Survival in Adult Italian Cancer Patients, 1978–1989

Breast Cancer Prevalence Measured by the Lombardy Cancer Registry

Aims and background

Breast cancer is the most important malignant neoplasm affecting women in Western countries. An increasing number of women undergo regular medical checkups, especially during the first years following the diagnosis. Therefore, from the health planning point of view, it is essential to have prevalence measures to furnish estimates for the demands that the health care system could possibly undergo.

Methods

By means of PREVAL, a computerized program, breast cancer prevalence has been measured in the Varese province using incidence and follow-up data from the Lombardy Cancer Registry (LCR).

Results

During the 1986–1988 period, breast cancer prevalence for patients alive within 10 years from diagnosis was about 625 per 100,000 resident women. Of these, 54% were over 60 years and 9% were under 45 years of age. Patients alive within 2 years from diagnosis were about 200 per 100,000 residents; considering the 1978–1980 period, patients alive within 2 years from diagnosis were just 140 per 100,000 residents. This dramatic increase in breast cancer prevalence is present also for long-term survivors (i.e. patients alive at 10–13 years from the diagnosis). Extrapolating breast cancer prevalence measured in the Varese province to the whole Lombardy region, the expected number of prevalent cases alive within 10 years of the diagnosis, presently living in Lombardy, would be 27,500. LCR's breast cancer prevalence figures were compatible with available data provided by the Finnish Cancer Registry.

Conclusion

Owing to aging of the population, the improvement in survival and the increasing incidence, the number of prevalent cases will increase. This phenomenon has and will have great importance for the health planning.

Cancer Prevalence in Italian Regions with Local Cancer Registries

Objective

To provide estimates and projections of cancer incidence and prevalence for those Italian regions whose population is partially covered by a cancer registry (CR) and to determine to what extent local CRs can be considered representative of the region, thus improving the potential of the information provided by CRs.

Methods

A statistical method, MIAMOD (mortality-incidence analysis model), was used to estimate regional cancer incidence and prevalence from regional cancer mortality data and patient survival data recorded by the cancer registries. Estimates of the cancer incidence and prevalence in the various regions have thus been obtained for a number of major cancer sites. A first and important step in validating the regional estimates has been the comparison of the MIAMOD estimates in the areas covered by the cancer registries with empirical incidence and prevalence observed by CRs, in order to assess the consistency in data, methods and assumptions. Empirical prevalence has been calculated by counting patients with a diagnosis of cancer who were alive on the reference date by PREVAL method. A correction factor has been applied to include patients diagnosed before the period of activity of the registry.

Results

General consistency was found between empirical and estimated (by MIAMOD) incidence and prevalence in the registry areas, which is indicative of the quality and the completeness of all data involved as well as the appropriateness of model choices. The prevalence of all cancers combined for Italian regions with CRs was estimated and projected to the year 2000 as ranging between 1,240 per 100,000 in Sicilia and 2,781 in Emilia-Romagna for men, while for women these figures were 1,765 in Sicilia and 4,019 in Liguria. Comparison of cancer prevalence in CR areas with regional estimates shows quite good consistency for Piemonte, Liguria and Lombardia, which means that the local CRs (of Torino, Genova and Varese, respectively) are representative of their respective regions. Prevalence in Emilia-Romagna appears to be rather well represented by only one, the Parma CR, of the three local CRs. The southern Italian registries of Latina and Ragusa recorded a lower cancer prevalence than was actually estimated in their respective regions.

Discussion

Cancer registries with a longer period of activity showed better agreement between empirical and estimated figures due to the more precise information provided, particularly regarding survival and incidence trends. In conclusion, this work shows the potential of the cancer registries not only to represent their population with respect to cancer morbidity but also as an invaluable tool to extrapolate this information to the larger areas they represent.

Cancer Patient Survival in the Elderly in Italy

Aims and background

Italy, like most western populations, is sharply aging and changing its age structure with a striking increase in the oldest segment of the elderly. Since age is related to an exponential growth of cancer incidence rates and to a worsening of prognosis, the progressive aging of the population will constitute, in the future, an issue increasingly more important for public health. The present study is the first effort to present and analyze survival rates in Italian elderly cancer patients in order to provide a starting point for the development of better clinical strategies addressed to the aged.

Materials and methods

The presented data come from a large data set consisting of survival data relating to 25,798 men and 20,479 women, aged 65–84 years at diagnosis, collected by Italian cancer registries participating in the ITACARE project. Relative survival rates of patients have been calculated by sex, quinquennial age classes and the considered entire age class for overall malignant neoplasms and the 10 most frequent cancer sites in the elderly.

Results

When all Italian data for all cancers in the 65–84 year age group were pooled, survival rates at 5 years from the diagnosis was 27% and 39% in men and women, respectively. As regards specific sites, survival rates below 50% were observed for lung, stomach and ovary cancer at 1 year from diagnosis. At 5 years from diagnosis, the rates were less than 50% for colon, prostate, cervix, multiple myeloma, non-Hodgkin's lymphoma and melanoma (only in men). The best survival at 5 years from diagnosis (above 50%) was in women for melanoma and corpus uteri and breast cancer. For all cancers, the prognosis for women was better in each considered age group even though a dramatic decrease in survival with age was observed in both sexes. In general, a similar decline in survival with increasing age characterized all considered specific sites. However, at closer observation, the patterns of a decrease revealed some differences. The ratio between the survival rates of 55–64 vs 65–84 year age class indicated that the sites with the greatest advantage of survival for younger patients (ratio >1.5) were ovary, lung and melanoma (only in men), whereas the least advantage was observed for colon, corpus uteri, breast and prostate. By calendar periods, excluding non-Hodgkin's lymphoma for women, an increase in survival was observed for all considered sites, improving an encouraging successful trend in diagnostic and therapeutic progresses.

Age at Diagnosis, Extent of Disease and Breast Cancer Survival: A Population-Based Study in Florence, Italy

Background

The effect of age at diagnosis on the prognosis of breast cancer is still controversial. The study described the variation by age at diagnosis of some clinical-pathologic features and evaluated the relationship between age and survival, taking into account the effect of extent of disease.

Materials

The study comprised a large population-based series of 1,182 invasive breast cancers, incident in the period 1985–1986 in the province of Florence.

Results

The proportion of cases without nodal involvement progressively lowered from 59% in the age group ≤39 years to 22% in the age group ≥80 years. The extent of disease was unknown in 14% of cases aged 70–79 years and in 43% of those aged ≥80 years (other age groups: 3%–5%). A lower rate of surgical treatment and axillary surgery were the main reasons for inadequate staging in the elderly. Ten-year observed survival progressively decreased from 71% for age ≤39 years to 12% for age ≥80 years. Ten-year relative survival showed less evident differences, dropping from 72% for age ≤39 years to 57% for age ≥80 years. In the relative survival analysis, the differences in relative risks of death among age groups were not significant, either in the univariate or multivariate analysis. Nevertheless, the model with adjustment for extension of disease showed a flattening of the estimated relative risks in age groups over 59 years.

Conclusions

Age at diagnosis was not significantly related to 10-year breast cancer relative survival, suggesting that the worse prognosis in the elderly was largely related to the risk of death from other causes, rather than to a different malignant potential of the tumor. The worse distribution by extent of disease in older women indirectly suggested that diagnostic delays also influenced the different prognosis observed among age groups.

Studying Survival of Cancer Patients in Different Populations: Its Potential and Role

Rationale

Survival figures from a population-based study incorporate the overall practice in diagnosis, cure and clinical follow-up for a specific disease within a given health care system. Being the outcome of a number of individual, social and economical aspects, population-based survival may be thought as index for measuring the level of a country's development.

Data

The EUROCARE project, a European Cancer Registries (CR) concerted action, provided reliable information on survival for more than 800,000 cancer patients from 11 European countries. A great deal of epidemiologic information has derived from EUROCARE. Women had a longer survival than men for all studied tumour sites, except for the colon. European survival variability was fairly high for several cancers, but it was lower for cancers with a relatively good prognosis and those sensitive to treatment. The ranking of populations of cancer survival tended to be fairly stable for many cancers: CR of Switzerland and Finland ranked high and Polish CR low. Denmark, Italian and France CR did not substantially differ from the European survival average. For most cancers, prognosis improved during the studied period (years of diagnosis: 1978–1985). Survival figures for colon (r = 0.74, males; r = 0.73, women) and female breast cancer (r = 0.57) well correlated with the national health expenditure of different participating countries. The ITACARE study, a new Italian Cancer Registries collaborative project involving more than 100,000 cancer patients, was set up to study survival differences within the country. Survival of cancer patients was not homogeneous in 7 studied Italian regions (the estimated 5-year relative survival for all malignant neoplasms combined ranked from 37.8% in CR of Sicily to 42.1% in those of Emilia-Romagna). The lowest levels of regional health expenditures were accompanied by the lowest levels of prognosis for overall cancers. However, a relatively low correlation among patient cancer survival and the regional health expenditure (r = 0.21) was found, suggesting that other factors such as different efficiency in managing cancer may play a role in explaining the intracountry differences.

Conclusions

Population-based survival figures may be used to study epidemiologic aspects, comparing different health systems, and may be interpreted as indexes for discussing inequalities in health in different populations.

The Itacare Study

ITACARE is a collaborative study on the survival of Italian cancer patients diagnosed in the period 1978–1989. The study involves 11 Italian population-based cancer registries (CRs) (Firenze, Forlì-Ravenna, Genova, Latina, Modena, Parma, Ragusa, Torino, Varese, the childhood CR of Piedmont and the colorectal CR of Modena), and its principal aim is to identify and analyze possible differences between the areas covered by the CRs. This article describes the ITACARE database. Ten percent of the Italian population is covered by the participating CRs, most of which are located in the northern part of the country. All malignant cancer sites (classified by ICD-9) except skin cancers were included. For bladder cancers, papillomas and transitional cell tumours grade 1 and 2 were also included. Survival data on over 100,000 cases were collected. The principal information variables were sex, date of birth, diagnosis and end of follow-up, life status, ICD-9 code for tumour site, diagnosis modality (clinical, cytologic confirmation, histologic confirmation), ICD-0 morphology code, and tumour stage (grouped into broad categories). Follow-up is active in all registries. All cases were checked systematically for errors and inconsistencies, following which about 0.2% of cases were excluded from the analyses. The percentage of cases microscopically verified, which is an indicator of diagnostic accuracy and data reliability, was higher among patients under 65 years of age (90%), breast cancer patients (92%) and cases covered by the Varese, Torino and Forlì-Ravenna CRs (more than 82%). The percentage of cases known by death certificate only (an indicator of the completeness and quality of registration) was about 3% of total cases and was higher among older patients (4%). Province-specific mortality, used to compute relative survival from cancer (i.e., survival adjusted for competing causes of death), varied according to period of diagnosis, sex and area: the highest mortality was among women of the Ragusa CR (Sicily) and men in northern CRs. Overall mortality decreased during the period, more markedly in the north and among women.

Interpreting Survival Differences and Trends

Since 1990 a concerted action between European population-based cancer registries (the EUROCARE project) has been carried out with the aims of establishing whether there are differences in cancer patient survival in Europe, and the reasons for such differences. Survival differences actually exist for cancer sites for which the stage of disease at diagnosis is the major prognostic factor (such as breast, stomach and colon cancer). However, for most cancer sites, survival increases over time and the survival rates of different countries tend to converge towards higher values. Interpreting survival differences and trends is not an easy task. Longer survival may be achieved by postponing death through better treatment or by anticipating diagnosis. However, an earlier diagnosis may or may not make a treatment more effective in postponing death. The computation of stage-specific or stage-adjusted survival is not sufficient for interpretation of survival differences, because staging procedures change over time and may vary in different hospitals and countries. In addition to an early diagnosis and more effective treatment, a number of factors may bias survival estimates. They may be classified into factors that can be controlled in the analysis (at least partially), such as mortality from other causes, demographic factors, epoch of diagnosis, different statistical methodology, and factors depending on the validity of cancer registry data, such as definition of the illness, exhaustiveness and quality of registration, completeness of follow-up, definition of the date of diagnosis, and definition of disease stage including the diagnostic procedure used to establish stage. To help disentangle the effects of early diagnosis and better treatment, several statistical approaches are being developed: multivariate analysis on relative survival data, new modeling analysis to separately estimate the proportion of cured patients and the length of survival for those patients destined to die, and the standardized collection of information on stage at diagnosis and staging procedures.

Estimating Relative Survival of Italian Cancer Patients from Sparse Cancer Registries Data

Purpose

A method is presented for estimating relative survival of cancer patients at the national level from survival data provided by cancer registries covering only a subset of the general population and referring to different, and not necessarily overlapping, incidence periods.

Methods

Relative survival rates are estimated as a function of the covariates sex, age, epoch of diagnosis, and registry area by means of a multiple regression model. National estimates are then computed by appropriate weighting of the sex-, age-, time- and registry-specific expected relative survival values.

Results

The method is illustrated by a sample application to survival data of female breast cancer patients in Italy. The national estimates of breast cancer survival pattern show a mild decrease of survival with age and a marked increase with period of diagnosis.

Variations in the Survival of Adult Cancer Patients in Italy

Aims

As part of the ITACARE project, the present study analyzed and compared population-based data on the survival of adult cancer patients in Italy, according to sex, age, period of diagnosis and geographical area.

Methods

Nine Italian population-based cancer registries provided data on all their cancer patients (total 90,431 cases) followed for at least 5 years and diagnosed during the period 1978–1989. About 10% of the Italian population is covered by these registries. The data was analyzed by means of a multivariate model.

Results

The major findings were that there was a general improvement in 5-year relative survival over the study period (from 33% to 39%) and that there were significant differences in survival between different areas of the country, particularly for cancer sites which respond well to treatment. In general, the area covered by the Ragusa (Sicily) registry was characterized by significantly worse survival than other registry populations. Other important findings were that for all malignant cancer sites 5-year relative survival decreased with age from 50% for the youngest age class (15–44 years) to 27% for the oldest age class (75+ years) and that women have a better prognosis for most cancer sites (overall 5-year relative survival in women 48% vs 32% in men).

Conclusions

The significant regional differences in survival may reflect unequal provision of care, particularly between northern-central Italy and the south. The reasons for the general survival improvement with time are not completely understood, whereas the marked overall sex difference is related to the fact that the commonest cancer in women (breast cancer) is eminently more treatable than the commonest malignancy in men (lung cancer). The unfavorable trend with increasing age may be due to increasing difficulty in applying complete therapy protocols as general health declines, sometimes in relation to an advanced cancer stage at diagnosis.

Metabolic syndrome and breast cancer prognosis

Metabolic syndrome (MS), conventionally defined by the presence of at least three out of five dysmetabolic traits (abdominal obesity, hypertension, low plasma HDL-cholesterol, high plasma glucose and high triglycerides), has been associated with an increased risk of several age-related chronic diseases, including breast cancer (BC). This may have prognostic implications for BC survivors. 2,092 early stage BC survivors aged 35-70, recruited in eleven Italian centres 0-5 years after surgical treatment (1.74 years on average), were followed-up over 2.8 years on average for additional BC-related events, including BC-specific mortality, distant metastasis, local recurrences and contralateral BC. At recruitment, 20 % of the patients had MS. Logistic regression models were carried out to generate OR and 95 % confidence intervals (CI) for new BC events associated with MS, adjusting for baseline pathological prognostic factors. New BC events occurred in 164 patients, including 89 distant metastases. The adjusted ORs for women with MS versus women without any MS traits were 2.17 (CI 1.31-3.60) overall, and 2.45 (CI 1.24-4.82) for distant metastasis. The OR of new BC events for women with only one or two MS traits was 1.40 (CI 0.91-2.16). All MS traits were positively associated with new BC events, and significantly so for low HDL and high triglycerides. MS is an important prognostic factor in BC. As MS is reversible through lifestyle changes, interventions to decrease MS traits in BC patients should be implemented in BC clinics.

Gefitinib (ZD1839): therapy in selected patients with non-small cell lung cancer (NSCLC)?

PURPOSE

To evaluate response rate, toxicity and epidermal growth factor (EGFR) mutations and gene copy number as outcome predictive factors in Italian patients with non-small cell lung cancer (NSCLC) treated with gefitinib (Iressa) in an expanded access program (EAP).

PATIENTS AND METHODS

A total of 137 patients with advanced NSCLC received gefitinib as first line treatment or after failure of chemotherapy. In 43 cases, tissue specimens were available for EGFR status evaluation: immunohistochemical (IHC) for EGFR, fluorescence in situ hybridisation (FISH) or Chromogenic in situ hybridisation (CISH)-(ISH) analysis for EGFR and HER2 gene copy number, and PCR-DNA sequencing for mutational analysis of EGFR were performed.

RESULTS

In the study population, response rate (PR) was 13%; disease stabilization (DS) 26%; overall disease control rate 39%; median survival 6.3 months and time to progression 2.7 months. Toxicity was mild (G3 skin toxicity in 3% and G3 liver toxicity in 4% of patients). An EGFR-mutation was detected in 9/43 patients: Eight deletions in exon 19 and 1 missense mutation in exon 21. Increased gene copy number for EGFR and/or HER2 was detected in 17/43 patients. Response rate was significantly higher in women, non-smokers, in mutation carriers than in wild type carriers, in EGFR-trisomy/polysomy carriers and HER2-trisomy/polysomy carriers.

CONCLUSIONS

In this study, response rate and toxicity to gefitinib treatment were consistent with previously reported data for whites. Female gender, absence of smoking history, EGFR-mutations, EGFR and HER2-polysomy were significantly associated with response to gefitinib therapy in NSCLC patients.

Insight into the treatment of cancer in older patients: Developments in the last decade

In the last decades there has been an increased interest in the treatment of elderly cancer patients and a change in attitude of both clinicians and their patients has occurred. Drugs are now available that might be considered "elderly-friendly" and the enormous advances in surgical procedures and supportive treatments over the recent years have enabled adverse effects to be minimized. A Geriatric Assessment is increasingly used as a tool to define those patients who are more suitable for aggressive chemotherapy or, on the contrary, palliative treatment. For almost all cancers, older patients are better treated today than they were in the past, even though we are still far from optimal management. Despite the perceived barriers to including elderly patients in clinical trials, there are few data to support excluding them. We must not permit increased age in cancer patients to continue to be an important and independent risk factor for receiving inadequate care.

Sequential chemotherapy of cisplatin and vinorelbine followed by paclitaxel and gemcitabine in advanced non-small-cell lung cancer

BACKGROUND

To determine the activity and safety of a sequential regimen of cisplatin and vinorelbine followed by paclitaxel and gemcitabine in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Treatment was two cycles of cisplatin 80 mg/m(2) on day 1 and vinorelbine 30 mg/m(2) on days 1 and 8 every 3 weeks followed by two cycles of paclitaxel 175 mg/m(2) on day 1 and gemcitabine 1250 mg/m(2) on days 1 and 8 every 3 weeks.

RESULTS

Fifty-five patients with inoperable NSCLC, performance status 2 or less were enrolled, including 19 patients with brain lesions. There were 23 partial responses (42%; 95% confidence interval 29-55). The median time to progression and overall survival were 5.8 and 10.3 months, respectively (6.5 and 12.8 in the patient subset without brain metastases). One-year survival rate was 47.5%. Grade III/IV neutropenia was the major side effect; it occurred in 56% of patients and was mainly limited to the first two chemotherapy cycles with cisplatin and vinorelbine.

CONCLUSIONS

Sequential combination of cisplatin and vinorelbine followed by paclitaxel and gemcitabine is a manageable and active regimen for patients with NSCLC. It deserves to be tested against a standard two-drug scheme in a phase III trial.

Epidemiology of pleural mesothelioma in Italy

The incidence of malignant mesothelioma (MM) in Italy is increasing and is assumed to be a consequence of high levels of asbestos exposure. Establishment of the National Mesothelioma Registry (ReNaM) and the co-operation of five regional centers has allowed the estimation of the incidence of malignant mesothelioma in major parts of Italy and the definition of exposure to asbestos.

Decrease in Length of Hospitalization before Death of Cancer Patients in the Italian Province of Imperia

Although the overall cure rates for cancer in Italy are comparable to those of other developed countries, these results are the product of very heterogeneous facilities. In order to assess the possible impact of improved acute cancer care services on the last phase of life, a retrospective study was carried out which included 4238 patients registered at the Division of Medical Oncology of Imperia Province from January 1995 to December 2002. In 1998 the Province of Imperia, with a population of 217,000, had only two doctors and five day-hospital beds. During 1999 and 2000, resources increased to include five oncology specialists and 10 day-hospital beds. Compared to 1998, in 2002 the number of new patients registering at the Division of Medical Oncology and the number of day-hospital treatments increased by 76% and 67%, respectively.

Since end-of-life care for advanced cancer patients is expensive, the length of hospitalization of cancer patients dying in acute hospital settings was analyzed for the years 1995-2002. Of the 4238 patients registered during the eight-year period, 1433 (33.8%) died before 31 December 2002. Among these 1433 patients, the records relative to hospitalization and death were available for 571 cancer patients, 324 males (56.7%) and 247 females (43.3%) with a median age of 70 years (range, 21-91). The average number of days of hospitalization declined from 14.6 (range, 1-76) in 1998 to 8.2 (range, 1-29) in 2002, a decrease of approximately 44%.

The length of hospitalization prior to death has declined considerably for cancer patients in the Imperia Province and the costs of acute hospital facilities for end-of-life care in cancer patients have decreased. In addition, fewer days in hospital before death may have had an important impact on the quality of life of these cancer patients.

The use of surgery to treat lung cancer in elderly patients

Lung cancer is a leading cause of cancer death and its cure depends on an adequate surgical approach. More than half of all lung cancers are diagnosed in patients aged 65 years or over. However, surgical risk increases in patients over 65 years old. Therefore, surgical procedures for lung cancer are far less frequent in elderly patients. Many clinicians avoid surgery, or minimise surgical procedures on the basis of age but recent advances in preoperative risk assessment and surgical and anaesthetic techniques have resulted in a significant decrease in operative mortality and morbidity for older patients. The treatment of lung cancer in elderly patients should no longer be based on the premise that surgery is too risky for elderly patients. Every effort should be made to assess risk and optimise treatment for this large and expanding proportion of the population.

A historical cohort mortality study among shipyard workers in Genoa, Italy

BACKGROUND

A historical cohort mortality study was conducted among 3984 shipyard workers assigned to ship repair, refitting, and construction in the harbor of Genoa, Italy, between 1960 and 1981. These workers were exposed to asbestos fibers, welding fumes and gases, silica dust, polycyclic aromatic hydrocarbons, and solvents.

METHODS

Workers were classified in 20 different job-titles depending upon the type of activity. Standardized mortality ratios (SMRs) were computed using male residents of the Province of Genoa as the referent population.

RESULTS AND CONCLUSIONS

For the whole cohort significantly increased SMRs were detected for all causes, all cancers, liver, larynx, lung, pleural and bladder cancers, respiratory tract diseases, and cirrhosis of the liver. The analysis by job-title showed increased SMRs not only for pleural cancer, but also for lung, laryngeal cancers and respiratory tract diseases in occupations entailing heavy asbestos exposure. Bladder and liver cancers and liver cirrhosis mortality also appeared to be related to occupational exposure.

Efficacy in standard clinical practice of colonoscopic polypectomy in reducing colorectal cancer incidence

BACKGROUND

Colorectal cancer is one of the leading causes of death from cancer in Western countries. Removal of adenomas is based on the assumption that it could lead to a reduction in the incidence of colorectal cancer, as demonstrated by the National Polyp Study in the USA. A critical issue is whether the benefit observed in clinical trials can also be observed in standard clinical practice. To address the issue, a multicentre Italian collaborative study was organised.

METHODS

The study cohort comprised 1693 subjects of both sexes, aged 40-69 years, enrolled between 1980 and 1987 following a total colon examination (TCE) (that is, total colonoscopy or colonoscopy and double contrast barium enema), with removal of at least one adenoma larger than 5 mm in diameter. Exclusion criteria were genetic syndromes, previous adenomas or colorectal cancer, previous colonic resection, inflammatory bowel disease, or sessile adenomas more than 3 cm in diameter. Follow up ended in December 1996 by TCE or telephone interview, and review of the medical records, clinical files, or death certificates. Incidence ratios for colorectal cancer were compared with expected age and sex specific incidences in the Italian general population.

RESULTS

Follow up data were obtained for 97.3% of cases for a total of 14 211 person/years. Mean follow up was 10.5 years. Six colorectal cancer cases (four in males, two in females) at various stages were ascertained (one at 29 months, two at five years, one at seven years, one at eight years, and one at 10 years from the index examination). The number of cancers expected in the reference population was 17.7 for an incidence ratio of 0.34 (confidence interval 0.23-0.63; p<0.01).

CONCLUSIONS

Colonoscopic polypectomy substantially reduced the incidence of colorectal cancer in the cohort compared with that expected in the general population. These results are of particular relevance considering that those with adenomas are at increased risk of colorectal cancer and that this retrospective study was performed on data obtained in standard clinical practice. This observation strengthens the concept of effective population screening in view of the fact that adenomatous polyps are the most frequent neoplastic outcome of screening and their removal is associated with a decrease in the incidence of colorectal cancer.

Primary chemotherapy with adriamycin, cisplatin, vincristine and cyclophosphamide in locally advanced thymomas: a single institution experience

From 1990 to 1997, 16 consecutive patients with stage III and IVa invasive thymoma were treated in a single institution with primary chemotherapy consisting in adriamycin (40 mg m(-2)), cisplatin (50 mg m(-2)) administered intravenously on day 1, vincristine (0.6 mg m(-2)) on day 2 and cyclophosphamide (700 mg m(-2)) on day 4 (ADOC). The courses were repeated every 3 weeks. The aim was to evaluate the impact of this cytotoxic regimen with respect to response rate, per cent of patients radically resected, time to progression and overall survival. Two complete responses (one clinical and one pathological) and 11 partial responses were observed (overall response rate 81.2%); two patients had stable disease and one progressed. Toxicity was mild as only two patients developed grade III/IV neutropenia and one patient grade III nausea/vomiting. Nine patients were radically resected (five out of ten with stage III, and four out of six with stage IVa). Median time to progression and overall survival was 33.2 and 47.5 months respectively. Three patients were alive and disease free after more than 5 years. The ADOC scheme is highly active and manageable in the treatment of locally advanced thymoma. As a preoperative approach it should be offered to patients not amenable to surgery or to those surgically resectable but with a great deal of morbidity.

The Prevalence of Tumors of the Breast and Female Genital Tract in Italy

Data from 10 Italian population-based cancer registries were used to estimate the prevalence of female tumors of the breast and genital tract. The total prevalence, expressed in number per 100,000, was highest for breast cancer (1,117), followed by cancer of the corpus (264) and cervix uteri (146), ovary (110), and vagina and vulva (23). For all tumors the prevalence increased with age at diagnosis.

The cancer prevalence was divided into intervals from diagnosis, expressing different health needs in terms of therapy and intensity of clinical follow-up. For all tumors considered, 1-year prevalence was higher than 1-2-year prevalence, reflecting a high death risk due to perioperative mortality and to the proportion of patients diagnosed at advanced stages. The prevalence decreased in the following intervals considered.

Noticeable geographic variability was observed in the prevalence across Italy, with higher proportions being registered in the northern-central regions than in the South. The two extreme 0-5-year prevalence figures (per 100,000) were: for breast cancer 568 (Genova) and 259 (Ragusa); for corpus uteri cancer 94 (Romagna) and 21 (Latina); for cervix uteri cancer 63 (Romagna) and 26 (Latina); for ovarian cancer 49 (Parma) and 21 (Latina); for cancer of the vagina and vulva 17 (Genova) and 5 (Ragusa). This variability depends mainly on incidence and on the proportion of elderly in the general population.

From 1987 to 1992 there was an increase in the prevalence of tumors of the breast, ovary and vagina and vulva, especially in the elderly. The prevalence of corpus uteri cancer decreased slightly in the elderly only, whereas that of cervix uteri cancer decreased at all ages.