Regionalization and regulation: impact on access to cancer treatment.

INTRODUCTION
In 2023, 125,200 new cases of cancer were estimated in the state of São Paulo
(excluding non-melanoma skin cancer), 51.3% of which were in women. The most common
types were: breast, prostate, colorectal, trachea, bronchus and lung, stomach, and cervix
1
.
In Brazil, cancer care for diagnosis and treatment is organized into three main types
of specialized services: the Unidades de Assistência de Alta Complexidade em
Oncologia (Unacon - High Complexity Oncology Care Units), which treat the most
prevalent types of cancer; the Centros de Assistência de Alta Complexidade em
Oncologia (Cacon - High Complexity Oncology Care Centers), which offer treatment for
all types of cancer, except, in some cases, rare or pediatric tumors; and the
general hospitals, which perform cancer surgeries and, when necessary, refer
patients for complementary therapies
2
.
The Ministry of Health has implemented two initiatives with the aim of improving the
organization and flow of cancer patients in the Unified Health System (SUS). The
first, in 2008, was the introduction of Regulation in the SUS, with the aim of
structuring the supply of services, guaranteeing fair access and ensuring
comprehensive care
3
. The second initiative, in 2010, was the creation of Redes de Atenção à Saúde
(RAS - Health Care Networks), designed to reduce the fragmentation of the system,
increase accessibility and integrate services of different levels of complexity,
with the support of logistical and management systems
4,5
.
In the state of São Paulo, these policies resulted, in 2010, in the creation of the
Central de Regulação de Ofertas de Serviços de Saúde (Cross - Health Services Offer
Regulation Center) and, later, in the implementation of Oncology Regulation
6
. In 2012, the Redes Regionais de Atenção à Saúde (RRAS - Regional Health Care
Networks) were established, with the aim of organizing services in a regionalized
and integrated manner
7
.
Despite the progress made in organizing the system, geographical accessibility to
cancer treatment is still a major challenge. National data shows that between 49.2%
and 60.7% of cancer patients need to travel from their municipalities of residence
to receive specialized care
8
. This situation is the result of the planned centralization of cancer
services, which does not provide treatment in all municipalities. Although this
guideline aims to guarantee quality and comprehensive care, it entails additional
financial and emotional costs for patients and their families
13
.
The concept of accessibility goes beyond simple access to health services, as it
encompasses both the user’s entry into the system and the capacity to provide care
and respond to the population’s health needs. Accessibility can be analyzed in two
dimensions: socio-organizational, which covers the characteristics of the services
on offer, except for those of a geographical nature, and geographical, which
considers the spatial aspects that can represent barriers to the user’s movement.
The latter can be measured using indicators such as linear distance, travel time and
cost, among others
14
.
The aim of this study was to assess the impact of RRAS and Oncology Regulation on
geographical accessibility to cancer treatment for the main types of cancer in the
state of São Paulo, helping to fill gaps in knowledge about the evolution of
geographical accessibility to cancer treatment in the SUS and the effects of
specific policies implemented in this area.

METHODS
This before-after study compared two independent three-year periods: pre-intervention
(2007–2009), before the implementation of the RRAS and Oncology Regulation in the
state of São Paulo, and post-intervention (2017–2019), after the consolidation of
these strategies. The use of three-year periods reduces the influence of one-off
variations in patient displacement, contributing to the stability of the
indicators.

Characterization of the Study Area
Despite occupying only 2.9% of Brazil’s territory, the state of São Paulo
concentrates 21.9% of the country’s population, i.e. more than 44 million
inhabitants spread over 645 municipalities
15
. In this analysis, the RRAS were adopted as the geographical reference
units. Although this regionalization was not yet in force in the 2007–2009
triennium, it was decided to use it in both periods to ensure comparability of
results. The RRAS are not limited to geographical or administrative divisions,
but reflect epidemiological, demographic, and socioeconomic characteristics and
the organization of the local health services network. In 2024, the São Paulo
State Health Department promoted a reorganization, increasing the number of RRAS
to 18
16
. In this study, however, the division into 17 RRAS was maintained,
according to the configuration in force during the two periods analyzed.

Database
We used data from the Registro Hospitalar de Câncer de São Paulo (RHC/SP - São
Paulo Cancer Hospital Registry), a state system managed by the Fundação
Oncocentro de São Paulo (FOSP - São Paulo Oncocenter Foundation), which gathers
information on cases treated in highly complex oncology establishments
17
.
In the two three-year periods analyzed, 66 institutions registered cancer cases
in the RHC/SP, 48 of which were Unacon, 15 Cacon, and three general hospitals.
Although the total number of services remained stable between the periods, there
were changes in two RRAS: in RRAS 6, there was a reduction from six to five
Unacons; and in RRAS 8, there was an increase from two to three Unacons.

Inclusion Criteria
Patients ≥ 20 years old, living in the state of São Paulo, diagnosed with cancer
during the study periods and according to the International Classification of
Diseases for Oncology (ICD-O-3)
18
for stomach (C16), colorectal (C18 to C20), bronchus and lung (C34),
female breast (C50), cervix (C53), or prostate (C61) cancer, including
in situ cases, undergoing at least one of the treatments,
surgery, radiotherapy, or chemotherapy, were included. The final sample
comprised 52,128 patients between 2007 and 2009 and 69,750 patients between 2017
and 2019.

Study Variables
Geographical accessibility was assessed by two indicators adapted from Dama et al.
19
:
Patient displacement:

Patient attraction:

The triennium of diagnosis, primary tumor location, tumor staging according to
the TNM system
20
, and therapeutic modality (surgery, radiotherapy, or chemotherapy) were
analyzed. Moreover, the sociodemographic characteristics of the patients were
examined, including gender (male or female), education level (illiterate,
complete or incomplete primary education, secondary education, or higher
education), and age (in years).

Data Analysis
Inter-RRAS displacements were categorized into quartiles (< 25%, 25%–49%,
50%–74%, and ≥ 75%), for ease of interpretation and to generate more accessible
and intuitive scientific evidence. The temporal analysis was carried out using
thematic maps comparing the periods (QGIS, version 3.28) and the chi-square test
(α = 5%). R software (version 4.2.0) was used for the analysis procedures.

Ethical Aspects
The study was approved by the Research Ethics Committee (CAAE:
75425623.0.0000.5421), in accordance with the guidelines of Resolutions 466/12
and 510/16 of the National Health Council.

RESULTS
Between the periods 2007–2009 and 2017–2019, there was an increase in the number of
registrations at the RHC/SP for all the types of cancer analyzed. Colorectal cancer
showed the highest percentage increase (58.2%), from 8,159 to 12,906 cases. This was
followed by breast cancer, with an increase of 46.3% (from 16,413 to 24,007). Lung,
cervical, and prostate tumors increased by almost 20.0% each: from 4,748 to 5,787,
from 5,755 to 6,845, and from 12,932 to 15,920 cases, respectively. Stomach cancer
had the smallest variation, with an increase of just 3.4% (4,121 to 4,285).
There was a similar profile among the patients who moved in the two three-year
periods analyzed, with close proportions of men and women moving for cancer
treatment (around 25%) and an average age of 58. Between the first and second
three-year periods, there was a reduction in the number of people with no schooling
(from 30.8% to 24.4%) and an increase among those with primary schooling (from 19.0%
to 21.0%). The frequencies of early (TNM I and II) and advanced (TNM III and IV)
tumor stages by RRAS were also similar between the periods. However, among
individuals from RRAS 4, 6, 12, 14, and 16 with tumors in early stages, there was an
increase in displacement, while RRAS 13 and 15 showed a decrease. Among patients
with advanced tumors, there was a reduction in displacement in RRAS 9, 13, and
15.
Around a quarter of cancer patients in the state of São Paulo had to travel outside
their RRAS of residence for treatment. Cervical cancer was the only one to show an
overall reduction in displacements for all therapeutic modalities. Prostate cancer
saw a reduction in total displacement. Lung cancer, on the other hand, saw an
increase, especially in surgeries (+13.6%). Stomach, colorectal, and breast tumors
maintained stable total displacements (Table
1).

Figure 1 shows the variations in quartiles of
patient movements between RRAS, by type of cancer and three-year period. The mapping
reveals distinct regional patterns of mobility for cancer treatment. In the
Northwest region (RRAS 10, 11, and 12), there was a reduction in displacements for
all tumors in RRAS 11 and 12. The North and Central regions (RRAS 9 and 13)
maintained low displacement percentages, indicating relative self-sufficiency in
cancer care. In the East region (RRAS 14 to 17), there were heterogeneous variations
in displacement, depending on the type of cancer. In the South (RRAS 7 and 8), the
percentage of displacements remained stable, except for RRAS 8. In the Southeast
(RRAS 1 to 5), RRAS 3 and 5 stand out, as they do not have establishments qualified
in high-complexity oncology, resulting in compulsory displacements. Furthermore,
RRAS 6 maintained low percentages of displacement, indicating good installed
capacity and local resolution.

Figure 2 shows the variations in patient
displacement between the RRAS, according to therapeutic modality. In the Northwest
region (RRAS 10, 11, and 12), there were reductions in displacements by modality;
while in the South of the state (RRAS 7 and 8), there was an increase in
displacements. In the Southeast (RRAS 1 to 5), the RRAS maintained high percentages
of displacement, except for RRAS 2, which showed a reduction for all therapeutic
modalities.

Table 2 shows the proportions of patients
attracted by RRAS in the two three-year periods. Three RRAS - 6, 9 and 13 - stood
out as reference centers, receiving more than 25% of cases from other regions, in
all therapeutic modalities. RRAS 6 covers the capital, and RRAS 9 and 13 bring
together populous municipalities with good health infrastructure. RRAS 9 includes
Bauru, Botucatu, and Jaú, and RRAS 13 includes Ribeirão Preto, Franca, São Carlos,
Araraquara, and Barretos - all with more than 100,000 inhabitants. These RRAS showed
different trends in attracting patients. RRAS 6 saw an increase in the volume of
cases referred to from other regions, but RRAS 9 and 13 saw a reduction in this
flow.

Although they treat patients from all over the state, most cases attracted by these
three RRAS remained concentrated in adjacent regions, a pattern observed in both
three-year periods (Table 3).

DISCUSSION
The results showed significant changes in geographical accessibility to oncology
services in the state of São Paulo after the implementation of the RRAS and Oncology
Regulation. There was an increase in patients with lung cancer traveling outside
their RRAS of residence in search of treatment, while cases of cervical and prostate
cancer showed a reduction in displacement.
The North and Northeast regions of the state showed a reduction in travel for all
types of cancer treatment. In contrast, the South saw an increase in these
displacements, especially for surgical procedures. The percentage of trips from
neighboring regions to the capital remained high, showing inequalities in the
distribution of cancer care services in the Metropolitan Region of São Paulo.
The data from this study show significant inequality in access to cancer care in the
state of São Paulo, reflecting persistent challenges, even after the organization of
the RRAS and Oncology Regulation. There is a concentration of services in specific
centers, such as RRAS 6 (São Paulo - Capital) and RRAS 13 (Barretos and Ribeirão
Preto region), which concentrate large reference centers with a high capacity to
attract patients. On the other hand, the scarcity of high-complexity services in
regions such as RRAS 3 (Franco da Rocha) and RRAS 5 (Rota dos Bandeirantes) forces
residents to travel to other territories in search of care.
The study also showed that even in RRASs with qualified oncology services, notably
RRAS 1 (Grande ABC), 2 (Alto Tietê), 4 (Mananciais), 8 (Sorocaba region), and 10
(Marília region), the percentage of population displacement exceeded the state
average. The greatest vulnerabilities in cancer care in the state are concentrated
in the regions adjacent to the capital and in the south and southeast.
The displacement of cancer patients has been widely documented by studies carried out
in Brazil. In the state of Rio de Janeiro, a study based on social network analysis
showed significant differences in the flow of care and displacement of patients with
digestive tract cancer, highlighting the persistent centrality of the capital
11
. In São Paulo, a study carried out at a Unacon located in São Bernardo do
Campo found that 43% of patients came from other states and revealed inconsistencies
in address records in 10% of medical records
9
. Nationwide, an analysis of more than 12 million cancer procedures found that
patients from the North and Central West regions travel the greatest distances for
treatment due to the concentration of cancer care centers in the Southeast and
Northeast regions
12
. These disparities continue over time, highlighting the need to review the
distribution of specialized oncology services in the country.
In addition to the presence of qualified services, it is important to consider the
number and type of oncology services, as these factors allow us to identify care
gaps in the state. RRAS 1, 2, 4, 8, 10, 11, 12, 16, and 17, although they all have
Unacon and, in some cases (RRAS 7, 10, and 12), also Cacon, showed high percentages
of displacement. On the other hand, as expected, RRASs with a large number of
qualified services (6, 9, and 13) stood out as centers of attraction. However, RRAS
14 and 15, despite having a large network of qualified institutions, did not show a
high degree of attraction in either three-year period
17
.
This evidence indicates that assessing accessibility goes beyond simply considering
the number and type of services provided in each region. Other variables must be
considered. An essential aspect is the monitoring by the responsible bodies of
compliance by qualified services with the reference parameters for regional planning
and for the spatial distribution of these units, as recommended by the Ministry of Health
2
.
The displacement of patients for the treatment of stomach and colorectal tumors
remained stable in the two three-year periods analyzed. The scarcity of
investigations into geographical accessibility in the treatment of stomach cancer in
Brazil limits comparison between studies and hinders more in-depth analysis. A
Canadian study identified an association between distance from health regions to
radiotherapy centers and colorectal cancer mortality, regardless of sociodemographic factors
21
. In the state of São Paulo, although displacement patterns have remained
stable, there has been an increase in mortality from this type of cancer
1
.
The increase observed in the displacement of lung cancer patients for surgical and
chemotherapy treatments may reflect barriers in access to care. A study carried out
in Minas Gerais
22
identified various obstacles to the diagnosis of this neoplasm, such as poor
infrastructure, limitations in the public health network, lack of professional
training, and the need for long journeys for treatment. In the state of São Paulo,
there is probably a similar scenario, especially in regions with poor
infrastructure.
Between the three-year periods analyzed, there was a reduction in the displacement of
patients in the three therapeutic modalities related to cervical cancer. However,
this decrease was not reflected in mortality. Between 2014 and 2020, there was an
increase in mortality rates for this neoplasm
23
, suggesting that less mobility did not translate into better quality of care.
Despite the expansion in the supply of services, the fragmentation of the SUS
network remains a major obstacle, compromising the continuity of care throughout all
stages of care. This disarticulation negatively affects the effectiveness of
screening, the time taken for diagnostic confirmation after altered results and the
speed with which treatment can be started
24
. These gaps in care help explain the difficulty in achieving significant
results in controlling the disease, even in the face of the reduction observed in
displacements.
Between the periods before and after the implementation of Oncology Regulation and
RRAS, there was an increase in the number of patients diagnosed with breast cancer
traveling to surgery. In Brazil, there is evidence that many women travel long
distances to receive cancer treatment. Studies of SUS patients have shown that most
of them must travel between 150 and 320 km from their homes to receive care
8,10
. This is a global reality: the greater the distance between the patient’s
home and the place of treatment, the worse the prognosis. A study carried out in the
United States highlighted the importance of geographical proximity to specialized
centers for the appropriate management of early-stage breast cancer
25
.
In the case of prostate cancer, there was a reduction in the number of patients
traveling for chemotherapy and radiotherapy between the three years analyzed. This
decrease may be associated with a reduction in the need for these treatments. A
study based on SUS data identified a drop in the availability of radiotherapy and
chemotherapy for prostate cancer, concomitant with an increase in surgical procedures
26
.
Regarding the RRAS of attraction, no significant changes were observed in the regions
of attraction of patients between the three years analyzed. These centers have a
high capacity for care in various specialties, which explains the shift towards
these regions. The concentration of highly complex services is justified by the need
to specialize and gain scale, and the effect of distance is less decisive in these
cases. However, in the context of primary health care and basic specialized
services, territorial dispersion becomes fundamental, given that geographical
accessibility has a strong correlation with the use of services
5
. We therefore recommend an oncology care planning model that combines the
strategic concentration of highly complex services with the optimized distribution
of primary health care and basic specialized services.
For health managers, it is essential to understand the demands for human and material
resources in their region. Analysis of patient flows in the territory makes it
possible to assess the supply of cancer services close to the areas of residence of
the reference population, helping to optimize access to specialized treatment. In
the long term, better geographical accessibility has consequences for critical
determinants of therapeutic adherence, with a reduction in direct costs, such as
transportation, accommodation, and meals for patients and companions, and mitigation
of psychosocial costs
11
.
The second three-year period analyzed coincided with a regulatory change in Brazilian
oncology: the definition of minimum annual parameters for surgical, radiotherapy,
and chemotherapy procedures as a criterion for qualifying high-complexity services
2
. Although the impact of this change was not measured in this study, since the
ordinance was published at the end of 2019, it is plausible to assume that this
measure will contribute to reducing displacements by strengthening regional planning
and consolidating the cancer diagnosis and treatment network.
Inequalities in accessibility to cancer treatment involve multiple aspects. It is
important to note that the criteria for qualifying high-complexity oncology health
facilities, according to Brazilian legislation
2
, consider factors such as the territory covered by care and its corresponding
population, the general and specialized services offered by each hospital, the
functioning of regional regulation mechanisms, and the minimum production of health
actions. However, planning access to cancer services must be guided by social
conditions and the real needs of the population, to reduce inequalities.
The sociodemographic profile of the patients remained stable between the periods
analyzed, except for the education variable. The literature on geographical
accessibility and sociodemographic factors is still scarce, which limits broader
comparisons. In the case of schooling, the results of this study suggest that
greater travel among individuals with a higher level of education may be associated
with greater availability of financial resources for travel.
The distribution of tumors by staging remained stable between the three-year periods.
However, the analysis by RRAS revealed variations in the movement of patients
towards the centers of attraction and certain adjacent RRAS. Despite the recognized
epidemiological relevance of sociodemographic and biological factors, it is likely
that the changes observed in displacement patterns are more directly associated with
transformations in the social determinants of health in the state of São Paulo.
These determinants include increased access to health services and greater
availability of complementary diagnostic tests. Moreover, it is important to
consider the improvements in the social and economic conditions of part of the
population, reflected in the increase in displacement among patients with higher
levels of education in the second three-year period.
Brazilian legislation makes it compulsory for institutions qualified in high
complexity oncology to keep and send data, regardless of whether they are public or private
2
. A limitation of this study is the failure to include cases from part of the
oncology services in the RHC/SP, i.e. private institutions in the state that are not
licensed by the SUS. This omission may restrict the generalization of the results to
the entire population of São Paulo and to the full range of health establishments in
the state. This omission may restrict the generalization of the results to the
entire population of São Paulo and to the state’s health establishments. Another
limitation of the study was the inclusion of only analytical cases - i.e. diagnosed
and treated in the institution that registered the case - whose data was available
for analysis. The exclusion of non-analytical cases, referring to patients who
arrived at the institution with an established diagnosis, is due to the lack of
information on where the previous procedures were carried out, which made it
impossible to analyze the journeys made.
A central methodological contribution of this study is the analysis of patient flows
between the RRAS, going beyond conventional approaches to assessing geographical
accessibility. While previous studies have focused on the municipality as the unit
of analysis and emphasized long-distance travel for treatment
8
, our RRAS-based approach offers a more comprehensive perspective by
incorporating the principles of comprehensive care in the regional context of
patients’ residence.

CONCLUSION
The implementation of the RRAS and Oncology Regulation in the state of São Paulo has
led to significant changes in the patterns of access to cancer treatment, with
marked variations between regions, tumor types, and therapeutic modalities. There
was stability in the distribution of referral centers between the periods analyzed,
while the macro-regions showed heterogeneous dynamics: a reduction in displacements
in the North and Northwest regions, and an increase in the South region. Regarding
the type of tumor, three distinct patterns of displacement were identified: a
reduction for cervical and prostate cases, stability for breast, stomach, and
colorectal tumors, and a specific increase for lung cancer. It should be noted that
in the case of cervical cancer, the decrease in displacements occurred in all
therapeutic modalities. On the other hand, there was an increase in referrals for
surgery in patients with lung cancer. These results highlight the importance of
systematic monitoring of care flows and continuous qualification of regionalized
planning in oncology, with attention to territorial and clinical specificities. This
approach is essential for organizing the network, increasing its effectiveness and
promoting greater equity in access to cancer treatment for the population of São
Paulo.