Luire Campelo (Cidacs/Fiocruz Bahia)
Women living in economically segregated areas, with few resources and poor access to health services, are more likely to die from breast cancer. However, these risk factors can be mitigated with income transfer programs, such as the Bolsa Família Program (PBF, in the Portuguese acronym). A recent study, published in the journal Jama Network conducted by researchers from Fiocruz Bahia's Center for Data and Knowledge Integration for Health (Cidacs), evaluated more than 20 million adult women – between the ages of 18 and 100 – and found that the higher the level of segregation of the living area, the greater the risk of dying from breast cancer. When comparing beneficiaries and non-beneficiaries, women who did not receive Bolsa Família had a 17% higher risk of breast cancer mortality compared to beneficiaries of the program.
Women who did not receive Bolsa Família had a 17% higher risk of breast cancer mortality
Among women who received the PBF, those who lived in municipalities with high-income segregation had a 13% higher risk of dying from breast cancer compared to those who lived in municipalities with low segregation. Among those who did not receive the program, those who lived in municipalities with high segregation had a 24% higher risk of dying from breast cancer compared to those who lived in municipalities with low segregation.
The study also reinforces the results of a previous study, also carried out by researchers from Cidacs/Fiocruz Bahia, in which black women had a 10% higher risk of dying from the disease compared to white women. This previous evaluation also took into account women registered on the Cadastro Único – CadÚnico (Unified Registry), i.e. who are part of poor or extremely poor families.
For researcher Joanna Guimarães, associated with Cidacs/Fiocruz Bahia, most of the studies on the effects of the PBF focus on child health and infectious diseases, such as leprosy and tuberculosis, women's health being less explored. "This was the first study to investigate the association between the PBF and breast cancer mortality, which is the type of cancer that kills the most women in Brazil and worldwide," says the researcher.
The incidence of breast cancer mortality in municipalities with low segregation was 6.4 women per 100,000 inhabitants. In municipalities with medium segregation, the incidence of mortality was 6.7, while in municipalities with high-income segregation, this rate was as high as 8.2 deaths per 100,000.
"The study also shows the importance of where people live as a determinant of inequalities in mortality from this type of cancer (in addition to traditional individual risk factors such as diet, smoking, and other health behaviors), and how the PBF helped protect women from the negative effects of living in poorer areas," explains Joanna.
Of the 21,680,930 women studied, 11,549,000 (53.3%) were brown, 7,110,375 (32.8%) were white, 1,772,843 (8.2%) were black, 104,252 (0.5%) were indigenous, and 96,085 (0.4%) were Asian. Of these, there were 7,227,998 women in municipalities with low segregation, 7,309,565 women in municipalities with medium segregation, and 7,143,367 women living in municipalities with high segregation.
Segregation and the health-disease process
People with lower incomes and residents of places with marked inequalities are subject to structural and environmental factors that shape their behavior and living conditions. "The research showed the results of a public policy, Bolsa Família, in reducing inequalities in breast cancer mortality among women. This is possibly due to the increase in family income and thus greater access to medications, quality food, and transportation services, allowing people to seek preventive cancer services, such as mammograms, in other places," says Joanna.
For the researchers, supported by previous studies, the evidence also shows that living in economically disadvantaged areas is associated with more limited access to screening and care services, as well as unfavorable breast cancer outcomes. These include diagnosis at an advanced stage, less adequate treatment, and shorter survival and higher mortality rates.
According to the study, income segregation, also called residential segregation by income, is the systematic separation of individuals in different geographical areas, where discriminatory housing policies have historically marginalized people with lower incomes. The research also showed that income segregation, even among women who received Bolsa Família, was associated with an increased risk of breast cancer mortality for those who received the benefit for less time – up to four years.
The study conducted by researchers from Cidacs/Fiocruz Bahia found that the PBF was associated with a reduction in breast cancer mortality. Such association is probably due to the improvement in women's income and access to preventive cancer services, leading to early detection and treatment and, ultimately, reduced mortality.
"The conditionalities of the PBF impose greater use of health services, increasing early detection and timely treatment, potentially reducing mortality. The study has political implications, as it suggests including breast screening and clinical examination among the conditionalities of the PBF," says Joanna.
The study was carried out in collaboration with researchers from Cidacs/Fiocruz Bahia, the Faculty of Epidemiology and Population Health at the London School of Hygiene and Tropical Medicine, the Ubuntu Center on Racism, Global Movements and Population Health Equity at Drexel University, from Bahia's Diabetes and Endocrinology Center of the Bahia State Health Department, and the Institute of Collective Health at the Federal University of Bahia. The study used data from the Cohort of 100 Million Brazilians, a population cohort put together by Cidacs/Fiocruz Bahia, based on the federal government's Cadastro Único, which comprises data of more than 114 million low-income Brazilians (almost 55% of the country's population) from 2001 to 2015.
What is suggested by the results
• The study's evidence shows that the association between segregation and breast cancer deaths was different for women who did and did not receive Bolsa Família.
• The results show that women who lived in municipalities with high-income segregation were more likely to be older, indigenous or black, with a higher level of education, and less likely to be beneficiaries of Bolsa Família compared to those who lived in municipalities with medium or low segregation.
• Municipalities with higher income segregation were larger, had a higher population density, and had a higher proportion of women living in urban areas than municipalities with lower income segregation.
• When comparing women who received Bolsa Família with those who did not, non-beneficiaries were more likely to be white, older and better educated, and tended to live in more urban and segregated municipalities than Bolsa Família beneficiaries.
• Stratification by time in years receiving the PBF benefit showed that income segregation was associated with mortality only among women who had received the benefit for less time.