Abstract

Introduction: Disparities in prostate cancer care have been evidenced and associated with sociodemographic and clinical factors, which establish the time for diagnosis and initiation of treatment. Objective: To evaluate the association of sociodemographic and clinical variables with the onset of prostate cancer treatment. Methods: This is a prospective longitudinal cohort study with secondary data with a population of men with prostate cancer attended in the periods 2010-2011 and 2013-2014 at the Santa Rita de Cássia Hospital in Vitória, Espírito Santo, Brazil. Results: The study population consisted of 1,388 men. Of the total, those younger than 70 years (OR = 1.85; CI = 1.49-2.31), nonwhite (OR = 1.30; CI = 1.00-1.70), less than 8 years of schooling (OR = 1.52; CI = 1.06-2.17) and referred by the Unified Health System services (OR = 2.52; CI = 1.84-3.46) were more likely to have a delayed treatment. Similarly, the lower the Gleason score (OR = 1.78; CI = 1.37-2.32) and Prostate-Specific Antigens levels (OR = 2.71; CI = 2.07-3.54), the greater the likelihood of delay for the onset of treatment. Conclusion: Therefore, sociodemographic and clinical characteristics exerted a strong influence on the access to prostate cancer treatment.

Keywords
Health services accessibility; Health equity; Time-to-treatment; Prostatic neoplasms

Introduction

Prostate cancer is the second most common form of cancer among men and the fifth leading cause of death for men around the world¹1 Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015; 136(5):E359-E386.. In Brazil, 61,200 new cases are estimated for the biennium 2016/2017, representing an estimated risk of 61.82 cases per 100,000 men²2 Brasil. Estimativa 2016: incidência de câncer no Brasil. Rio de Janeiro: INCA; 2015.. It has a growing mortality and incidence rate, although its magnitude is lower²2 Brasil. Estimativa 2016: incidência de câncer no Brasil. Rio de Janeiro: INCA; 2015..

Although survival rates after the diagnosis of prostate cancer have improved in the last two decades, survival analyses of socioeconomic status suggest inequalities, indicating a worse prognosis for lower income individuals³3 Klein J, von dem Knesebeck O. Socioeconomic inequalities in prostate cancer survival: A review of the evidence and explanatory factors. Soc Sci Med 2015; 142:9-18.. Black men also have a higher risk of being affected and dying from this type of cancer, which may be related to the difficult access to health services and different therapeutic approach⁴4 Barocas DA, Penson DF. Racial variation in the pattern and quality of care for prostate cancer in the USA: mind the gap. BJU Int 2010; 106(3):322-328.^,55 Siegel R, Ward E, Brawley O, Jemal A. The Impact of Eliminating Socioeconomic and Racial Disparities on Premature Cancer Deaths. CA Cancer J Clin 2011; 61(4):212-236..

The study revealed that men diagnosed in health systems that serve mainly populations of low socioeconomic status tend to have a significantly higher risk and disease staging compared to those seen in other services (even at comparable ages), a phenomenon that cannot be explained only by racial distributions⁶6 Cooperberg MR. Re-Examining Racial Disparities in Prostate Cancer Outcomes. J Clin Oncol 2013; 31(24):2979-2980.. Thus, unequal access to health services clearly plays a crucial role in delayed diagnosis and treatment⁷7 Barocas DA, Grubb R, Black A, Penson DF, Fowke JH, Andriole G, Crawford D. Association Between Race and Follow-Up Diagnostic Care After a Positive Prostate Cancer Screening Test in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Cancer 2013; 119(12):2223-2229..

In 2012, the Brazilian government published Law 12.732, which establishes a 60-day deadline for the onset of treatment in the Unified Health System (SUS) after diagnosis for all types of neoplasms, with the objective of minimizing and eliminating gaps in the access to cancer treatment⁸8 Brasil. Lei nº 12.732, de 22 de novembro de 2012. Dispõe sobre o primeiro tratamento de paciente com neoplasia maligna comprovada e estabelece prazo para seu início. Diário Oficial da União 2012; 23 nov.. A universal and comprehensive approach, according to the doctrinal precepts of SUS is required to achieve this.

Thus, in order to verify whether access to prostate cancer treatment has been equitably promoted by the health care network, this study aims to evaluate the association of sociodemographic and clinical variables with the time to begin treatment of men attended at a an oncology hospital of reference in the State of Espírito Santo, Brazil.

Methods

This is a prospective longitudinal cohort study with secondary data. The study population consisted of men with prostate cancer treated in the period from 2010 to 2014, except for the year 2012, at the Hospital Santa Rita de Cássia Hospital - Women’s Association of Education and Fight against Cancer (HSRC-AFECC), located in the municipality of Vitória, Espírito Santo, Brazil. The hospital is accredited by the SUS as a High Complexity Oncology Center (CACON) and is a reference in the State of Espírito Santo.

We excluded men who started treatment at another hospital, in active surveillance, with treatment paid by health plans or private outlay, as well as cases with incomplete records of time-related variables. The exclusion of these individuals is justified because the study was carried out in a reference hospital and it was interested in evaluating the population at all stages of the treatment funded by SUS. Cases diagnosed in 2012 were not included in the survey in order to avoid the possible effect of adapting the service to comply with Law 12.732. Thus, since 2012 was the year of implementation, it was decided not to include it.

Data were extracted from the Tumor Registry Data Sheets that provide data for the Hospital Cancer Records Information System (SISRHC) and medical records. For the collection of data that were not included in the Tumor Registry Data Sheets, a specific tool developed by the researcher was used to analyze medical records and contained the following variables: clinical staging, Gleason score, prostate-specific antigen (PSA) levels, outcome, date of last consultation and of referral to HSRC-AFECC.

Data were tabulated in the Microsoft Office Excel 2007 program and later analyzed through the Statistical Package for Social Sciences (SPSS), version 20.0. The statistical analysis used frequency calculations, measures of central tendency (mean and median) and variability (standard deviation). Chi-square tests of association between the times of diagnosis and the onset of treatment and between the first consultation and the onset of treatment with the sociodemographic and clinical variables of the study were applied. The level of significance was set at 0.05. Odds ratios were calculated and adjusted by the logistic regression model for all variables with a p-value < 0.10.

The project was submitted to the Research Ethics Committee of the Health Sciences Center of the Federal University of Espírito Santo and approved.

Results

In the study period, 1,940 men with a diagnosis of prostate cancer were attended at the HSRC-AFECC. Of this total, we excluded 304 (15.6%) because they started treatment outside the HSRC-AFECC, 190 (9.8%) because they were on active surveillance and/or did not generate an income value, 34 (1.7 %) because their treatment was funded by a health plan or private outlay and 14 (0.7%) because they lacked information. The study population was arrived at 1,388 men.

Table 1 shows the results of the associations of sociodemographic variables and service times.

We found that the highest percentage of men who had started treatment within 60 days, counted from the first consultation at the HSRC-AFECC were those aged 71 years or older (p = 0.001). However, non-whites had a time interval greater than 60 days between the first consultation and treatment (p = 0.050). As for schooling, most of those enrolled started treatment within 60 days, both from the date of diagnosis (p = 0.027) and the date of the first consultation at the hospital (p = 0.022). Thus, being under 70 years of age, being non-white and having less than eight years of schooling were determinants of delayed treatment initiation.

In relation to the effects of Law 12.732, there was no difference in the time between diagnosis and the onset of treatment, however, there was a greater interval between the date of the first consultation and the onset of treatment (p = 0.020).

Subjects who were referred to the hospital without diagnostic confirmation had a shorter time to treatment, both from diagnosis (p = 0.001) and first consultation at the HSRC-AFECC (p = 0.001). This was the case with those whose referral origin was non-SUS services, most of which showing a time interval of under 60 days to start treatment, counted from the first consultation to the institution (p = 0.001).

Table 2 shows the clinical variables. We can observe that the greater the clinical staging, the Gleason score and PSA levels, the higher the probability of the treatment starting within 60 days, both when based on the date of diagnosis (p = 0.001) and the date of the first consultation at the HSRC-AFECC (p = 0.001). Men with more advanced disease have priority in establishing and initiating definitive treatment, whereas those with localized disease tend to wait longer to start treatment.

Table 3 shows crude and adjusted odds of the logistic regression model of the sociodemographic and clinical variables that showed p < 0.10, when associated to the time between diagnosis and first consultation at the specialized service. The adjusted OR showed a greater risk of delay in time between diagnosis and first consultation at the HSRC-AFECC of men who arrived at the institution with diagnosis (OR = 3.08; CI = 1.79-5.29), who were referred by SUS services (OR = 2.45, CI = 1.56-3.85), who had a Gleason score from 2 to 6 (OR = 2.59, CI = 1.55-4.32) and PSA levels below 10 ng/dL (OR = 4.42, CI = 2.59-7.54).

While Table 4 expresses crude and adjusted odds of sociodemographic and clinical variables associated with the time between the first consultation and onset of treatment at the HSRC-AFECC, we can identify that the adjusted OR poses a greater risk of delay for treatment in men with up to 54 years (OR = 2.59; CI = 1.13-5.96), non-white (OR = 1.45; CI = 1.01-2.11), with up to 8 years of study (OR = 2.04; CI = 1.20-3.48), originating from the SUS (OR = 2.26; CI = 1.49-3.44), with PSA below 10 ng/dL (OR = 2.38; CI = 1.60-3.54), and in those with PSA ranging from 10 to 19 ng/dL (OR = 2.18, CI = 1.43-3.33). However, reaching the hospital with diagnosis and no treatment was a protective factor (OR = 0.03; CI = 0.01-0.09).

Discussion

This study assumes the analysis of factors associated with delayed care, diagnosis and onset of treatment of men with prostate cancer attended at a state hospital of reference in oncology.

We observed that men older than 71 years mostly began treatment within 60 days of the first consultation at the institution, while those under 70 years of age exceeded this period. A study conducted in Canada⁹9 Stevens C, Bondy SJ, Loblaw A. Wait times in prostate cancer diagnosis and radiation treatment. Can Urol Assoc J 2010;4(4):243-248. identified that individuals over 70 years of age had a longer delayed referral to the urologist. However, those under 70 took longer to receive the first fraction of radiotherapy. A research conducted in Baltimore, USA¹⁰10 O'Brien D, Loeb S, Carvalhal GF, McGuire BB, Kan D, Hofer MD, Casey JT, Helfand BT, Catalona WJ. Delay of surgery in men with low risk prostate cancer. J Urol 2011; 186(6):2143-2147. found that the mean age of men who had a delay of less than six months for surgery was 59 years, while the mean age of those who delayed more than six months for surgery was 61 years. In the United Kingdom¹¹11 Redaniel MT, Martin RM, Gillatt D, Wade J, Jeffreys M. Time from diagnosis to surgery and prostate cancer survival: a retrospective cohort study. BMC Cancer 2013; 13:559-564., long intervals between diagnosis and surgery were associated with increased age and individuals over 65 years had on average 97 days of waiting for surgery. The results found in this research seem to indicate that the health institution has reduced obstacles to access and use of health actions, giving priority to meeting the individual needs of the elderly.

Skin color/ethnicity has been treated as a variable that conditions access to health services. In this study, more than half (55%) of non-whites took more than 60 days to start treatment from the first consultation, pointing to the interrelationships between the socioeconomic and racial inequalities that generate these gaps in access to health. In the United States¹²12 Kinlock BL, Thorpe Junior RJ, Howard DL, Bowie JV, Ross LE, Fakunle DO, LaVeist TA. Racial Disparity in Time Between First Diagnosis and Initial Treatment of Prostate Cancer. Cancer Control 2016; 23(1):47-51., research also identified that black men were more likely to delay initiating treatment when compared to white men. Another American study¹³13 Stokes WA, Hendrix LH, Royce TJ, Allen IM, Godley PA, Wang AZ, Chen RC. Racial differences in time from prostate cancer diagnosis to treatment initiation: a population-based study. Cancer 2013; 119(13):2486-2493. found that African Americans had the longest intervals between diagnosis and treatment in all risk groups, and this difference is exacerbated in the high-risk group. In Brazil¹⁴14 Nardi AC, Reis RB, Zequi SC, Nardozza Junior A. Comparison of the epidemiologic features and patterns of initial care for prostate cancer between public and private institutions: a survey by the Brazilian Society of Urology. Int Braz J Urol 2012; 38(2):150-161., a research indicated that skin color influenced the type of treatment, in which blacks were less prone to the surgical procedure. Ethnical disparities in prostate cancer care have been documented in all neoplasm management stages, from introduction, diagnosis, treatment, survival to death, and black men had the highest burden in the whole care process¹⁵15 Chornokur G, Dalton K, Borysova M, Kumar N. Disparities at presentation, diagnosis, treatment and survival in african american men, affected by prostate cancer. Prostate 2011; 71(9):985-997.. Such disparities are complex and involve determinants of biological, socioeconomic and sociocultural nature¹⁵15 Chornokur G, Dalton K, Borysova M, Kumar N. Disparities at presentation, diagnosis, treatment and survival in african american men, affected by prostate cancer. Prostate 2011; 71(9):985-997.

16 Xu J, Janise J, Ruterbusch J, Ager J, Schwartz KL. Racial differences in treatment decision-making for men with clinically localized prostate cancer: a population-based study. J Racial and Ethnic Health Disparities 2016; 3(1):35-45.^-1717 Schmid M, Meyer CP, Reznor G, Choueiri TK, Hanske J, Sammon JD, Abdollah F, Chun FK, Kibel AS, Tucker-Seeley RD, Kantoff PW, Lipsitz SR, Menon M, Nguyen PL, Trinh QD. Racial differences in the surgical care of medicare beneficiaries with localized prostate cancer. JAMA Oncol 2016;2(1):8593.. Despite the recent debate on prejudice and discrimination, as in other societies marked by a history of colonization and slavery, ethnic and racial prejudice is still very much alive in Brazil, as are inequalities unfavorable to blacks, browns and indigenous people¹⁸18 Schmidt MI, Ducan BB, Azevedo e Silva G, Menezes AM, Monteiro CA, Barreto SM, Chor D, Menezes PR. Doenças crônicas não transmissíveis no Brasil: carga e desafios atuais. Lancet 2011; 377(9781):61-74..

Regarding the constraints or inequalities in access to diagnostic procedures and treatment in Brazil, it is important to note that people who identify their ethnicity or skin color as brown or black tend to belong to lower income and schooling groups¹⁹19 Paim J, Travassos C, Almeida C, Bahia L, Macinko J. O sistema de saúde brasileiro: história, avanços e desafios. Lancet 2011; 377(9781):11-31.. Schooling influenced both the time between diagnosis and treatment and between the first consultation at the HSRC-AFECC and the onset of treatment. In both cases, men under eight schooling years generally started treatment at a time interval greater than 60 days, while the ones with higher schooling years received the first treatment at a shorter interval. In the two US studies cited above¹²12 Kinlock BL, Thorpe Junior RJ, Howard DL, Bowie JV, Ross LE, Fakunle DO, LaVeist TA. Racial Disparity in Time Between First Diagnosis and Initial Treatment of Prostate Cancer. Cancer Control 2016; 23(1):47-51.^,1313 Stokes WA, Hendrix LH, Royce TJ, Allen IM, Godley PA, Wang AZ, Chen RC. Racial differences in time from prostate cancer diagnosis to treatment initiation: a population-based study. Cancer 2013; 119(13):2486-2493., both found that black men were younger, had lower income and with a lower educational level when compared to whites. However, a Spanish study²⁰20 Bonfill X, Martinez-Zapata MJ, Vernooij RW, Sánchez MJ, Suárez-Varela MM, de la Cruz J, Emparanza JI, Ferrer M, Pijoán JI, Ramos-Goñi JM, Palou J, Schmidt S, Abraira V, Zamora J Clinical intervals and diagnostic characteristics in a cohort of prostate cancer patients in Spain: a multicentre observational study. BMC Urol 2015; 15:60-69. did not find an association between the time elapsed from the diagnosis to the first treatment with the educational level. Although inequalities by schooling level in the use of health services are decreasing consistently in Brazil¹⁹19 Paim J, Travassos C, Almeida C, Bahia L, Macinko J. O sistema de saúde brasileiro: história, avanços e desafios. Lancet 2011; 377(9781):11-31., it is still a huge challenge. However, these inequalities can also be attributed to different behaviors when seeking health care. People in the lower schooling groups may postpone the decision to seek health care due to negative experiences to obtain care in the basic network, or prejudices and fears related to the rectal touch problematized by hegemonic masculinity²¹21 Gomes R, Rebello LEFS, Araújo FC, Nascimento EF. A prevenção do câncer de próstata: uma revisão da literatura. Cien Saude Colet 2008; 13(1):235-246., or due to other factors such as the impossibility of missing work.

Regarding Law 12.732, it can be seen that it has not yet had any impact on the time between diagnosis and treatment in the hospital institution, only negatively affecting the interval between the first consultation and the treatment. In the years following the Law, approximately 60% of men with prostate cancer started receiving therapy after 60 days of the first hospital visit. Surveys regarding the waiting time for the treatment of men with prostate cancer in the country are incipient and did not exist in the period after the publication of the Law. In this context, an important aspect to be considered concerns recommendations for the prevention and treatment of prostate cancer, which are both diverse and somewhat controversial between different takes²¹21 Gomes R, Rebello LEFS, Araújo FC, Nascimento EF. A prevenção do câncer de próstata: uma revisão da literatura. Cien Saude Colet 2008; 13(1):235-246., including the indication of expectant behavior as a therapeutic approach, especially for older individuals or those with other important health problems.

It was observed that arriving at the hospital without diagnosis and without treatment presupposes a greater probability of starting the treatment within 60 days, counted both from the first consultation at the institution and from the date of diagnosis. This fact is also identified in a study that analyzed the time between diagnosis and treatment of elderly women with breast cancer, reporting that women who received the diagnosis and all the treatment in the service evaluated achieved better times²²22 Souza CB, Fustinoni SM, Amorim MHC, Zandonade E, Matos JC, Schirmer J. Estudo do tempo entre o diagnóstico e início do tratamento do câncer de mama em idosas de um hospital de referência em São Paulo, Brasil. Cien Saude Colet 2015; 20(12):3805-3816.. However, previous research in the HSRC-AFECC²³23 Zacchi SR, Amorim MHC, Souza MAC, Miotto MHMB, Zandonade E. Associação de variáveis sociodemográficas e clínicas com o estadiamento inicial em homens com câncer de próstata. Cad. Saúde Colet 2014; 22(1):93-100. identified that men who arrived with diagnosis and without treatment were less likely to be in the late stage, whereas those who came without diagnosis and without treatment tended to have more advanced stages. In this case, it is necessary to consider, in particular, the poor organization of the regionalized service network, with mechanisms that are still ineffective in terms of regulation and referrals and counter-referrals due to structural, procedural and political obstacles, such as imbalance of power between among network members, the lack of accountability of stakeholders involved, administrative discontinuities and high turnover of managers.

Regarding the origin of referrals, men referred by establishments of the SUS had longer intervals between the diagnosis and the treatment and consultation and the treatment, in comparison with individuals referred by private health establishments. A North American study¹⁵15 Chornokur G, Dalton K, Borysova M, Kumar N. Disparities at presentation, diagnosis, treatment and survival in african american men, affected by prostate cancer. Prostate 2011; 71(9):985-997. highlighted that adequate coverage of health plans can be an important determinant in the detection of the tumor of prostate cancer in curable stage, enabling a timely treatment and reducing disparity. Another study developed in the United States²⁴24 Schymura MJ, Kahn AR, German RR, Hsieh M, Cress RD, Finch JL, Fulton JP, Shen T, Stuckart E. Factors associated with initial treatment and survival for clinically localized prostate cancer: results from the CDCNPCR Patterns of Care Study (PoC1). BMC Cancer 2010; 10:152. found an association between having a public health plan with conservative treatment, as well as advanced age, blacks, singles, PSA above 20 ng/dl, low Gleason score (2-4) and comorbidities. A study conducted in the State of São Paulo¹⁴14 Nardi AC, Reis RB, Zequi SC, Nardozza Junior A. Comparison of the epidemiologic features and patterns of initial care for prostate cancer between public and private institutions: a survey by the Brazilian Society of Urology. Int Braz J Urol 2012; 38(2):150-161. described the profile of men with prostate cancer from the SUS as being black, elderly, with high PSA, greater probability of metastasis and less likely to receive definitive treatment, such as surgery. Findings of the Brazilian research show similarities with the aforementioned American research, although both were carried out in different health system contexts, one of which was universal, and the other not. While the use of services varies widely between those who have health plans and those who do not, we have found that the gap between these two groups is decreasing¹⁹19 Paim J, Travassos C, Almeida C, Bahia L, Macinko J. O sistema de saúde brasileiro: história, avanços e desafios. Lancet 2011; 377(9781):11-31.. However, according to these authors, as the private sector market increases, interactions between public and private sectors create contradictions and unfair competition, generating negative results in equity, access to health services and health conditions¹⁹19 Paim J, Travassos C, Almeida C, Bahia L, Macinko J. O sistema de saúde brasileiro: história, avanços e desafios. Lancet 2011; 377(9781):11-31.^,2121 Gomes R, Rebello LEFS, Araújo FC, Nascimento EF. A prevenção do câncer de próstata: uma revisão da literatura. Cien Saude Colet 2008; 13(1):235-246.. The different care between SUS and Non-SUS remind us the double gateway issue, which refers to institutions that attend SUS patients and private patients, as is the case of the HSRC-AFECC, which is a philanthropic hospital. This highlights possible shortcuts that individuals with a health or private plan use to jump the waiting queue for care in the hospital paid by the SUS. In healthcare establishments with a double gateway, there is a clear tendency to prioritize private care over patients funded by the public system²⁵25 Teixeira MF, Patrício RG. O fenômeno da "fila dupla" ou "segunda porta" no Sistema Único de Saúde e a inobservância ao princípio da impessoalidade: um exercício de aproximação de conceitos. Rev. Direito Sanitário 2011; 11(3):50-62.

26 Cohn A, Elias PE, Ianni AMZ. "Subsídio Cruzado" ou "Dupla Porta": o público e o privado no Hospital das Clínicas de São Paulo. Série Didática n° 6. 2002. [acessado 2016 Out 9]. Disponível em: http://www.cedec.org.br/files_pdf/didati6-hc.pdf
http://www.cedec.org.br/files_pdf/didati... ^-2727 Van den Bergh RC, Albertsen PC, Bangma CH, Freedland SJ, Graefen M, Vickers A, van der Poel HG. Timing of curative treatment for prostate cancer: a systematic review. Eur Urol 2013; 64(2):204-215.. Criticisms point to the fact that the “double gateway” generates a double waiting queue and course within the institution, therefore segregating and/or excluding not only from the outside, but also within the hospital²⁶26 Cohn A, Elias PE, Ianni AMZ. "Subsídio Cruzado" ou "Dupla Porta": o público e o privado no Hospital das Clínicas de São Paulo. Série Didática n° 6. 2002. [acessado 2016 Out 9]. Disponível em: http://www.cedec.org.br/files_pdf/didati6-hc.pdf
http://www.cedec.org.br/files_pdf/didati... .

Regarding the clinical variables, in both times, an association between advanced stage, high Gleason score and high PSA (above 20 ng/dL) was found, with shorter times to start treatment. In Canada⁹9 Stevens C, Bondy SJ, Loblaw A. Wait times in prostate cancer diagnosis and radiation treatment. Can Urol Assoc J 2010;4(4):243-248., a research revealed that from the diagnosis to the start of radiotherapy, intermediate- and high-risk men had a shorter waiting time when compared to those at low risk. As in Spain²⁰20 Bonfill X, Martinez-Zapata MJ, Vernooij RW, Sánchez MJ, Suárez-Varela MM, de la Cruz J, Emparanza JI, Ferrer M, Pijoán JI, Ramos-Goñi JM, Palou J, Schmidt S, Abraira V, Zamora J Clinical intervals and diagnostic characteristics in a cohort of prostate cancer patients in Spain: a multicentre observational study. BMC Urol 2015; 15:60-69., men with high PSA and high Gleason score obtained a lower interval between diagnosis and treatment.

Authors emphasize that for men of intermediate and high risk, the three-month period is acceptable for the choice of treatment, and the waiting lists of these patients should not exceed this period²⁷27 Van den Bergh RC, Albertsen PC, Bangma CH, Freedland SJ, Graefen M, Vickers A, van der Poel HG. Timing of curative treatment for prostate cancer: a systematic review. Eur Urol 2013; 64(2):204-215.. They further evidence that delayed treatment may favor the loss of the curability opportunity in men at high-risk, however, the delay may have no impact on the results among men with a lower risk tumor²⁷27 Van den Bergh RC, Albertsen PC, Bangma CH, Freedland SJ, Graefen M, Vickers A, van der Poel HG. Timing of curative treatment for prostate cancer: a systematic review. Eur Urol 2013; 64(2):204-215..

We found that determinants that condition the therapeutic approach of men with prostate cancer attended at the HSRC-AFECC, revealing inequitable access, since men of low socioeconomic level (non-white, less educated and SUS services users) are the ones with the greatest delays in the onset of treatment. Associations found between the times with the sociodemographic variables reveal differences that are unfair, as they harm the ones that need care the most, and there is no basis or recommendation for such an approach. This finding suppresses the principle of equity that should underlie the actions of health services, which seeks equal access of different population groups to SUS by reducing systematic differences that are unnecessary and avoidable²⁸28 Organização Pan-americana de Saúde (OPS). Monitoreo de equidad en el acceso a los servicios básicos de salud: guía metodológica. Washington: OPS, OMS; 2000..

However, regarding the findings of the research in relation to the clinical variables, it is in agreement with what is advocated in prostate cancer care. Individuals in more advanced stages take priority to start treatment, while those with earlier stages tend to wait longer for the definition of therapy, since prostate cancer is a slow-developing neoplasm in the vast majority of cases. However, Law 12.732 applies to all types of neoplasms, not going into detail about specificities of each cancer. Thus, the 60-day deadline to start treatment should be applied in all situations.

Disparate attendance in a service that is intended to be universal, comprehensive and equitable should never prevail; on the contrary, it is necessary to eliminate it from the work process. To this end, evaluating work and health service organization practice is a key tool for planning and promoting adaptations in the modalities of care. Thus, enabling minimum conditions of access to the population should be the basic premise of all services, since it is the gateway to interact with the health system. The growing population requires seeking formulas that meet quantitatively increasing needs and, at the same time, more equitably, efficiently and effectively²⁹29 Franco SC, Campos GWS. Acesso a ambulatório pediátrico de um hospital universitário. Rev Saude Publica 1998; 32(4):352-360..

Access does not only focus on characteristics related to geographical issues or the availability of a service at any given time and/or place³⁰30 Cunha ABO, Vieira-da-silva LM. Acessibilidade aos serviços de saúde em um município do Estado da Bahia, Brasil, em gestão plena do sistema. Cad Saude Publica 2010; 26(4):725-737.^,3131 Souza ECF, Vilar RLA, Rocha NSPD, Uchoa AC, Rocha PM. Acesso e acolhimento na atenção básica: uma análise da percepção dos usuários e pro?ssionais de saúde. Cad Saude Publica 2008; 24(Supl.1):100-110., it is how people get in touch with the health system³²32 Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Organização das Nações Unidas para a Educação, a Ciência e a Cultura, Ministério da Saúde; 2004.. Ensuring this right to the population requires thinking of all the aspects that may affect the institutionalization of this analytical category, such as socioeconomic, cultural, demographic and relational factors³²32 Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Organização das Nações Unidas para a Educação, a Ciência e a Cultura, Ministério da Saúde; 2004.

33 Paskulin LMG, Valer DB, Vianna LAC. Utilização e acesso de idosos a serviços de atenção básica em Porto Alegre (RS, Brasil). Cien Saude Colet 2011; 16(6):2935-2944.^-3434 Unglert CVS, Rosenburg CP, Junqueira CB. Acesso aos serviços de saúde: uma abordagem de geografia em saúde pública. Rev Saude Publica 1987; 21(5):439-446.. Thus, having access as a tool for evaluating health actions presumes a greater vision of the processes operationalized by the SUS health care network, as well as the organization of work methods, within an ethical and right to citizenship²⁹29 Franco SC, Campos GWS. Acesso a ambulatório pediátrico de um hospital universitário. Rev Saude Publica 1998; 32(4):352-360. perspective.

The limitations of the study are related to possible information and selection bias, since a secondary data source was used and was subject to variations in records and incomplete information. Another limitation is the possible sampling bias, since a greater number of late-stage cases may have been referred to the HSRC-AFECC more frequently, since it is a reference institution in oncology²³23 Zacchi SR, Amorim MHC, Souza MAC, Miotto MHMB, Zandonade E. Associação de variáveis sociodemográficas e clínicas com o estadiamento inicial em homens com câncer de próstata. Cad. Saúde Colet 2014; 22(1):93-100..

Therefore, in order to overcome the challenges faced by the Brazilian health system, a deep review of public-private relationships and persistent inequalities will be necessary in order to ensure universal and equitable access at all levels of care. Managers and professionals must analyze the flows of care and attendance to promote adaptations in the organization and structure of the work process, in order to develop a humanized, welcoming and inequality-free practice.

References

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