title: Temporal trends in female breast cancer mortality in Brazil and correlations with social inequalities: ecological time-series study.
abstract: BACKGROUND
  Breast cancer is the most common cause of death from cancer in women in less developed regions. Therefore, the objective of this study was to provide data on the temporal trends in female breast cancer mortality between 1990 and 2011 and to evaluate its association with the social inequalities present in Brazil.
  
  
  METHODS
  Breast cancer mortality data and estimates for the resident population were obtained from the Brazilian National Health Service database for the 1990-2011 period. Age-standardized mortality rates were calculated (20-39, 40-49, 50-69 and ≥70 years) by direct standardization using the 1960 standard world population. Trends were modeled using joinpoint regression model and linear regression. The Social Exclusion Index and the Human Development Index were used to classify the 27 Brazilian states. Pearson's correlation was used to describe the association between the Social Exclusion Index and the Human DeveIopment and the variations in mortality rates in each state.
  
  
  RESULTS
  Age-standardized mortality rates in Brazil were found to be stable (annual percent change [APC] = 0.3; 95% CI: -0.1 - 0.7) between 1994 and 2011. Considering the Brazilian states, significant decreases in mortality rates were found in Rio Grande do Sul, Rio de Janeiro and São Paulo. Increases in mortality rates were most notable in the states of Maranhão (APC = 11.2; 95 %CI: 5.8 - 16.9), Piauí (APC = 9.8; 95% CI: 7.6 - 12.1) and Paraíba (APC = 9.3; 95% CI: 6.0 - 12.8). There was a statistically significant correlation between Social Exclusion Index and a change in female breast cancer mortality rates in the Brazilian states between 1990 and 2011 and between Human Development Index and mortality between 2001 and 2011.
  
  
  CONCLUSIONS
  Female breast cancer mortality rates are stable in Brazil. Reductions in these rates were found in the more developed states, possibly reflecting better healthcare.
authors.affiliation: Health Sciences, Federal University of Goiás (UFG), Goiânia, Brazil. cmrgonzaga@gmail.com.
authors.forename: Carolina Maciel Reis
authors.initials: CM
authors.lastname: Gonzaga
authors.affiliation: Department of Obstetrics and Gynecology, Federal University of Goiás (UFG), Goiânia, Brazil. ruffojr@terra.com.br.|, Alameda das Rosas, 533, Setor Oeste, 74110-060, Goiânia, GO, Brazil. ruffojr@terra.com.br.
authors.forename: Ruffo
authors.initials: R
authors.lastname: Freitas-Junior
authors.affiliation: Health Sciences, Federal University of Goiás (UFG), Goiânia, Brazil. maria-paula.curado@i-pri.org.|Hospital Araújo Jorge, Goiás Anticancer Association (ACCG), Goiânia, Brazil. maria-paula.curado@i-pri.org.|International Prevention Research Institute (IPRI), Lyon, France. maria-paula.curado@i-pri.org.
authors.forename: Maria-Paula
authors.initials: MP
authors.lastname: Curado
authors.affiliation: Health Sciences, Federal University of Goiás (UFG), Goiânia, Brazil. demmilima@gmail.com.
authors.forename: Ana-Luiza Lima
authors.initials: AL
authors.lastname: Sousa
authors.affiliation: Federal University of Goiás (UFG), Goiânia, Brazil. augustonetojs@hotmail.com.
authors.forename: José-Augusto
authors.initials: JA
authors.lastname: Souza-Neto
authors.affiliation: Institute of Tropical Pathology and Public Health, Federal University of Goiás (UFG), Goiânia, Brazil. martary@gmail.com.
authors.forename: Marta Rovery
authors.initials: MR
authors.lastname: Souza
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D001938:Brazil / Q000453:epidemiology; D001943:Breast Neoplasms / Q000401:mortality*; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D016014:Linear Models; D008875:Middle Aged; D012931:Social Environment; D012959:Socioeconomic Factors; D055815:Young Adult