2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Lung Cancer in Brazil
Overview: Cancer is now the second leading cause of death
in Brazil (after cardiovascular diseases) and a public health
problem, with around 500,000 new cases in 2012. Excluding
nonmelanoma skin cancer, lung cancer is the second most
incident cancer type in men, with 17,210 expected new cases.
In women, it is the fifth most incident cancer, with 10,110
expected new cases. The estimated age-adjusted lung cancer
mortality rate is about 13/100,000 for men and 5.4/100,000 for
women. Lung cancer rates in men increased until the early
1990s and decreased thereafter, especially in the younger
population. In contrast, a steady upward trend was observed
for women. The positive effects in men were probably due to
the successful anti-tobacco campaign conducted in Brazil
over the last decades, which led to a decrease in the adult
WORLDWIDE, LUNG cancer is the number one cause
of cancer death in men and the second in women,
with more than 1.6 million new cases and 1.4 million deaths
every year. Notably, the majority of lung cancer cases now
occur in developing countries (55%), a substantial increase
since the 1980s, when only one-third of cases occurred in
these regions. 1
Considering that cigarette smoking is the main causative
factor for about four of five lung cancer deaths in men and for
one-half of deaths in women, the variation in incidence
largely reflects the patterns of tobacco consumption. Environmental
exposure to other causative factors—such as
asbestos, radon, arsenic, radiation, air pollution, coal smoke,
and indoor emission from unventilated coal-fueled stoves
and cooking—is also relevant in specific regions. 2
Epidemiology
Brazil is the largest country in South America, with an
estimated population of more than 190 million. Cancer is
now the second most common cause of death in most
geographic regions in the country (Fig. 1). In 2012, more
than 500,000 new cancer cases are estimated, equally distributed
between genders. Lung cancer will be responsible
for around 17,210 new cancer cases in men and 10,110 new
cases in women (Fig. 2). Male lung cancer increased until the
early 1990s and decreased in the 2000s, especially in the
younger population. In women, there was a steady upward
trend for cancers of the lung during the same period. 3
Recent data from the Brazilian National Cancer Institute
estimate that lung cancer is the second and fifth most
common type of cancer among men and women, respectively
(not including nonmelanoma skin cancers) (Fig. 2). Trends
in lung cancer mortality showed that the age-adjusted
mortality rate among men increased from 10.6 to 13.1/
100,000 between the years 1979 and 2004, with an increase
from 3.0 to 5.4/100,000 among women during the same
period. As a rule, lung cancer mortality rates in Brazil are
significantly higher among men. Specific rates for men over
the age of 64 and for women of all ages are increasing.
Notably, there is a lesser risk of mortality among men born
after 1950 and an increasing risk across all cohorts among
women. The results regarding younger generations indicate
that present trends are likely to continue. Interestingly, the
cohort effect in women points to an increasing trend in
426
By Gilberto Schwartsmann, MD, PhD
smoking population, from 32% in the early 1980s to 17% in the
2000s. Although the Brazilian National Cancer Institute is
strongly committed to providing excellence in multimodality
care to cancer patients, limitations in availability and adequate
geographic distribution of specialists and wellequipped
cancer centers are evident. Major disparities in
patient access to proper staging and state-of-the-art treatment
still exist. Considering that World Health Organization
(WHO) officials estimate that cancer will become the number
one cause of death in most developing countries, including
Brazil, in the next decades, it is highly recommended for
government authorities to implement firm actions to face this
tremendous challenge.
mortality rates, whereas the reduction in rates in men
younger than age 65 suggests that the above-mentioned
trend should continue, probably as a consequence of the
tobacco control measures adopted after the 1980s. 4
Lung Cancer in Never Smokers
As previously reported, patients who have never smoked
tend to have a better survival rate than patients who did
smoke, regardless of gender and histologic type. This was
also illustrated by a report by Brazilian investigators from a
large academic hospital in Sao Paulo, Brazil, where 56 of
285 (19%) patients with non-small cell lung cancer (NSCLC)
were never smokers. They were more likely to be female
(68% vs. 32%) and have adenocarcinoma (70% vs. 51%). 5
Prevention and Early Diagnosis
Brazil was one of the first countries to support the WHO
Framework Convention on Tobacco Control and, over the
last few decades, implemented several tobacco control measures,
including banning smoking in public places, restricting
tobacco advertising and promotion, counter-advertising,
raising the price of cigarettes, and providing counseling for
tobacco dependence. As a result, the rate of active smokers
dropped from approximately 32% in the late 1980s to 17% in
the 2000s. Brazilian authorities are projecting a further
0.3% annual reduction in smoking, with an expected smoking
population of approximately 11% by 2020. 6
Worldwide, late diagnosis is a critical component of the
dismal survival rates of patients with lung cancer. As
localized disease can be treated with curative intent, new
hope is derived from the identification of effective screening
efforts. Recent trials have demonstrated that lung cancer
From the Department of Medical Oncology, Hospital de Clínicas de Porto Alegre, Federal
University of Rio Grande do Sul, Porto Alegre, Brazil; and South-American Office for
Anticancer Drug Development, Porto Alegre, Brazil.
Author’s disclosure of potential conflicts of interest are found at the end of this article.
Address reprint requests to Gilberto Schwartsmann, MD, PhD, Department of Medical
Oncology, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul,
Rua Ramiro Barcelos 2350/s399, CP 90 035-903, Porto Alegre, RS, Brazil; email:
gilberto.ez@terra.com.br.
© 2012 by American Society of Clinical Oncology.
1092-9118/10/1-10