all-neoplasms  50–54 years 4.0 4.8 20.0 0.02 (−0.01; 0.05) 0.14 0.147  55–59 years 4.2 4.4 4.4 −0.01 (-0.04; 0.02) 0.02 0.620  60–64 years 4.1 3.7 −9.2 −0.01 (−0.03; 0.02) 0.02 0.578  65–69 years 4.2 3.6 −14.2 −0.01 (-0.05; 0.02) 0.06 0.363  70–74 years 3.4 3.7 8.5 −0.01 (−0.03; 0.01) 0.14 0.152  75–79 years 2.9 3.3 10.4 0.02 (−0.00; 0.05) 0.19 0.089 Age groups Year PC APC 2000 2015 β (95% CI) r2 P* Standardized mortalitya  50–54 years 27.1 34.7 28.4 0.24 (0.03; 0.45) 0.29 0.031  55–59 years 34.9 39.4 12.9 0.18 (−0.08; 0.44) 0.14 0.151  60–64 years 38.7 37.6 −2.8 0.07 (−0.18; 0.32) 0.02 0.559  65–69 years 42.9 38.6 −9.9 0.03 (−0.31; 0.37) 0.00 0.860  70–74 years 33.9 38.9 14.7 0.02 (−0.18; 0.23) 0.00 0.828  75–79 years 25.7 32.2 25.1 0.43 (0.15; 0.70) 0.44 0.005 Proportional mortality to all-causes  50–54 years 1.1 1.6 48.0 0.02 (0.01; 0.03) 0.62 <0.001  55–59 years 1.1 1.5 26.9 0.02 (0.01; 0.02) 0.47 0.003  60–64 years 1.0 1.1 13.2 0.01 (0.01; 0.02) 0.53 0.001  65–69 years 0.9 0.9 1.4 0.01 (0.00; 0.01) 0.26 0.043  70–74 years 0.6 0.8 24.4 0.00 (0.00; 0.01) 0.26 0.043  75–79 years 0.5 0.6 23.7 0.01 (0.00; 0.01) 0.50 0.002 Proportional mortality to all-neoplasms  50–54 years 4.0 4.8 20.0 0.02 (−0.01; 0.05) 0.14 0.147  55–59 years 4.2 4.4 4.4 −0.01 (-0.04; 0.02) 0.02 0.620  60–64 years 4.1 3.7 −9.2 −0.01 (−0.03; 0.02) 0.02 0.578  65–69 years 4.2 3.6 −14.2 −0.01 (-0.05; 0.02) 0.06 0.363  70–74 years 3.4 3.7 8.5 −0.01 (−0.03; 0.01) 0.14 0.152  75–79 years 2.9 3.3 10.4 0.02 (−0.00; 0.05) 0.19 0.089 *Linear regression. aAge-standardized mortality per 100 000 inhabitants. PC = percent change; APC = annual percentage change; 95% CI = 95% confidence interval. Table 4 Time trend of mortality and magnitude of ovarian cancer in Brazilian women aged 50–79 according to age groups Age groups Year PC APC 2000 2015 β (95% CI) r2 P* Standardized mortalitya  50–54 years 27.1 34.7 28.4 0.24 (0.03; 0.45) 0.29 0.031  55–59 years 34.9 39.4 12.9 0.18 (−0.08; 0.44) 0.14 0.151  60–64 years 38.7 37.6 −2.8 0.07 (−0.18; 0.32) 0.02 0.559  65–69 years 42.9 38.6 −9.9 0.03 (−0.31; 0.37) 0.00 0.860  70–74 years 33.9 38.9 14.7 0.02 (−0.18; 0.23) 0.00 0.828  75–79 years 25.7 32.2 25.1 0.43 (0.15; 0.70) 0.44 0.005 Proportional mortality to all-causes  50–54 years 1.1 1.6 48.0 0.02 (0.01; 0.03) 0.62 <0.001  55–59 years 1.1 1.5 26.9 0.02 (0.01; 0.02) 0.47 0.003  60–64 years 1.0 1.1 13.2 0.01 (0.01; 0.02) 0.53 0.001  65–69 years 0.9 0.9 1.4 0.01 (0.00; 0.01) 0.26 0.043  70–74 years 0.6 0.8 24.4 0.00 (0.00; 0.01) 0.26 0.043  75–79 years 0.5 0.6 23.7 0.01 (0.00; 0.01) 0.50 0.002 Proportional mortality to all-neoplasms  50–54 years 4.0 4.8 20.0 0.02 (−0.01; 0.05) 0.14 0.147  55–59 years 4.2 4.4 4.4 −0.01 (-0.04; 0.02) 0.02 0.620  60–64 years 4.1 3.7 −9.2 −0.01 (−0.03; 0.02) 0.02 0.578  65–69 years 4.2 3.6 −14.2 −0.01 (-0.05; 0.02) 0.06 0.363  70–74 years 3.4 3.7 8.5 −0.01 (−0.03; 0.01) 0.14 0.152  75–79 years 2.9 3.3 10.4 0.02 (−0.00; 0.05) 0.19 0.089 Age groups Year PC APC 2000 2015 β (95% CI) r2 P* Standardized mortalitya  50–54 years 27.1 34.7 28.4 0.24 (0.03; 0.45) 0.29 0.031  55–59 years 34.9 39.4 12.9 0.18 (−0.08; 0.44) 0.14 0.151  60–64 years 38.7 37.6 −2.8 0.07 (−0.18; 0.32) 0.02 0.559  65–69 years 42.9 38.6 −9.9 0.03 (−0.31; 0.37) 0.00 0.860  70–74 years 33.9 38.9 14.7 0.02 (−0.18; 0.23) 0.00 0.828  75–79 years 25.7 32.2 25.1 0.43 (0.15; 0.70) 0.44 0.005 Proportional mortality to all-causes  50–54 years 1.1 1.6 48.0 0.02 (0.01; 0.03) 0.62 <0.001  55–59 years 1.1 1.5 26.9 0.02 (0.01; 0.02) 0.47 0.003  60–64 years 1.0 1.1 13.2 0.01 (0.01; 0.02) 0.53 0.001  65–69 years 0.9 0.9 1.4 0.01 (0.00; 0.01) 0.26 0.043  70–74 years 0.6 0.8 24.4 0.00 (0.00; 0.01) 0.26 0.043  75–79 years 0.5 0.6 23.7 0.01 (0.00; 0.01) 0.50 0.002 Proportional mortality to all-neoplasms  50–54 years 4.0 4.8 20.0 0.02 (−0.01; 0.05) 0.14 0.147  55–59 years 4.2 4.4 4.4 −0.01 (-0.04; 0.02) 0.02 0.620  60–64 years 4.1 3.7 −9.2 −0.01 (−0.03; 0.02) 0.02 0.578  65–69 years 4.2 3.6 −14.2 −0.01 (-0.05; 0.02) 0.06 0.363  70–74 years 3.4 3.7 8.5 −0.01 (−0.03; 0.01) 0.14 0.152  75–79 years 2.9 3.3 10.4 0.02 (−0.00; 0.05) 0.19 0.089 *Linear regression. aAge-standardized mortality per 100 000 inhabitants. PC = percent change; APC = annual percentage change; 95% CI = 95% confidence interval. Discussion Main findings When analyzing the behavior of OC mortality between 2000 and 2015 in Brazil, we found that: there is stabilization of age-standardized mortality rates in Brazil; and there was increase in rates in the North, Northeast and Midwest regions, and decrease in the South and Southeast regions. To understand the results, some aspects must be considered. First, some caveats must be made regarding the variable ‘age’: the age of onset—50 years—was defined considering that OC seems to be related to the postmenopausal period, although the pathophysiological mechanism is still under discussion.17 In Brazilian women, menopause occurs around the age of 48.18 In turn, the final age—79 years—was established due to the impossibility of adjusting data of ages greater than 79 years by the WHO standard population, due to the way in which the data are made available in DATASUS. In addition, life expectancy at birth for Brazilian women is around 79.1 years, according to the official sense of the IBGE of 2015,19 making the study of the age groups above this mark of little relevance in national terms. With regard to OC, there are health disparities due to the neoplasm worldwide.1 Thus, it is expected that there will be differences in its incidence and mortality rates in countries with different development levels.20 In this context, the incidence and mortality rates of the USA, for example, differ from those found for Brazil. In the first one, there was a practically constant drop in both indices since 1975;21 in the second, it was found that mortality rates fluctuated, over time, oscillating within a constant interval. Also in this context, one can extrapolate the above statement, hoping that different mortality rates will be found in the same country, whose administrative regions present different levels of development—in the present article, we find that the less developed regions showed a tendency to raise OC mortality rates. To support this hypothesis, it suffices to consider that Brazil is a country in which inequality is very present, which is demonstrated by a high Gini index (54.7),22 despite the Human Development Index (HDI) of 0.754.23 Besides, there are already some studies that point to the relation between inequality and mortality by other types of cancer in Brazil—as with breast cancer, for example.24 As for the analysis of mortality rates by age group, it is known that, in general, the risk for development—and consequent incidence of OC—is usually expected to rise with age.25 However, our findings show a positive trend regarding mortality due to the neoplasm in all age groups—even though only two are statistically significant (P < 0.05). It should be noted here that, over time, the trend lines referring to OC mortality in the age groups of 50–54 and 75–79 years—the two that presented statistical significance—approached, almost matching. To understand the finding above, some points should be considered. First, the life expectancy of the Brazilian citizen—of interest, the woman—has increased considerably since the 1940s26—which is relevant, since the risk of developing OC increases with age.27 In addition, younger women tend to have better prognosis than the older ones28—which would explain why the higher mortality increase occurred in the older age group (75–79 years). Finally, it should be taken into account that OC is a neoplasm of difficult diagnosis, with signs and symptoms that are sometimes non-specific—although it may present some clinical patterns29—and whose medical advances have not yet been able to develop an applicable screening method30 for the general population. In this sense, studies such as the present paper are extremely important, since they portray the specific mortality behavior of the population, which can serve as a control for the government and also as a basis for the development and implementation of future public policies. What is already known on this topic OC is the most lethal gynecological tumor, having its incidence a tendency to increase with age.3,25 However, previous research has shown that its incidence and mortality rates ought to present themselves differently in countries which display different development levels.20 What this study adds Epidemiological studies are the basis for the formation of effective public policies, and since resources are limited, the public health manager must choose the best cost-efficient ratio for a given pathology and population.31 Once the epidemiological profile of a disease, the behavior of epidemiological indicators and their impact on a given population are known, public policies of national and/or regional scope can be established according to the findings. In this sense, this is the first work of the authors’ knowledge, to give an overview about the development of OC mortality over time in Brazil and its regions, which could serve as a starting point for new discussions on the way the disease is being approached across the country, as well as its consequences for its citizens. Limitations The extrapolation of the data presented here should be viewed with caution. Since it is an analysis done with secondary data, these results may be under-reporting the actual number of cases. Besides, there are differences in data coverage between regions, which does not reach 100%. Also, since the data acquired and used were not individualized, it is not possible to extrapolate them to other units of analysis. Conclusion During the period studied ovarian cancer mortality has fluctuated in Brazil and in all administrative regions of the country for women between 50 and 79 years. However, mortality rates remained stable. Conflict of interest The authors have no conflicts of interest to disclose. Funding There was no funding for this research. Ethical aspects The data analyzed are public and of unrestricted access and use, and there is no need for the ethical assessment of the Research Ethics Committee in accordance with the terms of the National Health Council (CNS) Resolution No. 466 of 12 December 2012. Availability of data and material All data used in the present article is available online and for free at DATASUS. References 1 Chornokur G , Amankwah EK , Schildkraut JM et al. Global ovarian cancer health disparities . Gynecol Oncol 2013 ; 129 ( 1 ): 258 – 64 . Google Scholar Crossref Search ADS PubMed 2 Doubeni CA , Doubeni AR , Myers AE . Diagnosis and management of ovarian cancer . Am Fam Physician 2016 ; 93 ( 11 ): 937 – 44 . Google Scholar PubMed 3 Permuth-Wey J , Sellers TA . Epidemiology of ovarian cancer . Methods Mol Biol 2009 ; 472 : 413 – 37 . doi:10.1007/978-1-60327-492-0_20 . Google Scholar Crossref Search ADS PubMed 4 Lowe KA , Chia VM , Taylor A et al. An international assessment of ovarian cancer incidence and mortality . Gynecol Oncol 2013 ; 130 ( 1 ): 107 – 14 . Google Scholar Crossref Search ADS PubMed 5 Siegel RL , Miller KD , Jemal A . Cancer statistics, 2017 . CA Cancer J Clin 2017 ; 67 ( 1 ): 7 – 30 . doi:10.3322/caac.21387. Epub 2017 Jan 5. Google Scholar Crossref Search ADS PubMed 6 Instituto Nacional de Câncer (INCA) . http://www2.inca.gov.br/wps/wcm/connect/tiposdecancer/site/home/ovario (2 September 2017 , date last accessed). 7 Barbosa IR , Souza DLB , Bernal MM et al. Cancer mortality in Brazil—temporal trends and predictions for the year 2030 . Medicine (Baltimore) 2015 ; 94 ( 16 ): e746 . Google Scholar Crossref Search ADS PubMed 8 Instituto Nacional de Câncer (INCA) . Atlas da Mortalidade por Câncer no Brasil ( 2016 ). https://mortalidade.inca.gov.br/MortalidadeWeb/ (26 November 2017, date last accessed). 9 Santos SS , Melo LR , Koifman RJ et al. Cancer incidence, hospital morbidity, and mortality in young adults in Brazil . Cad Saude Publica 2013 ; 29 ( 5 ): 1029 – 40 . Google Scholar Crossref Search ADS PubMed 10 Malta DC , Abreu DM , Moura Ld et al. Trends in corrected lung cancer mortality rates in Brazil and regions . Rev Saude Publica 2016 ; 50 : 33 . Google Scholar Crossref Search ADS 11 Júnior, Helvécio Miranda Magalhães. Diário Oficial da União. ‘Portaria N° 458, de 21 de Maio de 2012’. http://www.brasil.gov.br/saude/2012/05/publicada-portaria-que-padroniza-diagnostico-e-tratamento-de-cancer-de-ovario (14 March 2018 , date last accessed). 12 DATASUS—NOTAS TECNICAS. http://tabnet.datasus.gov.br/cgi/sim/Mortalidade_Geral_1996_2012.pdf (26 November 2017 , date last accessed). 13 Escalante JJC , Neto DLR . Coordenação Geral de Informações e Análise Epidemiológica—CGIAE. Consolidação da base de dados de 2011. Brasilia, 28 de maio de 2013. 14 World Health Organization (WHO). http://www.who.int/classifications/icd/en/ (4 August 2017 , date last accessed). 15 Ahmad OB , Boschi-Pinto C , Lopez AD et al. Age standardization of rates: a new who standard. GPE Discussion Paper Series: No.31 EIP/GPE/EBD World Health Organization 2001 . 16 Fay MP , Tiwary RC , Feuer EJ et al. Estimating average annual percent change for disease rates without assuming constant change . Biometrics 2006 ; 62 : 847 – 54 . Google Scholar Crossref Search ADS PubMed 17 Reid BM , Permuth JB , Sellers TA . Epidemiology of ovarian cancer: a review . Cancer Biol Med 2017 ; 14 ( 1 ): 9 – 32 . Google Scholar Crossref Search ADS PubMed 18 Fonseca AMD , Bagnoli VR , Massabki JOP et al. Brazilian women’s health after 65 years of age . Rev Bras Ginecol Obstet 2017 ; 39 ( 11 ): 608 – 13 . doi:10.1055/s-0037-1604200. Epub 2017 Aug 10. Google Scholar Crossref Search ADS PubMed 19 Instituto Brasileiro de Geografia e Estatística (IBGE) . Tábua completa de mortalidade para o Brasil—2015 Breve análise da evolução da mortalidade no Brasil. Brasilia, 2016 . 20 Martínez-Mesa J , Werutsky G , Michiels S et al. Exploring disparities in incidence and mortality rates of breast and gynecologic cancers according to the Human Development Index in the Pan-American region . Public Health 2017 ; 149 : 81 – 8 . Google Scholar Crossref Search ADS PubMed 21 National Institutes of Health (NIH). Cancer Stat Facts: Ovarian Cancer. https://seer.cancer.gov/statfacts/html/ovary.html (26 November 2017 , date last accessed). 22 United Nations . United Nations Development Programme. http://hdr.undp.org/en/content/income-gini-coefficient (26 November 26 2017 , date last accessed). 23 United Nations , Brazil. United Nations Development Programme. http://www.br.undp.org/content/brazil/pt/home/presscenter/articles/2017/03/21/relat-rio-do-pnud-destaca-grupos-sociais-que-n-o-se-beneficiam-do-desenvolvimento-humano.html (26 November 2017 , date last accessed). 24 Winter dos Santos Figueiredo F , Adami F . Income inequality and mortality due to breast cancer: evidence from Brazil . Clinical Breast Cancer 2017 . 10.1016/j.clbc.2017.11.005 . 25 Sopik V , Iqbal J , Rosen B et al. Why have ovarian cancer mortality rates declined? Part I. Incidence . Gynecol Oncol 2015 ; 138 ( 3 ): 741 – 9 . Google Scholar Crossref Search ADS PubMed 26 Brazil . http://www.brasil.gov.br/governo/2016/12/expectativa-de-vida-no-brasil-sobe-para-75-5-anos-em-2015 (26 November 2017 , date last accessed). 27 American Cancer Society . https://www.cancer.org/cancer/ovarian-cancer/causes-risks-prevention/risk-factors.html (26 November 2017 , date last accessed). 28 Chan JK , Urban R , Cheung MK et al. Ovarian cancer in younger vs older women: a population-based analysis . Br J Cancer 2006 ; 95 ( 10 ): 1314 – 20 . doi:10.1038/sj.bjc.6603457 . Google Scholar Crossref Search ADS PubMed 29 Goff B . Symptoms associated with ovarian cancer . Clin Obstet Gynecol 2012 ; 55 ( 1 ): 36 – 42 . Google Scholar Crossref Search ADS PubMed 30 Rauh-Hain JA , Krivak TC , Del Carmen MG et al. Ovarian cancer screening and early detection in the general population . Rev Obstet Gynecol 2011 ; 4 ( 1 ): 15 – 21 . Google Scholar PubMed 31 Laxminarayan R , Chow J , Shahid-Salles SA . Intervention Cost-effectiveness: overview of main messages. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in Developing Countries. 2nd edition. Washington, DC: The International Bank for Reconstruction and Development/The World Bank; 2006. Chapter 2. https://www.ncbi.nlm.nih.gov/books/NBK11784/ Co-published by Oxford University Press, New York. Chapter 2. https://www.ncbi.nlm.nih.gov/books/NBK11784/. Co-published by Oxford University Press, New York. © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Public Health Oxford University Press

Time trend and regional variability of mortality rate due to ovarian cancer in Brazil: a 15-year analysis

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Abstract

Abstract Introduction Ovarian cancer (OC) is the most lethal gynecological tumor. In Brazil, there are important regional differences regarding mortality rates for the same cancer type. Objectives To analyze the progression of OC mortality rates in Brazil and its regions, in age groups over 50 years, between 2000 and 2015. Methods Ecological longitudinal study carried out using secondary data from DATASUS (Brazil’s public health system database) regarding deaths due to OC in women living in Brazil between 2000 and 2015. We calculated gross and adjusted mortality, estimated the impact of death of OC and proportional mortality rate of all cancer types in women between the age of 50 and 79 years. Results There were 34.335 deaths due to OC in women in the referred age interval, with a 9% increase in mortality adjusted for age, a 0.05% (P = 0.012) trend and a 24.67% increase in the proportional mortality due to all causes with a 0.02% (P < 0.001) trend. There were statistically significant increases in mortality rates due to OC in the age groups of 50–54 (28,4%, P < 0,05) and 75–79 years (25,1%, P < 0,05). Conclusion Although there are oscillations in mortality rates of OC in Brazil and its regions over the period studied, this parameter has remained relatively stable. cancer, public health, women’s health Introduction Overall, ovarian cancer (OC) is the sixth most frequent neoplasm in women, being the most lethal gynecological tumor.1–3 Typically, the disease has a higher incidence in women around the age of 60, and when there is heredity, cases appear ~10 years earlier.4 According to estimates, 60% of patients diagnosed with new cases of OC in 2017 in the USA will die as a consequence of their condition.5 In Brazil, data from the National Cancer Institute (INCA) point to OC as the gynecological neoplasm with lowest chance of cure.6 In addition to the regional differences existent in the country—Brazil is a developing country of great territorial extension in which important social and income inequalities occur—there are disagreements on the number of expected cases and mortality from various types of cancer.7 These differences are evidenced by the existence of different mortality rates for the same type of cancer and administrative region.8–10 With respect to OC, in particular, it should be noted that the standardization of its diagnosis and treatment at the national level occurred only in 2012,11 which could have led to a consequent standardization of its mortality among the regions of the country after its implementation. Therefore, the aim of this study was to analyze the behavior of OC mortality rate in Brazil and its administrative regions, in the age groups above 50 years, between the years of 2000 and 2015. Methods Study design A longitudinal ecological study based on secondary data on OC mortality in Brazilian women between 2000 and 2015. Data source, coverage and collection The present study was performed using secondary data of women residing in Brazil between 2000 and 2015. The units of analysis were Brazil and its five administrative regions (North, Northeast, South, Southeast and Midwest). Data were obtained from the Department of Informatics of the Unified Health System (DATASUS), maintained by the Brazilian Ministry of Health. DATASUS provides for public access a database where there are several specific systems with information about hospitalizations, deaths and hospital services, e.g. all of which regarding the public health system. The Mortality Information System (SIM) is a database run by the Departments of State and Municipal Health, as well as by the Health Surveillance Department.12 The source document of the obtained data is the declaration of death, according to guidelines of the World Health Organization (WHO).12 According to data from the General Coordination of Information and Epidemiological Analysis (CGIAE) of the Ministry of Health, mortality data coverage has improved since the last decade, reaching 96.1% in 2011.13 However, in order to know the reliability of the data used in this study and to guarantee its internal validity, we estimated the coverage of the SIM for neoplasms in women throughout the study period. For this, we obtained the number of deaths reported in the SIM and the total number of deaths recorded by active search in registry offices in each administrative region. Since this information was only available until 2013 – and data presented a normal distribution (Shapiro–Wilk, P > 0.05)—we used a linear regression model to estimate coverage by 2015. In the Supplementary Material 1, we present the percentage variation in the coverage of data due to mortality by neoplasms in women aged 50–79 years in the available period, i.e. between 2000 and 2013. Study variables Number of deaths due to OC Two researchers independently collected data on OC deaths reported by the Mortality Information System (SIM) in women aged 50–79 between 2000 and 2015. Deaths have not been divided by cancer stage, due to the impossibility of the system from which they were collected. OC was defined according to the 10th revision of the International Classification of Diseases (ICD10) by code C.56.14 Disagreements on the number of deaths—when present—were resolved by consensus with a third researcher. Age-standardized mortality from OC To calculate the OC mortality, we used the number of deaths in women aged between 50 and 79 years and the resident female population. The resident female population was obtained from the Demographic and Socioeconomic Information of the Brazilian Institute of Geography and Statistics (IBGE), also accessible by DATASUS. Gross mortality was calculated from the ratio between the number of deaths and the resident population (per 100 000 women) of each administrative region of the country for each year between 2000 and 2015. Gross mortality rates for the 4-year intervals were also estimated. To allow comparison with other studies and across regions, gross rates of OC mortality in administrative regions were standardized by age. Standardization was performed by the direct method, based on the standard population of the World Health Organization (WHO).15 Proportional mortality from all causes and for all cancers The magnitude of OC deaths in relation to all defined causes of ICD-10 deaths and in relation to all deaths due to neoplasms was calculated from data from the SIM. For the calculation, deaths reported with ICD in the interval between R00 and R99 were not included because they do not present the defined cause of death. In turn, proportional mortality for all cancers in women in the age range studied was estimated by the ratio of the amount of OC deaths and all deaths from cancer (as defined in Chapter 2 of ICD-10). It should be noted that, for all calculations, the female population comprised between 50 and 79 years of age was the only one considered. Statistical analysis To describe OC mortality, descriptive statistics were performed. Linear regression was used to analyze the relationship between mortality and the administrative regions of Brazil, constituting a time trend. The dependent variable is the ‘mortality adjusted by the standard population’ and the independent variable, the ‘calendar years’ and the administrative regions. The percent change (PC) and the annual percentage change (APC) are the two trend measures in this analysis. Both are represented below16: PC=NumberofeventsinA−NumberofeventsinBNumberofeventsinB×100 APC = log β, where β is the slope of the linear regression. The level of confidence was 5%. The statistical program used was Stata® (Stata Corp., College Station, EUA) 11.0. Results Between 2000 and 2015, 34 335 deaths due to OC were registered in women aged 50–79 years in Brazil, representing a mortality rate of 10.5 per 100 000 women for the age group. In this period, OC deaths accounted for 4.4% of all deaths due to neoplasms, and 1% of deaths due to defined causes occurred in the country (Table 1). Table 1 Deaths, mortality and proportional mortality (for all types of neoplasms and all deaths) of ovarian cancer in Brazil between 2000 and 2015 Variables Deaths Mortalitya (95% CI) Proportional mortality (95% CI) All-neoplasms All-cause Brazil 34 335 10.5 (10.29; 10.69) 4.5 (4.42; 4.56) 1.1 (1.01; 1.09) Regions  North 1001 6.1 (5.42; 6.86) 3.1 (2.87; 3.42) 0.7 (0.64; 0.79)  Northeast 6344 7.6 (6.87; 8.27) 4.1 (3.91; 4.22) 0.8 (0.79; 0.90)  Southeast 18 302 11.8 (11.46; 12.17) 4.8 (4.65; 4.87) 1.1 (1.09; 1.17)  South 6684 12.5 (12.17; 12.85) 4.5 (4.36; 4.61) 1.2 (1.12; 1.24)  Midwest 2004 10.5 (9.65; 11.31) 4.4 (4.08; 4.70) 1.0 (0.89; 1.07) Age groups  50–54 years 4451 30.6 (29.45; 31.68) 4.3 (4.16; 4.43) 1.3 (1.28; 1.41)  55–59 years 5177 37.2 (35.94; 38.41) 4.3 (4.19; 4.46) 1.3 (1.24; 1.36)  60–64 years 5313 39.6 (38.47; 40.70) 4.1 (3.98; 4.19) 1.1 (1.07; 1.15)  65–69 years 5245 40.1 (38.59; 41.62) 3.8 (3.68; 3.98) 0.9 (0.88; 0.95)  70–74 years 4966 37.2 (36.29; 38.11) 3.6 (3.46; 3.66) 0.7 (0.70; 0.74)  75–79 years 4040 28.6 (27.01; 30.27) 3.0 (2.90; 3.17) 0.5 (0.48; 0.53) Variables Deaths Mortalitya (95% CI) Proportional mortality (95% CI) All-neoplasms All-cause Brazil 34 335 10.5 (10.29; 10.69) 4.5 (4.42; 4.56) 1.1 (1.01; 1.09) Regions  North 1001 6.1 (5.42; 6.86) 3.1 (2.87; 3.42) 0.7 (0.64; 0.79)  Northeast 6344 7.6 (6.87; 8.27) 4.1 (3.91; 4.22) 0.8 (0.79; 0.90)  Southeast 18 302 11.8 (11.46; 12.17) 4.8 (4.65; 4.87) 1.1 (1.09; 1.17)  South 6684 12.5 (12.17; 12.85) 4.5 (4.36; 4.61) 1.2 (1.12; 1.24)  Midwest 2004 10.5 (9.65; 11.31) 4.4 (4.08; 4.70) 1.0 (0.89; 1.07) Age groups  50–54 years 4451 30.6 (29.45; 31.68) 4.3 (4.16; 4.43) 1.3 (1.28; 1.41)  55–59 years 5177 37.2 (35.94; 38.41) 4.3 (4.19; 4.46) 1.3 (1.24; 1.36)  60–64 years 5313 39.6 (38.47; 40.70) 4.1 (3.98; 4.19) 1.1 (1.07; 1.15)  65–69 years 5245 40.1 (38.59; 41.62) 3.8 (3.68; 3.98) 0.9 (0.88; 0.95)  70–74 years 4966 37.2 (36.29; 38.11) 3.6 (3.46; 3.66) 0.7 (0.70; 0.74)  75–79 years 4040 28.6 (27.01; 30.27) 3.0 (2.90; 3.17) 0.5 (0.48; 0.53) aAge-standardized mortality per 100 000 inhabitants. 95% CI = 95% confidence Interval. Table 1 Deaths, mortality and proportional mortality (for all types of neoplasms and all deaths) of ovarian cancer in Brazil between 2000 and 2015 Variables Deaths Mortalitya (95% CI) Proportional mortality (95% CI) All-neoplasms All-cause Brazil 34 335 10.5 (10.29; 10.69) 4.5 (4.42; 4.56) 1.1 (1.01; 1.09) Regions  North 1001 6.1 (5.42; 6.86) 3.1 (2.87; 3.42) 0.7 (0.64; 0.79)  Northeast 6344 7.6 (6.87; 8.27) 4.1 (3.91; 4.22) 0.8 (0.79; 0.90)  Southeast 18 302 11.8 (11.46; 12.17) 4.8 (4.65; 4.87) 1.1 (1.09; 1.17)  South 6684 12.5 (12.17; 12.85) 4.5 (4.36; 4.61) 1.2 (1.12; 1.24)  Midwest 2004 10.5 (9.65; 11.31) 4.4 (4.08; 4.70) 1.0 (0.89; 1.07) Age groups  50–54 years 4451 30.6 (29.45; 31.68) 4.3 (4.16; 4.43) 1.3 (1.28; 1.41)  55–59 years 5177 37.2 (35.94; 38.41) 4.3 (4.19; 4.46) 1.3 (1.24; 1.36)  60–64 years 5313 39.6 (38.47; 40.70) 4.1 (3.98; 4.19) 1.1 (1.07; 1.15)  65–69 years 5245 40.1 (38.59; 41.62) 3.8 (3.68; 3.98) 0.9 (0.88; 0.95)  70–74 years 4966 37.2 (36.29; 38.11) 3.6 (3.46; 3.66) 0.7 (0.70; 0.74)  75–79 years 4040 28.6 (27.01; 30.27) 3.0 (2.90; 3.17) 0.5 (0.48; 0.53) Variables Deaths Mortalitya (95% CI) Proportional mortality (95% CI) All-neoplasms All-cause Brazil 34 335 10.5 (10.29; 10.69) 4.5 (4.42; 4.56) 1.1 (1.01; 1.09) Regions  North 1001 6.1 (5.42; 6.86) 3.1 (2.87; 3.42) 0.7 (0.64; 0.79)  Northeast 6344 7.6 (6.87; 8.27) 4.1 (3.91; 4.22) 0.8 (0.79; 0.90)  Southeast 18 302 11.8 (11.46; 12.17) 4.8 (4.65; 4.87) 1.1 (1.09; 1.17)  South 6684 12.5 (12.17; 12.85) 4.5 (4.36; 4.61) 1.2 (1.12; 1.24)  Midwest 2004 10.5 (9.65; 11.31) 4.4 (4.08; 4.70) 1.0 (0.89; 1.07) Age groups  50–54 years 4451 30.6 (29.45; 31.68) 4.3 (4.16; 4.43) 1.3 (1.28; 1.41)  55–59 years 5177 37.2 (35.94; 38.41) 4.3 (4.19; 4.46) 1.3 (1.24; 1.36)  60–64 years 5313 39.6 (38.47; 40.70) 4.1 (3.98; 4.19) 1.1 (1.07; 1.15)  65–69 years 5245 40.1 (38.59; 41.62) 3.8 (3.68; 3.98) 0.9 (0.88; 0.95)  70–74 years 4966 37.2 (36.29; 38.11) 3.6 (3.46; 3.66) 0.7 (0.70; 0.74)  75–79 years 4040 28.6 (27.01; 30.27) 3.0 (2.90; 3.17) 0.5 (0.48; 0.53) aAge-standardized mortality per 100 000 inhabitants. 95% CI = 95% confidence Interval. The Southeastern region had the highest number of deaths and mortality proportional to all neoplasms (18 302 deaths in total and 4.8%, respectively). The South region had the highest mortality rate (12.5 deaths per 100 women aged 50–79 years) and mortality proportional to all causes (1.2% of all deaths due to defined causes). The majority of deaths occurred in the age group of 60 to 64 years (5313 deaths) and the highest mortality was recorded in the age group of 65–69 years (40.1 deaths per 100 000 women). The highest mortality proportional to all neoplasms (4.3%) and the highest proportional mortality for all causes (1.3%) occurred in the age groups between 50 and 54 and between 55 and 59 years (Table 1). With regard to the behavior of OC rates between 2000 and 2015, there was a 9% increase in age-standardized mortality, with a trend of 0.05% (ranging from 0.01 to 0.08% per year, P = 0.012) and 24.67% in mortality proportional to all causes, with a trend of 0.02% (ranging from 0.01 to 0.02% per year, P < 0.001) (Table 2). Data behavior over time and be easily seen in Fig. 1. Table 2 Temporal trend of mortality and magnitude of ovarian cancer in Brazilian women aged 50–79 years between 2000 and 2015 Ovarian cancer Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya 9.9 10.9 9.01 0.05 (0.01; 0.08) 0.37 0.012 Proportional mortality  To all defined causes 0.9 1.1 24.67 0.02 (0.01; 0.02) 0.89 <0.001  To all neoplasms 4.3 4.5 5.75 0.01 (−0.00; 0.03) 0.24 0.056 Ovarian cancer Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya 9.9 10.9 9.01 0.05 (0.01; 0.08) 0.37 0.012 Proportional mortality  To all defined causes 0.9 1.1 24.67 0.02 (0.01; 0.02) 0.89 <0.001  To all neoplasms 4.3 4.5 5.75 0.01 (−0.00; 0.03) 0.24 0.056 *Linear regression. aAge-standardized mortality per 100 000 inhabitants PC = percent change; APC = annual percentage change; 95% CI = 95% confidence interval. Table 2 Temporal trend of mortality and magnitude of ovarian cancer in Brazilian women aged 50–79 years between 2000 and 2015 Ovarian cancer Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya 9.9 10.9 9.01 0.05 (0.01; 0.08) 0.37 0.012 Proportional mortality  To all defined causes 0.9 1.1 24.67 0.02 (0.01; 0.02) 0.89 <0.001  To all neoplasms 4.3 4.5 5.75 0.01 (−0.00; 0.03) 0.24 0.056 Ovarian cancer Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya 9.9 10.9 9.01 0.05 (0.01; 0.08) 0.37 0.012 Proportional mortality  To all defined causes 0.9 1.1 24.67 0.02 (0.01; 0.02) 0.89 <0.001  To all neoplasms 4.3 4.5 5.75 0.01 (−0.00; 0.03) 0.24 0.056 *Linear regression. aAge-standardized mortality per 100 000 inhabitants PC = percent change; APC = annual percentage change; 95% CI = 95% confidence interval. Fig. 1 View largeDownload slide Temporal trend of ovarian cancer mortality in Brazil between 2000 and 2015. Fig. 1 View largeDownload slide Temporal trend of ovarian cancer mortality in Brazil between 2000 and 2015. There was an increase in all indicators related to OC mortality in the North, Northeast and Midwest regions. In the Southeast region, although there was a reduction in mortality, there was an increase in mortality proportional to all causes and no significant changes were observed in mortality proportional to all neoplasms (P = 0.809). On the other hand, in the South region, although there were no significant changes in mortality (P = 0.741), there was an increase in mortality proportional to all causes and mortality proportional to all neoplasms (Table 3). Table 3 Temporal trend of mortality and magnitude of ovarian cancer in Brazilian women aged 50–79 years according to administrative regions Regions Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya  North 4.9 7.7 57.6 0.24 (0.15; 0.33) 0.71 <0.001  Northeast 5.6 8.3 48.4 0.24 (0.16; 0.32) 0.76 <0.001  Southeast 12.4 11.9 −4.44 −0.08 (−0.14; −0.02) 0.34 0.018  South 12 12.5 3.78 −0.01 (−0.09; 0.06) 0.01 0.741  Midwest 8.5 11.9 40.4 0.21 (0.07; 0.36) 0.42 0.007 Proportional mortality to all-causes  North 0.6 0.8 35.64 0.02 (0.01; 0.03) 0.61 <0.001  Northeast 0.7 0.9 20.86 0.02 (0.01; 0.02) 0.72 <0.001  Southeast 1.0 1.3 22.97 0.01 (0.01; 0.02) 0.54 0.001  South 0.9 1.3 41.31 0.02 (0.02; 0.03) 0.83 <0.001  Midwest 0.7 1.2 63.17 0.03 (0.02; 0.04) 0.70 <0.001 Proportional mortality to all-neoplasms  North 2.9 3.5 20.84 0.07 (0.03; 0.12) 0.47 0.004  Northeast 3.9 3.9 −0.43 0.03 (0.00; 0.06) 0.28 0.035  Southeast 4.7 4.9 5.62 −0.003 (-0.03; 0.02) 0.01 0.809  South 4.0 4.5 11.22 0.02 (0.00; 0.05) 0.25 0.049  Midwest 3.7 5 35.24 0.09 (0.04; 0.14) 0.49 0.003 Regions Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya  North 4.9 7.7 57.6 0.24 (0.15; 0.33) 0.71 <0.001  Northeast 5.6 8.3 48.4 0.24 (0.16; 0.32) 0.76 <0.001  Southeast 12.4 11.9 −4.44 −0.08 (−0.14; −0.02) 0.34 0.018  South 12 12.5 3.78 −0.01 (−0.09; 0.06) 0.01 0.741  Midwest 8.5 11.9 40.4 0.21 (0.07; 0.36) 0.42 0.007 Proportional mortality to all-causes  North 0.6 0.8 35.64 0.02 (0.01; 0.03) 0.61 <0.001  Northeast 0.7 0.9 20.86 0.02 (0.01; 0.02) 0.72 <0.001  Southeast 1.0 1.3 22.97 0.01 (0.01; 0.02) 0.54 0.001  South 0.9 1.3 41.31 0.02 (0.02; 0.03) 0.83 <0.001  Midwest 0.7 1.2 63.17 0.03 (0.02; 0.04) 0.70 <0.001 Proportional mortality to all-neoplasms  North 2.9 3.5 20.84 0.07 (0.03; 0.12) 0.47 0.004  Northeast 3.9 3.9 −0.43 0.03 (0.00; 0.06) 0.28 0.035  Southeast 4.7 4.9 5.62 −0.003 (-0.03; 0.02) 0.01 0.809  South 4.0 4.5 11.22 0.02 (0.00; 0.05) 0.25 0.049  Midwest 3.7 5 35.24 0.09 (0.04; 0.14) 0.49 0.003 *Linear regression. aAge-standardized mortality per 100 000 inhabitants. PC = percent change; APC = annual percentage change; 95% CI = 95% confidence interval. Table 3 Temporal trend of mortality and magnitude of ovarian cancer in Brazilian women aged 50–79 years according to administrative regions Regions Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya  North 4.9 7.7 57.6 0.24 (0.15; 0.33) 0.71 <0.001  Northeast 5.6 8.3 48.4 0.24 (0.16; 0.32) 0.76 <0.001  Southeast 12.4 11.9 −4.44 −0.08 (−0.14; −0.02) 0.34 0.018  South 12 12.5 3.78 −0.01 (−0.09; 0.06) 0.01 0.741  Midwest 8.5 11.9 40.4 0.21 (0.07; 0.36) 0.42 0.007 Proportional mortality to all-causes  North 0.6 0.8 35.64 0.02 (0.01; 0.03) 0.61 <0.001  Northeast 0.7 0.9 20.86 0.02 (0.01; 0.02) 0.72 <0.001  Southeast 1.0 1.3 22.97 0.01 (0.01; 0.02) 0.54 0.001  South 0.9 1.3 41.31 0.02 (0.02; 0.03) 0.83 <0.001  Midwest 0.7 1.2 63.17 0.03 (0.02; 0.04) 0.70 <0.001 Proportional mortality to all-neoplasms  North 2.9 3.5 20.84 0.07 (0.03; 0.12) 0.47 0.004  Northeast 3.9 3.9 −0.43 0.03 (0.00; 0.06) 0.28 0.035  Southeast 4.7 4.9 5.62 −0.003 (-0.03; 0.02) 0.01 0.809  South 4.0 4.5 11.22 0.02 (0.00; 0.05) 0.25 0.049  Midwest 3.7 5 35.24 0.09 (0.04; 0.14) 0.49 0.003 Regions Year PC APC 2000 2015 β (95% CI) r2 P* Age-standardized mortalitya  North 4.9 7.7 57.6 0.24 (0.15; 0.33) 0.71 <0.001  Northeast 5.6 8.3 48.4 0.24 (0.16; 0.32) 0.76 <0.001  Southeast 12.4 11.9 −4.44 −0.08 (−0.14; −0.02) 0.34 0.018  South 12 12.5 3.78 −0.01 (−0.09; 0.06) 0.01 0.741  Midwest 8.5 11.9 40.4 0.21 (0.07; 0.36) 0.42 0.007 Proportional mortality to all-causes  North 0.6 0.8 35.64 0.02 (0.01; 0.03) 0.61 <0.001  Northeast 0.7 0.9 20.86 0.02 (0.01; 0.02) 0.72 <0.001  Southeast 1.0 1.3 22.97 0.01 (0.01; 0.02) 0.54 0.001  South 0.9 1.3 41.31 0.02 (0.02; 0.03) 0.83 <0.001  Midwest 0.7 1.2 63.17 0.03 (0.02; 0.04) 0.70 <0.001 Proportional mortality to all-neoplasms  North 2.9 3.5 20.84 0.07 (0.03; 0.12) 0.47 0.004  Northeast 3.9 3.9 −0.43 0.03 (0.00; 0.06) 0.28 0.035  Southeast 4.7 4.9 5.62 −0.003 (-0.03; 0.02) 0.01 0.809  South 4.0 4.5 11.22 0.02 (0.00; 0.05) 0.25 0.049  Midwest 3.7 5 35.24 0.09 (0.04; 0.14) 0.49 0.003 *Linear regression. aAge-standardized mortality per 100 000 inhabitants. PC = percent change; APC = annual percentage change; 95% CI = 95% confidence interval. In relation to the age groups, there was a 28.4% increase in OC mortality in the age group of 50–54 years, with an increasing trend of 0.24% per year (ranging from 0.03 to 0.45%, r2 = 0.29, P = 0.031), and an of 25.1% in the age group of 75–79 years, with an increasing trend of 0.43% per year (ranging from 0.15 to 0.70%; r2 = 0.44, P = 0.005). Additionally, in all age groups studied, there was an increase in mortality proportional to all causes (P < 0.05) and there were no differences in mortality proportional to all neoplasms (Table 4). Table 4 Time trend of mortality and magnitude of ovarian cancer in Brazilian women aged 50–79 according to age groups Age groups Year PC APC 2000 2015 β (95% CI) r2 P* Standardized mortalitya  50–54 years 27.1 34.7 28.4 0.24 (0.03; 0.45) 0.29 0.031  55–59 years 34.9 39.4 12.9 0.18 (−0.08; 0.44) 0.14 0.151  60–64 years 38.7 37.6 −2.8 0.07 (−0.18; 0.32) 0.02 0.559  65–69 years 42.9 38.6 −9.9 0.03 (−0.31; 0.37) 0.00 0.860  70–74 years 33.9 38.9 14.7 0.02 (−0.18; 0.23) 0.00 0.828  75–79 years 25.7 32.2 25.1 0.43 (0.15; 0.70) 0.44 0.005 Proportional mortality to all-causes  50–54 years 1.1 1.6 48.0 0.02 (0.01; 0.03) 0.62 <0.001  55–59 years 1.1 1.5 26.9 0.02 (0.01; 0.02) 0.47 0.003  60–64 years 1.0 1.1 13.2 0.01 (0.01; 0.02) 0.53 0.001  65–69 years 0.9 0.9 1.4 0.01 (0.00; 0.01) 0.26 0.043  70–74 years 0.6 0.8 24.4 0.00 (0.00; 0.01) 0.26 0.043  75–79 years 0.5 0.6 23.7 0.01 (0.00; 0.01) 0.50 0.002 Proportional mortality to all-neoplasms  50–54 years 4.0 4.8 20.0 0.02 (−0.01; 0.05) 0.14 0.147  55–59 years 4.2 4.4 4.4 −0.01 (-0.04; 0.02) 0.02 0.620  60–64 years 4.1 3.7 −9.2 −0.01 (−0.03; 0.02) 0.02 0.578  65–69 years 4.2 3.6 −14.2 −0.01 (-0.05; 0.02) 0.06 0.363  70–74 years 3.4 3.7 8.5 −0.01 (−0.03; 0.01) 0.14 0.152  75–79 years 2.9 3.3 10.4 0.02 (−0.00; 0.05) 0.19 0.089 Age groups Year PC APC 2000 2015 β (95% CI) r2 P* Standardized mortalitya  50–54 years 27.1 34.7 28.4 0.24 (0.03; 0.45) 0.29 0.031  55–59 years 34.9 39.4 12.9 0.18 (−0.08; 0.44) 0.14 0.151  60–64 years 38.7 37.6 −2.8 0.07 (−0.18; 0.32) 0.02 0.559  65–69 years 42.9 38.6 −9.9 0.03 (−0.31; 0.37) 0.00 0.860  70–74 years 33.9 38.9 14.7 0.02 (−0.18; 0.23) 0.00 0.828  75–79 years 25.7 32.2 25.1 0.43 (0.15; 0.70) 0.44 0.005 Proportional mortality to all-causes  50–54 years 1.1 1.6 48.0 0.02 (0.01; 0.03) 0.62 <0.001  55–59 years 1.1 1.5 26.9 0.02 (0.01; 0.02) 0.47 0.003  60–64 years 1.0 1.1 13.2 0.01 (0.01; 0.02) 0.53 0.001  65–69 years 0.9 0.9 1.4 0.01 (0.00; 0.01) 0.26 0.043  70–74 years 0.6 0.8 24.4 0.00 (0.00; 0.01) 0.26 0.043  75–79 years 0.5 0.6 23.7 0.01 (0.00; 0.01) 0.50 0.002 Proportional mortality to all-neoplasms  50–54 years 4.0 4.8 20.0 0.02 (−0.01; 0.05) 0.14 0.147  55–59 years 4.2 4.4 4.4 −0.01 (-0.04; 0.02) 0.02 0.620  60–64 years 4.1 3.7 −9.2 −0.01 (−0.03; 0.02) 0.02 0.578  65–69 years 4.2 3.6 −14.2 −0.01 (-0.05; 0.02) 0.06 0.363  70–74 years 3.4 3.7 8.5 −0.01 (−0.03; 0.01) 0.14 0.152  75–79 years 2.9 3.3 10.4 0.02 (−0.00; 0.05) 0.19 0.089 *Linear regression. aAge-standardized mortality per 100 000 inhabitants. PC = percent change; APC = annual percentage change; 95% CI = 95% confidence interval. Table 4 Time trend of mortality and magnitude of ovarian cancer in Brazilian women aged 50–79 according to age groups Age groups Year PC APC 2000 2015 β (95% CI) r2 P* Standardized mortalitya  50–54 years 27.1 34.7 28.4 0.24 (0.03; 0.45) 0.29 0.031  55–59 years 34.9 39.4 12.9 0.18 (−0.08; 0.44) 0.14 0.151  60–64 years 38.7 37.6 −2.8 0.07 (−0.18; 0.32) 0.02 0.559  65–69 years 42.9 38.6 −9.9 0.03 (−0.31; 0.37) 0.00 0.860  70–74 years 33.9 38.9 14.7 0.02 (−0.18; 0.23) 0.00 0.828  75–79 years 25.7 32.2 25.1 0.43 (0.15; 0.70) 0.44 0.005 Proportional mortality to all-causes  50–54 years 1.1 1.6 48.0 0.02 (0.01; 0.03) 0.62 <0.001  55–59 years 1.1 1.5 26.9 0.02 (0.01; 0.02) 0.47 0.003  60–64 years 1.0 1.1 13.2 0.01 (0.01; 0.02) 0.53 0.001  65–69 years 0.9 0.9 1.4 0.01 (0.00; 0.01) 0.26 0.043  70–74 years 0.6 0.8 24.4 0.00 (0.00; 0.01) 0.26 0.043  75–79 years 0.5 0.6 23.7 0.01 (0.00; 0.01) 0.50 0.002 Proportional mortality to all-neoplasms  50–54 years 4.0 4.8 20.0 0.02 (−0.01; 0.05) 0.14 0.147  55–59 years 4.2 4.4 4.4 −0.01 (-0.04; 0.02) 0.02 0.620  60–64 years 4.1 3.7 −9.2 −0.01 (−0.03; 0.02) 0.02 0.578  65–69 years 4.2 3.6 −14.2 −0.01 (-0.05; 0.02) 0.06 0.363  70–74 years 3.4 3.7 8.5 −0.01 (−0.03; 0.01) 0.14 0.152  75–79 years 2.9 3.3 10.4 0.02 (−0.00; 0.05) 0.19 0.089 Age groups Year PC APC 2000 2015 β (95% CI) r2 P* Standardized mortalitya  50–54 years 27.1 34.7 28.4 0.24 (0.03; 0.45) 0.29 0.031  55–59 years 34.9 39.4 12.9 0.18 (−0.08; 0.44) 0.14 0.151  60–64 years 38.7 37.6 −2.8 0.07 (−0.18; 0.32) 0.02 0.559  65–69 years 42.9 38.6 −9.9 0.03 (−0.31; 0.37) 0.00 0.860  70–74 years 33.9 38.9 14.7 0.02 (−0.18; 0.23) 0.00 0.828  75–79 years 25.7 32.2 25.1 0.43 (0.15; 0.70) 0.44 0.005 Proportional mortality to all-causes  50–54 years 1.1 1.6 48.0 0.02 (0.01; 0.03) 0.62 <0.001  55–59 years 1.1 1.5 26.9 0.02 (0.01; 0.02) 0.47 0.003  60–64 years 1.0 1.1 13.2 0.01 (0.01; 0.02) 0.53 0.001  65–69 years 0.9 0.9 1.4 0.01 (0.00; 0.01) 0.26 0.043  70–74 years 0.6 0.8 24.4 0.00 (0.00; 0.01) 0.26 0.043  75–79 years 0.5 0.6 23.7 0.01 (0.00; 0.01) 0.50 0.002 Proportional mortality to all-neoplasms  50–54 years 4.0 4.8 20.0 0.02 (−0.01; 0.05) 0.14 0.147  55–59 years 4.2 4.4 4.4 −0.01 (-0.04; 0.02) 0.02 0.620  60–64 years 4.1 3.7 −9.2 −0.01 (−0.03; 0.02) 0.02 0.578  65–69 years 4.2 3.6 −14.2 −0.01 (-0.05; 0.02) 0.06 0.363  70–74 years 3.4 3.7 8.5 −0.01 (−0.03; 0.01) 0.14 0.152  75–79 years 2.9 3.3 10.4 0.02 (−0.00; 0.05) 0.19 0.089 *Linear regression. aAge-standardized mortality per 100 000 inhabitants. PC = percent change; APC = annual percentage change; 95% CI = 95% confidence interval. Discussion Main findings When analyzing the behavior of OC mortality between 2000 and 2015 in Brazil, we found that: there is stabilization of age-standardized mortality rates in Brazil; and there was increase in rates in the North, Northeast and Midwest regions, and decrease in the South and Southeast regions. To understand the results, some aspects must be considered. First, some caveats must be made regarding the variable ‘age’: the age of onset—50 years—was defined considering that OC seems to be related to the postmenopausal period, although the pathophysiological mechanism is still under discussion.17 In Brazilian women, menopause occurs around the age of 48.18 In turn, the final age—79 years—was established due to the impossibility of adjusting data of ages greater than 79 years by the WHO standard population, due to the way in which the data are made available in DATASUS. In addition, life expectancy at birth for Brazilian women is around 79.1 years, according to the official sense of the IBGE of 2015,19 making the study of the age groups above this mark of little relevance in national terms. With regard to OC, there are health disparities due to the neoplasm worldwide.1 Thus, it is expected that there will be differences in its incidence and mortality rates in countries with different development levels.20 In this context, the incidence and mortality rates of the USA, for example, differ from those found for Brazil. In the first one, there was a practically constant drop in both indices since 1975;21 in the second, it was found that mortality rates fluctuated, over time, oscillating within a constant interval. Also in this context, one can extrapolate the above statement, hoping that different mortality rates will be found in the same country, whose administrative regions present different levels of development—in the present article, we find that the less developed regions showed a tendency to raise OC mortality rates. To support this hypothesis, it suffices to consider that Brazil is a country in which inequality is very present, which is demonstrated by a high Gini index (54.7),22 despite the Human Development Index (HDI) of 0.754.23 Besides, there are already some studies that point to the relation between inequality and mortality by other types of cancer in Brazil—as with breast cancer, for example.24 As for the analysis of mortality rates by age group, it is known that, in general, the risk for development—and consequent incidence of OC—is usually expected to rise with age.25 However, our findings show a positive trend regarding mortality due to the neoplasm in all age groups—even though only two are statistically significant (P < 0.05). It should be noted here that, over time, the trend lines referring to OC mortality in the age groups of 50–54 and 75–79 years—the two that presented statistical significance—approached, almost matching. To understand the finding above, some points should be considered. First, the life expectancy of the Brazilian citizen—of interest, the woman—has increased considerably since the 1940s26—which is relevant, since the risk of developing OC increases with age.27 In addition, younger women tend to have better prognosis than the older ones28—which would explain why the higher mortality increase occurred in the older age group (75–79 years). Finally, it should be taken into account that OC is a neoplasm of difficult diagnosis, with signs and symptoms that are sometimes non-specific—although it may present some clinical patterns29—and whose medical advances have not yet been able to develop an applicable screening method30 for the general population. In this sense, studies such as the present paper are extremely important, since they portray the specific mortality behavior of the population, which can serve as a control for the government and also as a basis for the development and implementation of future public policies. What is already known on this topic OC is the most lethal gynecological tumor, having its incidence a tendency to increase with age.3,25 However, previous research has shown that its incidence and mortality rates ought to present themselves differently in countries which display different development levels.20 What this study adds Epidemiological studies are the basis for the formation of effective public policies, and since resources are limited, the public health manager must choose the best cost-efficient ratio for a given pathology and population.31 Once the epidemiological profile of a disease, the behavior of epidemiological indicators and their impact on a given population are known, public policies of national and/or regional scope can be established according to the findings. In this sense, this is the first work of the authors’ knowledge, to give an overview about the development of OC mortality over time in Brazil and its regions, which could serve as a starting point for new discussions on the way the disease is being approached across the country, as well as its consequences for its citizens. Limitations The extrapolation of the data presented here should be viewed with caution. Since it is an analysis done with secondary data, these results may be under-reporting the actual number of cases. Besides, there are differences in data coverage between regions, which does not reach 100%. Also, since the data acquired and used were not individualized, it is not possible to extrapolate them to other units of analysis. Conclusion During the period studied ovarian cancer mortality has fluctuated in Brazil and in all administrative regions of the country for women between 50 and 79 years. However, mortality rates remained stable. Conflict of interest The authors have no conflicts of interest to disclose. Funding There was no funding for this research. Ethical aspects The data analyzed are public and of unrestricted access and use, and there is no need for the ethical assessment of the Research Ethics Committee in accordance with the terms of the National Health Council (CNS) Resolution No. 466 of 12 December 2012. Availability of data and material All data used in the present article is available online and for free at DATASUS. References 1 Chornokur G , Amankwah EK , Schildkraut JM et al. Global ovarian cancer health disparities . Gynecol Oncol 2013 ; 129 ( 1 ): 258 – 64 . Google Scholar Crossref Search ADS PubMed 2 Doubeni CA , Doubeni AR , Myers AE . Diagnosis and management of ovarian cancer . Am Fam Physician 2016 ; 93 ( 11 ): 937 – 44 . Google Scholar PubMed 3 Permuth-Wey J , Sellers TA . Epidemiology of ovarian cancer . Methods Mol Biol 2009 ; 472 : 413 – 37 . doi:10.1007/978-1-60327-492-0_20 . 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Chapter 2. https://www.ncbi.nlm.nih.gov/books/NBK11784/. Co-published by Oxford University Press, New York. © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

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Journal of Public Health – Oxford University Press

Published: Dec 1, 2018

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