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Conteúdo (article):

Accident and social security benefits granted to cancer patients in Brazil, 2008-2014

Nuria Sales-Fonseca1; Ubirani Barros Otero2; Rosalina Jorge Koifman1,3; Sabrina da Silva Santos1,3

1 Oswaldo Cruz Foundation, National School of Public Health Sérgio Arouca, Postgraduate Program in Public Health and Environment

2 National Cancer Institute, Ministry of Health, Conprev. Rua Marquês de Pombal, 125 - 5th floor, CEP 20230-240 - Rio de Janeiro, RJ - Brazil.

3 Oswaldo Cruz Foundation, National School of Public Health Sérgio Arouca, Department of Epidemiology and Quantitative Methods in Health. Av. Leopoldo Bulhões, 1480, CEP 21041-210 - Rio de Janeiro, RJ. Brazil.

Authors\' ORCID:
Nuria Sales-Fonseca: 0000-0003-0369-8806.
Ubirani Barros Otero: 0000-0003-1464-2410.
Rosalina Jorge Koifman: 0000-0002-2746-7597.
Sabrina da Silva Santos: 0000-0001-8327-3546.

ABSTRACT

Objective: To describe the distribution of cancer among the benefits granted by the General Social Security Registry, from 2008 to 2014, in Brazil. Methods: Ecological study using data given by the National Social Security Institute. The proportion of accidental (work-related) and social security (general) benefits granted by cancer in Brazil was determined, among the benefits granted for all causes, and a spatial analysis was conducted to assess the geographical distribution of these proportions, with the states Brazilians as a unit of analysis. Results: Cancer was the reason for granting 533,438 benefits (2.9% of the total benefits granted for all causes), with a predominance of females in social security benefits (53.7%) and males in accidental benefits (71.6 %). The highest proportions of social security benefits for cancer occurred in North and Midwest regions. In 19 of the 26 Brazilian states (including all states in the southern region) and in the Federal District, there was no granting of accident benefits for cancer. Conclusion: The analysis of the occurrences of cancer that generated benefit concessions suggests a disproportionality in granting of social security benefits in relation to accident workers, mainly in North, Northeast and South regions of Brazil.

Keywords: Neoplasms, Social Security, Occupational Health.


INTRODUCTION

Cancer is a public health problem that affects approximately 19.3 million people worldwide (age-adjusted incidence rate of 201.0 cases per 100,000 population) and causes almost 10.0 million deaths (100.7/100,000) each year, according to estimates for 2020. In Brazil, for the same year, it was estimated that there would be 592,212 new cases (241.3/100,000 in men and 198.2/100,000 in women) and 259,949 deaths 1.
The diagnosis and treatment of cancer demand human and technological resources that generate financial costs to the Brazilian Health System 2. Furthermore, when the diagnosed individual is a worker protected by Social Security, the need for leave from work (duly evaluated by the medical expert from the National Institute of Social Security - INSS) generates the granting of social security or accident benefits 3.
The association between occupational exposures and cancer is well established for various tumor locations. The International Agency for Research on Cancer (IARC) classifies 38 agents present in work environments and 12 exposure circumstances (industries and occupations) as known carcinogens (group 1) and 41 agents and 6 exposure circumstances as likely to cause cancer (group 2A) 4. Thus, the global cancer burden attributable to occupational exposures has been estimated to be between 2% and 5% since the 1980s. For lung cancer, which is the most prevalent occupational cancer, this population attributable fraction (PAF) to occupational exposure is as high as 25%, with occupational exposures to asbestos, silica, and diesel engine emissions being the major contributing factors 5-6.
Most countries have invested in estimating workers exposed to carcinogens and in surveillance systems for exposures. However, failure to quantify the true burden of work-related cancer cases is a global problem. To reduce this information gap it is necessary to invest in other strategies such as identification of suspected work-related cancer cases and improvements in surveillance systems 7.
In Brazil, since 2004, there is a module "work-related cancer" in the Notification of Diseases Information System, but the number of cases reported is incipient considering the large number of workers in the country and the annual number of cancer cases 8, which makes it unfeasible to use these data for epidemiological surveillance purposes. In this context, the databases of the General Register of Social Security (GRSS) are alternative forms of information on cancer illness and its relationship to work, allowing the analysis of variables that are not usually obtained in cancer registries. However, these data are still little used for research purposes. Thus, considering that for surveillance purposes, cancer requires studies of its epidemiological distribution, not only in the general population, but in specific populations, such as the economically active population, the objective of this paper is to describe the distribution of cancer among benefits granted by the GRSS, in the period from 2008 to 2014, in Brazil, comparing the proportions of accident (work-related) and social security (general) benefits.

METHODS

This is a descriptive study of ecological type, concerning the pattern of granting of benefits by the GRSS for malignant neoplasms, in men and women who are members of that health system, in the period from 2008 to 2014, in Brazil. The data were made available in aggregate by INSS, in physical media, after being requested through the Electronic System of the Citizen Information Service (https://falabr.cgu.gov.br/publico/Manifestacao/SelecionarTipoManifestacao.aspx?ReturnUrl=%2f), created based on law no. 12.527, of November 18, 2011, which regulated the constitutional right of access to information 9.
Four types of benefits were selected for the study: social security sickness benefit (B31), social security disability retirement (B32), accidental disability benefit (B91) and accidental disability retirement (B92), for all malignant neoplasms (C00 to C97), other causes and unclassified causes, according to the International Classification of Diseases (ICD-10). The benefits of the sickness aid type (B31 and B91) are granted to the insured when he/she is unable to exercise his/her routine activity for a period exceeding 15 consecutive days. The disability pensions (B32 and B92) are granted to insured people who are considered incapable and unrehabilitated for subsistence activities and will be paid while they remain in this condition. Accident benefits (B91 and B92) differ from social security benefits (B32 and B92) by the fact that the insured has suffered an accident at work, and by the provisional stability that the accident benefit establishes for the worker after returning to work (3). It should be noted that according to article 20 of Law 8,213/91, diseases arising from a certain activity, or arising or aggravated by work or conditions of its performance, are considered work-related accidents. Thus, work-related cancer must also be classified as an accident 10.
The following variables were entered: sex (male and female), clientele (urban and rural), and affiliation (unemployed; employed; specially insured; self-employed; domestic worker; optional; individual taxpayer and opting for Law 6.184/74). In regard to filiation, some definitions are applicable, except for the unemployed and employed status, which do not require further details. Specially insured: an individual that, individually or in family economy regime, develops activities as a rural producer, artisan fisherman or similar, spouse or partner, as well as a child over 16 years of age that proves to have an active participation in the rural activities of the family group; Temporary workers: all those who render services to several companies, but are contracted by labor unions and labor management agencies; Domestic workers: those who provide services in the home of another person or family, as long as this activity is not for the employer\'s profit; Optional: people over 16 years old, who have no income of their own, but decide to contribute to Social Security; Individual taxpayers: those who work for themselves (autonomously) or who render services of a casual nature to companies, without an employment relationship 10.

Data Analysis
The proportional distributions of the benefit grants in the selected period were calculated. For this purpose, the numerators were the number of benefits of each kind (B31; B32; B91 and B92) granted according to ICD-10 groups (malignant neoplasms - C00-C97 - and other causes), sex, clientele, and affiliation.
Furthermore, the following were used as numerators: (a) number of benefits of each type granted by each ICD-10 code, referring to malignant neoplasms (C00-C97), according to sex, for Brazil, from 2008 to 2014; (b) number of benefits of each type granted for malignant neoplasms, for each Brazilian state, from 2008 to 2014.
The appropriate denominators in this study were: (a) the number of benefits, of each type, granted for all causes, from 2008 to 2014, in the states and in Brazil, according to each variable of the study; (b) the number of benefits, of each type, granted for malignant neoplasms, from 2008 to 2014, in Brazil, according to sex.
Spatial analysis methods were used to assess the geographic distribution of the proportions of social security and accident benefits granted for cancer, among the benefits granted for all causes, by Region and Brazilian state, in the period from 2008 to 2014. The QGIS program, version 2.18.15, was used for this step.


Ethical Aspects
This study was submitted to the Research Ethics Committee of the National School of Public Health of the Oswaldo Cruz Foundation and was exempted from registration in the CEP-CONEP System.

RESULTS

In Brazil, in the period between 2008 and 2014, a total of 17,875,518 social security and accident benefits were granted to insured members of Social Security for all causes of diseases, of which 9,929,530 were for males (55.5%) and 7,945,988 for females (44.5%); (Table 1).
Cancer was the reason for the granting of 533,438 benefits, which represented 2.9% of the total benefits granted. Of these, 248,293 (46.5%) were granted for men and 285,145 (53.4%) for women. We found a 100 times greater number of social security sickness benefits (B31) (443,714), compared to accident-related sickness benefits (B91) (4,263). Regarding sickness benefits (B31), the highest number of grants for all causes was found among men (52.6%) and for cancer among women (55.1%). In accident benefits for sickness aid (B91), the relationship is reversed with a greater number of benefits granted for cancer for males (71.6%) compared to females (28.4%) (Table 1).
Table 2 shows the proportional distribution of benefits generated by cancer, according to clientele, affiliation, and age. For accident benefits, one can observe a higher proportion of concessions for cancer for rural clients (1.70%) compared to urban clients (0.12%). In relation to affiliation, for welfare aid, "domestic worker" (4.11%), "optional taxpayer" (5.55%) and "individual taxpayer" (5.44%) stand out. In aid for accidents at work, the affiliation with the highest proportion of concessions for cancer was that of the "specially insured" (1.71%). In the analysis of the distribution by age group, it is possible to see that as the age increases, the proportion of the distribution of benefits by neoplasm also increases. However, it is important to note that the analysis of this variable presents some limitations such as the lack of homogeneity in the width of the age groups presented and the nonclassification of benefits granted for the age groups <20 years and >64 years (Table 2).
Table 3 presents the proportional distribution of the 10 main neoplastic locations that motivated the concession of social security and accident benefits in Brazil, according to sex. For welfare benefits (B31), in men, the main locations were prostate cancer (17.9%), followed by cancers of the stomach (6.2%), colon (6.2%), bronchus and lung (4.3%), rectum (4.1%), esophagus (3.8%), other malignant neoplasms of the skin (3.4%), testicles (3.2%), larynx (3.2%), and Brain (3.2%). In women, the cancers were breast (42.4%), cervix (10.4%), thyroid gland (6.4%), colon (4.4%), ovary (3.4%), rectum (2.3%), stomach (2.3%), bronchus and lungs (2.2%), uterine body (2.1%), and other malignant skin neoplasms (1.7%). The pattern of concessions for accident sickness benefits (B91) shows important differences in relation to social security benefits (B31). In men, malignant neoplasms of the skin (56.7%), take the first place of the concessions, followed by cancers of the bronchus and lungs (8.1%), myeloid leukemia (7.3%), stomach (6.7%), bladder (3.5%), larynx (3.4%), lymphoid leukemia (3.0%), pancreas (2.1%), bones (1.42%), and unspecified leukemia (0.9%). Some cancers present in this list, such as hematological, bladder, pancreas, and bone cancers, did not appear in the B31 grant types. In women, the same pattern is found, this time cancers of the skin (62.3%), bronchus and lungs (6.4%), stomach (4.9%), and myeloid leukemia (4.8%) gain prominence in B91 grants. Additionally, this ranking includes pancreatic (1.5%), bladder (1.5%), and sinus (1.1%) cancers that did not appear in the B31 as the top ten types that generated the most grants.
Retirement benefits resemble some cancer grants, with the insertion or substitution of some neoplastic locations in the ranking of the top 10 most granted, in both sexes. In the social security disability benefits (B32), more or less the same types of cancers are observed as in the social security sickness benefits (B31) up to the 5th position (prostate, bronchus and lungs, stomach, colon, and rectum, for men), reversing one or another location in the ranking. In women, the difference is observed for cancer of the thyroid gland, which occupies the 3rd position in the ranking of social security sickness aid and does not appear in social security disability retirements. The other types are similar. Among those generated by accidental disability (B92), these are close to those generated by accidental disability (B92), but with the insertion in B92 of larynx cases that gain greater prominence, in men, and the cases of multiple myeloma in both sexes.
Figure 1 presents the spatial distribution of the proportion of social security benefits (B31 and B32) granted for cancer, among the total benefits (social security and accident benefits) granted for all causes, in each state, during the period from 2008 to 2014. All states in Brazil granted cancer social security benefits. It can be seen that the proportions varied from 2.24% to 42.46% (range 40.22%; interquartile range 7.65%), among the states. The following states were above the 75th percentile: Rondônia (42.46%), Mato Grosso (22.87%), Tocantins (14.69%), Acre (12.50%), Amapá (12.50%), and Amazonas (11.76%); and the states below the 25th percentile were: Rio Grande do Norte (2.24%), Pernambuco (2.79%), Paraná (2.86%), Minas Gerais (2.90%), São Paulo (3.02%) and Espírito Santo (3.21%). This analysis reflects a great discrepancy between the regions of the country. In the North region the proportion of benefits varied from 10.00 to 42.46% (range 32.46%); in the Southeast region the proportion varied from 3.33% to 2.90% (range 0.43%).
The analysis of the proportions of accident benefits (B91 and B92) granted for cancer, among the total benefits (social security and accident benefits) granted for all causes, in each state, in the period from 2008 to 2014 showed that in 19 of the 26 states (including all states in the Southern region) and in the Federal District there was no granting of accident benefits for cancer. The eight states that generated these concessions were: in the Northeast region, Bahia (0.03%); in the North region, Rondônia (0.79%); in the Midwest region, Mato Grosso (0.51%) and Mato Grosso do Sul (0.06%); in the Southeast region, all states, namely: Rio de Janeiro, São Paulo, Minas Gerais (0.01% each) and Espírito Santos (0.03%). These proportions are shown in parentheses in Figure 1.

DISCUSSION

This study found a high number of benefits granted for malignant neoplasms (> 500,000, from 2008 to 2014). However, this number represents less than 3% of the total number of grants for the period.
In general, in Brazil, the statistics related to morbidity by chronic noncommunicable diseases (NCDs) mention hypertension, depression, arthritis, and diabetes as the most prevalent. However, cancer is becoming increasingly relevant, not only because of morbidity, but also because of mortality, the disabilities generated by the disease, and the repercussion on the granting of social security benefits. Moura et al. (2007) when analyzing the main NCDs that generated the concession of benefits, from 2000 to 2002, in Recife, found that high blood pressure, diabetes mellitus, arthrosis, breast cancer, and bowel cancer were the main causes for the concession of sickness benefits. And for disability retirements it was cerebrovascular diseases, diabetes mellitus, arthritis, digestive tract cancer, and schizophrenia 12.
In the health sector, 1,023 cases of work-related cancer were reported in the Information System on Notifiable Diseases since the system was created in 2004 until 2016. In other words, an average of 78 cases/year 13. Considering the fraction attributable to occupational risk factors for cancer, approximately 5%, and the estimate of 625,000 cancer cases in 2021 in Brazil, 31,250 new cases of work-related cancer would be expected in this year alone. It should be noted that the problem of little recognition of the relationship between cancer and work is not unique to Brazil but is a worldwide problem. In Taiwan, for example, 3,500-4,000 cases are registered every year, while the expected number would be 75,000. In Norway, only 300 cases of cancer suspected of being work-related have been reported, when one would expect about 1,200-1,300 cases per year. Only 200 of these (66.7% of reported cases) are recognized by the National Insurance System to claim compensation for occupational disease 14. Langard and Lee (2011) further report that in Australia, Singapore, Japan and South Africa there are significant numbers of cancer cases identified as work-related, but far from what is expected, considering the attributable fraction of 5% 15.
In our study, we believe that the quantitative discrepancy between the concession of social security benefits (B31, B32) and accident benefits (B91, B92), may be centered in some factors such as: (I) difficulty in identifying and recognizing the causal link between the diagnosed cancer and the occupation and/or exposures to chemical, physical or biological agents with carcinogenic potential in the workplace 16; (II) in the restriction of categories for the concession of accident benefits, which only allows the inclusion of employees, independent workers and special insured members, different from the social security ones, which contemplate all affiliations 3; (III) in the absence of the Communication of Work Accident (CAT) and other documents issued by the work physician, by the public or private hospital network, signaling the possibility of that cancer being attributed to work. This responsibility is up to the medical expert, who, based on his decision-making autonomy, can deny the accident characterization of the nexus, should he not be imbued with an anamnesis of the occupational history and have at hand other instruments that help him in this decision 14.
Another difficulty, concerns the long latency periods between exposure and disease observed for most solid tumors (average of 20 years) 17. Thus, if the occupational history is not recovered, the causal link may not be established, since the current occupation may not be the same that led to the illness, or the worker may already be retired at the time of diagnosis, no longer being eligible for the benefits analyzed in this study 14.
Observing the proportions of benefits granted for all causes, in Brazil, men received 55.55% and women 44.45% of the benefits. This distribution may reflect the population aged 16 to 59 years protected by Social Security, which, in the year 2014, was composed of 55.95% men and 44.05% women 18. However, a female predominance was observed in the total number of cancer benefits granted and in cancer welfare assistance. This female predominance in cancer benefit recipients was also seen in a study of Dutch welfare recipients (64.00%) 19. However, it is interesting to note that cancer incidence rates are higher in men, than in women, both in Brazil and in the Netherlands 1.
In relation to accident aids, both for all causes and for cancer, the highest amount was granted to males. This result is consistent with the higher number of men in economic sectors with greater contact with chemical, physical and biological agents with carcinogenic potential, such as civil construction, industry and agriculture, for example 20.
In the distribution of benefits, according to clientele, in Brazil, we observed a predominance of urban clientele over rural clientele. However, there was a discrete predominance of the rural clientele over the urban clientele in accident benefits granted for cancer. Since this article has no information regarding the neoplastic locations that motivated the granting of benefits according to the type of clientele, there is no way to hypothesize occupational exposure in this case, but it should be pointed out that in the National Household Sample Survey (PNAD-2014), the urbanization rate, measured by the proportion of people living in urban areas, was 84,8% 21, therefore, it would be expected that more benefits would be granted to the urban clientele, unlike the results of this study. However, studies conducted in Brazil have been indicating an increase in cases and deaths from cancer among rural workers 22 and in comparison with workers in other economic sectors 23, consolidating our findings.
The types of malignant neoplasms that represented the highest costs for Finland were found to be breast, prostate, colorectal, lung, and leukemia 24. Apparently, breast, prostate, colorectal and lung cancers also generate high costs for Brazilian social security, since they appear among the main cancer locations that generate benefits. For the Mexican Institute of Social Security, the main malignant neoplasms that motivated the granting of disability retirement, in the period from 2006 to 2012, were: breast, colon, Brain, lung, and stomach25.
The analysis of the main cancer locations that granted benefits also shows that the types of cancer that generated accident or social security benefits are different. In the welfare type, the first neoplasms observed are breast and cervical cancer in women and prostate, stomach and lung cancer in men, mainly reflecting the high incidence rates of these neoplasms estimated for Brazil in the year 2014 26. In the accident type, skin cancer and lung cancer are the most granted. It can be observed that leukemias appear only in the rankings of the top 10 topographies that generated accident benefits. These results are consistent with the literature, since leukemias, in general, are related to exposure to benzene 27, to formaldehyde 28, to chemical agents used during rubber production and vulcanization 29, to radiations 30, among other agents 31. Other neoplasms that may be work-related, such as cancer of the stomach, bladder, larynx, prostate, and breast, are present in the list of accident benefits, in men and women, to a greater or lesser degree.
In relation to breast cancer, besides the well-known risk factors, we highlight work-related factors, such as radiation, exposure to pesticides, polychlorinated biphenyls, and night work, some of which still have limited evidence 31. Other factors cited are clerical work, due to lifestyle and reproductive factors (long period of study, late first pregnancy, low parity) compared to women working in sales, transportation and production 32, as well as environmental exposure to polycyclic aromatic hydrocarbons 33.
The risk factors for prostate cancer are age, race, ethnicity, obesity 34 and first-degree family history of the same type of cancer 35. Associated occupational risk factors (although with limited evidence) are arsenic and inorganic arsenic compounds; cadmium and its compounds; occupational exposure as a firefighter; malathion pesticide; night work; exposure to chemical agents during rubber production and exposure to ionizing radiation 31. The small number of this type of cancer among those that generated accident-related sickness benefits is striking (only 32 cases of disability - B92), compared to 35,762 of the social security type (B91).
It is worth mentioning the concession of 2,486 benefits of the type of accidental illness aid (B91) for non-melanoma skin cancer, in both sexes, which represents 60.00% of all benefits of this type. This is also the main neoplasm that generates accidental disability retirements. On the one hand, a large number of concessions for this neoplasm is expected, since non-melanoma skin cancer was the most incident neoplasm in the year 2014, for Brazil 26. In addition, cumulative sun exposure is known to be an important risk factor for non-melanoma skin cancer 36 and that many workers, who work outdoors, are exposed most of their lives to solar radiation 37. Thus, one can believe that it was unequivocal to the medical expertise the occupational exposure to the sun as a result of the activity performed outdoors. On the other hand, it is important to point out that, in general, the treatment for non-melanoma skin cancer consists of curative surgery, performed as an outpatient 38, not requiring time off work.
Regarding thyroid cancer, which was the third most common neoplasm that led to the granting of benefits for social security sickness in women, it is important to note the increase in incidence over the past three decades in high- and middle-income countries such as Brazil. This increase has been called the epidemic of overdiagnosis, due to the detection by imaging technology of lesions without clinical significance. Recent data suggest that this increase in incidence and over diagnosis is slowing down 4. Thus, future studies, which verify the concession of benefits for cancer, in more recent periods, may verify a reduction in the concession of benefits for thyroid cancer, in relation to the present work.
We observed a higher proportion of cancer accident benefits in all the states of the southeastern region, including Mato Grosso do Sul in the central region and the state of Bahia in the northeastern region. This study took place after the implementation of the Epidemiological Social Security Nexus, and still, 19 states did not grant cancer benefits for occupational accidents, suggesting that, in these states, the occupational exposure and cancer nexus is not yet apparent.
Recognizing occupational carcinogens is important for primary prevention, financial compensation, and surveillance of the exposed worker, as well as identifying the causes of cancer in the world population 39. All these findings point out that more studies are needed to evaluate the association between occupational activities and cancer. For this purpose, Social Security data are a good tool. Moreover, it is necessary to ensure that other information systems, such as population-based cancer registries and hospital-based cancer registries, have complete information on occupation, allowing for future studies. It is also important to stress the importance of filling out the module work-related cancer of the Sistema de Informação de Agravos de Notificação - SINAN (Information System of Notifiable Diseases) established by the Administrative Rule 777, of April 28, 2004, to give visibility to cancer as a work-related disease 40.
Studying the occurrences of cancer that generated the granting of benefits in the GRSS requires a broad reflection. First, considering the interests involved in the receipt of a benefit, and later, concerning the surveillance of workers\' health. The main limitation of this work is the use of secondary data made available by the INSS in different spreadsheets, one for each variable studied, instead of a single database, thus making it impossible to cross-reference the analyzed variables. Furthermore, the data collected could only be analyzed as absolute and relative frequencies of benefits granted, since the lack of information on the average monthly number of contributors made it impossible to estimate the incidence of cancer in the population insured under the GRSS. However, the data were analyzed with caution so that these limitations, inherent in the ecological study design, would not produce bias in the data presented. Despite these limitations, one should point out the uniqueness of the data used, due to the presence of variables that are not usually obtained in cancer registries. In addition, the strength of this study is the evaluation of the data for an 8-year period, allowing a more homogeneous and precise analysis, because it reduces possible annual oscillations.
There is no doubt that Brazil has been improving its attention on work-related cancer surveillance 16, but it seems that, starting with the professionals who compose the first care to the patient until those who record the information in these systems, proper importance is not given to the completeness of the information. Perhaps there should be, in the training of these professionals, awareness of this issue since cancer control requires concrete information.
The present article does not aim to show the link between cancer and work, but to allow reflection on the non-measurement of malignant neoplasms peculiar to the work environment in Brazil.

CONCLUSION

The distribution of cancer occurrences that generated concessions of Social Security benefits from 2008 to 2014 suggests a disproportionality of the concession of social security benefits in relation to accident benefits, mainly in the North, Northeast and South regions of Brazil.


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