Abstract
To analyze mortality from head and neck cancer (HNC) in the State of Santa Catarina from 1979 to 2023. Ecological study of data available in the Mortality Atlas of the National Cancer Institute and in the Mortality Information System. Approximately 13,309 deaths due to HNC were recorded in the Mortality Atlas, considering the period from 1979 to 2021 and 11,027 deaths recorded in SIM in the period from 1996 to 2023. The profile of these patients consisted predominantly of subjects aged 60–69 years old, male, white, married and with 1–3 years of education. Regarding types of cancer, most deaths occurred from laryngeal cancer, followed by oropharyngeal cancer. There is a need to improve health services, with an emphasis on diagnosis of the highest risk profiles, prevention and health promotion with publicity campaigns.
Keywords: Neoplasms, Head and neck neoplasms, Mortality registry, Santa Catarina
Introduction
Head and neck cancer (HNC) can be defined as malignant neoplasms diagnosed in the upper aerodigestive tract, encompassing several anatomical regions, such as the mouth, tongue, pharynx, larynx, paranasal sinuses, and salivary glands [1, 2].
Mortality from this disease causes concern to health systems worldwide. A number of characteristics contribute to its high lethality rate, such as late diagnosis, the aggressiveness of the tumor, presence of metastases, and the complexity of the affected areas [3].
The initial symptoms are often neglected or confused with other diseases, which delays the correct diagnosis [4]. When detected in advanced stages, the chances of a cure decrease considerably, making treatment more complex and less effective [5]. No access to health services and the lack of prevention and awareness raising programs are also determining factors for the high mortality.
Analysis of cancer trends indicates that increased exposure to reproductive and hormonal risk factors and changes in dietary patterns are linked to economic and social transitions occurring in several low- and middle-income countries. For this reason, it is essential to monitor cancer incidence and mortality in a given population to define priorities and plan actions aimed at controlling the disease, besides evaluating the effectiveness of implemented interventions [6].
In Santa Catarina, there are still few studies aimed at understanding HNC mortality. In view of this, this study aimed to analyze HNC mortality in the state of Santa Catarina from 1979 to 2023, aiming to understand the main epidemiological characteristics of the temporal and spatial distribution in this scenario.
Methods
This was an ecological study that analyzed the distribution of deaths due to HNC available in the Mortality Atlas (INCA) and in the Mortality Information System (SIM) of the Ministry of Health. Death data referring to the state of Santa Catarina were extracted from the period corresponding to 1979 to 2023, according to the availability of each database. The population was composed of all HNC deaths recorded in the period under analysis, considering the structures: oral cavity (lips, tongue, gums, floor of the mouth, hard and soft palate); facial sinuses (maxillary, frontal, ethmoidal and sphenoidal); pharynx (nasopharynx, oropharynx and hypopharynx); larynx (supraglottis, glottis and subglottis); salivary glands, and thyroid gland.
The data source for these systems is the death certificate (DC), which is mandatory for physicians to complete throughout the national territory. The DC presents several blocks and fields that allow the analysis of the Brazilian population’s health situation and mortality profile. This was used from the website of the Epidemiological Surveillance Directorate of the state of Santa Catarina. Resident population data were extracted from the Demographic Censuses and intercensal projections made by the Brazilian Institute of Geography and Statistics (IBGE), and accessed through the TABNET tool website of the Unified Health System Department of Informatics (DATASUS) in August 2023.
The structured access aimed to analyze the distribution of deaths according to the available sociodemographic variables: age, sex, schooling, race/color, municipality, and health region. The following filters were used: period, location, ICD-10, sex, age, health region, and race/color. The analysis covered the period from January 1979 to August 2023. However, one decided to present the data according to two different sources because of differences in relation to the time periods available, namely: INCA data refer to 1979 to 2021, and SIM data refer to 1996 to 2023.
Crude death rates were calculated using the ratio of the number of HNC deaths to the estimated population in the state of Santa Catarina and in the respective health macro-regions in each year, and are presented per 100,000 inhabitants. Seven health macro-regions of the state were evaluated, available on the DATASUS website in accordance with Deliberation No. 458/CIB/127.7 Microsoft Excel 2019 spreadsheets were used for the data processing stage. The variables were described using absolute and relative frequencies (n) (%). Furthermore, the percentage variation in death rates was calculated using the following formula:
 |
It is worth noting that as the study used secondary public domain data, there was no need for it to be accessed by the Research Ethics Committee.
Results
In the exploratory analysis of mortality data, one verified in the analyzed period – total of 44 years – that 13,309 deaths were recorded in the Online Mortality Atlas (INCA) from 1979 to 2021, and 11,025 deaths in the SIM/DATASUS from 1996 to 2023. SIM data are presented in Table 1, showing that the profile of patients who died from HNC consisted predominantly of subjects aged 60–69 years, male, white, married, and with low schooling. Regarding types of cancer, most deaths occurred from laryngeal cancer-C32, followed by oropharyngeal cancer-C10.
Table 1.
Description of HNC deaths according to sociodemographic variables and to the ICD-10 classification in Santa Catarina, Brazil (SIM/DATASUS:1996-2023)
| International Classification of Diseases (ICD) | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Variables | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 30 | 31 | 32 | 73 | Total (n) | Total (%) |
| Age group | |||||||||||||||||||||
| 0-19 | 0 | 0.17 | |||||||||||||||||||
| 20-29 | 5 | 6 | 0.5 | ||||||||||||||||||
| 30-39 | 8 | 9 | 5 | 8 | 7 | 4 | 80 | 1.61 | |||||||||||||
| 40-49 | 0 | 5 | 27 | 3 | 8 | 0 | 0 | 8 | 73 | 3 | 1 | 8 | 4 | 33 | 2 | 208 | 10.85 | ||||
| 50-59 | 3 | 56 | 73 | 2 | 4 | 54 | 7 | 3 | 0 | 93 | 4 | 4 | 68 | 69 | 5 | 8 | 40 | 37 | 178 | 28.56 | |
| 60-69 | 7 | 6 | 63 | 3 | 5 | 55 | 3 | 54 | 2 | 9 | 45 | 77 | 1 | 6 | 174 | 31 | 268 | 29.37 | |||
| 70-79 | 4 | 8 | 42 | 2 | 2 | 86 | 1 | 6 | 1 | 60 | 3 | 8 | 78 | 2 | 1 | 45 | 97 | 122 | 19.07 | ||
| ≥ 80 | 4 | 8 | 6 | 1 | 1 | 35 | 5 | 3 | 17 | 7 | 8 | 2 | 3 | 5 | 74 | 69 | 91 | 9.8 | |||
| Ignored | 4 | 0.3 | |||||||||||||||||||
| Total | 1 | 91 | 94 | 2 | 67 | 98 | 54 | 49 | 1 | 43 | 531 | 28 | 1 | 89 | 39 | 0 | 20 | 610 | 19 | 1,127 | 100 |
| Sex | |||||||||||||||||||||
| Male | 4 | 42 | 55 | 38 | 56 | 69 | 61 | 2 | 17 | 348 | 28 | 4 | 42 | 9 | 4 | 5 | 252 | 19 | 15 | 82.25 | |
| Female | 7 | 9 | 39 | 2 | 9 | 85 | 8 | 9 | 6 | 83 | 7 | 30 | 6 | 5 | 58 | 36 | 946 | 17.75 | |||
| Total | 1 | 91 | 94 | 2 | 67 | 96 | 54 | 49 | 1 | 43 | 531 | 28 | 1 | 89 | 39 | 20 | 610 | 55 | 961 | 100 | |
| Color/Race | |||||||||||||||||||||
| Caucasian | 2 | 33 | 66 | 7 | 49 | 75 | 2 | 17 | 13 | 286 | 88 | 6 | 77 | 66 | 3 | 1 | 7 | 47 | 185 | 93.23 | |
| Black | 6 | 2 | 6 | 1 | 1 | 4 | 5 | 4 | 3.8 | ||||||||||||
| Asian | 2 | 0.22 | |||||||||||||||||||
| Mixed race | 6 | 4 | 1 | 7 | 6 | 8 | 22 | 3 | 37 | 3.42 | |||||||||||
| Indigenous people | 3 | 0.3 | |||||||||||||||||||
| Total | 7 | 66 | 12 | 0 | 58 | 86 | 59 | 29 | 5 | 23 | 391 | 3 | 8 | 14 | 20 | 5 | 6 | 243 | 66 | 851 | 100 |
| Marital status | |||||||||||||||||||||
| No information | 7 | 1 | 6 | 7 | 1 | 4 | 1.86 | ||||||||||||||
| Single | 6 | 35 | 9 | 3 | 42 | 1 | 69 | 8 | 3 | 39 | 2 | 91 | 41 | 566 | 14.28 | ||||||
| Married | 3 | 16 | 93 | 3 | 1 | 10 | 97 | 24 | 6 | 2 | 6 | 81 | 2 | 83 | 21 | 1 | 5 | 96 | 18 | 48 | 55.17 |
| Widow/widower | 0 | 2 | 4 | 2 | 7 | 46 | 3 | 4 | 82 | 6 | 9 | 36 | 4 | 2 | 55 | 17 | 560 | 14.23 | |||
| Separated | 7 | 2 | 7 | 9 | 3 | 8 | 72 | 3 | 1 | 9 | 78 | 9 | 122 | 10.23 | |||||||
| Ignored | 6 | 3 | 5 | 6 | 7 | 8 | 7 | 59 | 5 | 61 | 4.2 | ||||||||||
| Total | 1 | 91 | 94 | 2 | 67 | 96 | 54 | 49 | 1 | 43 | 531 | 28 | 1 | 89 | 1 | 20 | 610 | 55 | 961 | ||
| Schooling | |||||||||||||||||||||
| None | 3 | 6 | 4 | 1 | 5 | 5 | 13 | 6 | 9 | 9 | 40 | 6 | 67 | 8.21 | |||||||
| 01-Mar | 4 | 1 | 31 | 1 | 3 | 47 | 3 | 6 | 18 | 9 | 7 | 22 | 64 | 2 | 76 | 48 | 892 | 30.46 | |||
| 04-Jul | 5 | 18 | 36 | 8 | 2 | 39 | 2 | 9 | 2 | 1 | 3 | 3 | 46 | 38 | 7 | 4 | 38 | 48 | 876 | 30.32 | |
| 08-Nov | 1 | 30 | 5 | 4 | 29 | 2 | 8 | 44 | 3 | 9 | 8 | 8 | 38 | 503 | 15.83 | ||||||
| ≥ 12 | 6 | 3 | 7 | 4 | 6 | 5 | 8 | 8 | 40 | 4.63 | |||||||||||
| Ignored | 7 | 9 | 3 | 4 | 7 | 28 | 5 | 8 | 3 | 88 | 8 | 15 | 10.69 | ||||||||
| Total | 6 | 43 | 63 | 1 | 4 | 81 | 21 | 23 | 9 | 21 | 350 | 2 | 5 | 98 | 82 | 3 | 7 | 88 | 46 | 9,493 | 100 |
Legend: lip (C00), base of tongue (C01), other and unspecified parts of tongue (C02), gum (C03), floor of mouth (C04), palate (C05), other and unspecified parts of mouth (C06), parotid gland (C07), other and unspecified major salivary glands (C08), tonsil (C09), oropharynx (C10), nasopharynx (C11), pyriform sinus (C12), hypopharynx (C13), other and ill-defined sites in the lip, oral cavity and pharynx (C14), nasal cavity and middle ear (C30), accessory sinuses (C31), larynx (C32), and thyroid gland (C73). Source: SIM / DATASUS
Source Author’s elaboration based on information from SIM/DATASUS (2023)
Table 2 presents the number of HNC deaths distributed across the health macro-regions of the state of Santa Catarina over the last five decades. I is possible to observe that only from 1996 onwards such data were made available by DATASUS and that from this year onwards, despite having a common data source, the information presents discrepancies according to the two tools analyzed.
Table 2.
Description of HNC deaths according to health macro-regions and to the period (decades) in Santa Catarina, Brazil (1979–2023)
| Mortality Atlas (INCA) | SIM/DATASUS | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Year Macro-region |
1979 | 1980–1989 | 1990–1999 | 2000–2009 | 2010–2019 | 2020–2021 | 1996–1999 | 2000–2009 | 2010–2019 | 2020–2023 |
| South | 09 (10.5%) | 274 (16.2%) | 382 (15.8%) | 549 (15.9%) | 845 (18.3%) | 154 (15%) | 161 (15.2%) | 545 (5.9%) | 846 (18.1%) | 289 (15.2%) |
| North and Northeast Plateau | 19 (22.1%) | 308 (18.2%) | 493 (20.4%) | 693 (29%) | 971 (21%) | 207 (20.2%) | 215 (20.3%) | 688 (20%) | 972 (20.9%) | 380 (20%) |
| Central-West and Serra Catarinense | 15 (17.4%) | 321 (19%) | 394 (16.3%) | 429 (12.4%) | 541 (11.7%) | 126 (12.3%) | 163 (15.4%) | 421 (12.2%) | 539 (11.5%) | 237 (12.5%) |
| Great West | 10 (11.6%) | 205 (12.1%) | 316 (13%) | 379 (10.9%) | 433 (9.4%) | 98 (9.5%) | 136 (12.8%) | 382 (11.1%) | 434 (9.3%) | 181 (9.5%) |
| Great Florianópolis | 13 (15.1%) | 224 (13.4%) | 335 (13.8%) | 525 (15.2%) | 721 (15.6%) | 196 (19.1%) | 142 (13.4%) | 524 (15.3%) | 752 (16.1%) | 350 (18.5%) |
| Mouth of Itajaí River | 3 (3.5%) | 96 (5.7%) | 156 (14%) | 307 (16.4%) | 393 (8.5%) | 93 (9.1%) | 71 (6.5%) | 297 (8.6%) | 392 (8.4%) | 168 (8.8%) |
| Itajaí’s High Valley | 17 (19.8%) | 261 (15.4%) | 338 (14%) | 567 (16.45%) | 716 (15.5%) | 147 (14.3%) | 167 (15.8%) | 566 (16.5%) | 714 (15.3%) | 286 (15.1%) |
| Total | 86 (100%) | 1,689 (100%) | 2,414 (100%) | 3,449 (100%) | 4,620 (100%) | 1,021 (100%) | 1,055 (100%) | 3,443 (100%) | 4,649 (100%) | 1,891 (100%) |
Source Prepared based on the INCA Mortality Atlas for 1979–2021 and SIM for 1996–2023
In relation to the temporal monitoring of the absolute number of deaths, there has been an evolution in all health macro-regions of the state over the last five decades, and it is most evident from 2010 to 2019. Considering Online Mortality Atlas alone, which has data for all years of the period, it was observed that of the total number of deaths in relation to the four complete decades (1980–2019), the highest incidence was recorded between the years 2010 to 2019, and the North and Northeast Plateau is the region where cases occurred the most. Moreover, it was the region with the highest mortality over the years, with the exception of the decade (1980–1989), in which the Central-West and Serra Catarinense region had the highest number of deaths.
Table 3 shows death rates by health macro-regions at two moments: 1996 (beginning of data availability on DATASUS) and in 2000 and 2010 (census years with population data available for the regions studied). Therefore, heterogeneity can be seen in relation to the several macro-regions of the state, with an increase in all locations, except in the Central-West and Serra Catarinense macro-region and Greater Florianópolis, which decreased when making a comparison between 1996 and 2010.
Table 3.
HNC deaths and mortality rate in the health macro-regions of Santa Catarina, Brazil, in years defined in the study
| Macro-region | Deaths SIM (n) |
Deaths SIM (%) |
xM 1996 | xM 2000 | xM 2010 | % Variation (1996–2010) |
|---|---|---|---|---|---|---|
| South | 1841 | 16.7% | 5.45 | 3.82 | 8.15 | + 0.50 |
| North and Northeast Plateau | 2,255 | 20.5% | 4.27 | 6.21 | 6.86 | + 0.61 |
| Central-West and Serra Catarinense | 1,360 | 12.4% | 4.96 | 4.73 | 3.98 | -0.20 |
| Great West | 1,133 | 10.3% | 4.76 | 5.00 | 5.29 | + 0.11 |
| Great Florianópolis | 1,768 | 16.0% | 7.64 | 6.37 | 5.33 | -0.30 |
| Mouth of Itajaí River | 928 | 8.4% | 2.69 | 6.08 | 5.75 | + 1.14 |
| Itajaí’s High Valley | 1,733 | 15.7% | 5.58 | 4.60 | 6.40 | + 0.15 |
| Total | 11,018 | 100% |
Legend SIM - Mortality Information System / TxM = death rate calculated per 100,000 inhabitants
Source Author’s elaboration based on data from SIM/DATASUS (2023)
Furthermore, the highest death rate observed was in the Southern region, with 8.15 deaths per 100,000 inhabitants. However, the greatest variation occurred in the Mouth of the Itajaí River macro-region, where the death rate went from 2.69 (1996) to 5.75 deaths per 100,000 inhabitants (2010), demonstrating a 1.14% increase in the period prior to the COVID-19 pandemic.
Figure 1 shows HNC death rates in Santa Catarina, drawn up from DATASUS data available since 1996 and every five-year intervals until 2022 (complete data for the entire year). Thus, it became possible to make a temporal analysis and realize that deaths from the disease have been increasing over the years in both sexes. The general HNC death rate in the state in 2022 was of 7.12 deaths per 100,000 inhabitants. It is noted that men are the most affected by negative HNC outcomes, presenting a death rate of 11.59 deaths, while women present a rate of 2.69 deaths. In relation to the percentage variation in rates between the beginning and end of the analyzed period, it is clear that the general rate, for men and women, had a homogeneous increase, and were of 0.33%, 0.39% and 0.31%, respectively.
Fig. 1.
Temporal analysis of HNC mortality, overall and by sex in the state of Santa Catarina in the five-year period between 1996 and 2022.
Source Author’s elaboration based on data from SIM/DATASUS (2023)
Discussion
The state of Santa Catarina has an estimated population of 7,610,361 inhabitants according to the 2022 demographic census [7, 8]. According to the 2017 Cancer Mortality Atlas [9], cancer is the main cause of death in the state, representing 23.5% of the total. This information is very significant, serving as an important indicator of health strategies aimed at this population, as the economic cost of cancer treatment in the state has also to be considered.
The data obtained and the literature itself demonstrated that HNC incidence was more frequent in men [ 9,10]. Associating these elements per sex enables the possibility of characterizing the disease, helping guide preventive actions and more effective treatment strategies.
The ICD-10 Codes with the highest number of deaths were C32 and C10 (larynx and oropharynx), corroborating the Brazilian literature regarding the clinical and epidemiological aspects of the disease [10, 11].
Laryngeal cancer was the main cause of mortality in men in all macro-regions of the state. It is important to highlight that men are less likely to search for health services [12], and late diagnosis is one of the aggravating factors for oncological mortality. In Brazil, it was identified that 76% of patients are diagnosed in stage III and IV (34.5% and 41.5%, respectively) when considering general cancer data [12, 13]. With regard to women, the prevalence of thyroid cancer is observed in practically all macro-regions of the state. However, laryngeal cancer predominates in the Central-West and Serra Santa Catarina macro-region, and the rates are similar to those observed for men.
Laryngeal cancer in both sexes can be associated with factors such as smoking, alcoholism, stress, gastroesophageal reflux, obesity, environmental pollution and genes and, although it is not very common, also with the Human Papilloma Virus (HPV). Subtypes of laryngeal cancer can be observed, and squamous cell carcinoma or squamous cell carcinoma are the most common [1]. The most prevalent types of HNC (larynx and thyroid) found by this study affected mainly married individuals. This category influences an individual’s physical and mental health directly. Studies indicate that people who are married or in a stable relationship tend to have healthier habits [14]. This, added to emotional and social support, can contribute directly to a lower incidence of diseases, including HNC [15].
In relation to age, results show that HNC was lethal for male and female patients aged between 50 and 79 died. In general, the neoplasm develops mainly in men, over the age of 40. This is partly due to the fact that the older the age, the greater the exposure to risk factors, such as tobacco and alcohol consumption throughout life, carcinogens associated with diet, sedentary lifestyle, and professional activity, among others [16]. The low HNC incidence in children noted in the study may be associated with a lower propensity of children and adolescents to develop this neoplasm. One of the possible factors for the low incidence may be related to genetic susceptibility and predisposition to HNC, environmental factors, and the reduced time of exposure to carcinogens [17].
When associated with HNC mortality, low education is relevant in epidemiological terms, considering that it, accompanied by lower economic income, can lead to poor access to health insurance, examinations and appropriate and specialized treatments, which, sometimes, demand a waiting list for appropriate care in the public service. This also includes the longer delay in searching for specialized services by this population, which seek health services when the disease is in advanced stage, reducing the chances of successful treatment and prognosis [18].
Considering the miscegenation of the population of Santa Catarina, this study observed that the majority of deaths were in white subjects, which is in line with the literature that indicates that there is a greater genetic predisposition for the development of HNC in this population. It is important to analyze the population’s cultural habits, such as tobacco and alcohol consumption [19]. Santa Catarina has a tradition in tobacco cultivation, and it is responsible for a significant portion of the total national production of this product, especially the two macro-regions in which the highest mortality rate was found (South and North and Northeast Plateau), a factor that can impact directly on availability and consumption, in addition to exposure of consumers and workers to carcinogenic agents.
It is also important to verify the access to health services by the population of the macro-regions with the highest death rates, as regular examinations and medical consultations are essential to identify possible symptoms and initiate appropriate treatments [16]. Accuracy in analyzing the geographic distribution of HNC mortality, with the identification of regions with the highest disease incidence, can assist in the allocation of financial resources and the implementation of specific prevention and control strategies and tracking actions, encouraging the population to undergo periodic examinations and more intensive screening programs.
In relation to lifestyle, the exposure of adolescents to smoking cigarettes can contribute to addiction and unhealthy habits and the incidence of mortality in the medium and long term [20–22]. In numbers, men are the largest consumers and represent the greatest number of tobacco farmers, and therefore are more exposed to cigarettes and pesticides [23]. Besides, evidence shows that these are the people who most often abandon attempts to quit smoking [24]. Municipalities with a higher rate of smoking and excessive alcohol consumption tend to have higher HNC death rates. This reinforces the importance of awareness raising campaigns and prevention programs.
It was found that data regarding income were not made available on the websites surveyed, which could help the mapping of the population and its association with the HNC mortality incidence. Furthermore, people with lower income are more exposed to risk factors, such as smoking and excessive alcohol consumption, which are directly related to the development of this type of cancer or other neoplasms [25].
Conclusion
Therefore, data on HNC mortality in the state of Santa Catarina demonstrated considerable numbers of deaths in the North/Northeast and South Plateau macro-region, which coincide with greater planting of tobacco in the State and possible exposure to carcinogenic factors from these agricultural products. The majority of subjects who died were men, white, over 60 years of age, with low education, and due to laryngeal cancer. Women had a higher thyroid cancer death rate, with the exception of the Central-West and Serra Catarinense macro-region.
This study constitutes an important tool for managers, researchers, and health professionals, as it highlights the need to improve the health service, with an emphasis on prevention and health promotion services, greater access by the population that comes from greater socioeconomic and socio-demographic restrictions, access to specialized health services, in addition to raising this population’s awareness to improve their quality of life.
Funding
This research received no external funding.
Declarations
Ethical Approval
While formal ethical approval was not obtained for this study, we ensured that all aspects of the research were conducted ethically and with respect for the rights and well-being of the participants.
Informed Consent
Informed consent was obtained from all participants involved in the study, and this information has been appropriately included in the manuscript.
Conflict of Interest
There are no conflicts of interest to declare related to this research.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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