# Geographical and Temporal Variations in Female Breast Cancer Mortality in the Municipalities of Andalusia (Southern Spain)

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## Abstract

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## 1. Introduction

^{2}and a population of 8,399,618 in 2015 (4,153,659 males and 4,245,959 females), it accounts for 17% of the Spanish territory and 18% of the Spanish population [5]. As the most populated and second largest autonomous region in Spain, it is comparable in extension and population to many European countries. Administratively, Andalusia is divided into eight provinces (Almeria, Cadiz, Cordoba, Granada, Huelva, Jaen, Malaga and Seville) and 771 municipalities, which are considered small geographical areas (Figure 1).

## 2. Materials and Methods

#### 2.1. Epidemiological Design and Scope

#### 2.2. Variables

- Mortality: Number of deaths from female breast cancer recorded in each municipality for each year and age group (International Classification of Diseases (ICD)-9 174 and ICD-10 C50).
- Population: Number of women living in each municipality for each year and age group.
- Spanish mortality rate: Number of deaths from female breast cancer per 10,000 women in Spain for each year and age group.

#### 2.3. Sources of Information

#### 2.4. Statistical Data Analysis

## 3. Results

#### 3.1. Trend of the Age-Specific Mortality Rate in the Municipalities of Andalusia, 1981–2012

#### 3.2. Geographical Variation of the Age-Specific Mortality Rate in the Municipalities of Andalusia, 1981–2012

#### 3.3. Geographical Variation of the Age-Specific Mortality Rate Ratio in the Municipalities of Andalusia, 1981–2012

## 4. Discussion

## 5. Conclusions

## Acknowledgments

## Author Contributions

## Conflicts of Interest

## References

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**Figure 1.**Andalusia (southern Spain) and its administrative division into eight provinces and 771 municipalities. Colored circles represent the female population of each municipality, which is directly proportional to the circle size.

**Figure 2.**Possible graphical forms of the age-specific mortality trend for each municipality of Andalusia (southern Spain) according to the value of the linear and the quadratic term of its time function.

**Figure 3.**Trend of age-specific mortality rate per 10,000 women with respect to female breast cancer in Spain, 1981–2012.

**Figure 4.**Trend of age-specific mortality rate from female breast cancer in the municipalities of Andalusia (southern Spain), 1981–2012.

**Figure 5.**Geographical variations of age-specific mortality rate per 10,000 women from female breast cancer in the municipalities of Andalusia (southern Spain), 1981–2012.

**Figure 6.**Geographical variations of the probability that the age-specific mortality rate ratio in each Andalusian municipality is greater than 1 using Spain as the reference, 1981–2012.

**Table 1.**Modelling spatio-temporal distribution of mortality from female breast cancer in small-areas of Andalusia (southern Spain).

Specific Mortality Rate | Specific Mortality Rate Ratio | |
---|---|---|

Distribution | ${o}_{imt}$~$Poisson\left({\mathsf{\mu}}_{imt}\right)$ | ${o}_{imt}$~$Poisson\left({\mathsf{\mu}}_{imt}\right)$ |

Mean | ${\mathsf{\mu}}_{imt}={p}_{imt}{r}_{imt}$ | ${\mathsf{\mu}}_{imt}=\left({p}_{imt}{R}_{it}\right)R{R}_{imt}$ |

Model | $\mathrm{log}\left({r}_{imt}\right)={\mathsf{\beta}}_{0i}+\left({\mathsf{\beta}}_{1i}+{\mathsf{\delta}}_{1im}\right)\left(t-\overline{t}\right)+\left({\mathsf{\beta}}_{2i}+{\mathsf{\delta}}_{2im}\right){\left(t-\overline{t}\right)}^{2}+{u}_{im}+{v}_{im}$ | $\mathrm{log}\left(R{R}_{imt}\right)={\mathsf{\beta}}_{0i}+\left({\mathsf{\beta}}_{1i}+{\mathsf{\delta}}_{1im}\right)\left(t-\overline{t}\right)+\left({\mathsf{\beta}}_{2i}+{\mathsf{\delta}}_{2im}\right){\left(t-\overline{t}\right)}^{2}+{u}_{im}+{v}_{im}$ |

Constant terms | ${\mathsf{\beta}}_{0i}$~flat, ${\mathsf{\beta}}_{1i}$~$N\text{}\left(0,\text{}0.00001\right)$, ${\mathsf{\beta}}_{2i}$~$N\text{}\left(0,\text{}0.00001\right)$ | |

Temporal random structure | ||

Structured effect | $\left[{\mathsf{\delta}}_{aim}|{\mathsf{\delta}}_{ain},\text{}m\ne n\right]$~$N\text{}\left({\overline{\mathsf{\delta}}}_{aim},\text{}1/{\mathsf{\gamma}}_{aim}\right)$, ${\overline{\mathsf{\delta}}}_{aim}=\frac{{\displaystyle \sum _{n\ne m}{\mathsf{\omega}}_{mn}{\mathsf{\delta}}_{ain}}}{{\displaystyle \sum _{n\ne m}{\mathsf{\omega}}_{mn}}},\text{}{\mathsf{\gamma}}_{aim}=\frac{{\mathsf{\gamma}}_{{\mathsf{\delta}}_{ai}}}{{\displaystyle \sum _{s\ne t}{\mathsf{\omega}}_{mn}}}$, a = 1, 2 | |

Hyperparameter | ${\mathsf{\gamma}}_{{\mathsf{\delta}}_{ai}}$~$Gamma\text{}\left(0.5,\text{}0.0005\right)$, a = 1, 2 | |

Spatial random structure | ||

Structured effect | $\left[{u}_{im}|{u}_{in},\text{}m\ne n\right]$~$N\left({\overline{u}}_{im},\text{}1/{\mathsf{\lambda}}_{im}\right)$, ${\overline{u}}_{im}=\frac{{\displaystyle \sum _{n\ne m}{\mathsf{\omega}}_{mn}{u}_{in}}}{{\displaystyle \sum _{n\ne m}{\mathsf{\omega}}_{mn}}},\text{}{\mathsf{\lambda}}_{im}=\frac{{\mathsf{\lambda}}_{{u}_{i}}}{{\displaystyle \sum _{s\ne t}{\mathsf{\omega}}_{mn}}}$ | |

Non-structured effect | ${v}_{im}$~$N\left(0,\text{}1/{\mathsf{\lambda}}_{{v}_{i}}\right)$ | |

Hyperparameters | ${\mathsf{\lambda}}_{{u}_{i}}$~$Gamma\text{}\left(0.5,\text{}0.0005\right)$ ${\mathsf{\lambda}}_{{v}_{i}}$~$Gamma\text{}\left(0.5,\text{}0.0005\right)$ | |

Notation | ${o}_{imt}$: deaths within age subgroup i in municipality m at time t | ${p}_{imt}$: population within age subgroup i in municipality m at time t |

${r}_{imt}$: specific mortality rate in municipality m at time t | ${R}_{it}$: specific mortality rate in Spain at time t | |

$\overline{t}$: Median year | $R{R}_{imt}$: specific rate ratio of municipality m compared with Spain at time t | |

${\mathsf{\omega}}_{mn},\text{}m\ne n$: adjacency matrix (${\mathsf{\omega}}_{mn}=1$ if m and n are neighbour areas and ${\mathsf{\omega}}_{mn}=0$ otherwise) |

**Table 2.**Summary of mortality from female breast cancer in Andalusia (southern Spain) every ten years and for the full period (1981–2012), by age groups.

Age Group | 15–44 | 45–64 | ||||||||

Year | 1981 | 1991 | 2001 | 2012 | 1981–2012 | 1981 | 1991 | 2001 | 2012 | 1981–2012 |

Deaths from female breast cancer | 71 | 106 | 102 | 79 | 2677 | 268 | 348 | 340 | 319 | 9998 |

Female population | 1,301,212 | 1,552,496 | 1,727,353 | 1,771,291 | 52,076,904 | 673,832 | 716,606 | 761,630 | 1,050,092 | 25,077,188 |

Age-specific mortality rate per 10,000 | 0.55 | 0.68 | 0.59 | 0.45 | 0.51 | 3.98 | 4.86 | 4.46 | 3.04 | 3.99 |

Age group | 65–74 | 75–84 | ||||||||

Year | 1981 | 1991 | 2001 | 2012 | 1981–2012 | 1981 | 1991 | 2001 | 2012 | 1981–2012 |

Deaths from female breast cancer | 159 | 190 | 262 | 197 | 5900 | 105 | 159 | 205 | 271 | 5625 |

Female population | 238,227 | 272,957 | 342,834 | 347,981 | 9,672,430 | 124,954 | 162,496 | 200,940 | 281,236 | 6,129,090 |

Age-specific mortality rate per 10,000 | 6.67 | 6.96 | 7.64 | 5.66 | 6.10 | 8.40 | 9.78 | 10.20 | 9.64 | 9.18 |

**Table 3.**Age-specific mortality trend, age-specific mortality rate and age-specific mortality rates ratio from female breast cancer in the municipalities of Andalusia, 1981–2012.

A | 15–44 | 45–64 | 65–74 | 75–84 | ||||||||||||

Age-specific mortality trend | Municipalities | Percentage | Municipalities | Percentage | Municipalities | Percentage | Municipalities | Percentage | ||||||||

Decreasing during the whole period | 0 | 0.0% | 39 | 5.0% | 1 | 0.1% | 0 | 0.0% | ||||||||

From increasing to decreasing | 7 | 0.9% | 93 | 12.1% | 29 | 3.8% | 6 | 0.8% | ||||||||

Non-significant | 764 | 99.1% | 639 | 82.9% | 741 | 96.1% | 755 | 97.9% | ||||||||

From decreasing to increasing | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | ||||||||

Increasing during the whole period | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 10 | 1.3% | ||||||||

B | 15–44 | 45–64 | 65–74 | 75–84 | ||||||||||||

Age-specific mortality rate per 10^{4} | 1981 | 1991 | 2001 | 2012 | 1981 | 1991 | 2001 | 2012 | 1981 | 1991 | 2001 | 2012 | 1981 | 1991 | 2001 | 2012 |

Maximum | 2.71 | 0.72 | 0.68 | 2.58 | 8.35 | 5.72 | 5.63 | 8.54 | 13.76 | 8.46 | 7.92 | 13.73 | 18.43 | 12.67 | 13.76 | 26.20 |

Percentile 75 | 0.59 | 0.54 | 0.53 | 0.54 | 3.98 | 4.42 | 4.27 | 3.28 | 5.44 | 6.12 | 6.23 | 5.62 | 7.92 | 8.97 | 9.60 | 9.79 |

Percentile 50 | 0.49 | 0.50 | 0.49 | 0.45 | 3.30 | 3.93 | 3.66 | 2.69 | 4.51 | 5.66 | 5.71 | 4.51 | 6.36 | 8.07 | 8.50 | 7.78 |

Percentile 25 | 0.40 | 0.48 | 0.46 | 0.37 | 2.81 | 3.63 | 3.36 | 2.25 | 3.65 | 5.29 | 5.35 | 3.63 | 5.43 | 7.27 | 7.78 | 6.41 |

Minimum | 0.19 | 0.42 | 0.40 | 0.19 | 1.54 | 2.96 | 2.91 | 1.23 | 1.96 | 4.08 | 4.44 | 1.70 | 3.16 | 5.87 | 6.78 | 3.43 |

Interquartile range | 0.19 | 0.06 | 0.07 | 0.17 | 1.17 | 0.79 | 0.91 | 1.03 | 1.89 | 0.83 | 0.88 | 1.99 | 2.49 | 1.70 | 1.82 | 3.38 |

Spanish age-specific mortality rate | 0.47 | 0.63 | 0.49 | 0.40 | 3.89 | 4.95 | 3.93 | 3.03 | 5.72 | 7.00 | 6.54 | 5.00 | 7.00 | 9.86 | 9.73 | 9.30 |

C | 15–44 | 45–64 | 65–74 | 75–84 | ||||||||||||

Age-specific mortality rates ratio | 1981 | 1991 | 2001 | 2012 | 1981 | 1991 | 2001 | 2012 | 1981 | 1991 | 2001 | 2012 | 1981 | 1991 | 2001 | 2012 |

Significantly higher than 1 | ||||||||||||||||

Number of municipalities | 0 | 1 | 5 | 2 | 2 | 4 | 20 | 9 | 4 | 2 | 1 | 12 | 4 | 5 | 5 | 5 |

Percentage | 0.0% | 0.1% | 0.6% | 0.3% | 0.3% | 0.5% | 2.6% | 1.2% | 0.5% | 0.3% | 0.1% | 1.6% | 0.5% | 0.6% | 0.6% | 0.6% |

Not significantly different from 1 | ||||||||||||||||

Number of municipalities | 760 | 715 | 763 | 768 | 704 | 458 | 632 | 754 | 711 | 392 | 557 | 745 | 750 | 533 | 576 | 758 |

Percentage | 98.6% | 92.8% | 99.0% | 99.6% | 91.3% | 59.4% | 82.0% | 97.8% | 92.2% | 50.8% | 72.3% | 96.6% | 97.3% | 69.2% | 74.8% | 98.4% |

Significantly lower than 1 | ||||||||||||||||

Number of municipalities | 11 | 55 | 3 | 1 | 65 | 309 | 119 | 8 | 56 | 377 | 213 | 14 | 17 | 233 | 190 | 8 |

Percentage | 1.4% | 7.1% | 0.4% | 0.1% | 8.4% | 40.1% | 15.4% | 1.0% | 7.3% | 48.9% | 27.6% | 1.8% | 2.2% | 30.2% | 24.6% | 1.0% |

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**MDPI and ACS Style**

Ocaña-Riola, R.; Montaño-Remacha, C.; Mayoral-Cortés, J.M.
Geographical and Temporal Variations in Female Breast Cancer Mortality in the Municipalities of Andalusia (Southern Spain). *Int. J. Environ. Res. Public Health* **2016**, *13*, 1162.
https://doi.org/10.3390/ijerph13111162

**AMA Style**

Ocaña-Riola R, Montaño-Remacha C, Mayoral-Cortés JM.
Geographical and Temporal Variations in Female Breast Cancer Mortality in the Municipalities of Andalusia (Southern Spain). *International Journal of Environmental Research and Public Health*. 2016; 13(11):1162.
https://doi.org/10.3390/ijerph13111162

**Chicago/Turabian Style**

Ocaña-Riola, Ricardo, Carmen Montaño-Remacha, and José María Mayoral-Cortés.
2016. "Geographical and Temporal Variations in Female Breast Cancer Mortality in the Municipalities of Andalusia (Southern Spain)" *International Journal of Environmental Research and Public Health* 13, no. 11: 1162.
https://doi.org/10.3390/ijerph13111162