Social determinants and regional disparities in place of death among breast cancer decedents in Brazil: a 25-year population-based analysis

Place of death is a population-level indicator of end-of-life care pathways and health system organization, but its interpretation depends on service availability, care coordination, and patient preferences. In resource-constrained settings, deaths outside healthcare facilities may reflect structural barriers, although mortality records cannot determine whether the recorded location was preference-concordant. This study examined temporal trends and social determinants of health associated with place of death among breast cancer decedents in Brazil over 25 years. Nationwide population-based study using the Brazilian Mortality Information System from 1999 to 2023. The analysis included 339,425 breast cancer-related deaths. The primary outcome was death outside healthcare facilities, comprising deaths recorded at home, in a public place, or in another location, compared with deaths in hospitals or other healthcare establishments. Joinpoint regression assessed trends in annual percentages, while age-standardized rates were presented separately as a measure of population burden. Regional socioeconomic context was examined ecologically using the Human Development Index. Univariate analysis estimated crude descriptive associations. Overall, 286,134 deaths (84.3%) occurred in healthcare facilities and 53,291 (15.7%) occurred outside healthcare facilities. The percentages of deaths outside healthcare facilities was highest in the Northeast (25.2%) and North (21.0%) and lowest in the Southeast (11.6%; p < 0.01). The ecological correlation with regional macroregional Human Development Index was inverse ( r = −0.943; p = 0.016). The modelled annual percentages of deaths outside healthcare facilities declined over the study period (annual percent change, −1.0%; p < 0.001), whereas the age-standardized rate series followed a distinct trajectory and showed a pandemic-period elevation. Higher crude odds were observed among individuals with lower educational attainment, Black and Mixed-race individuals (OR, 1.12), and Indigenous individuals (OR, 1.94). Persistent territorial, educational, and racial or ethnic inequalities were observed in deaths outside healthcare facilities among breast cancer decedents in Brazil. These findings identify inequitable end-of-life care pathways but should not be interpreted as direct evidence of care quality or patient preference because the outcome is heterogeneous and information on health service use and preferences was unavailable.