The current and future costs of colorectal cancer attributable to red and processed meat consumption in Brazil

Colorectal cancer is the third most common cancer for both men and women in Brazil, with an estimated 40,990 newly diagnosed cases in 2021, approximately 10% of all cancers (excluding non-melanoma skin cancer) [1]. By 2040, colorectal cancer is expected to increase by over 74% due to demographic changes (population growth and aging) [2]. The projected burden of colorectal cancer suggests an escalating economic impact on the treatment and care costs the Brazilian Health System will have to cope with.

The Brazilian Health System has a coexistence of public, private, and army systems. The Brazilian Unified Health System (Sistema Único de Saúde Brasileiro – SUS) is the most extensive public health system in the world benefiting approximately 200 million inhabitants. Over 70% of Brazilians rely exclusively on SUS [3]. The SUS Outpatient Information System (SIA/SUS) and the Inpatient Information System (SIH/SUS) are nationwide sources of direct healthcare costs and provide publicly available and deidentified inpatient and outpatient care data. In 2018, the federal government spent approximately US$1.7 billion on direct healthcare costs of cancer in Brazil, of which 15% (US$269 million out of US$1.7 billion) were due to colorectal cancer [4].

Primary cancer prevention is pivotal in cancer control, particularly considering the limited access to affordable and effective preventive screening and cancer treatment in low- and middle-income countries. In principle, colorectal cancer is one of the most preventable common cancers. In Brazil, approximately half of colorectal cancer cases and deaths could be prevented or postponed through primary prevention strategies focused on lifestyle risk factors, including diet and nutrition [5].

The International Agency for Research on Cancer (IARC) [6] and the World Cancer Research Fund, and the American Institute for Cancer Research (WCRF/AICR) [7] consider the evidence that processed meat consumption increases the risk of colorectal cancer as sufficient/convincing. This classification is based on consistent evidence showing that consumption of processed meat increases the risk of colorectal (increased risk per 50 g increase in consumption per day) and robust evidence for mechanisms operating in human [7]. Red meat consumption has been classified as probably carcinogenic to humans [6, 7]. WCRF/AICR [7] and the Brazilian National Cancer Institute (INCA) [8] recommend limiting red meat consumption to no more than three portions per week (< 500 g/week). For processed meat, the recommendation is to eat very little, if any. Despite these recommendations, per capita meat consumption has increased [9‐11]. The average global consumption of all meats in 2010 was 122 g/day, with high-income and Latin American countries, including Brazil, eating the most [12]. Quantifying the current and future economic burden of colorectal cancer attributable to red and processed meat consumption in Brazil may help inform potential policy and prevention initiatives.

In this study, we estimated the current (2018) and future (2030) federal direct healthcare costs of colorectal cancer in the SUS attributable to red and processed meat consumption. In addition, we estimated potential savings in federal direct healthcare costs of colorectal cancer in 2040 by considering different counterfactual scenarios of reduction in red and processed meat consumption to be achieved in 2030.

Our study quantified that red and processed meat consumption in 2008–2009 was responsible for US$ 20.6 million in direct healthcare costs of colorectal cancer in the SUS in 2018. Considering the changes in meat consumption from 2008–2009 to 2017–2018, and the projected growing economic burden of colorectal cancer in Brazil, we estimated that red and processed meat consumption will be responsible for US$ 86.6 million in 2030. Reduced processed meat consumption to levels fixed in the counterfactual scenarios in 2030 could save US$13.7 to 74.4 million in direct healthcare costs of colorectal cancer in 2040.

Meat consumption has some adverse effects on human health [9]. Epidemiological studies have consistently reported that meat consumption increases the risk of noncommunicable diseases, such as cardiovascular diseases, diabetes, and cancer [6, 7, 26, 27]. The most robust evidence is for the harmful effect of processed meat consumption on colorectal cancer risk [6, 7]. IARC and WCRF have classified processed meat as carcinogenic to humans, whereas red meat is probably carcinogenic to humans [6, 7]. Globally, diets high in processed meats are responsible for 34 thousand cancer deaths per year, whereas diets high in red meat are responsible for 50 thousand cancer deaths per year [28]. In Brazil, red meat was responsible for 1,900 cancer cases and 1,000 cancer deaths, and processed meat for 1,700 cancer cases and 1,000 cancer deaths in 2012 [5].

Few comparative risk assessment studies have modeled the potential impact of constraining red and processed meat on health and economic outcomes, particularly on the financial burden of cancer [5, 29‐31]. Our study showed that meat consumption also had escalated economic impact on the SUS over the years. In Canada, $CAN 168 million in direct ($CAN 29 million) and indirect ($CAN 139 million) costs with colorectal cancers were attributable to red meat consumption in 2014. For processed meat, these values were $CAN 202 million in direct ($CAN 34 million) and indirect ($CAN 167 million) costs of colorectal cancer in the same year [29]. In the US, the cost-effectiveness of implementing nutritional policies on processed meat consumption on the burden of cancer has been recently evaluated. The model showed that excise tax and warning labels would avert 77,000 to 85,400 cases of colorectal cancer, with net savings of $2.7 billion to $4.5 billion from a societal perspective, including $1.3 billion in healthcare costs saved [30]. These studies suggest that nutritional policies may be a cost-saving strategy that substantially benefits health and the economy. Our results showed that policies aimed at reducing processed meat consumption may significantly impact colorectal cancer costs. For instance, our projected costs saved in 2040 were 5–sevenfold higher for reducing processed meat than red meat consumption.

Changing population diets, especially foods considered “natural, normal, necessary or nice” [9, 32], is challenging. For instance, a systematic review of health-related values and preferences regarding meat consumption found that omnivores consume meat because they consider it an essential component of a healthy diet, like food, feel that meat is part of their traditions, and believe they have not the culinary knowledge and skills to prepare a proper meatless meal [33]. In addition, there is insufficient evidence of the effectiveness of interventions to reduce meat consumption [9]. The diversity of factors that influence the price and availability of meat and how it is processed and marketed determines a socioeconomic scenario that profoundly affects and is affected by norms and behavior. Changing dietary behaviors in response to interventions takes a lot of work. Still, social norms can and must change, and the coordinated efforts of civil society, health organizations, and government can aid this process. Governmental interventions could transform food systems through economic, political, and legal actions. Decreasing the production and consumption of meat and, consequently, its adverse environmental, health, social, and economic effects, as shown in our study, would be aligned with the 2030 United Nations Agenda for Sustainable Development Goals and the World Health Organization targets to reduce premature mortality from noncommunicable diseases [34]. However, the World Trade Organization rules may limit state-sponsored interventions in food systems. Recently, there has been a discussion about other interventions targeting unconscious/automatic behavioral choices for meat (e.g., choice architecture, environmental restructuring, and marketing and advertising) [9], but the effectiveness and ethics of these actions aimed at manipulating population behaviors are concerned [35]. Among the interventions proposed to reduce the consumption of red and processed meat is taxation, which has been used, e.g., as an effective tool to reduce the consumption of sugar-sweetened beverages. Efforts to raise consumer awareness of meat’s adverse health and environmental impacts, like warning labels, can also change behavior, redirecting meat subsidies to more sustainable and nutritious crops such as fruits and vegetables. Finally, national dietary guidelines can also play an essential role in decreasing red and processed meat consumption [36].

To our knowledge, this is the first study to quantify the direct costs of colorectal cancer treatment attributable to combined red and processed meat consumption. We used two nationally representative dietary survey data from over 60 thousand Brazilian adults, RR from meta-analysis, and 5.7 million nationwide registries of the SUS direct-healthcare costs of colorectal cancers. However, our study has some limitations. To estimate the PIF/PAF for Brazil, we used information on red and processed meat consumption from two 24-h real-time food records. However, we did not consider food preparations in 2008–2009 and 2017–2018, which could lead to an underestimation of meat consumption. We assumed the portability of the pooled RR from meta-analysis, which did not include Brazilian cohort studies. However, we incorporated the uncertainty of these estimates in the models via the Monte Carlo simulation approach. We also assumed at least a 10-year time lag between exposure and outcome based on the average follow-up time of prospective cohort studies [13]. We further recognize that non-linear changes concerning the cost of colorectal cancer treatment may occur. During data analysis, we tested multiple regression models by including predictor variables: time, aging, cancer incidence, cancer mortality, technological incorporation, and judicialization of health care. However, the multiple regression did not fit better than simple linear regression, and we opted for parsimony. Future modeling approaches using proportional multistate lifetable modeling of preventive interventions may be helpful to incorporate a time dimension more appropriately [37]. Our model did not account for recurring events or include the interaction between exposures and substitutions of meats from other food options.

Red and processed meat consumption has an escalating economic impact on the SUS. We found that 8.4% or US$ 20.6 million in direct healthcare costs of colorectal cancer in 2018 were attributable to red and processed meat consumption. In 2030, the direct healthcare costs of colorectal cancer will increase to 19.3% or US$ 86.6 million. We estimated that reducing red meat consumption could save approximately US$ 2.2 to 11.9 million in 2040. Decreasing processed meat to levels fixed in the counterfactual scenarios in 2030 could save US$ 13.7 to 74.4 million in 2040. Our findings may help support policies to reduce meat consumption and cancer prevention strategies in Brazil. Considering the limited and finite resources available to health systems, it is urgent to prioritize primary prevention actions, especially in the context of exponential cancer treatment costs.