Italian Group for Lap-Band System: results of multicenter study on patients with BMI < or =35 kg/m2

BACKGROUND

The Lap-Band System is the most common bariatric operation world-wide. Current selection criteria do not include patients with BMI < or = 35. We report the Italian multicentre experience with BMI < or = 35 kg/m(2) over the last 5 years.

PATIENTS AND METHODS

Data were obtained from 27 centres involved in the Italian Collaborative Study Group for Lap-Band System. Detailed information was collected on a specially created electronic data sheet (MS Access 2000) on patients operated in Italy since January 1996. Items regarding patients with BMI < or = 35 were selected. Data were expressed as mean +/- SD except as otherwise indicated.

RESULTS

225 (6.8%) out of 3,319 Lap-Band patients were recruited from the data-base. 15 patients, previously submitted to another bariatric procedure (BIB =14; VBG= 1) were excluded. 210 patients were eligible for study (34M/176F, mean age 38.19+/-11.8, range 17-66 years, mean BMI 33.9+/-1.1, range 25.1-35 kg/m(2), mean excess weight 29.5+/-7.1, range 8-41). 199 comorbidities were diagnosed preoperatively in 55/210 patients (26.2%). 1 patient (0.4%) (35 F) died 20 months postoperatively from sepsis following perforation of dilated gastric pouch. There were no conversions to laparotomy. Postoperative complications presented in 17/210 patients (8.1%). Follow-up was obtained at 6, 12, 24, 36, 48 and 60 months. At these time periods, mean BMI was 31.1+/-2.15, 29.7+/-2.19, 28.7+/-3.8, 26.7+/-4.3, 27.9+/-3.2, and 28.2+/-0.9 kg/m(2) respectively. Co-morbidities completely resolved 1 year postoperatively in 49/55 patients (89.1%). At 60 months follow-up, only 1 patient (0.4%) has a BMI >30.

CONCLUSIONS

Although surgical indications for BMI < or = 35 remain questionable, the Lap-Band in this study demonstrated that all but 1 patient achieved normal weight, and most lost their co-morbidities with a very low mortality rate.

Breast density as a determinant of interval cancer at mammographic screening

The association of breast density (% of breast volume involved by fibro-glandular densities) with the risk of interval cancer (IC) was investigated by reviewing a consecutive series of 346 cancers detected at screening (SDC) during 1996-1999 and of 90 ICs, reported as negative in the same period and diagnosed in the following 2 years, and comparing them to a random sample of 360 healthy controls. The probability of IC was significantly associated with breast density, whatever grouping (0/1-25/26-74/>74%; 0-25/26-60/61-74/>74%; 0-25/26-74/>74%) was considered (chi(2)=30.67-34.08, P<0.<0.01): 27.8% of all ICs were classified in the >74% density class, as compared to 7% of SDC and 5% of healthy controls. No significant association to IC was observed for Wolfe pattern (P2/Dy vs N1/P1: chi(2)=0.30, P=0.960), number of used mammographic views (single oblique vs oblique+craniocaudal: chi(2)=0.02, P=0.90) or screening round (first vs repeat: chi(2)=1.41, P=0.23). Multivariate analysis confirmed the independent association of breast density to IC, the highest risk being observed for >74% density class (OR vs 0% class=13.4, 95% CI 2.7-65.6, OR vs all other density classes=5.1, 95% CI 2.6-10.0). Age showed an independent association too, older women having a lower risk of IC (OR=0.52 95% CI 0.3-09). Breast density (>74%) resulted as being a major determinant of IC. Special screening protocols (shorter rescreening interval, routine use of ultrasonography) might be suggested for these subjects in order to improve screening sensitivity and efficacy.

Incidence of second cancers among women with in situ carcinoma of the breast

A population-based cohort of 371 women with carcinoma in situ (CIS) of the breast, collected by the Tuscany Cancer Registry, has been analysed for further invasive cancers. All cases, diagnosed between 1985 and 1997, have been followed up to the end of 1997. During 1707 person-years of follow-up, 27 further invasive cancers were diagnosed while 13.7 were expected (Observed/Expected=2.0, P<0.05). The relative risk for invasive breast cancers was 3.7 (P<0.05). According to the surgical treatment for CIS and the site of further invasive breast cancer, no side specific difference was evident. No significant increase was evident for other cancer sites; only non-melanomatous skin cancers occurred more frequently than expected (O/E=4.2). The cumulative risk of developing an invasive cancer after CIS was 13.2% at 10 years. There were also two deaths due to breast cancer (O/E=8.3; P<0.05) corresponding to a cumulative mortality risk of 2% at 10 years. We have quantified the risk of developing an invasive breast cancer among women with CIS of the breast as four times that of the general population.

Colorectal cancer screening programme by faecal occult blood test in Tuscany: first round results

Screening with faecal occult blood test (FOBT) has been shown to be effective in reducing mortality from colorectal cancer. Tuscany was the first region in Italy in which a screening programme for colorectal cancer by FOBT was initiated region-wide. The aim of the paper was to describe organizational aspects, a quality control model and the results of this experience. From June 2000 to December 2001, 192583 subjects aged 50-70 were invited to undergo a 1-day immunochemical test without any dietary restriction. A total of 78505 subjects (41%) performed the screening test, of whom 4537 responders had a positive test result (5.8%). Among them, 1122 refused any form of assessment or underwent a colonoscopy outside the screening referral centres, with an overall assessment compliance of 75.3%. Malignancies were found in 193 patients and at least a high-risk adenomatous polyp in 692 patients. In about a quarter of the positive subjects who underwent assessment, cancer or high-risk adenoma was detected. In conclusion, data from this experience supported the feasibility of biennial colorectal screening programme by FOBT, particularly regarding invitation compliance and positivity rate. Further efforts are necessary to implement screening extension and to improve data collection.

Comparison of standard and double reading and computer-aided detection (CAD) of interval cancers at prior negative screening mammograms: blind review

The study evaluates the role of computer-aided detection (CAD) in improving the detection of interval cancers as compared to conventional single (CONV) or double reading (DOUBLE). With this purpose, a set of 89 negative cases was seeded with 31 mammograms reported as negative and developing interval cancer in the following 2-year interval (false negative (FN)=11, minimal signs (MS)=20). A total of radiologists read the set with CONV and then with CAD. Overall, there were 589 cancer and 1691 noncancer readings with both CONV and CAD. Double reading was simulated by combining conventional readings in all 171 possible combinations of 19 radiologists, resulting in a total of 5301 cancer and 15 219 noncancer readings. Conventional single, DOUBLE and CAD readings were compared in terms of sensitivity and recall rate. Considering all 19 readings, cancer was identified in 190 or 248 of 589 readings (32.2 vs 42.1%, χ²=11.80, df=1, P<0.01) and recalls were 287 or 405 of 1691 readings (16.9 vs 23.9%, χ²=24.87, df=1, P<0.01) at CONV or CAD, respectively. When considering FN and MS cases separately, sensitivity at CONV or CAD was 50.2 or 62.6% (χ²=6.98, df=1, P=0.01) for FN and 22.3 or 30.7% (χ²=6.47, df=1, P=0.01) for MS cases, respectively. Computer-aided detection (average of 19 readings) was slightly and not significantly less sensitive (sensitivity: 42.1 vs 46.1%, χ²=3.24, df=1, P=0.07) but more specific (recall rate 23.9 vs 26.1%, χ²=3.8, df=1, P=0.04) as compared to DOUBLE (average of 171 readings). Average sensitivity for FN cases only was 62.6% for CAD and 64.8% for DOUBLE (χ²=0.32, df=1, P=0.58). Corresponding values for MS cases were 30.7% for CAD and 35.7% for DOUBLE (χ²=3.53, df=1, P=0.06). Compared to CONV, CAD allowed for improved sensitivity, though with reduced specificity, both effects being statistically significant. Computer-aided detection was almost as sensitive as DOUBLE but significantly more specific. Computer-aided detection might be used in the current practice to improve sensitivity of conventional single reading. Based on estimates of screening sensitivity and FN/MS interval cancer expected frequency, the absolute increase of screening sensitivity expected by introducing CAD-assisted reading may be estimated around 0.9%. The use of CAD as a possible surrogate to conventional DOUBLE needs to be confirmed by further studies, which should include a cost-effective analysis.

Clinical impact (cost-effectiveness) of qualifying atypical squamous cells of undeterminate significance (ASCUS) in cases favoring a reactive or dysplastic process

The cost-effectiveness of qualifying ASCUS cases into two different subcategories, favoring a reactive (ASCUS-R) or dysplastic process (ASCUS-S), was evaluated at the Centro per lo Studio e la Prevenzione Oncologica of Florence in a prospective study. The study determined the positive predictive value (PPV) for histologically confirmed cervical intraepithelial neoplasia grade 2 (CIN2) or more (CIN>) severe lesion of the two ASCUS subgroups. ASCUS-S had a PPV (10.78%) comparable to low-grade squamous intraepithelial lesions (LSIL) (11.40%). For ASCUS-R cases, the recommendation of 6-mo repeat cytology prompting colposcopy in cases of persistent ASCUS or more severe cytology was also effective, as it selected a subgroup with a relatively high PPV (10.34%). The cost-effectiveness of a protocol based on ASCUS qualification was compared with two other possible options for nonqualified ASCUS cases: immediate colposcopy and colposcopy in persistent ASCUS at 6-mo repeat cytology. The detection rate of CIN2> was substantially higher using ASCUS qualification (35.9 vs 14.8 or 17.1). The cost per ASCUS subject was euro 24.99, 27.11, or 25.14 and that per CIN2> detected was euro 697, 1,831 or 1,470 for the three options, respectively. The evidence that ASCUS detection option implies a higher detection rate of CIN2> and subsequently a lower cost per CIN2> detection must be considered with caution and deserves confirmation by other comparative studies.

Practice of opportunistic PSA screening in the Florence District

The widespread use of the prostate-specific antigen (PSA) test had a great impact on the rise of incidence of prostate cancer. The magnitude of opportunistic screening by PSA varies across countries, being highest in the US, and considerably lower in Europe. To estimate the opportunistic use of PSA over the period of one year (2000) in the District of Florence, we analysed the Regional Database of diagnostic exams. According to the Regional Database, subjects having at least one PSA test during the year 2000 ranged from 5.8 to 6.7%, 8.8-10.8%, 11.7-15.0%, 16.5-22.3%, 18.0-24.3%, 17.0-23.8% and 14.1-18.3% in the 50-54, 55-59, 60-64, 65-69, 70-74, 75-79 and >79 years age groups, respectively. Minimum and maximum values are reported according to exclusion or inclusion of PSA determinations with incomplete subject identification data. Such a high use of PSA should deserve special attention from both the medical and health care provider community. The aim of the present study was to evaluate the frequency of opportunistic screening by PSA in the District of Florence in the general population.

Two cases of cerebral aspergillosis successfully treated with voriconazole

Described here are two cases of cerebral aspergillosis successfully treated with voriconazole after the failure of first-line treatment with amphotericin B deoxycholate. In both cases, clinical and radiological cure was achieved within 6 weeks. Voriconazole should be considered as first-line therapy for cerebral aspergillosis.

Surveillance for endometrial cancer with transvaginal ultrasonography of breast cancer patients under tamoxifen treatment

The association of endometrial thickness with the risk of developing endometrial cancer (EC) within 2 years was investigated in a consecutive cohort of 1205 breast cancer patients under tamoxifen treatment, undergoing transvaginal ultrasonography (TVUS) for follow-up purpose (asymptomatic, 1068) or for abnormal uterine bleeding (AUB, 137). Linkage with tumour registry allowed for the follow-up of 3184.3 person-years. According to underlying incidence, 1.85 EC cases were expected in the study cohort while 12 were observed (observed/expected ratio=6.49, 95% CI 3.35-11.33; asymptomatic=4.09, 95% CI 1.65-8.43, symptomatic=35.71, 95% CI 11.59-83.34). No EC was observed with thickness (half layer) <3 mm. Raising this threshold increased specificity with a substantial loss of sensitivity (>or=3, >or=4, >or=6, >or=9 mm; spec.=25.8, 44.5, 76.1, 91.5%, sens.=100, 91.6, 75.0, 66.6%). The presence of AUB was rather specific (88.94%) but poorly sensitive (41.67%). A combination of AUB presence/absence and thickness allowed the best accuracy (AUB + thickness >or=3, >or=4 or >or=5; sens.=100, 81.6 or 91.6%; spec.=22.8, 40.4, or 56.7%). Breast cancer patients under tamoxifen might be selected for further invasive assessment on the basis of AUB and endometrial thickness assessed at TVUS.

Basic variables at different positivity thresholds of a quantitative immunochemical test for faecal occult blood

OBJECTIVES

Screening by faecal occult blood testing (FOBT) is effective in decreasing mortality and incidence of colorectal cancer (CRC). Immunochemical tests have proved to be more cost effective than guaiac FOBTs. The latex agglutination test (LAT) has the advantage of being a fully automated, quantitative test. The aim of this study is to interpret the overall experience with LAT according to different positivity thresholds.

SETTING

A population based screening programme is currently running involving subjects aged 50-70, invited every 2 years to have an FOBT. LAT is the standard screening test and has a positivity threshold for further diagnostic tests of 100 ng haemoglobin/ml of sample solution.

METHODS

Positivity rates, detection rates for CRC high risk adenomas, and positive predictive values for CRC, high risk adenomas, and low risk adenomas were calculated for several positivity thresholds.

RESULTS

19,132 attendances at screening were recorded (11,774 at first screening, 7358 at subsequent screenings). Progressively increasing the positivity threshold from 100 to 200 ng/ml showed (a) a decrease in positivity rate; (b) a decrease in detection rates for CRC or high risk adenomas; (c) an increase in positive predictive values for cancer; (d) an increase in positive predictive value for high risk adenomas.

CONCLUSIONS

Increasing the positivity threshold of the LAT reduces recall rate and improves positive predictive value for cancer or high risk adenomas but substantially decreases the detection rate of CRC and high risk adenomas. For this reason increasing the positivity cut off for LATs is not advisable. On the other hand decreasing the positivity threshold would increase recall rate and sensitivity of screening. Careful evaluation of sensitivity of the quantitative results of the LAT for interval cancers is needed to definitively assess the optimal positivity threshold for LATs in population based screening programmes.

Lap Band adjustable gastric banding system: the Italian experience with 1863 patients operated on 6 years

BACKGROUND

The Lap Band system procedure is currently the most common bariatric surgical procedure worldwide. This is an interim report of the experience of the 27 Italian centers participating in the national collaborative study group for Lap Band (GILB).

METHODS

An electronic database was specifically created. It was mailed and e-mailed to all of the surgeons now performing the laparoscopic gastric banding operation in Italy.

RESULTS

Beginning in January 1996, 1893 patients were recruited for the study. There were 1534 women and 359 men with a mean body mass index (BMI) of (range 30.4-83.6) and a mean age of 37.8 +/- 10.9 years (range; 17-74). The mortality rate has been 0.53% (n = 10), mainly due to cardiovascular complications (myocardial infarction, pulmonary embolism). The laparotomic conversion rate has been 3.1% (59/1893) and was higher in superobese patients (BMI>50) than in to morbidly obese patients (BMI <50) (p <0.05). Postoperative complications occurred in 193 patients (10.2%), including tube port failure (n = 79; 40.9%), gastric pouch dilation (GPD) (n = 93; 48.9%), and gastric erosion (n = 21, 10.8%). Most GPD (65.5%) occurred during the first 50 patients treated at each center. The incidence of GPD decreased as the surgeons acquired more experience. Surgery for complications was often performed by laparoscopic access, rarely via laparotomy. No death was recorded as a consequence of surgery to treat complications. Weight loss has been evaluated at the following intervals: 6, 12, 24, 36, 48, 60, and 72 months, with BMI 37.9, 33.7, 34.8, 34.1, 32.7, 34.8, and 32.

CONCLUSIONS

The Lap Band system procedure has a very low mortality rate and a low morbidity rate and it yields satisfactory weight loss. Surgery for complications can be performed safely via laparoscopic access.

Results of the Italian multicenter study on 239 super-obese patients treated by adjustable gastric banding

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) is the most common bariatric operation. This study is a retrospective analysis of the multicenter Italian experience in patients with BMI > 50 over the last 4 years.

METHODS

An electronic data sheet made for LAGB-operated patients since January 1996, was mailed and e-mailed to all surgeons involved in this kind of procedure in Italy. Items regarding patients with BMI > 50 were selected. Analysis used Fisher's exact test and logarithmic regression analysis (P < 0.05 significant). Data were expressed as mean +/- SD.

RESULTS

239 patients (13.3%), out of 1,797 Lap-Band operated patients entered the study (179F / 60M), with mean age 37.6 +/- 11.3 years (19-69) and mean BMI 54.6 +/- 4.8 (50.1-83.6). Laparotomic conversion rate was 5.4% (44/239). Postoperative complications occurred in 24 / 239 patients (9.0%). Follow-up was obtained in 218 / 218, 198 / 198, 121 /147, 75 / 93, 30 / 38 LAGB patients at 6,12, 24, 36, and 48 months respectively. At these time periods, mean BMI was 46.7, 43.9, 42.2, 41.9, and 39.3 kg/m2. At the same intervals, mean %EWL was 24.1, 34.1, 38.8, 38.9, and 52.9%. The number of patients with < 25% EWL at 12, 24, 36, and 48 months follow-up were 34, 10, 4, and 0. Serious co-morbidities (189 in 124 of 239, 57%) had completely resolved 1 year postoperatively in 74 / 124 of the patients (59.6%).

CONCLUSION

Although super-obese patients following the LAGB remain obese with BMI > 35, in the short-term most lose their co-morbidities, with a very low morbidity and mortality rate.

Monitoring interval cancers in mammographic screening: the Florence District programme experience

The aim of the present study was to monitor the occurrence of interval (breast) cancers (IC) as an interim outcome measure of quality assurance in the mammographic screening programme of the District of Florence. IC were identified by linking breast screening data with registrations of breast cancers from the Tuscany Tumour Registry. The main outcome measures were the numbers, rates, and the proportionate incidence of IC. Overall, 90 invasive IC were observed among women who attended the breast screening programme in the District of Florence from 1 January 1985 to 31 December 1993, respectively, 23, 50, on 17 cases, at 1, 2, and 3 years after the last negative screening test. Expressed as a proportion of underlying incidence, the figures are 16, 44, and 46%. As to risk factors for IC, mammographic density was the most important one in the present survey, whereas no effect of age emerges from the present study.

Time trends in cancer incidence and mortality in central Italy

Time trends in cancer incidence and mortality represent an essential tool for monitoring the changes in population lifestyle and in the environmental risks and the effectiveness of the health system on cancer control in a specific area. During 1985-1997 82 506 malignant tumours were diagnosed in the Tuscany Cancer Registry, central Italy (about 1 200 000 inhabitants) and 54 979 cancer deaths registered in the period 1985-1999 by the Regional Mortality Registry were analysed. A statistically significant decrease in incidence was evidenced for stomach and gallbladder in both sexes, and for oesophagus, larynx and lung among males. Significant increases were documented for melanomas of the skin, kidney and non-Hodgkin's lymphoma in both sexes for colon, prostate and Kaposi's sarcoma among males and for breast, thyroid and multiple myeloma among females. Mortality decreased significantly for stomach and thyroid in both sexes and for oral cavity and pharynx, oesophagus, rectum, larynx, lung, bone, prostate, testis and Hodgkin's disease among males and colon, gallbladder and breast among females. Mortality increased for soft tissue, brain and multiple myeloma. In conclusion, most of these data can be explained as the effect of the modifications that occurred in smoking habits between the sexes and as the consequence of the primary and secondary prevention activities that are ongoing in the area.

Quantification of the effect of mammographic screening on fatal breast cancers: The Florence Programme 1990-96

Breast cancer cases diagnosed in women aged 50-69 since 1990 to 1996 in the City of Florence were partitioned into those who had been invited to screening prior to diagnosis and those who had not. All cases were followed up for vital status until 31 December 1999. The cumulative number of breast cancer deaths among the cases were divided by screening and invitation status, to give the rates of cancers proving fatal within a period of 8 years of observation (incidence-based mortality). We used the incidence-based mortality rates for two periods (1985-86, 1990-96), pre and during screening. The incidence-based mortality ratio comparing 1990-96 and 1985-86 was 0.50 (95% CI : 0.38-0.66), a significant 50% reduction. For noninvited women, compared to 1985-86, there was a 41% significant mortality reduction (RR=0.59, 95% CI : 0.42-0.82). The comparable reduction in those invited was a significant 55% (RR=0.45, 95% CI : 0.32-0.61). The incidence ratio of rates of cancers stage II or worse was close to one when the noninvited in 1990-96 were compared with 1985-86 (RR=0.97, 95% CI : 0.78-1.21). Excluding prevalent cases, the rate of stage II+ breast cancer cases was 42% lower in Screened women compared with the noninvited (RR=0.58, 95% CI : 0.45-0.74). This study confirmed that new treatments and the first rounds of the screening programme contributed to reducing mortality from breast cancer.

Interlaboratory reproducibility of the immunocytochemical assessment of oestrogen and progesterone receptors and proliferative activity in fine needle aspiration of breast cancer

The purpose of this study was to establish the interlaboratory reproducibility of immunocytochemical analysis of oestrogen (ER) and progesterone (PR) expression and Mib1 growth fraction on fine needle aspiration (FNA) smears. A set of 44 immunostained slides for ER, PR and Mib1 were randomly selected from the archives of the Center for the Study and Prevention of Cancer (CSPO) of Florence, Italy, and submitted for reading to 6 Italian laboratories. The generalized kappa statistic was used as an indicator of agreement among the six laboratories. A good correlation for ER and PR was evident. For Mib1 the results showed some discrepancies. In addition to adequate standardization of procedures, these data confirm that the reliability of the immunocytochemistry is strictly linked to accurate analysis of the results.

Pre-operative prediction of invasive vs intraductal breast cancer type: multivariate analysis of the accuracy of clinical and imaging findings

Two consecutive series of 107 invasive carcinomas and 108 carcinomas in situ of the breast were considered retrospectively. The main symptomatic, clinical and cytological features were retrieved from clinical records, whereas the features at mammography and/or ultrasonography were reclassified at a blinded review by an expert radiologist. The power of predicting invasion on the basis of these features was then evaluated. The accuracy of such a prediction was compared to that of a mathematical model using the same diagnostic features by multivariate logistic regression analysis. Neither approach reached a satisfactory accuracy, but the radiologist's judgment (sensitivity 97.1%, specificity 81.9%, positive predictive value 98.4%, negative predictive value 71.6%, overall accuracy 95.8%) was slightly superior to the mathematical model (sensitivity 93.2%, specificity 87.9% positive predictive value 98.8%, negative predictive value 53.7%, overall accuracy 92.8%). Although some presentations are significantly associated with invasive or in situ status, diagnostic features alone are not sufficiently accurate to bypass histological confirmation, although they might give useful clinical indications.

Transperineal sonography guided biopsy of the prostate: critical review of 1107 cases

PURPOSE

To assess the predictive value for a positive biopsy of different indicators (rectal examination, transrectal ultrasonography, total PSA, PSA density).

MATERIAL AND METHODS

Positive predictive value was assessed on 1107 consecutive US-guided transperineal biopsies performed from 1991 to 2001 (cancer=344, dysplasia (PIN)=64, atypical hyperplasia=4, benign hyperplasia=686, inadequate=9) with univariate and multivariate analysis.

RESULTS

Increasing age (chi square for trend 52.2, p <0.001), positive rectal examination (chi square 233, df=1, p<0.001) or ultrasonography (chi square 191, df=1, p<0.001), total PSA (chi square for trend 68.9, p<0.001) and PSA density (cutoff 0.15, chi square 104, df=1, p<0.001; cutoff 0.20, chi square 104, df=1, p<0,001) were all significantly associated to the likelihood of a positive biopsy outcome. Multivariate analysis stresses the independent role of Psa density over total PSA. If the parameters studied had determined the biopsy, spared benign biopsies [positive rectal examination=505 (66%), positive ultrasonography=467 (61%), PSA>4=124 (16%), PSA>10=159 (74%), PSA density >0,15=426 (62%), PSA density >0.20=517 (75%)] would not have justified the amount of delayed cancer biopsies [positive rectal examination=103 (29%), positive ultrasonography=55 (15%), PSA>4=42 (12%), PSA>10=569 (46%), PSA density >0,15=73 (25%), PSA density >0,20=107 (37%)].

CONCLUSIONS

The parameters currently available prior to biopsy, if used alone, allow no reliable prediction of biopsy outcome. Positive predictive value, particularly for PSA density, allows a better evaluation of biopsy indication, particularly for random sextant biopsies in the 4-10 ng/ml PSA range, which are frequently negative.

Assessment of the early impact of the population-based breast cancer screening programme in Florence (Italy) using mortality and surrogate measures

The aim of this study was to evaluate the effects by the end of 1999 of the Florence breast screening programme that started in 1990. Approximately 60000 women (aged 50-69 years) were enrolled from 1990 to 1993. Breast cancer cases diagnosed from 1990 to 1996 were partitioned by the method of detection, classified by their tumour size and nodal status and followed-up for mortality at on the 31 December 1999. Incidence-based mortality in the 50-74-year-old women and advanced carcinomas rates were assessed. Due to low compliance (approximately 60%) and the long enrollment phase, only approximately 35% of the total age-specific population person-years were screened. The number of invasive cases diagnosed was 1122, 17% higher than the 958 expected. After the prevalence screening, a reduction of approximately a quarter in advanced carcinomas was observed in the invited women (Odds Ratio (OR): 0.74; 95% Confidence Interval (CI): 0.55-0.98). In the period 1990-1999, 547 breast cancer deaths were observed: 78 (14%) occurred in women invited and half of these in never responders, 385 (70%) occurred in cases diagnosed before screening started. Disproportionate numbers of deaths occurred in women with advanced tumours. The 19% mortality reduction for the invited women was of borderline statistical significance (observed/expected (O/E) deaths: 0.81; 95% CI: 0.64-1.01); by a one-sided test the result would be unequivocally significant. The mortality reduction attributable to screening in the whole population over the 10-year period was 3.2%. The incidence-based mortality analysis confirmed the current follow-up time is too short for screening to have had a major effect on the breast cancer mortality trends. Screening performance might be improved by a higher level of compliance and shorter interval times, but the estimate of the mortality reduction for the invited and the lower rate of advanced carcinomas confirmed that the effect of the programme is in the expected direction.

Effectiveness of influenza vaccination in the elderly in a community in Italy

OBJECTIVES

Assess the effectiveness of influenza vaccination in reducing hospitalization due to pneumonia and influenza among elderly subjects in a community in central Italy. Estimate the hospitalization fraction preventable by extending the vaccination program.

METHODS

Case-control study. Cases were subjects aged 65+ at hospital admission (1 December 1994-31 March 1995). For each case two population controls were randomly chosen, matched by sex, age and residence. Variables of interest were recorded through a postal questionnaire and telephone interview. A matched-set analysis was carried out adjusting for concomitant chronic diseases, education, type of home heating, and smoking habits. The preventable fraction of hospitalization was computed through the application of the attributable risk estimate. The setting was 33 municipalities in central Italy including 169,370 residents aged 65 years or more.

RESULTS

Two hundred and seventy-five cases 550 controls were analyzed. Influenza vaccination was effective in preventing 33% of hospitalization due to pneumonia/influenza. The fraction of hospital admissions preventable by extending the vaccination was 17%. When the analysis was limited to self-respondents to the questionnaire (excluding next-of-kin) and to pneumonia/influenza as primary discharge diagnosis, protection from hospitalization by vaccination almost reached 50%, a better result in comparison with most case-control studies.

CONCLUSIONS

Influenza vaccination was shown to be successful in reducing hospital admissions due to pneumonia and influenza. A large number of hospitalizations could be reduced extending the vaccination campaign.

An application of the two-source capture-recapture method to estimate the completeness of the Tuscany Cancer Registry, Italy

The purpose of this study was to apply a two-way capture-recapture method to estimate the Tuscany Cancer Registry completeness, taking into account the presence of dependence between sources. Cases incident during 1995-1996 were flagged according to three sources of information: clinical notes, pathological reports and death certificates. For each group of cases notified by one source the dependence between the other two has been quantified and the completeness has been estimated by a two-way capture-recapture method. When only two (or substantially two) sources are dependent on each other it is possible to correct for it by pooling the two sources in a single group and comparing it with the remainder source by a two-way capture-recapture method. The capture-recapture method has been applied to the overall 12 387 incident cases and to 1569 female breast and 1443 lung cancer cases. After correction for the greatest dependence among the three couples of sources of information, the estimates of completeness were 97.4% for the whole case series, 88.7% for female breast and 99.6% for lung cancer. With the limit of multiple strong dependence between sources, the two-way capture-recapture method seems a simple and useful tool for estimating the completeness of cancer registration.

Puberty in perinatal HIV-1 infection: a multicentre longitudinal study of 212 children

OBJECTIVE

To define age at entry into Tanner stages in children with perinatal HIV-1 infection.

DESIGN

Multicentre longitudinal study including 212 perinatally HIV-1-infected children (107 girls and 105 boys) followed-up during puberty (from 8 and 9 years onwards in girls and boys, respectively). Healthy children (843 girls and 821 boys) provided reference percentiles. P2 or B2 stages in girls and P2 or G2 stages in boys defined onset of puberty.

METHODS

The cumulative probability [95% confidence limit (CI)] of entry into each stage at different ages was estimated by the Kaplan-Meier product-limit method; differences were evaluated by log rank test. Relationships were tested using the Spearman's rank correlation coefficient.

RESULTS

Ages of girls [years (95%CI)] at P2 [12.9 (12.6-13.2)], P3 [13.4 (13.0-13.8)], P4 [14.6 (14.0-15.2)], B2 [12.7 (12.2-13.2)], B3 [13.3 (12.8-14.0)] and B4 [14.6 (14.0-15.2)] stages were > 97th percentile (> or = 21 month delay) of controls. Ages of boys [years (95%CI)] at P2 [12.6 (12.1-13.1)], P3 [13.9 (13.4-14.4)], P4 [14.9 (14.2-15.6)], G2 [12.1 (11.5-12.7)], G3 [13.6 (13.1-14.1)] and G4 [14.9 (14.1-15.7)] stages were at the 75-97th percentiles (< or = 15 month delay). Age at onset of puberty was not related to clinical and immunological condition, antiretroviral treatment, weigh for height and age at onset of severe disease or immune suppression.

CONCLUSION

Perinatal HIV-1 infection interferes with sexual maturation. The mechanisms by which this occurs should be elucidated and intervention strategies designed. Intervention could save much psychological distress, since associated linear growth failure can exacerbate adolescents' feelings of being different and unwell.

Cell age-related monovalent cations content and density changes in stored human erythrocytes

Conversion of erythrocyte membrane protein 4.1b to 4.1a occurs through a non-enzymatic deamidation reaction in most mammalian erythrocytes, with an in vivo half-life of approximately 41 days, making the 4.1a/4.1b ratio a useful index of red cell age [Inaba and Maede, Biochim. Biophys. Acta 944 (1988) 256-264]. Normal human erythrocytes distribute into subpopulations of increasing cell density and cell age when centrifuged in polyarabinogalactan density gradients. We have observed that, when erythrocytes were stored at 4 degrees C under standard blood bank conditions, the deamidation was virtually undetectable, as cells maintained the 4.1a/4.1b ratio they displayed at the onset of storage. By measuring the 4.1a/4.1b values in subpopulations of cells of different density at various time points during storage, a modification of the normal 'cell age/cell density' relationship was observed, as erythrocytes were affected by changes in cell volume in an age-dependent manner. This may stem from a different impact of storage on the imbalance of monovalent cations, Na(+) and K(+), in young and old erythrocytes, related to their different complement of cation transporters.

Iron status and HFE genotype in erythrocyte pyruvate kinase deficiency: study of Italian cases

We evaluated the iron status and searched for mutations C282Y and H63D in the hereditary hemochromatosis gene (HFE) in 34 pyruvate kinase (PK)-deficient patients from 29 unrelated families. Nine had received multiple transfusions. Thirteen of the 25 nontransfused patients displayed increased serum ferritin concentration, in the absence of conditions known to raise this parameter. HFE genotype was abnormal in 9 of 34 patients. The allele frequency was 1.8% for mutation 845G--> (C282Y) and 16.1% for mutation 187C-->G (H63D). Nontransfused subjects with abnormal genotype had serum ferritin and transferrin saturation values significantly higher than those with wild-type genotype. Of the 12 adult nontransfused patients with increased iron status parameters, 1 was C282Y homozygous, 1 compound heterozygous for C282Y and H63D, 3 H63D heterozygous, and 7 had a normal HFE genotype. Serum ferritin and transferrin saturation were not related to hemoglobin, reticulocytes, and bilirubin concentration. At multivariate analysis serum ferritin was independently associated with age and gender, but not with splenectomy and HFE genotypes. The retrospective evaluation of the iron status profile of 10 patients (3 with abnormal and 7 with wild-type HFE genotype) with at least 10 years follow-up showed that overt iron accumulation requiring iron chelation had occurred only in the 3 patients (2 of whom were splenectomized) with the mutated HFE gene.

Measuring interval cancers in population-based screening using different assays of fecal occult blood testing: the District of Florence experience

The fecal occult blood test (FOBT) has demonstrated its efficacy in reducing mortality from colorectal cancer (CRC). The guaiac-based FOBT has been criticized for its low sensitivity. In this study, two different assays for FOBT (guaiac or an immunochemical test based on reversed passive hemagglutination [RPHA]) were tested for comparison within a population-based screening program for colorectal cancer in the province of Florence (Italy). The proportional incidence method was used to calculate sensitivity for both FOBTs, according to rank of screening (first or repeat), age at entry (two groups of 50 to 59 and 60 to 70 years old) and lesion site (colon or rectum). When comparing FOBTs, the sensitivity multivariate Poisson regression was used to adjust for other variables. The sensitivity after the first 2 years was 50% (95% confidence interval [CI] 34% to 63%) for the guaiac test versus 82% (95% CI 67% to 92%) for RPHA. At multivariate analysis the risk of developing an interval cancer after a guaiac test is almost 3 times that after RPHA (rate ratio = 2.64; 95% CI 1.3 to 5.4). Our study confirms that RPHA is more sensitive than the guaiac test. The assumption that FOBT screening for CRC has to be based on a guaiac test should be reconsidered, and RPHA should be recommended as the standard FOBT for screening purposes.

Measuring interval cancers in population-based screening using different assays of fecal occult blood testing: the District of Florence experience

The fecal occult blood test (FOBT) has demonstrated its efficacy in reducing mortality from colorectal cancer (CRC). The guaiac-based FOBT has been criticized for its low sensitivity. In this study, two different assays for FOBT (guaiac or an immunochemical test based on reversed passive hemagglutination [RPHA]) were tested for comparison within a population-based screening program for colorectal cancer in the province of Florence (Italy). The proportional incidence method was used to calculate sensitivity for both FOBTs, according to rank of screening (first or repeat), age at entry (two groups of 50 to 59 and 60 to 70 years old) and lesion site (colon or rectum). When comparing FOBTs, the sensitivity multivariate Poisson regression was used to adjust for other variables. The sensitivity after the first 2 years was 50% (95% confidence interval [CI] 34% to 63%) for the guaiac test versus 82% (95% CI 67% to 92%) for RPHA. At multivariate analysis the risk of developing an interval cancer after a guaiac test is almost 3 times that after RPHA (rate ratio = 2.64; 95% CI 1.3 to 5.4). Our study confirms that RPHA is more sensitive than the guaiac test. The assumption that FOBT screening for CRC has to be based on a guaiac test should be reconsidered, and RPHA should be recommended as the standard FOBT for screening purposes.

Molecular characterization of the PK-LR gene in sixteen pyruvate kinase-deficient patients

We studied the PK-LR gene in 16 unrelated patients with congenital haemolytic anaemia associated with erythrocyte pyruvate kinase deficiency. Fifteen different mutations were detected among the 28 mutated alleles identified: two deletions (del 1010G, del 1042--1044); one four nucleotide duplication (nt 1515--1518, GGTC); one splice site [IVS6(-2)t]; nine missense (991A, 1003A, 1151T, 1160G, 1181T, 1181A, 1456T, 1483A, 1529A); and two nonsense (721T, 1675T) mutations. Eight of them [del 1010G, del 1042--1044, dupl 1515--1518, IVS6(-2)t, 1003A, 1160G, 1181T, 1181A] were novel. The deletion 1042-1044 causes the loss of Lys 348. Deletion 1010G and duplication 1515-1518 determine a frameshift and the creation of a stop codon at nucleotides 1019 and 1554 respectively. Mutation IVS6(-2)t leads to an alteration of the 5' and 3' splice site consensus sequence; the cDNA analysis shows a 67-bp deletion in the first part of exon 11 (del 1437--1503). All the four new missense mutations involve highly conserved amino acids. The most frequent mutation in Italy would appear to be 1456T. Correlation was made between mutations, biochemical characteristics of the enzyme and clinical course of the disease.

[Impact of replacement hormone therapy in menopause on breast radiologic density and possible complications of mammography in the assessment of breast masses]

PURPOSE

To analyse the association of hormone replacement therapy (HRT) and radiological density, defined as the fraction of breast volume occupied by fibroglandular opacity.

MATERIAL AND METHODS

We considered 678 postmenopausal women, consecutively undergoing mammography within an organized screening program, 188 (27.7%) of whom were receiving HRT. Attribution of radiological density was performed prospectively and blind as to HRT status.

RESULTS

Both radiological density (p = 0.12) and exposure to HRT (p < 0.001) were found to correlate with age (younger women are more likely to use HRT and to have denser breasts, even without HRT) so the analysis of the correlation between HRT and radiological density was adjusted for the possible confounding effect of age. After stratification by age group, univariate analysis showed a significant correlation between HRT and radiological density (density = > 50%: HRT+ = 34.0%, HRT- = 17.6%: F-value 18.86, df = 1, p < 0.001). Also the duration of HRT was significantly associated to radiological density (Pearson coeff. = 0.12: p = 0.0011). Multivariate analysis adjusting for the confounding effect of age showed an increased risk of dense breast (17% or 7% for a radiological density > 25% or > 50%, respectively) in HRT users with respect to non users.

DISCUSSION

The study design, the adoption of a classification of breast density less exposed to intraobserver variability and multivariate analysis of a large series, allows a reliable evaluation of the association of HRT to breast density. As no threshold value is known for the masking effect of density on breast cancer, the negative effect of HRT on screening sensitivity cannot be accurately quantified.

CONCLUSIONS

This study confirms the effect of HRT on radiological density in postmenopausal women, suggesting a possible reduction of screening sensitivity and efficacy. Such a hypothesis still needs validation by means of a prospective analysis of the correlation between HRT and the frequency of interval cancer occurrence (the best indicator of sensitivity).

Screening for colorectal cancer by faecal occult blood test: comparison of immunochemical tests

OBJECTIVE

To compare two immunochemical faecal occult blood tests based on reversed passive haemagglutination (RPHA) or latex agglutination (Hdia) in a population based screening setting.

METHOD

Hdia was interpreted according to three positivity thresholds: 100, 150, or 200 ng of haemoglobin/mg of specimen solution. A total of 5844 subjects were recruited into the study, from 17432 invited subjects aged 50-70.

RESULTS

Positivity rates were 3.3% for RPHA, Hdia100 3.5%, Hdia150 2.5%, Hdia200 2.0%. Among subjects complying with the diagnostic work up, colorectal cancer (CRC) was detected in 19 subjects (17 RPHA positive, 16 Hdia100 positive, 15 Hdia150 positive, 14 Hdia200 positive) and high risk adenoma/s in 41 subjects (28 RPHA positive, 32 Hdia100 positive, 29 Hdia150 positive, 25 Hdia200 positive). The prevalence of screen positive CRC in the population was for RPHA 2.9 per thousand, Hdia100 2.7 per thousand, Hdia150 2.6 per thousand, Hdia200 2.4 per thousand. The prevalence of screen positive high risk adenomas in the population was for RPHA 4.8 per thousand, Hdia100 5.5 per thousand, Hdia150 5.0 per thousand, Hdia200 4.3 per thousand.

CONCLUSION

Hdia100 was as sensitive as RPHA for cancer and high risk adenomas. As Hdia is less technically complex than RPHA, it is a valid alternative to the latter, provided that full automation of the development procedure is available. Increasing the positivity threshold of Hdia up to 150 or 200 ng of haemoglobin/mg of specimen solution is not advisable as the increase in specificity is too small to justify the corresponding decrease in the detection of screen positive cancers in the population.

[The assessment of the impact of a double reading by expert readers in a mass mammographic study]

PURPOSE

To evaluate the role of double reading of screening mammograms by expert radiologists.

MATERIAL AND METHODS

We analyzed the results of independent readings of a proficiency test of screening mammography (140 cases, 32 cancers) performed by four expert radiologists. Double reading was simulated by matching the four original readings in 6 possible combinations. The impact of double reading over single reading was evaluated in terms of increased sensitivity and increased recall rate.

RESULTS

Of 32 carcinomas 22, 6, or 4 were identified by 4, 3, or 2 readers, respectively. Of 108 cases negative for cancer a recall for further investigations was suggested by 4, 3, 2, 1 or no reader(s) in 3, 3, 9, 14, or 79 cases, respectively. Inter-reader diagnostic repeatability was good (k = 0.65). Single readers achieved an average sensitivity of 89% (range 87.5-90.6%) and an average recall rate of 12.2% (range 7.4-16.6%). Simulated double reading achieved an average increase in sensitivity of 8.8% (range 6.2-10.95%) and an average increase of recall rate of 6.2% (range 3.8-8.3%).

CONCLUSIONS

Even though the relative increase of recall rate is relevant (+53.2%), the corresponding gain in sensitivity justifies the use of double reading, which was confirmed to be worthwhile also when expert radiologists are involved. This study confirms the opportunity of adopting double reading as a routine procedure in mammographic screening.

Prostate cancer screening: the problem of overdiagnosis and lessons to be learned from breast cancer screening

Screening for prostate cancer is a relatively new procedure, still under experimental evaluation within prospective randomised trials. The design of prospective studies has been mainly based on the experience of other cancer screenings, particularly breast cancer, for which data of several controlled studies are available. Unfortunately, breast cancer is very different from prostate cancer, particularly for aspects such as early diagnosis and, thus the screening process, originally modelled on the basis of the lesson taught by breast cancer screening, needs continuous re-evaluation and adjustment, based on data which are now being produced from ongoing screening experiences. In this paper, we will consider the most controversial aspects of prostate cancer screening and compare prostate screening with breast cancer screening in order to promote a better understanding of the current problems and lessons to be learned.

Predictive value of the HIV paediatric classification system for the long-term course of perinatally infected children

BACKGROUND

To compare the Centers for Disease Control and Prevention (CDC) paediatric classification system with the long-term course of perinatal human immunodeficiency virus type 1 (HIV-1) infection.

METHODS

Prospective study on 366 perinatally infected children followed-up from birth and checked at least every 2 months. Survival, smoothed hazard, adjusted hazard ratio of death, and transition probabilities in clinical and immunological categories were outcome measures.

RESULTS

Survival was 49% (95% CI : 40-58%) at 8 years. The risk of death was high before the age of 2, relatively low between ages 2 and 7, and contained thereafter. Children did not advance through the categories sequentially. Survival at 8 years was 61.7% (95% CI : 49.8-73.6%) in those children who had passed through clinical category A; the hazard ratio of death was 2.5 (95% CI : 1.7-3.8) for 175 (47.9%) children who skipped this category. Transition probability in clinical category B was 39.9% (95% CI : 32.3-45.6%) after one year, but 59.1% (95% CI : 51.4-66.8%) after 5 years. Before 2 years of age, the probability of entry into category C (40%; 95% CI : 35-45%) was higher than that of entry into immunological category 3 (28%; 95% CI : 22-34%). Conclusions The classification system stands comparison with the clinical reality, but the CD4-positive cell thresholds in infancy should be adjusted and category B indicator diseases better distributed to improve their predictive value.

A case of complete adenylate kinase deficiency due to a nonsense mutation in AK-1 gene (Arg 107 --> Stop, CGA --> TGA) associated with chronic haemolytic anaemia

Two siblings of Italian origin with mild chronic haemolytic anaemia, psychomotor impairment and undetectable adenylate kinase (AK) activity are reported. The other red cell enzyme activities were normal except for a slight decrease of PFK. 2,3-DPG levels were increased in both siblings, and AMP decreased in one only. The parents were not consanguineous and displayed intermediate AK activity. The sequence of complete erythrocyte AK-1 cDNA showed the presence of a nonsense homozygous mutation at codon 107 (CGA --> TGA, Arg --> Stop) in the siblings. The mutation results in a truncated protein of 107 amino acids in comparison with the 194 of the normal one. Moreover a 37 bp deletion in the first part of exon 6 (from nt 326 to nt 362 of the cDNA sequence) was detected in one allele; this deletion is not likely to further affect the enzyme structure, being localized after the stop codon. The new variant was named AK Fidenza, from the origin of the patients.

Overdiagnosis of prostate carcinoma by screening: an estimate based on the results of the Florence Screening Pilot Study

OBJECTIVES

To estimate overdiagnosis (detection of latent carcinomas) as a consequence of screening for prostate cancer.

DESIGN

Based on actual screen (first or repeat) detected and interval prostate cancer rates observed in the Florence screening pilot study, a scenario was simulated where males aged 60 years (or 65) had six biennal screens and were followed up for four years. Overdiagnosis was determined as the proportional excess of cancers detected by screening with respect to that expected in its absence.

SETTING

City of Florence, Italy, from 1992 through 1995.

POPULATION

2,740 resident males, aged 60 to 74 years.

RESULTS

Overdiagnosis was estimated to be 51% (95% confidence limits: 44%-55%) or 93% (85%-101%) for age 60 or 65 at entry. Comparison with other screening experiences obtaining higher detection rates suggests that a more aggressive screening approach could be associated with overdiagnosis estimates as big as 200%-250%.

CONCLUSIONS

Screening for prostate cancer is associated with a relevant risk of overdioagnosis. As latent carcinomas can not be presently identified, this would lead to overtreatment in most overdiagnosed cases. The negative consequences of overdiagnosis (knowledge of having a cancer) and of overtreatment (impotence, incontinence, perioperatory death) may be extremely serious. In absence of any scientific evidence of screening benefits (if any) screening should not be recommended as a current practice, but should be limited to prospective controlled studies designed to assess its cost-effectiveness.

Measurement of the Cost of Screening for Cervical Cancer in the District of Florence, Italy

AIMS AND BACKGROUND

To estimate the cost per woman examined and per CIN II or more severe lesion detected in a population-based cytologic screening program for cervical cancer prevention. An organized cytologic screening program has been ongoing in the Florence District since 1973, and a call-recall system using mail invitation has been ongoing since 1980. Smear reading and assessment of screening positives is centralized at the screening unit.

METHODS AND STUDY DESIGN

All relevant resources (costs) consumed by the program were listed and measured. The unit cost per examined woman and per each CIN II or more severe lesion detected was estimated for each screening phase (recruitment, screening, assessment).

RESULTS

The cost per examined woman was $24.60, whereas that per CIN II or more severe lesion detected was $13,600. Staff accounted for 80% of total amount.

CONCLUSIONS

Although the cost for a single procedure is low, the cost per detected lesion is quite remarkable due to the low detection rate in a population screened for a long time. Different approaches and longer interval screening tests are discussed.

A multicenter prospective study on the risk of acquiring liver disease in anti-hepatitis C virus negative patients affected from homozygous beta-thalassemia

Although the risk of transfusion-transmitted hepatitis has been recently reduced, transfusion-dependent beta-thalassemia patients may still develop liver disease due to viral infection or iron overload. We assessed the frequency and causes of liver dysfunction in a cohort of anti-hepatitis C virus (HCV) negative thalassemics. Of 1,481 thalassemics enrolled in 31 centers, 219 (14.8%) tested anti-HCV- by second-generation assays; 181 completed a 3-year follow-up program consisting of alanine-aminotransferase (ALT) measurement at each transfusion and anti-HCV determination by third-generation enzyme-immunoassay (EIA-3) at the end of study. Serum ferritin levels were determined at baseline and at the end of follow-up. Ten patients were anti-HCV+ by EIA-3 at the end of follow-up. Of them, seven were already positive in 1992 to 1993 when the initial sera were retested by EIA-3, one tested indeterminate by confirmatory assay, and two had true seroconversion (incidence, 4. 27/1,000 person years; risk of infection, 1/7,100 blood units, 95% confidence interval [CI], 1 in 2,000-1 in 71,000 units). At baseline, 67 of 174 thalassemics had abnormal ALT. Of those with normal ALT, seven subsequently developed at least one episode of moderate ALT increase (incidence, 24.6/1,000 person-years). All of the 20 patients with ferritin values >/=3,000 ng/mL had clinically relevant ALT abnormalities, as compared with 53 of 151 with <3,000 ng/mL (P < .005). Hepatic dysfunction is still frequent in thalassemics. Although it is mainly attributable to siderosis and primary HCV infection, the role of undiscovered transmissible agents cannot be excluded.