The findings of this investigation demonstrated that the population size of the cities, the socioeconomic status of the population and the availability of public dental services influence the risk of hospitalization due to oral cancer in Brazil. Two previous studies have developed similar analyses of oral cancer rates, involving socioeconomic characteristics and dental coverage in the SUS among the regions and states of Brazil13,15. However, the present study considered for analysis a more comprehensive period and all cities in the country as sample units.
It was shown that cities with large populations and high M-HDI had a higher frequency of hospitalized cases of oral cancer. In general, larger, and more developed cities have a better structured health service network, with greater encouragement and training of professionals for active disease tracking15,16. In addition, the population of those cities has higher life expectancy, which increases the proportion of the risk group for advanced age, in addition to greater access to diagnosis and hospitalization17,18. Inverse associations between HDI and oral cancer were found in studies that evaluated mortality rates9,10,18. These findings show that the largest number of oral cancer cases is concentrated in more developed regions. However, mortality is higher in less developed areas, revealing the impact of social inequalities on the prognosis of the disease19.
This analysis revealed that cities with strong inequality in the income distribution have a higher risk of presenting hospitalized cases of oral cancer. Socioeconomically disadvantaged individuals are often diagnosed with lesions in advanced clinical stages and with cervical metastases, which require complex treatments performed in the hospital setting8. Previous studies that used regions and states as sample units found no association between the Gini coefficient and oral cancer rates13,15. However, other studies with more specific and similar populations, considering cities and neighborhoods, were able to detect a positive association between income inequality and oral cancer, like the present study20,21.
The average number of hospitalized cases of oral cancer increased as of 2004, coinciding with the implementation of the NOHP in Brazil. This relation is explained by the increase in the frequency of diagnoses in the SUS, as well as referral to hospital units and registration of cases in the information systems22. The scenario observed before this policy was characterized by a curative and individualized dental care model, centered on private services23. With its implementation, prevention started guiding oral health care, and procedures for detecting changes in the oral mucosa and biopsies started to be recommended in primary care and in the DSC24.
The lower coverage of oral health in primary care and the absence of DSC are related to the higher risk of hospitalization for oral cancer, according to the findings of this investigation. Studies have also found similar impacts of these variables on oral cancer mortality rates in Brazil in recent decades13,15. The lack of access to health services is one of the main factors related to the delay in the diagnosis of oral cancer, which often results in the need for more aggressive and mutilating treatments, reducing the individual's survival25.
Since the dentist in primary care acts as the entrance to the health system and the longitudinal character of this assistance in the SUS, it is able to develop educational actions to combat behavioral risk factors and self-detection of lesions through oral self-examination26. The DSC complement the assistance offered in primary care, representing the reference unit for suspected cases27. The relation between a greater number of DSC and a lower number of hospitalized cancer cases may indicate advances in terms of problem-solving, suggesting a higher frequency of cases detected in early stages, and reducing demand in hospital units. Additional studies should be conducted to verify the effects of the organization of the oral cancer care network in the country.
Despite the advances observed, some barriers still make it difficult to face oral cancer in Brazil. Some problems are inherent to the health system as a whole, which refer to insufficient coverage, unequal distribution of health care units and a decrease in government investments in health in recent years, with the advance of austerity policies14,15. The lack of training and insecurity of professionals in relation to the diagnosis of malignant lesions and biopsies should also be highlighted24. Furthermore, the global pandemic of Covid-19, in 2020, which required measures of social distance, as well as itslong-term impacts can contribute to the increase of cases that are diagnosed later28.
The present study has some limitations. The use of secondary data reduces the researchers' control over the registration of information systems, which may represent a bias. Due to its observational design, this study suggests associations, but it is not the most appropriate for establishing cause and effect relationships. The study considered population data, and the phenomenon of ecological fallacy may occur if its findings are interpreted at individual levels. Oral cancer is a complex disease, strongly influenced by behavioral risk factors, which are not fully explained by individuals' socioeconomic characteristics. Future studies must be developed considering these aspects as well. The use of official information systems, analysis at a city level throughout Brazil, the large sample size used, and the long period of analysis are strengths of this investigation. In addition, the survival analysis verified by the Hazard Ratio measure also characterizes the pioneer nature of this study.
Taking this into account, the expansion of oral health coverage in primary and specialized care, especially in the sense of equity, prioritizing populations in socioeconomic vulnerability, are essential strategies for improving the epidemiological scenario of oral cancer in Brazil13,24. In this sense, some urgent measures are highlighted, such as the increase in government investments in health, the implementation of public policies to combat social inequalities, the control of behavioral risk factors for oral cancer, the training of oral health professionals in the early identification of precancerous lesions and the expansion of health education measures for the general population.