Racial and Geographic Inequities in Prostate Cancer Mortality in Brazil: A 14-Year Population-Based Analysis of 209,368 Deaths

PURPOSE Prostate cancer is the second leading cause of cancer death among Brazilian men. While national age-standardized rates have declined, the racial and geographic distribution of mortality remains poorly characterized. We quantified national and state-level age-standardized mortality trends, racial inequities using population-denominated rates, statistically validated joinpoints, and the intersection between geographic mortality patterns and racial composition across Brazil from 2010 to 2023. METHODS Population-based ecological study using all prostate cancer deaths (ICD-10: C61) from Brazil's National Mortality Information System (SIM/DataSUS), 2010-2023. Age-standardized mortality rates (ASMR) per 100,000 men were computed using WHO 2000-2025 world standard population, with IBGE 2024 edition projections (Census 2022-based) as denominators. State-level ASMR was estimated through indirect standardization. Annual Percent Change (APC) with 95% CI was estimated via log-linear regression; joinpoints were identified through segmented regression with F test and 1,000-iteration permutation testing. Race-specific rates used IBGE Census 2010 and 2022 racial proportions with intercensal interpolation. RESULTS A total of 209,368 prostate cancer deaths were recorded. National ASMR declined from 16.8 to 14.7 per 100,000 men (–12.2%; APC = –1.18% [95% CI, −1.36 to –1.00]; P < .001), averting 24,781 deaths versus 2010-frozen-rate scenario. A statistically validated joinpoint at 2020 ( F -test P = .002; permutation P = .007) revealed post-pandemic stagnation: pre-pandemic APC = –0.96% (95% CI, –1.12 to –0.79); post-2020 APC = –0.14% (95% CI, –1.94 to +1.69). Black men maintained mortality rates 10%-12% higher than White men across all 14 years (21.1 v 18.9/100,000 in 2023), with Brown men showing fastest-growing burden (APC = +2.77 [95% CI, +2.19 to +3.35]). State-level ASMR varied 2.5-fold (Rio Grande do Sul: 22.0; Pará: 8.7), revealing inverse pattern: states with highest non-White share of deaths recorded lowest ASMR (Pará 79.3% non-White, ASMR = 8.7; Santa Catarina 8.0% non-White, ASMR = 13.8), consistent with diagnostic under-ascertainment in predominantly Afro-descendant Northern states. CONCLUSION Brazil's prostate cancer mortality reveals a geographic-racial paradox: declining national rates coexist with pandemic-era stagnation, persistent excess mortality among Black men, accelerating burden in Brown men, and an inverse association between non-White population share and recorded ASMR—indicating that the most racially vulnerable populations are also the most diagnostically invisible. These findings demand race-conscious, regionally-calibrated screening and diagnostic capacity-building, with direct implications for LMIC cancer control globally.