# Regionalization and regulation: impact on access to cancer treatment

## TL;DR

This study examines how regional health networks and cancer treatment regulations in São Paulo affected patients' geographic access to cancer care over ten years.

## Contribution

The paper provides empirical evidence on the heterogeneous impact of regional health policies on cancer treatment accessibility across different regions in São Paulo.

## Key findings

- Approximately 25% of patients traveled for cancer treatment, with regional disparities observed.
- The North and Northwest regions showed reduced patient displacement, while the South saw increased displacement.
- Lung cancer treatment saw increased displacement, especially for surgery, despite improvements in other cancer types.

## Abstract

To assess the impact of Redes Regionais de Atenção à Saúde (RRAS - Regional
Health Care Network) and Oncology Regulation on geographical accessibility
to oncology treatment for the main types of cancer in the state of São
Paulo.

A before-after study comparing the three-year periods before (2007–2009) and
after (2017–2019) the policies were implemented. Data from the São Paulo
Hospital Cancer Registry were used to analyze indicators of displacement and
attraction of patients for surgery, radiotherapy, or chemotherapy in six
types of cancer: stomach, colorectal, lung, female breast, cervix, and
prostate. The RRAS were adopted as the geographical units of analysis, and
inter-RRAS displacements were categorized into quartiles (< 25%, 25%–49%,
50%–74%, and ≥ 75%). Temporal analysis was carried out using thematic maps
(QGIS, version 3.28) and the chi-squared test (α = 5%).

Approximately 25% of patients traveled for treatment. RRAS 6 (Capital), 9
(Bauru), and 13 (Ribeirão Preto) remained the centers of attraction. In the
North and Northwest, RRAS 11 and 12 showed a reduction in displacements for
all types of cancer; in RRAS 10, the drop occurred for colorectal and lung
tumors. In the Southeast, RRAS 3 and 5 do not have qualified services,
requiring displacements, while RRAS 1, 2, and 4 maintained high percentages.
In the East, RRAS 14 to 17 saw a reduction in displacements, except for lung
cancer. In the South, displacements increased in RRAS 7 and 8. Overall,
there was a reduction in displacements for cervical and prostate cancer, and
an increase for lung cancer, especially for surgery.

The implementation of the RRAS and Oncology Regulation altered geographic
accessibility in a heterogeneous way: there was an improvement in the North
and Northwest, a worsening in the South, and stability in the reference
centers. There is a need to improve regional planning, paying attention to
territorial inequalities, the type of tumor, and the therapeutic
modality.

Avaliar o impacto das Redes Regionais de Atenção à Saúde (RRAS) e da
Regulação de Oncologia na acessibilidade geográfica ao tratamento oncológico
dos principais tipos de câncer no estado de São Paulo.

Estudo antes-depois, comparando os triênios anterior (2007–2009) e posterior
(2017–2019) à implementação das políticas. Utilizaram-se dados do Registro
Hospitalar de Câncer de São Paulo para analisar indicadores de deslocamento
e atração de pacientes para cirurgia, radioterapia ou quimioterapia em seis
tipos de câncer: estômago, colorretal, pulmão, mama feminina, colo do útero
e próstata. As RRAS foram adotadas como unidades geográficas de análise, e
os deslocamentos inter-RRAS foram categorizados em quartis (< 25%,
25%–49%, 50%–74% e ≥ 75%). Análise temporal foi realizada por mapas
temáticos (QGIS, versão 3.28) e teste de qui-quadrado (α = 5%).

Aproximadamente 25% dos pacientes se deslocaram para tratamento. As RRAS 6
(Capital), 9 (Bauru) e 13 (Ribeirão Preto) mantiveram-se como polos de
atração. No Norte e Noroeste, as RRAS 11 e 12 apresentaram redução nos
deslocamentos para todos os tipos de câncer; na RRAS 10, a queda ocorreu
para tumores colorretal e pulmão. No Sudeste, as RRAS 3 e 5 não possuem
serviços habilitados, exigindo deslocamentos, enquanto as RRAS 1, 2 e 4
mantiveram elevados percentuais. No Leste, as RRAS 14 a 17 registraram
redução dos deslocamentos, exceto para câncer de pulmão. No Sul, os
deslocamentos aumentaram nas RRAS 7 e 8. No geral, houve redução nos
deslocamentos para câncer de colo do útero e próstata, e aumento para
pulmão, especialmente cirurgia.

A implementação das RRAS e da Regulação de Oncologia alterou a
acessibilidade geográfica de forma heterogênea: houve melhora no Norte e
Noroeste, piora no Sul, e estabilidade dos polos de referência. Destaca-se a
necessidade de aperfeiçoamentos no planejamento regional, com atenção às
desigualdades territoriais, ao tipo de tumor e à modalidade terapêutica.