PONE-D-20-34094

SPATIAL DISTRIBUTION OF ADVANCED STAGE DIAGNOSIS AND MORTALITY OF BREAST CANCER: SOCIOECONOMIC AND HEALTH SERVICE OFFER INEQUALITIES IN BRAZIL

PLOS ONE

Dear Dr. de Souza,

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This is a very interesting and important paper. The paper needs to review some parts to improve the discussion and clarify some points, There are interesting results across regions of the countries that should have a more detailed discussion. I also would like to see a more detailed analysis of data quality (some additional references on the quality of information) and limitations of data use (death registration, population estimates). Please, see detailed comments by the reviewers are presented below. 

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Academic Editor

PLOS ONE

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Reviewers' comments:

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Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: Dear Editor:

Thank you for offering me the opportunity to contribute to the review of this study that may allow new perspectives to lessen the severe statistics of breast cancer.

This article envisions the spatial distribution pattern of the final stage of breast cancer diagnosis and mortality and its correlation with socio-economic aspects and population indicators related to the provision of health services. The theme is relevant, bring in robust data and the results found may reflect the high incidence of breast cancer mortality of the above-mentioned country. I also highlight that some variables assessed contributes greatly to reflect on the improvement of public health policies concerning breast cancer. Another highlight is that spatial analyzes in continental countries are essential for improving health policies due to the faced social barriers. Thus, I make some suggestions to the authors that may contribute to the disclosure of the study.

Introduction

In general, the introduction is relevant to data that refer to the objective of the study. I only suggest adding data from first world countries in the introduction show emphatically the magnitude of breast cancer in the country under study. Also, I suggest including data on breast cancer survivors diagnosed in late breast cancer diagnoses. These data would add even more relevance to the study.

Methods

1- I would suggest replacing “Materials and Methods” with “Methods”.

2- The section presents the distinct data that helps in understanding the methodological path. However, it is still unclear how the IRUA representation in data collection happened for a continental country like Brazil. I suggest adding a concise statement of this extent collection and the importance of using it in the study. And I would like to highlight positively that the authors have made the rate adjustments.

3- Also, it would be suitable for the authors to explain the socioeconomic and demographic indicators selected to be analyzed in the research.

4- The authors searched for mortality data up to 99 years of age. The suggestion is for the authors to explain the reason for not using a lower age range of mortality for the study and instead of seeming like a limitation of bias due to elderly women having other impairments, it may highlight a gap for older women’s lack of care concerning the disease.

Discussion:

This is a consistent research and can adequately explain the results found.

Greater concerns

1. In general, there was no explanation of the negative results found for the South and Southeast. For greater robustness of the study, the authors could give this information at the beginning of the discussion just as they did with the other regions of the country. There is no relation between socioeconomic variables and lack of professionals according to the other regions, but they show relevant data for these two regions that stand out the most in breast cancer mortality. Subsequently, a deeper interpretation of these findings is necessary.

Minor concerns:

1. Page 15, line 334-337: Although a limitation of the study was described in the paragraph, there is no link from the negative to the positive highlight of the information system. Furthermore, I suggest reviewing the writing so there is a continuity of data about the information system so that the content is globally understandable.

3. Page 15, line 337-339: there was an emphasis on other spatial analysis arrangements and other health determinants. As a suggestion to the authors, there is a need to be more specific in the gap signaled. Thus, researchers will be more supported to produce new research when reading this study.

Reviewer #2: Title: SPATIAL DISTRIBUTION OF ADVANCED STAGE DIAGNOSIS AND MORTALITY OF BREAST CANCER: SOCIOECONOMIC AND HEALTH SERVICE OFFER INEQUALITIES IN BRAZIL

First, the reviewer declares that no competing interests exist.

The article aims to analyze the spatial distribution pattern of late stage diagnosis and mortality for breast cancer and its correlation with socioeconomic and health service offer-related population indicators. Mortality data were collected from the Mortality Information System (MIS). Tumor staging data were extracted from the Hospital Cancer Registry (HCR). Socioeconomic variables were obtained from the Atlas of Human Development in Brazil. Global Moran's Index and Local Indicator of Spatial Association (LISA) were utilized to verify the existence of territorial clusters. Multivariate analysis used models with global spatial effects. The author found a very important result for the implementation of health policies to combat breast cancer: the proportion of late stage diagnosis of breast cancer was 39.7% (IC 39.4 – 40.0), and the proportion of late stage diagnosis presented positive spatial correlation with Gini’s Index (p = 0.001) and negative with the density of gynecologist doctors (p = 0.009).

The authors begin the article presenting information about the incidence of breast cancer in the world, and the authors contextualize the Brazilian case very well, when they argue that health-related inequalities related to the diagnosis and mortality of breast cancer are affected by contextual socioeconomic conditions and the offer and access to health services, in turn related to high social and income-related inequalities. Therefore, they carry out an updated bibliographic review.

In the section “Materials and Methods”, the first subsection “Study design and participants” could just be called “Study design”, because the authors presented only the selected unit of analysis. The choice for Immediate Geographic Regions of Urban Articulation (IGRUA) is justified due to its representativeness of the urban articulations and contextual reality of the period. In Brazil, there are more disaggregated geographical units, such as the micro-regions or even the municipalities. It is important that the authors justify the choice of the geographical unit in view of the quality of the data. For example, it was decided not to work with the municipalities as there are problems about quality in working with more disaggregated data, such as registration or coverage problems. It is common the use of statistical methods (such as empirical bayes) for the correction of records, in small areas. Therefore, even if such problems have not been identified, it is important to contextualize a little more the choice by IGRUA, in view of the other geographical units.

In the section “Study variables and data sources” a table must be created with the variables used, data sources and year of information. In this section, the data collected from ICD 10 were presented, obtained from the Brazilian Mortality Information System (MIS). The methods used to correct the data are adequate. I just suggest the citation of Preston et al (2001): Demography, Measuring and Modeling Population Processes, for direct standardization. In relation to the population estimates used for the denominator of rates, the IBGE estimates were used. There is no necessity of change, no doubt it is a good option, but best population estimates in Brazil today are from UFRN, from the Department of Demography and Actuarial Sciences. This group has been a reference in Brazil (including in IBGE committees) in the development of stochastic municipal projections, by sex and age. There is a project, called “Brazil three times”, financed by the Secretariat of Strategic Affairs of the Presidency of the Republic, which provides estimates (by sex and age) that are more robust, when compared to IBGE estimates. You do not need to change this information in the article, but this is a good option for the next publications.

In addition, in relation to the data processing stages, the authors are very careful, explaining how they dealt with situations of lack of data, missings, etc. I only suggest that a highlight is given to the fact that data on inequality were obtained from the Atlas of Human Development in Brazil for 2010, while mortality rates, for example, were estimated for the period between 2011-2015. Of course, it is a good assumption to consider that the socioeconomic context did not change significantly, for example, between 2010 and 2015. But these assumptions (which represent limitations of the data sources) need to be described in the methodology.

Regarding the geographic information system used, Terraview, it is a good GIS, created by INPE. But the maps need to be corrected. It's necessary to export them with a higher resolution (.dpi), since the low resolution is compromising the visualization, mainly of the thematic maps. This is a requirement for the publication of this article.

Regarding the cluster maps, it was evident that the authors printed the maps and graphs from the Geoda. There are ways to export the table of attributes of the results of spatial autocorrelation, to the elaboration of a more complete layout, in a more robust GIS. But, in this case, you don't need to change the cluster maps for the publication.

In the subsection “Statistical analysis”, both the auto correlation method and the spatial regression method were not detailed, but references were cited that allow the reader to known the methods, if interested. On the other hand, the parameters and procedures adopted in the models were presented (such as the neighborhood matrix and the residue analysis). Therefore, this section is well structured and does not need correction.

The “Results” section is well structured, the results are very interesting, and represent an important contribution to this field of knowledge. In Brazil, 39.7% of cases are diagnosed late, and statistical significance was found between late care and the incidence of the disease with inequality and the presence of specialized professionals. The “Discussion” section, on the other hand, analyzes the spatial inequalities observed in different regions of the country, putting in perspective the inequality in the offer of services (concentrated in large centers), added to the problem of deficiency in the public health service, responsible for attending 80% of the population. These two sections analyzed the results satisfactorily, in addition to highlighting the importance of the study, so there is no indication of correction in these sections.

The article is of great quality and contributes to the studies on breast cancer. I strongly suggest publication, after minor corrections.

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Reviewer #1: Yes: SHEILA CRISTINA ROCHA BRISCHILIARI

Reviewer #2: Yes: Járvis Campos - Professor of Demography and Acturial Sciences (UFRN) and the Demography Graduate Program (PPGDem/UFRN)

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SPATIAL DISTRIBUTION OF ADVANCED STAGE DIAGNOSIS AND MORTALITY OF BREAST CANCER: SOCIOECONOMIC AND HEALTH SERVICE OFFER INEQUALITIES IN BRAZIL

PONE-D-20-34094R1

Dear Dr. de Souza,

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Kind regards,

Bernardo Lanza Queiroz, Ph.D

Academic Editor

PLOS ONE

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Thank you for considering and incorporating the comments and suggestions made during the review process. We all agree the paper is a relevant and important contribution. 

Reviewers' comments: