The natural history of cervical cancer consists of a complication arising from intraepithelial alterations that gradually appear between 10 and 20 years and may evolve to an invasive cancerous lesion[4]. It is important to emphasize that infection by Human Papilloma Virus is the main risk factor, which can be added to poor socioeconomic conditions, multiple sexual partners, smoking, early initiation of sexually active life, multiparity, use of oral contraceptives, and low intake of vitamin A and C[4].
When it comes to the female public, it is the most incident type of cancer in the world, holding the same position when it comes to mortality[5]. In 2018 there were about 311,365 deaths worldwide[5]. Regarding Brazil, after the cases of non-melanoma skin neoplasms, cervical cancer is in the third position as the most incident type of cancer among women. By the end of 2022, 16,710 new cases are estimated[[6].
It is known that the Human Papilloma Virus (HPV) is a sexually transmitted infection with a strong transmission rate, it is estimated that approximately 75% of people who start sexual life become infected at some point in their lives. In the 1990s, studies have shown that HPV infection is necessary for the development of cervical cancer, but most of these infections behave in an asymptomatic and self-resolving way, more specifically, 80% regress without major interventions[7].
Thus, in 2014 the Ministry of Health of Brazil began the policy of implementing free vaccination against HPV in the Unified Health System, being selected as target group, girls from 9 to 13 years, due to present high production of antibodies and for having more chances of not yet having been exposed to the virus through sexual intercourse. In 2017, the vaccine was applied to boys aged 9 to 14 and boys aged 11 to 14, in addition to including people with HIV/Aids, individuals undergoing solid organ/bone marrow transplants, and oncology patients up to 26 years old. In addition, in 2021 immunosuppressed women between the ages of 26 and 45 were also added as a target audience. It is worth noting that it is possible to vaccinate against HPV in private networks[8].
Even with the advance of vaccination, it is essential to continue and expand the cytopathological examinations, because the vaccine restricts the care to types 6, 11, 16, and 18 of HPV, but there are more than 18 that offer medium to high risk of infection[9]. Thus, from 1998 to 2020, 27 ordinances were made in the Brazilian legislative power in order to offer the expansion in screening and treatment with new resources and materials to assist more and more women[10].
Therefore, screening with the pap smear remains the most effective form of prevention against cervical cancer, but in developing countries this plan is still less effective due to the low supply and adherence of the public. It is recommended, according to the Brazilian guidelines for cervical cancer screening, to be performed among women aged 25 to 64 years with a three-year interval after two normal exams (performed annually)[9]. Between 2015 and 2020, the Unified Health System (SUS in portuguese) performed 41,448,399 cervico-vaginal cytopathological exams, maintaining a number close to 7 million every year, except in 2020 where it showed a reduction due to the COVID-19 pandemic and performed 3,942,427, always being about 80% of the exams performed by SUS[11].
When preventive actions are not effective and the case evolves to diagnosis, the initial treatment is based on clinical management, through the destruction of the lesion by physical or chemical mechanisms. Surgical treatment may also be necessary in order to have a local control, with minimal mutilation, besides obtaining more information regarding the biological aspect of the tumor and its prognosis. Finally, there is treatment with radiotherapy and chemotherapy, depending on the subtype of cervical cancer[4].
As a result of health policies and existing financial investments in Brazil directed to the prevention and treatment of this type of cancer, it is estimated that there will be an important change in the behavior of mortality rates by 2030[12]. Despite the expected advances, the socioeconomic particularities of each region result in differences in access to information, prevention, screening, and treatment, which is reflected in the forecast for the coming years, where it is estimated that the regions North and Northeast have the lowest rate of decrease in mortality. Meanwhile, it is assumed that the regions with better health systems, good equipment, and good distribution throughout the territory will have lower mortality rates, promoted by the more effective coverage of health policies.
Breast cancer is the type of cancer that most kills women each year in Brazil since the first records of the SIM (Mortality Information System). When it comes to the Brazilian Northeast, this pattern is no different, since the mortality rates in this region have been gradually increasing for both types of cancer. Meanwhile, the recorded rates of deaths from cervical cancer in the North region is disproportionate to the rest of the country due to the low quality of early screening for this type of malignant neoplasm, in addition to the lack of guidance and adherence to preventive care in the lives of women in this region.
It is known that some indicators are related to regional disparities regarding the high rates of death from breast and cervical cancer, as is the case in the Northeast region, such as income, education, living conditions, and housing. Thus, the rates were higher in micro-regions with lower percentages of illiterate and poor elderly women, lower dependency ratios, and higher percentages of elderly women living in households with running water. Moreover, the reality of the North region is directly related to its lower development when compared to other regions of the country, as well as its socioeconomic conditions, showing the need for a more effective articulation of health networks, aiming to offer better care for the neediest regions, this is what a study says about regional inequalities in mortality from malignant neoplasm of the uterine cervix [13].
Breast cancer consists of the increase in the unrestrained multiplication of cells with invasive potential that can be from genetic changes, which can be inherited or acquired. Breast cancer is subdivided into several types with different characteristics, so that some progress quickly and others do not. When, early, most of the time it has a good prognosis. The most common types are those that arise in the breast ducts, with about 80% of cases, in addition to lobular carcinoma, accounting for about 5–10% of diagnoses[14].
Breast cancer is the cause that most afflicts women, as it is the most common type of cancer in the world and the type of cancer that kills the Brazilian female population the most, causing 28% of new cases of cancer in this population[15]. Still in Brazil, it is estimated that for 2020–2022 there will be 66,280 new cases, which is 61 cases per 100,000 women. It is important to note that it also affects men, but at a minimum percentile, reaching less than 1% of all cases of the disease[16].
The causes of breast cancer are many and can be classified into: environmental, hormonal and genetic, with external causes (environmental and hormonal) responsible for 80–90% of cases[17]. Environmental causes are focused on body weight gain mainly after menopause, physical inactivity, alcohol consumption, exposure to ionizing radiation. Regarding risk factors of a hormonal nature, menarche before 12 years of age, nulliparous, first pregnancy after 30 years of age, women who have never breastfed, the presence of late menopause (after 55 years), post-menopausal hormone replacement can be listed. Finally, genetic causes, focused on a family history of breast cancer[18].
For the diagnosis of breast cancer, suspicions are first raised through physical and clinical examinations, the most complete being mammography, but to close the diagnosis it is essential to perform a biopsy. In 2021, for example, the SUS performed 3,497,439 mammograms, of which 3,145,930 were screening tests and 351,309 were diagnostic mammograms[19]. Treatment is performed according to the need and type of neoplasm, when it is local, surgery is usually performed followed by radiotherapy. In systemic cases, chemotherapy, hormone therapy and treatment with antibodies are recommended, which can be performed orally or intravenously[20].
In 2018, the SUS spent BRL 3.4 billion on cancer treatment, of which more than 40% were related to three cancers considered to be associated with excess weight, including breast cancer, evidencing the importance of preventive measures[21]. The Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA), as the auxiliary body of the Ministry of Health in the development and coordination of integrated actions for the prevention and control of cancer in Brazil, has some programs and actions aimed at breast cancer, for example, the mammography quality program, which aims, among others, to improve the quality of exam images, applying criteria, monitoring and implementing automation[22].
The Brazilian guidelines for breast cancer screening indicate that mammography should be offered to women aged 50 to 69 years, every two years, since early detection is one of the factors that impact on a better prognosis and survival[23]. In this aspect, with the results obtained in this study, it appears that the South and Southeast regions have high numbers of deaths from breast cancer, rates that exceed the national average.
However, studies show that the two regions also have the highest rates of mammography performed by the year 2017, in addition to the diagnosis being performed primarily in the early stages of the disease. However, regarding the start of treatment after diagnosis, it is observed that both the Southeast and the South do not show satisfactory results, with an average above 60 days, while in other regions this average is 10 days shorter, which may be a strong indicator for the high mortality rates from breast cancer in the Southeast and South regions of Brazil[24].
The limitations of the study were the difficulty in accessing more up-to-date and specific data on breast and cervical cancer morbidity and mortality in Brazil, as well as the scarcity of information that could support the data obtained in the research in relation to national and loco-regional characteristics.