Cancer Health Disparities Among Patients With Early-Stage Estrogen Receptor-Positive Breast Cancer: Impact of Public Versus Private Health Care on Diagnosis-to-Treatment Interval in Brazil.

Abstract

In 2013, Brazil implemented a federal law (Law 12.732/2012) mandating cancer treatment to begin within 60 days of diagnosis. Among women with newly diagnosed estrogen receptor-positive (ER+) nonmetastatic breast cancer, we describe the diagnosis-to-treatment interval, patient and tumor characteristics, and the type of treatment received, and we assess these metrics by public versus private health care setting. The study included patients with early-stage ER+ breast cancer from 14 centers in Brazil who had completed locoregional care and received >6 months of adjuvant endocrine therapy (ET). Patient, tumor, and treatment characteristics were abstracted from clinical documentation and collected in REDCap. Qualitative variables were compared between groups using the chi-square or Fisher exact tests. For quantitative variables, the nonparametric Mann-Whitney test was used. <i>P</i> < .05 was considered significant. From June 2021 to March 2024, 774 women enrolled in the study. The mean age at diagnosis was 56.5 years, and 55.2% received public health care. Women who received care at public institutions were more likely to be premenopausal at diagnosis (45.3% public <i>v</i> 29.2% private, <i>P</i> < .0001), living with no partner (45.6% public <i>v</i> 34.7% private, <i>P</i> = .002), and have lower educational levels (43.6% public <i>v</i> 6.8% private, <i>P</i> < .0001). Women treated in the public sector had more advanced disease with stage III tumors (29.3% public <i>v</i> 13.5% private, <i>P</i> < .0001) and were more likely to receive mastectomies (36.8% public <i>v</i> 29.8% private, <i>P</i> = .0003), axillary dissections (43.1% public <i>v</i> 18.1% private, <i>P</i> < .0001), chemotherapy (73.8% public <i>v</i> 58.5% private, <i>P</i> < .0001), and radiotherapy (87.0% public <i>v</i> 78.7% private, <i>P</i> = .002). Regarding adjuvant ET, women treated in the public sector had lower ovarian function suppression (6.8% public <i>v</i> 18.8% private, <i>P</i> < .0001) and higher tamoxifen use (52.4% public <i>v</i> 29.4% private, <i>P</i> < .0001). The diagnosis-to-treatment interval was longer in the public versus private system (93 <i>v</i> 41 days, <i>P</i> < .0001). Our study revealed significant disparities in cancer care between patients with stage I to III ER+ breast cancer treated in public versus private health care systems in Brazil. Law 12.732/2012 has proven ineffective for patients treated in the public sector and is not being adequately observed or enforced by Brazilian authorities.