Melanoma is the most aggressive type of skin cancer, with a continuous increase in its incidence worldwide, with an estimated 324,635 new cases in 2020.
The highest frequency of cutaneous melanoma is in individuals between 40 and 60 years. However, this is one of the most frequently diagnosed neoplasms in young adults (20-29 years of age) and therefore a relatively important cause of years of life lost during productive ages.
In Brazil, the creation of the Unified Health System (SUS) aimed to guarantee and expand the accessibility to health services by the population. However, socioeconomic discrepancies, such as family income, quality of services offered, and travel costs, bring health access disparities.
The four main barriers to health access are structural, financial, and personal/cultural.
In this context, we aimed to evaluate the conditions of access to the health system for diagnosis and treatment and the social, economic, and cultural characteristics of melanoma patients treated in a public tertiary hospital.
This was a cross-sectional observational study with a consecutive collection of newly diagnosed cases of melanoma.
This study followed all ethical standard guidelines and was approved by the Barretos Cancer Hospital internal ethical review board (#1595/2018). All patients signed an informed consent form before answering to the sociodemographic questionnaire.
This study was conducted at Barretos Cancer Hospital (BCH), located in the city of Barretos -São Paulo, Brazil. The BCH is a specialized medical institution dedicated to providing comprehensive and accessible care to cancer patients, including those who rely on Brazil’s public healthcare system (SUS). With its multidisciplinary approach, state-of-the-art facilities, and a strong focus on research and innovation, the hospital offers a wide range of services, from diagnosis to treatment and palliative care, and stands as a leading institution in the field of oncology in Brazil, providing vital support to cancer patients within the framework of the SUS.
The data were collected from 101 melanoma patients treated at the Department of Melanoma, Sarcoma, and Mesenchymal Tumors of the BCH, from December 2018 to March 2020. The inclusion criteria were patients over 18 years old, diagnosed with cutaneous melanoma, and registered in the hospital up to 90 days before the inclusion in the study. The time pre-established by the researchers of 90 days after registration is based on the concept of long-term memory,
Clinical, histopathological, and treatment data were collected directly from the patient’s medical records. Patients’ tumors were classified into early stage (0, I, and II) and advanced stage (III and IV), using the 8th edition of the AJCC Cancer Staging Manual.
A sociodemographic questionnaire was adapted and applied during an interview with the patient before the medical appointment (Supplementary Form 1).
Data related to the Human Development Index (HDI) of the patient’s city were obtained through the Atlas of Human Development in Brazil
All data collected were stored on the REDCap (Research Electronic Data Capture) platform.
Melanoma cases were geocoded by obtaining the geographical coordinates of the subjects’ residence addresses, using the BatchGeo platform.
The statistical program SPSS 23.0 was used for data tabulation and analysis. The chi-square or Fisher’s test was used to identify possible associations between discrete variables of interest. Multivariate analysis of risk factors was performed according to exploratory findings of univariate analysis, through logistic regression, where all variables with p-value ≤0.2 were included in the model. The dependent variable was tumor staging.
The statistical significance for all analyses was p≤0.05 and 95% confidence intervals (CI).
One hundred and one patients were included in the study between December 2018 and March 2020.
The mean age of the patients at diagnosis was 54.8. Fifty-two patients came from the state of São Paulo.
| Characteristic | N (%) |
|---|---|
| Sex | |
| Male | 53 (52.5) |
| Female | 48 (47.5) |
| Self-declared color | |
| White | 75 (74.3) |
| Brown | 19 (18.8) |
| Black | 7 (6.9) |
| Sun exposure | |
| Chronicle | 47 (46.5) |
| Intermittent | 20 (19.8) |
| None | 21 (20.8) |
| No information | 13 (12.9) |
| Number of people in residence | |
| 1 | 15 (14.9) |
| 2-3 | 59 (58.4) |
| 4-7 | 27 (26.7) |
| Residence location | |
| Urban area | 82 (81.2) |
| Rural area | 19 (18.8) |
| Residence situation | |
| Own | 81 (80.2) |
| Rented | 7 (6.9) |
| Ceded | 13 (12.9) |
| Educational level | |
| Elementary school | 49 (48.5) |
| High School | 25 (24.8) |
| Higher education | 23 (22.8) |
| No study | 4 (4.0) |
| Monthly income | |
| Up to R$ 937.00 | 27 (26.7) |
| From R$ 937.00 to R$ 3,748.00 | 43 (42.6) |
| From R$ 3,748.00 to R$ 6,559.00 | 10 (9.9) |
| More than R$ 6,559.00 | 2 (2.0) |
| No income | 19 (18.8) |
| Median distance from residence to BCH, Km (range) | 330 (1.9 - 2.404) |
| Time from the residence to BCH | |
| Up to 1 hour | 18 (17.8) |
| 1-5 hours | 36 (35.6) |
| 5-10 hours | 29 (28.7) |
| More than 10 hours | 18 (17.8) |
| Means of transportation to BCH | |
| Offered by the city hall of origin | 47 (46.5) |
| Private vehicles | 40 (39.6) |
| Collective land transportation | 11 (10.9) |
| Other | 3 (3.0) |
| Gini index | |
| ≤0.50 | 45 (45.0) |
| ≥0.50 | 55 (55.0) |
| Municipal HDI | |
| Middle (0.550 - 0.699) | 13 (12.9) |
| High (0.700 - 0.799) | 79 (78.2) |
| Very high (0.800 - 1.000) | 9 (8.9) |
| Private healthcare plan | |
| Yes | 20 (19.8) |
| No | 81 (80.2) |
BCH: Barretos Cancer Hospital.
The municipal HDI average was 0.74 (0.64-0.82) and the municipal Gini index average was 0.50 (0.36-0.65). When categorizing both indexes (
The most common primary locations of the lesions were the trunk (32.7%) and lower limbs (25.7%), for both sexes. The superficial spreading histological subtype was the most frequent, representing 33.7% of the cases. The mean depth of the tumors (Breslow thickness) was 4.46mm (0.28-27.0mm). Most of the tumors did not present perineural invasion (69.3%), vascular invasion (71.3%), regression (60.4%), or microscopic satellitosis (62.4%). In addition, 45.5% of tumors did not present ulceration. According to the clinical stage, 54.4% of the patients presented tumors in the early stages and 45.6%, in the advanced stages (
| Characteristic | N (%) |
|---|---|
| Histological subtype | |
| Superficial spreading | 34 (33.7) |
| Nodular | 17 (16.8) |
| Acral lentiginous | 16 (15.8) |
| Fusocellular | 4 (4.0) |
| Lentigo maligna | 3 (3.0) |
| Ocular | 2 (2.0) |
| Verrucous | 1 (1.0) |
| Amelanotic | 1 (1.0) |
| Unclassifiable | 23 (22.8) |
| Missing | 29 (28.7) |
| Ulceration | |
| Yes | 30 (29.7) |
| No | 46 (45.5) |
| Missing | 25 (24.8) |
| Perineural invasion | |
| Yes | 5 (5.0) |
| No | 70 (69.3) |
| Missing | 26 (25.7) |
| Vascular invasion | |
| Yes | 5 (5.0) |
| No | 72 (71.3) |
| Missing | 24 (23.8) |
| Regression | |
| Yes | 12 (11.9) |
| No | 61 (60.4) |
| Missing | 28 (27.7) |
| Microscopic satelitosis | |
| Yes | 7 (6.90) |
| No | 63 (62.4) |
| Missing | 31 (30.7) |
| Tumor staging | |
| 0 | 10 (9.9) |
| I | 27 (26.7) |
| II | 18 (17.8) |
| III | 21 (20.8) |
| IV | 25 (24.8) |
| Sistemic treatment | |
| No indication | 70 (69.3) |
| Loco-regional or in transit disease | 2 (2.0) |
| Adjuvant treatment | 2 (2.0) |
| Non-visceral metastatic disease | 4 (4.0) |
| Visceral metastatic disease | 23 (22.8) |
According to the treatment of patients, 69.3% had no indication for systemic treatment. Of the 31 patients who underwent systemic treatment, 83.9% used only one therapeutic modality: 17 patients were treated with anti-PD-1 drugs, 8 with chemotherapy, and 1 with targeted therapy.
As the pathological staging is consistently associated with the prognosis,
Sex, time of suspicion of the lesion and the search for specialized help, time of appointment to the first consultation at the BCH, local HDI, type of means of transportation to the hospital, distance, and time of travel between the residence and the BCH were associated with different clinical stages (
| Characteristic | Initial stage N (%) | Advanced stage N (%) | p |
|---|---|---|---|
| Self-declared color | |||
| White | 44 (64.7) | 24 (35.3) | 0.161 |
| Non-white | 10 (47.6) | 11 (52.4) | |
| Age | |||
| ≤ 55 years | 29 (65.9) | 15 (34.1) | 0.317 |
| > 55 years | 25 (55.6) | 20 (44.4) | |
| Gender | |||
| Male | 20 (44.4) | 25 (55.6) | 0.002 |
| Female | 34 (77.3) | 10 (22.7) | |
| Residence location | |||
| Urban area | 46 (64.8) | 25 (35.2) | 0.115 |
| Rural area | 8 (44.4) | 10 (55.6) | |
| Educational level | |||
| Elementary school | 22 (52.4) | 20 (47.6) | 0.266 |
| High School | 17 (77.3) | 5 (22.7) | |
| Higher education | 13 (61.9) | 8 (38.1) | |
| No study | 2 (50.0) | 2 (50.0) | |
| Monthly income | |||
| Up to R$ 937.00 | 14 (56.0) | 11 (44.0) | 0.853 |
| More than R$ 937.00 | 30 (62.5) | 18 (37.5) | |
| No income | 10 (62.5) | 6 (37.5) | |
| Sun exposure | |||
| Chronicle | 25 (61.0) | 16 (39.0) | 0.750 |
| Intermittent | 9 (52.9) | 8 (47.1) | |
| None | 13 (65.0) | 7 (35.0) | |
| Time between suspicion and finding a doctor | |||
| Less than 3 months | 18 (72.0) | 7 (28.0) | 0.057 |
| More than 3 months | 26 (49.1) | 27 (50.9) | |
| Time between appointment and first BCH consultation | |||
| Less than 1 month | 49 (66.2) | 25(33.8) | 0.017 |
| More than 1 month | 5 (33.3) | 10 (66.7) | |
| Gini index | |||
| ≤ 0.50 | 27 (69.2) | 12 (30.8) | 0.144 |
| > 0.50 | 27 (54.0) | 23 (46.0) | |
| Municipal HDI | |||
| Medium | 2 (22.2) | 7 (77.8) | 0.037 |
| High | 47 (66.2) | 24 (33.8) | |
| Very high | 5 (55.6) | 4 (44.4) | |
| Private healthcare plan | |||
| Yes | 10 (52.6) | 9 (47.4) | 0.418 |
| No | 44 (62.9) | 26 (37.1) | |
| Means of transportation | |||
| Private vehicle | 22 (61.1) | 14 (38.9) | 0.025 |
| Provided by the City Hall | 29 (70.7) | 12 (29.3) | |
| Collective transportation | 2 (22.2) | 7 (77.8) | |
| Distance from the residence to the BCH | |||
| Up to 330 Km | 34 (70.8) | 14 (29.2) | 0.034 |
| More than 330 Km | 20 (48.8) | 21 (51.2) | |
| Travel time from residence to BCH | |||
| Up to 5 hours | 36 (70.6) | 15 (29.4) | 0.027 |
| More than 5 hours | 18 (47.4) | 20 (52.6) |
BCH: Barretos Cancer Hospital; HDI: Human Development Index.
Most (55.6%) of male patients had advanced-stage melanomas at diagnosis whereas 77.4% of female patients had early-stage melanomas (p=0.002). Regarding the time between the appointment and the first consultation in the BCH, 66.7% of the patients who took more than one month to be consulted arrived with advanced tumors, while 66.2% of the patients who were consulted within one month arrived with initial tumors (p=0.017) (
Figure 1 Association between the time from diagnosis to the first consultation at Barretos Cancer Hospital (BCH) and the clinical stage of the patients.
Figure 2 Association between the time from suspicion to the search for medical help and the patient’s clinical stage.
Finally, we performed a multivariate analysis to verify the chance of patients being diagnosed with advanced-stage melanoma. The variables self-declared color, sex, residence location, Gini index, municipal HDI, transportation used, the time between suspicion and search for a physician, the time between appointment and first visit at the BCH, and distance between the residence and the hospital were included in the model. The variables sex, HDI, means of transportation, and time between appointment and first BCH consultation remained independently associated with risk in our model (
| Characteristic | Odds Ratio | CI (95%) | p |
|---|---|---|---|
| Gender | |||
| Male | Reference | ||
| Female | 0.131 | 0.031 - 0.547 | 0.005 |
| HDI | |||
| Middle | Reference | ||
| High | 0.033 | 0.003 - 0.375 | 0.006 |
| Very high | 0.093 | 0.005 - 1.653 | 0.106 |
| Means of transportation | |||
| Collective transportation | Reference | ||
| Private vehicle | 0.043 | 0.005 - 0.394 | 0.005 |
| Provided by the City Hall | 0.025 | 0.003 - 0.228 | 0.001 |
| Time between appointment and first BCH consultation | |||
| More than 1 month | Reference | ||
| Less than 1 month | 0.063 | 0.012 - 0.345 | 0.001 |
CI: Confidence Interval; HDI: Human Development Index; BCH: Barretos Cancer Hospital
The results of this study demonstrated that the socioeconomic and demographic status of melanoma patients impact their diagnosis and, consequently, their treatment conditions. The male sex, the lower HDI of the municipality in which they reside, the public transportation used for displacement to the hospital, and the prolonged time elapsed between scheduling and first consultation was related to a higher stage at diagnosis of the patients.
Regarding sex, male patients showed a greater chance of presenting advanced tumors in diagnosis. This characteristic is in accordance with a previous retrospective study that included 1,073 patients, where the discrepancy between genders regarding TNM staging was evidenced.
Most of the patients included in this study came from locations with high HDI, agreeing with a global population-based study that assessed the pattern of cancer change and HDI levels and found a high incidence of melanoma in regions with higher HDI.
In addition, another study found these same factors associated with a higher risk of death, where patients residing in regions whose educational level of the population was lower had a 20.9% increased chance of death, and for regions where the average annual income was less than $38,000, patients with melanoma had a 23.7% higher chance of death.
As for the means of transportation used, patients who do not depend on public transportation to access treatment had a lower chance of reaching the hospital with advanced tumors. The means of transportation were previously described as a barrier to access to cancer diagnosis and treatment.
The elapsed time for the first consultation at BCH also influenced the stages of the disease, so those who had consultation less than one month of scheduling showed lower chances of presenting advanced disease. Majeed et al. (2018)
It is important to note that some factors such as monthly income, educational level, and possession of private health insurance did not influence the outcomes of this study’s patients. A possible reason for the non-significant impact of those parameters remains in the specific context of Barretos Cancer Hospital, which provides accessible and comprehensive public healthcare services, providing equitable access to medical care for melanoma patients regardless of their income, education, or insurance status. The present study has certain limitations that merit consideration. Firstly, the number of patients included in the study was constrained due to the ongoing global SARS-CoV-2 pandemic, which limited direct contact with patients attending the institution. This circumstance may introduce a potential bias as it could impact the representation of certain patient groups or demographics. Secondly, the data collection process relied on a socioeconomic questionnaire, which did not directly address the specific reasons hindering access to healthcare for the patients. This limitation may have obscured important factors contributing to the barriers faced by the patients in seeking medical care. Furthermore, the categorical approach employed for collecting some of the data limited the depth of analysis for certain findings. This restriction in data representation might have resulted in an oversimplification of complex relationships and nuances within the study population. Consequently, the conclusions drawn from this study may not fully capture the intricate interplay of various factors affecting healthcare access.
Future studies with a larger and more diverse patient cohort and comprehensive data collection methods are essential to establish more robust causal relationships and gain a comprehensive understanding of the barriers to accessing healthcare.
In conclusion, we found that socioeconomic and demographic factors of patients with melanoma are associated with the conditions of access to diagnosis and treatment. Through the characterization of these conditions and the survey of living conditions related to the city where the patients live, it was possible to identify the limiting barriers to access. The distance and time of travel to the BCH, sex, time until the first consultation, municipal HDI, and the type of means of transportation used presented relevance in the issues surrounding access difficulties, culminating in a late diagnosis. Public health interventions with improvements in education and access to health services are the way to change the panorama presented here.
RJT: Collection and assembly of data, Conception and design, Data analysis and interpretation, Manuscript writing.
BPS: Data analysis and interpretation, Manuscript writing.
RDVL: Data analysis and interpretation.
AGR: Data analysis and interpretation.
FLV: Conception and design.
VLV: Conception and design, Final approval of manuscript.
| Supplementary Form 1 | |||
|---|---|---|---|
| Avaliação da acessibilidade ao sistema de saúde para o diagnóstico e tratamento do paciente com melanoma no Hospital de Câncer de Barretos | |||
| Identificação | |||
| Data de coleta de dados DD/MM/AAAA | |||
| 1 | ID paciente | 1 | |
| 2 | RH __-_____ | 2 | |
| 3 | Iniciais | 3 | |
| 4 | Endereço | 4 | |
| 5 | Cidade | 5 | |
| 6 | Telefone (__)_____-____ | 6 | |
| 7 | Data de nascimento DD/MM/AAAA | 7 | |
| 8 | Gênero 1- Masculino; 2- feminino | 8 | |
| 9 | Estado civil 1- Solteiro; 2- Casado; 3- Divorciado; 4- Viúvo; 5- União estável | 9 | |
| 10 | Naturalidade | 10 | |
| 11 | Nacionalidade 1- Brasileira; 2- Estrangeira | 11 | |
| 12 | Raça (autodeclarada) 1- Branco; 2- Negro; 3-Parda; 4- Amarelo; 5- Indefinida | 12 | |
| 13 | Ocupação atual | 13 | |
| 14 | Ocupação anterior | 14 | |
| 15 | Diagnóstico médico | 15 | |
| 16 | Médico responsável | 16 | |
| Questionário | |||
| 17 | Quantas pessoas residem com vocé? 1- Uma; 2- Duas a três; 3- Quatro a sete; 4- Oito a dez; 5- Mais de dez | 17 | |
| 18 | Sua casa é: 1- Propria; 2- Alugada; 3- Cedida; 4- Sem residencia fixa | 18 | |
| 19 | Sua casa está localizada em: 1- Zona urbana; 2- Zona rural; 3- Outros | 19 | |
| 20 | Qual é o seu nivel de escolaridade? 1- 1a à 4a série do Ensino Fundamental (antigo primario); 2- 5a à 8a série do Ensino Fundamental (antigo ginásio); 3- Ensino Medio (antigo 2º grau); 4- Ensino Superior; 5-Não estudou | 20 | |
| 21 | Qual é o nivel de escolaridade do seu pai? 1-1a à 4a série do Ensino Fundamental (antigo primario); 2- 5a à 8a série do Ensino Fundamental (antigo ginásio); 3- Ensino Medio (antigo 2º grau); 4- Ensino Superior; 5- Não sei dizer; 6- Não estudou | 21 | |
| 22 | Qual é o nivel de escolaridade da sua mãe? 1-1a à 4a série do Ensino Fundamental (antigo primario); 2- 5a à 8a série do Ensino Fundamental (antigo ginásio); 3- Ensino Medio (antigo 2º grau); 4- Ensino Superior; 5- Não sei dizer; 6- Não estudou | 22 | |
| 23 | Quanto é, aproximadamente, a renda mensal da sua familia? 1- Até R$ 937,00 (um salário mínimo); 2- De R$ 937,00 a R$ 3.748,00; 3- De R$ 3.748,00 a R$ 6.559,00; 4- Mais de R$ 6.559,00; 5- Outros | 23 | |
| 24 | Qual é, aproximadamente, a sua renda mensal? 1- Até R$ 937,00 (um salário mínimo);2- De R$ 937,00 a R$ 3.748,00; 3- De R$ 3.748,00 a R$ 6.559,00; 4- Mais de R$ 6.559,00; 5- Outros | 24 | |
| 25 | Quantas horas por semana você trabalha? 1- De 11 a 20 horas semanais; 2- de 21 a 30 horas semanais; 3- De 31 a 40 horas semanais; 4- Mais de 40 horas semanais; 5- Aposentado; 6- Não se aplica | 25 | |
| 26 | Com qual idade você começou a trabalhar? 1- Antes dos 14 anos; 2- Entre 14 e 16 anos; 3- Entre 17 e 18 anos; 4- Após os 18 anos; 5- Não se aplica | 26 | |
| 27 | Quanto tempo levou entre a suspeita em relação à lesão (pinta, ferida, etc.) e a procura de um médico? 1- 1 dia a 1 semana; 2- 1 semana a 2 semanas; 3- 2 semanas a um mês; 4- 1 mês a 3 meses; 5- Acima de 3 meses | 27 | |
| 28 | Quanto tempo você precisou esperar entre quando a consulta foi inicialmente agendada e quando você visitou o especialista? 1- Menos de 2 semanas; 2- De 2 semanas a 1 mês; 3- De 1 mês a 3 meses; 4- Acima de 3 meses | 28 | |
| 29 | Na sua opinião, o tempo de espera foi: 1- Demorado; 2- Aceitável; 3- Rápido; 4- Sem opinião | 29 | |
| 30 | Na sua opinião o processo até chegar aqui foi: 1- Difícil; 2- Normal; 3- Fácil; 4- Sem opinião | 30 | |
| 31 | Qual a distância, em Km, da sua casa até o hospital de câncer? 1- De 1 a 10 km; 2- De 10 a 50 km; 3- De 50 a 100 km; 4- De 100 a 500 km; 5- Acima de 500 km | 31 | |
| 32 | Quanto a distância impactou no tempo em que você demorou para ter a primeira consulta? 1- Me causou muito atraso; 2- Me causou um pouco de atraso; 3- Não me causou atraso 4- Não sei dizer | 32 | |
| 33 | Quanto tempo, em horas, você demora para chegar da sua casa ao hospital de câncer? 1- Até 1 hora; 2- De 1 a 5 horas; 3- De 5 a 10 horas; 4- Acima de 10 horas | 33 | |
| 34 | Como você avaliaria os cuidados prestados até agora? 1- Ruim; 2- Normal; 3- Bom; 4- Excelente; 5- Nenhuma das alternativas | 34 | |
| 35 | Qual meio de transporte você utiliza para chegar ao hospital de câncer? 1- A pé; 2- Veiculo proprio; 3- Transporte coletivo terrestre (ônibus/van) pago com recursos próprios; 4- Transporte coletivo aéreo (avião) pago com recursos próprios; 5- Transporte oferecido pela prefeitura de sua cidade; 6- Ambulancia; 7- Outros | 35 | |
| 36 | Você possui algum plano de saúde particular? 1- Sim; 2-Não | 36 | |
| 37 | Se sim, qual o principal motivo para adquirir um plano de saúde? 1- Segurança com a saúde; 2- Qualificação profissional dos médicos; 3- Melhor atendimiento; 4- Posse de plano vinculado à empresa; 5- Emergencial; 6- Atendimento rápido; 7- Outros | 37 | |
| 38 | Se sim, há quanto tempo tem este plano? 1- De 1 a 6 meses; 2- De 6 meses a 1 ano;3- De 1 ano a 3 anos; 4- mais de 3 anos | 38 | |
| 39 | Se sim, precisou utilizar este plano para: 1- Consultas; 2- Exames; 3- Internações; 4- Remédios; 5- Não sei | 39 | |
| 40 | Se sim, qual o seu tipo de plano? 1- Individual; 2- Familiar; 3- Coletivo por adesão; 4- Coletivo empresarial | 40 | |
| 41 | Se não, qual o principal motivo para não adquirir um plano de saúde? 1- Valor muito alto; 2- Falta de necessidade; 3- Falta de qualidade dos planos; 4- Falta de interesse; 5- Empresa não oferece; 6- Cobertura ruim; 7- Uso de atendimento particular; 8- Não necessita; 9- Outros | 41 | |
| 42 | Você pagou por consultas ou tratamentos antes do atendimento no Hospital de Câncer? 1- Sim; 2- Não | 42 | |
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Journal: Brazilian Journal of Oncology
DOI: 10.1055/s-00059887
e-issn: 2526-8732
Publisher: Thieme Revinter Publicações Ltda.
Publisher address: Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil
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