Oral Cancer (OC) had a prevalence of 6.9% in this study, with greater proportions in the older, white and males. The risk classification was the main important factor in the likelihood of having OC diagnosis. Half of the patients with oral cancer had treatment initiation within 51 days and the median of individuals classified as high risk was significantly higher than those with low risk. No gender and race disparities in terms of TTI were found.
Since 2004, with the expansion of the National Oral Health Policy (PNSB / MS) [3], Brazil has implemented its strategies for prevention, early diagnosis, and control of OC. The PNSB implementation requires easy access to oral health services through the Family Health Strategy (ESF) and the Oral Health Teams as PHC interventions [23].
Articulated actions offered in a timely and resolutive way can prevent the late diagnosis and improve patients’ prognostics. In this sense, the OC approach must include the regular screening for early detection; assessment of oral lesions (active search, home visits, specific campaigns); monitoring of suspected cases; referral services for confirmed cases; and the establishment of partnerships for prevention, diagnosis, treatment, and recovery with universities and other organizations [24].
Public health programs are expected to provide adequate responses to the health problems for which they are intended and evaluated for implementation, access, and outcomes, guiding decision-making [25]. Thus, it is worth asking about the offer of oral health care within the scope of the PNSB in primary, secondary and specialized health services and how patients have covered the services they need.
There is a higher likelihood of receiving a diagnosis of OC for individuals over 60 years old, males, white, which corroborates with results of other studies regarding the profile of patients and location of lesions. [26,27]
When OC diagnosed patients were referred through the SISREG system, the average time to start cancer treatment (average of 50 days and median of 59 days) is within the federal legal time period of 60 days [28]. Nevertheless, the Rio de Janeiro municipality health regulation has a more restrictive TTI rule that establishes that patients diagnosed with cancer must be referred by PHC, via SISREG, for specialized care. Other studies that evaluated TTI in Brazil found it as 1-3 months [18], 23 days mean (1-116 days range) [17] and 71.1 days (1-142 days range) [19]. Nevertheless, they all used small hospital-based samples. A study from INCA found a TTI below 60 days 43.8% and 56.2 for male and female patients, respectively in the Southeast Region [29]. Studies carried out in foreign countries found an average TTI of 30 days [30] and greater than 46 days [31] for 25% of treated patients, a time considered worrying for the disease outcome.
When his risk is classified as high (red), this requires priority scheduling of up to 30 days. Yellow, scheduling up to 90 days, green and blue, scheduling up to 180 days or more, respectively, was found not to adhere [32]. As well established in the literature, the TTI can be decisive for the progress and incurability of the disease [33,34], and preventable delays should be avoided.
Among the causes for the time elapsed between the first registration of the patient in the regulation system and the beginning of treatment, one can assume the flow instituted by the health system since the PHC. For cases registered as having the highest risk for OC (red and yellow risk), the time to start treatment was longer than for the others. Serra et al. also found an inadequate organization of referral and counter-referral activities, with many of the patients not being referred by the official system, which produces double entry into the sector, resulting in losses or delays in some visits [35]. The opposite, such as decentralization and regionalization of assistance for cancer treatment, facilitate patient access, with an increase in the number of hospitalizations in some locations [36].
Another relevant factor is the difficulty in identifying a suspected lesion of these tumors, being most often diagnosed when its size exceeds 2 cm [37]. This situation and other factors can lead to a delay in diagnosis, as indicated by Costa-Jr and Serra [28]: few and nonspecific symptoms, patients' lack of knowledge about the disease, little familiarity of general practitioners who work in primary care with the diagnosis of cancer and difficulty in accessing the health system [38]. The late diagnosis is reflected in the most frequent treatments at the referral hospital, radiation therapy associated with surgery, knowing that the best prognosis is referred to as only surgical treatment [38].
As limitations it is important to mention that the regulation system does not include staging and other clinical information that would be helpful and could support and inform policy changes needed in the regulation and referral. Also, the SISREG is a secondary database and as such, can contain misclassifications of cases. Finally, only registered individuals that had their treatment through SUS were analyzed.