ABC | Volume 114, Nº2, February 2020

Original Article Martins et al. Mortality from cardiovascular disease and cancer Arq Bras Cardiol. 2020; 114(2):199-206 In the northeast region, between 2000 and 2010, CA mortality increased by 100% in white women, a population subgroup that increased by only 10% in size in the period. In contrast, there was a 183% increase in mortality among black women, with a respective population growth by 58%. 33 A possible explanation for the increase in late mortality rates from CA among men in Salvador is the high percentage of Afro-Brazilians living in this city. Prostate cancer is the leading cause of late mortality among men in Brazil 15 and a black man has 1.6 of being diagnosed and 2.4 higher odds of dying from prostate cancer than a white man. 34 Manaus greatly differs from the other capital cities regarding the pattern of the mortality curves from DCS and CA. Early mortality from CA significantly increased among women. Cervical cancer is the main type of cancer, 15 whose mortality rates increased in the north and northeast regions. 35-37 In Manaus, early mortality decreased whereas late mortality increased among men. The main causes of early death fromCA was gastric cancer followed by lung cancer. In Brazil, mortality rates from gastric cancer significantly increased in individuals older than 59 years. In the north region, mortality rates have increased in individuals of both sexes older than 75 years. 37 Prostate cancer mortality continues to increase in Brazil, with a vast number of under-reported or late-diagnosed cases. In Goiania, early mortality and late mortality from CA increased in both men and women. Early death from CA was mainly caused by breast CA in women. This may be explained by the difficult access to appropriate diagnosis, since only 18% of the mammography machines available in the whole State of Goias belong to the Unified Health System, and 80% of the population living in the state are users of the public health system. 38,39 Another possible reason is the fact that mammograms is performed at relatively late age in Goiania, 49 years old. 40 Differences between sexes in the trends of mortality from DCS and CA Early and late mortality rates from DCS were lower in women than in men in all studied capitals and showed a more marked decrease over the years among women than men. One hypothesis for these findings is the fact that women are more adherent to primary healthcare programs for the screening and prevention of diseases. With respect to CA, regional differences were found in the incidence of different tumors of varying mortality rates. For example, in Sao Paulo, colon CA ranks the second in incidence and cervical CA is in the fourth position, whereas in Manaus, cervical cancer ranks the first. 37 Breast CA is the most prevalent cancer among women in Brazil and in most of the studied capitals. The treatment may include surgery, chemotherapy, radiotherapy, and hormonal therapy. Despite many advances in the treatment of breast CA, such as the use of immunohistochemical tests and anti-HER-2 agents, the access to these therapies by users of the health public system occurred later, and probably had no effect on the outcome of the patients included in this research. Some limitations need to be considered when analyzing the results of this study. Data analyzed in this study were obtained from death certificates, and hence subject to inaccuracy. The diagnosis of CA is confirmed by imaging tests and/or anatomopathological examination, which confer greater reliability. The diagnoses of DCS are essentially established by clinical examination. Also, it is worth mentioning that the results were obtained from populations living in large urban centers; extrapolations to medium- and small-sized cities may not be appropriate, as reproducibility of these data is not necessarily guaranteed. Finally, determinants of mortality and estimates of trends can be influenced by public polices. Conclusion In general, and considering specific regional exceptions, there was a gradual and marked decrease in mortality rates from DCS in the five Brazilian capital cities studied, whereas mortality rates from CA remained unchanged or showed a slight increase from 2000 to 2015. Such events will lead to the intersection of the mortality curves, with perspective of a predominance of CA (old and new cases) mortality. Author contributions Conception and design of the research: Martins WA; Acquisition of data: Matos RCC, Silva WDS, Souza Filho EM; Analysis and interpretation of the data: Martins WA, Matos RCC, Silva WDS, Souza Filho EM; Statistical analysis: Rosa MLG, Matos RCC, Silva WDS, Souza Filho EM; Obtaining financing: Martins WA, Matos RCC; Writing of the manuscript: Martins WA, Rosa MLG, Matos RCC, Silva WDS, Souza Filho EM; Critical revision of the manuscript for intellectual content: Martins WA, Rosa MLG, Jorge AJL, Ribeiro ML, Silva EM. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding This study was partially funded by FAPERJ. Study Association This study is not associatedwith any thesis or dissertationwork. Ethics approval and consent to participate This article does not contain any studies with human participants or animals performed by any of the authors. 204