To the best of our knowledge, this is the first report to analyze the temporal trends in female breast cancer mortality in Brazil and to correlate them with social inequalities. The study of mortality trends is useful for monitoring changes in the epidemiological profile of the population.
The female breast cancer mortality rates in Brazil described in the present study are similar to rates found earlier in Chile, Costa Rica, Cuba, Puerto Rico and Venezuela , values expected for developing countries . However, they are higher than rates found in Colombia, Ecuador and Mexico (<10/100,000) . Female breast cancer mortality trends have remained stable in the country since 1994, this finding being in agreement with reports from another study (APC = 0.4%) .
A marked disparity was found between the different Brazilian states with respect to mortality rates, which ranged from 2-5/100,000 in the less developed areas of the country to 12-18/100,000 in the more developed regions. Although rates were higher in these states, there was a significant decrease in mortality rates in Rio Grande do Sul, Rio de Janeiro and São Paulo, similar to that seen in developed countries such as the US (APC = −1.9%)  and Portugal (APC = −0.9%) , and also in some developing countries such as Singapore (APC = −1.50%) . Nevertheless, the mortality rates here are lower than those found in these countries.
One possible hypothesis for the lower breast cancer mortality rates found in Brazil may be under-notification. It is known that the cancer registries cover only 6% of the Latin American population in comparison to 96% in the US and 32% in Europe . There are 17 population-based cancer registries in the country, 16 of which are located in state capital cities. Data collection varies from registry to registry and also from one year to another within a single registry .
Another hypothesis for the patterns of inequality in health found in Brazil with respect to breast cancer mortality may be the lack of available resources for treatment in the less developed states or the inaccessibility of the majority of the population to treatment. In some cases, the situation would be comparable to that found in Nigeria where there is no specific screening program within the national healthcare system and only two hospitals offering tertiary treatment (radiotherapy and chemotherapy) . Other problems identified in Brazil include: a lack of information on the disease, the time interval between the first signs/symptoms and first consultation (ranging from 1 to 60 months), delays in diagnosing and treating breast cancer and the time between histopathological diagnosis and the beginning of treatment.
The Amazona Project conducted by the Brazilian Group for Studies in Breast Cancer (GBECAM) collected data from 28 centers, including 4,912 cases of patients diagnosed with breast cancer in 2001 and 2006, representing all the geographical regions of the country and all socioeconomic levels. That study showed the disease to be more advanced at diagnosis in the women treated in public institutions, who had less access to modern therapies and poorer survival compared to patients treated in private institutions .
This study evaluated data from nationwide Brazilian surveys, databases and local studies, and its results highlight the gaps in information and the need to acquire further knowledge and to conduct more studies on various aspects. This report provides further information on female breast cancer mortality in Brazil, thus permitting actions to be implemented by enabling predictions to be made of what is required by women and by healthcare services. Although the treatment options for breast cancer are effective, they unfortunately remain inaccessible to many women living in developing areas. Lack of care has resulted in unnecessary deaths. The unequal distribution of resources for breast cancer care and control for women living in the same country is unacceptable.