Long-Term Sequelae of Breast Cancer Surgery

Background

Quality of care is today a major issue in oncology, and much attention is given to research on the outcome of breast cancer care. Too little attention has been devoted in the scientific literature to the consequences of treatment in long-term survivors, and in particular to the possible side effects. The specific aim of this contribution is to present population-based data about the long-term impact of breast cancer care in women who had an incident cancer in 1985/1986.

Patients and Methods

The cases are 476 breast cancers incident in the City of Florence in 1985-86. Women still living 5 years later were invited to have an interview and a physical examination. Lymphedema, peripheral nerve lesions and damage to the shoulder were assessed.

Results

Of the 346 5-year survivors, 238 accepted our invitation: 35.2% of the women reported some early postoperative sequelae, 30.2% had a chronic lymphedema and 18.9% a shoulder deficit. Comparing breast-conserving surgery with radical mastectomy, the risk of chronic lymphedema (OR=1.62; 95% CI: 0.91-2.88) and other lesions was higher for women who had a radical surgery. Women who had a breast-conserving surgery more often reported an early lymphedema (OR=1.60; 95% CI: 0.88-2.88).

Conclusions

The proportion of women who complained of (or manifested at the physical examination) a minor or major disability of the arm in our study was high. The impact of these functional problems in terms of quality of life should also be assessed, but it is our impression that there is need for much greater attention to the issue of long-term survivor sequelae.

Linkage between Aids Surveillance Systeml and Population-Based Cancer Registry Data in Italy: A Pilot Study in Florence, 1985-90

The role of the Tuscany population-based Cancer Registry (TCR) in the assessment of cancer incidence in AIDS patients, and the completeness of cancer reporting to the Italian AIDS surveillance system (RAIDS) was evaluated through a linkage between the TCR and the RAIDS in the period 1985-90. In the Province of Florence, the incidence of Kaposi's sarcoma in AIDS cases was underestimated by 24% (95% CI; 9.8%-47%; 6/25 cases) by RAIDS in comparison with the TCR. Of kaposi's sarcomas unknown to RAIDS, 2 were incident at the time of AIDS diagnosis (“truly” unreported cases) and 4 were late manifestations of AIDS. Moreover, 1 non-Hodgkin lymphoma unknown to RAIDS and 10 other malignancies (4 lung cancers) were identified through the TCR. In AIDS patients, the incidence of lung cancer was 95-fold (99% CI, 16-310) the expected one on the basis of age-sex-specific incidence rates in the general population of the same area. Altogether, about 25% of AIDS cases developed a cancer during HIV infection. In spite of the small size of the present study, the results confirm the role of population-based cancer registries in the assessment of the occurrence of malignancies in AIDS patients.

The Accuracy of Local Death Certificates in Cancer of the Lung and Stomach

The study analysed the accuracy of local death certificates (LDC) for patients with lung cancer (424 males, 36 females) and stomach cancer (99 males, 62 females) who died between 1979 and 1984. All the diagnoses were confirmed histologically. For a subgroup of lung cancer (males), we also evaluated the national death certificate (NDC) and the correspondence of LDC vs. NDC. The reliability of LDC was quite poor. This paper examines the different reasons for the underevaluation of cancer in LDC and the variables which modify the accuracy of cause of death on the death certificate.

The Role of Cancer Registration for Programming Health Services

The Italian National Health Plan 1998-2000 indicates quantitative and qualitative goals in the fight against cancer. This approach stresses the need of reliable and updated descriptive data to evaluate, at a population level, the burden of neoplastic disease, the results of primary and secondary preventive actions, and the efforts towards a more equal distribution of diagnostic and therapeutic services.

The aims of this paper is to evaluate the use of descriptive data to quantify the burden of neoplastic disease, using the data provided by the network of Italian cancer registries (the most reliable source of information on neoplastic disease in Italy). Crude rates are the most adequate for describing the “burden” of cancer patients who are expected in a certain period and will need specific diagnostic or therapeutic activities. Incidence, prevalence and mortality rates provide information on different phenomena (i.e., patients requiring diagnostic and therapeutic activities related with the first definition and treatment of the disease; patients requiring periodic follow-up or treatment of disease relapse; need palliative care). The use of these measures combined is highly informative in relation with the different objectives of health planners (i.e., patients requiring diagnostic and therapeutic activities related with the first definition and treatment of the disease; patients requiring periodic follow-up or treatment of disease relapse; need palliative care).

Analysis of Trends in Cancer Mortality in Italy 1951-1978; The Effects of Age, Period of Birth, and Period of Death

We describe trends in cancer mortality in Italy between 1951 and 1978 for 6 different sites (esophagus, lung, breast, cervix uteri, testis, and bladder) as well as all cancers. This is done using a statistical model which separates the contributions associated with age, period of birth and period of death. The results are related to equivalent analyses in England and Wales and also to trends in lifestyle in Italy (alcohol consumption, cigarette consumption, birth rates).

The Availability of Histologic Grading among 5,923 Italian Cancer Patients and Its Relationship with Survival: A Population-Based Study

Aim

The specific goal of the study was to evaluate the availability of the histologic grading of cancer and its effect on survival in an Italian population-based cancer series.

Methods

Data were drawn from the Tuscany Cancer Registry, active in central Italy since 1985. Among the cases incident during the period 1985 to 1989, bladder, prostate, colon, corpus uteri, rectum and stomach cancers, for which the proportion of graded cases exceeded 50%, were analyzed. Overall, 5,923 cancer cases were included. Ten-year relative survival rates by grade were computed.

Results

Overall, data on histologic grading was available only for 38% of cases. The sites most frequently graded were urinary bladder (80%), prostate (73%), colon (71%), corpus uteri (69%), rectum (65%) and stomach (56%). For all the cancer sites analyzed, the 10-year relative survival rates increased as the histologic grading improved. The grade distribution resulted related also to the disease extension, more limited the extension higher the proportion of well differentiated cases.

Conclusions

Due to the evidenced importance of histologic grading as a valuable prognostic factor, it should be requested by clinicians and reported by pathologists more frequently than has been done in the area.

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.

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.

The Italian register of cardiovascular diseases: attack rates and case fatality for cerebrovascular events

BACKGROUND

The Italian register of cardiovascular diseases is a surveillance system of fatal and nonfatal cardiovascular events in the general population aged 35-74 years. It was launched in Italy at the end of the 1990 s with the aim of estimating periodically the occurrence and case fatality rate of coronary and cerebrovascular events in the different geographical areas of the country. This paper presents data for cerebrovascular events.

METHODS

Current events were assessed through record linkage between two sources of information: death certificates and hospital discharge diagnosis records. Events were identified through the ICD codes and duration. To calculate the number of estimated events, current events were multiplied by the positive predictive value of each specific mortality or discharge code derived from the validation of a sample of suspected events. Attack rates were calculated by dividing estimated events by resident population, and case fatality rate at 28 days was determined from the ratio of estimated fatal to total events.

RESULTS

Attack rates were found to be higher in men than in women: mean age-standardized attack rate was 21.9/10,000 in men and 12.5/10,000 in women; age-standardized 28-day case fatality rate was higher in women (17.1%) than in men (14.5%). Significant geographical differences were found in attack rates of both men and women. Case fatality was significantly heterogeneous in both men and women.

CONCLUSIONS

Differences still exist in the geographical distribution of attack and case fatality rates of cerebrovascular events, regardless of the north-south gradient. These data show the feasibility of implementing a population-based register using a validated routine database, necessary for monitoring cardiovascular diseases.

Are sulphonylureas all the same? A cohort study on cardiovascular and cancer-related mortality

BACKGROUND

Aim of the present study is the comparison of all-cause, cardiovascular and non-cardiovascular mortality, and cardiac morbidity, between patients treated with glibenclamide and gliclazide.

METHODS

A retrospective observational cohort study was performed on a consecutive series of 568 outpatients (282 women, 286 men) with type 2 diabetes treated with either glibenclamide (n = 378) or gliclazide (n = 190). Information on all-cause mortality and on causes of death up to 31 December 2004 was obtained by the City of Florence Registry Office. Non-fatal cases requiring hospitalization were identified through the regional hospital discharge system using International Classification of Diseases.

RESULTS

Mean follow-up was 5.0 +/- 1.6 and 4.4 +/- 2.0 years for death and cardiac events, respectively; during follow-up, 33 and 11 deaths were observed in the glibenclamide and gliclazide groups, with a yearly mortality rate of 4.3 and 2.2%, respectively (p < 0.05). At Cox regression, after adjustment for potential confounders, including comorbidity, glibenclamide treatment was associated with a significant increase in all-cause mortality [OR 2.1(1.2;2.7), p < 0.05], while the difference in cardiovascular mortality was not statistically significant after adjustment for age and sex. Mortality for malignancies was significantly higher in patients treated with glibenclamide after adjustment for age, sex, BMI, and insulin and metformin treatment, [OR 3.6(1.1;11.9); p < 0.05]. A higher incidence of cardiac events was associated with glibenclamide treatment only in patients with previously known ischaemic heart disease.

CONCLUSIONS

Treatment with glibenclamide could be associated with higher mortality for cardiovascular diseases and malignancies, in comparison with gliclazide.

[Investigation on health status of silica exposed workers in "cotto Fiorentino" companies]

The manufactured in "cotto" is typical of Chianti Fiorentino with about 400 employees. In 2005. the UF PISLL encountered an exposure to silica more than TLV, particularly for some tasks; were prescribed interventions of prevention and was undertaken an investigation of the occupational health status with occupational health physician. We observed 227 workers, 208 males and 19 females, with average age of 43 years and average age working of 15 years. The habit of smoking tobacco was higher than for the general population. The assessment of exposure to silica has been detected for 59 workers (mean 0.05 mg / mc); at pulmonary function testing resulted: 10 with airway obstruction and 4 airflow limitation; by 140 chest X - ray acquired 1 was interstitial pulmonary disease and 1 was bronchopneumonia. Among the diseases not related to exposure to silica, emerging 42 cases of low back pain, 28 hearing loss, 7 with hypertension. Non uniformity in health surveillance and diagnostic criteria highlights the need to cooperate between occupational doctor in public prevention and control service and qualified occupational doctor to ensure a standard of quality in the prevention of disease in exposed to silica.

Use and efficacy of abciximab in an unselected population with acute myocardial infarction treated with primary angioplasty: data from AMI-Florence registry

AIMS

We sought to evaluate the determinants and the potential benefit of abciximab use in unselected patients with acute myocardial infarction treated with primary angioplasty.

METHODS AND RESULTS

Based on the AMI-Florence registry, we analyzed 461 consecutive acute myocardial infarction patients treated with primary angioplasty, 280 (61%) of whom received abciximab. For each patient, a propensity score indicating the likelihood of abciximab treatment was calculated. Compared to those not treated, patients treated with abciximab were at lower risk. At multivariate analysis, the direct admission to a hospital with angioplasty facilities significantly increased the probability of receiving abciximab (OR 1.99, 95% CI 1.30-3.03, p=.001), while older age (OR 0.97, 95% CI 0.95-0.98, p<.0001), non-anterior location (OR 0.58, 95% CI 0.38-0.88, p=.011) and Killip class >1 (OR 0.53, 95% CI 0.32-0.87, p=.013), were negative predictors of abciximab use. Primary angioplasty had a higher success rate in patients treated with abciximab (99.3% versus 96.5%, p=.03). In-hospital and 1-year mortality were significantly lower in patients treated with abciximab (2.5% versus 13.3%, p<.0001, and 7% versus 21%, p<.0001, respectively). At multivariate analysis patients treated with abciximab had a significantly lower risk of in-hospital mortality (OR 0.35, 95% CI 0.14-0.93, p=.035), and a marginally lower risk of death at 1-year follow-up (HR 0.58, 95% CI 0.32-1.03, p=.065). These results did not change when the propensity score was included into the analyses.

CONCLUSIONS

In the real practice, abciximab is more frequently used in patients at lower risk, particularly when directly admitted to a hospital with angioplasty facilities. Abciximab use is associated with a significant reduction in early mortality. A trend toward a reduced mortality is maintained also at 1 year.

Hospital care of patients with ST-elevation myocardial infarction in four different European regions. Data from four regional myocardial infarction registries in Berlin, Dijon, Florence, and Tartu

National surveys as well as European comparative studies suggest that differences in treatment of patients with ST-elevation myocardial infarction (STEMI) exist. The extent to which these variations influence the outcome of hospital care delivered to STE-MI patients in everyday routine is mostly unknown. In this study data representative of hospital care received by STEMI patients in four European regions (Berlin, Dijon, Florence and Tartu) were compared. The four registries are population based. The percentage of women and the mean age of the patients differed among the registries. Risk factors such as hypertension and hypercholesterolaemia also differed among the different regions, whereas a history of diabetes mellitus was similar among the registries. The percentage of patients receiving reperfusion therapy ranged from 47 to 81%. An appreciable difference also resulted after breaking down reperfusion therapy into thrombolysis and primary percutaneous coronary intervention (PCI). Hospital mortality as an outcome measure was very similar among the regions. After adjustment for age, the comparative magnitude of hospital mortality proportion was also very similar among three registries. Only the patients from Florence demonstrated a comparatively lower death rate, with a ratio of 0.81. In summary, there are important differences among baseline characteristics and hospital care of STE-Ml patients in the four study regions. Nevertheless, it was interesting to ascertain that the outcome measured in hospital mortality was very similar among the four registries compared.

Screen-detected vs clinical breast cancer: the advantage in the relative risk of lymph node metastases decreases with increasing tumour size

Screen-detected (SD) breast cancers are smaller and biologically more indolent than clinically presenting cancers. An often debated question is: if left undiagnosed during their preclinical phase, would they become more aggressive or would they only increase in size? This study considered a registry-based series (1988-1999) of 3329 unifocal, pT1a-pT3 breast cancer cases aged 50-70 years, of which 994 were SD cases and 2335 clinical cases. The rationale was that (1) the average risk of lymph node involvement (N+) is lower for SD cases, (2) nodal status is the product of biological aggressiveness and chronological age of the disease, (3) for any breast cancer, tumour size is an indicator of chronological age, and (4) for SD cases, tumour size is specifically an indicator of the duration of the preclinical phase, that is, an inverse indicator of lead time. The hypothesis was that the relative protection of SD cases from the risk of N+ and, thus, their relative biological indolence decrease with increasing tumour size. The odds ratio (OR) estimate of the risk of N+ was obtained from a multiple logistic regression model that included terms for detection modality, tumour size category, patient age, histological type, and number of lymph nodes recovered. A term for the detection modality-by-tumour size category interaction was entered, and the OR for the main effect of detection by screening vs clinical diagnosis was calculated. This increased linearly from 0.05 (95% confidence interval: 0.01-0.39) in the 2-7 mm size category to 0.95 (0.64-1.40) in the 18-22 mm category. This trend is compatible with the view that biological aggressiveness of breast cancer increases during the preclinical phase.

The impact of organised screening programmes on the stage-specific incidence of breast cancer in some Italian areas

The aim of this study was to examine the effects of mammographic screening programmes on stage-specific incidence of breast cancer. The study compared prescreening and screening periods in seven areas in Italy, primarily evaluating the first screening round. All 17617 breast cancers (16554 invasive, 1063 in situ) registered in women aged 40-79 years between 1988 and 1999 were analysed through age-standardised rates and Poisson regression models. For all areas, independent of the baseline rates, the introduction of screening increased incidence for invasive cancers overall and, more markedly, for early cancers (screening/prescreening ratio: range 1.07-1.47 and 1.23-1.82, respectively), modifying the pattern of age-specific rates. The multiple regression analysis showed that the percentage of cases diagnosed at screening explained most of the increase; a residual effect of diagnosis period (screening versus prescreening) suggested a role for 'spontaneous' early detection in ages outside of the screening programme. Advanced cases did not show consistent variations across the registries for those aged 40-79 years (range: 0.91-1.21), whereas a more coherent picture was observed for those aged 50-69 years. In one area, a moderate reduction in the number of 'advanced' cases in the second screening period was observed. For all stages, the age-specific incidence rates of cases diagnosed outside of the screening programme for the age groups 50-69 years were lower than the corresponding rates in the prescreening period, suggesting a shift from the usual clinical services to the screening programme. Our results confirmed the increase in early-stage cancers occurring at the start of screening, and substantially explained the rise in breast cancer incidence. In addition, our study confirms the importance of cancer registries in monitoring the effect of breast cancer screening and the validity, for this purpose, of the linkage between cancer registries and screening programme databases.

Long-term prognosis of gastric cancer in a European country: a population-based study in Florence (Italy). 10-year survival of cases diagnosed in 1985-1987

This paper analysed, in a population-based series of 1976 gastric cancers diagnosed in Florence (Italy), from 1985 to 1987, the relationship between prognostic variables (demographic, clinical and pathological) and 10-year survival rates. Gastric cancer was mostly detected in elderly patients (mean age: 70.5 years) and at advanced stages (i.e. approximately 50% of the patients could not undergo radical surgery). Ten-year observed survival was 12.1% (95% confidence interval (CI): 10.6-13.6%) for the whole series and 20.8% (95% CI: 18.3-23.3%) for resected cases; relative survival was, respectively, 20.9% (95% CI: 18.4-23.4%) and 32.0% (95% CI: 28.1-35.9%). Ten-year relative survival was 86% for stage IA (95% CI: 73-99%) and 67% for stage IB (95% CI: 52-82%). Multivariate analysis showed a significantly better prognosis in females and a significantly worse prognosis in patients aged 65 years or more (reference: < or = 59 years). In addition, an independent prognostic effect was observed for pT in the resected cases (reference: pT3; pT1: RR = 0.47, 95% CI: 0.34-0.64; pT2 = 0.71, 95% CI: 0.58-0.87; pT4: RR = 2.02, 95% CI: 1.49-2.75), pN (reference: pN0; pN1: RR = 2.13, 95% CI: 1.70-2.68; pN2-3: RR = 3.14, 95% CI: 2.42-4.07; pN+ no. nodes involved unspecified: RR = 4.26, 95% CI: 3.11-5.83) and surgical margin involvement (reference: not involved; involved: RR = 1.36, 95% CI: 1.08-1.72). In addition, the stage, after adjustment for age, gender and surgical margin involvement, showed a strong independent prognostic value (reference: stage II; IA: RR=0.37, 95% CI: 0.25-0.57; IB: RR=0.70, 95% CI: 0.50-0.98; IIIA: RR = 1.80, 95% CI: 1.40-2.33; IIIB: RR = 2.82, 95% CI: 2.14-3.72; IV: RR = 3.29, 95% CI: 2.36-4.59). In conclusion, on the basis of a large population-based series, our results confirm the prognostic effect on long-term gastric cancer survival of pathological and demographic variables. In addition, the study shows that Italy had a relatively good, long-term survival when diagnosis was performed at early stages. However, only a few cases were diagnosed at stages when cure by radical surgery is more likely (i.e. stage I accounted for approximately 20% of the resected cases and less than 10% of all incident cases).

Trends in breast cancer mortality, incidence, and survival, and mammographic screening in Tuscany, Italy

OBJECTIVE

The study describes breast cancer mortality trends in Tuscany (period 1970-97), comparing Florence with the rest of Tuscany (Florence excluded), and, for Florence, incidence (period 1985-94) and survival (1985-86 versus 1991-92) trends, taking into account the diffusion of screening.

METHODS

Mortality and incidence rates, age-adjusted on the European population, and 95% confidence intervals (95% CI). Five-year relative survival rates and estimates of risk of dying provided by the Cox model.

RESULTS

Mammographic screening, started at the beginning of the 1970s in some municipalities, largely involved the Florence area after 1990 (mammograms/years: from 8,000-9,000 to 28,000-29,000, respectively, before and after 1990). In the same period no population-based screenings were ongoing in the rest of Tuscany. A significant mortality drop was observed in Tuscany (-3.7%/year), starting at the beginning of the 1990s and observed for ages < or = 74 (especially ages 40-49: -11.2%/year). The drop was similar in Florence and in the rest of Tuscany. In ages 50-69, incidence, increasing between 1985-87 and 1988-90 (+6.5%), rose sharply in 1991-94 (+17.0%); it was stable in other ages. Local disease increased more markedly in ages 50-69 (globally: +88.3%), but also in other ages (+20-30%). Regional and metastatic cancers decreased. A significantly better 5-year survival was observed among cases diagnosed in 1991-92, persisting after adjustment by extent of disease.

CONCLUSION

Even if the causes of breast cancer mortality trends are not easy to clarify in an observational study. our data suggest that the drop in mortality observed in Tuscany at the beginning of the 1990s could be largely explained by both earlier detection, outside of an organized screening program, and by better treatments. The increase in incidence and the shift in stage distribution that occurred before the enlargement of the screening area and in age groups not involved in the program, supports the role of a 'spontaneous' widespread earlier detection. The better survival of the period 1991-92, only partly explained by the shift in stage at diagnosis, indirectly supports the role of improvement in therapy.

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.

Early diagnosis, place of diagnosis and persistent differences at 10 years in breast cancer survival. Hospitals and breast clinic cases prognosis

In the Province of Florence (central Italy), the Center for Cancer Prevention (CSPO) runs a breast clinic for early diagnosis of breast cancer at which women can present as self-referrals or be referred by a general practitioner. About 55% of breast cancers incident in the area were diagnosed at CSPO. This paper evaluates the differences observed in 10-year observed and relative survival between hospitals and breast clinic cases. A population-based data set of 1182 invasive cases diagnosed in the years 1985 and 1986 (Tuscany Cancer Registry) was analyzed. Cox models were used to evaluate the effects of place of diagnosis on observed survival. In comparison to hospital cases, breast clinic cases showed a significantly higher frequency of localized cancer (55% vs 37%) and a better relative survival, persistent at 10 years of follow-up (69% vs 58%). The better survival of breast clinic cases persisted after age adjustment (hospitals cases; RR = 0.71, 95% CI: 0.60-0.84) and after age + diffusion of disease adjustment (RR = 0.79, 95% CI: 0.66-0.93). For regionally diffused cancers, breast clinic cases showed a 10-year survival significantly better than hospital cases. In conclusion, even if some bias (i.e. lead-time and length bias) could affect the comparison, breast clinic cases showed a better survival persistent until 10 years after diagnosis. An earlier stage distribution explained, at least partly, the different prognosis.

Recent trends of in situ carcinoma of the breast and mammographic screening in the Florence area, Italy

OBJECTIVES

The study analyzes the relationship between the incidence trends of breast carcinoma in situ (CIS) and the spread of mammography screening in the Italian area of Florence (about 608,000 female residents).

SETTING

In this area, since the seventies, a mammographic screening by personal invitation was performed by the Center for Cancer Prevention (CSPO) in some rural municipalities. After 1990, the municipality of Florence and other municipalities were involved in the screening.

METHODS

The study included all cases of female breast carcinomas in situ reported to the population-based Tuscany Cancer Registry between 1985 and 1995. On the basis of information from the CSPO files, the cases were categorized into: "screen-detected", "self-referrals", and "other" (CSPO cases diagnosed in symptomatic women or at periodic check up after breast cancer plus hospital cases).

RESULTS

Overall, 332 women with breast carcinoma in situ (CIS) were registered between 1985 and 1995. The CIS incidence rate increased from 2.39/100,000 women in 1985-87 to 6.22/100,000 in 1994-95. The largest increase was observed for the ductal carcinoma in situ (2.9 times) and in women aged 50-69 years (3.8 times). In this age group, cases diagnosed at the screening by personal invitation accounted for 69% of the rise in CIS incidence. The proportion of mastectomy lowered from 41% before 1990 to 25% after 1990.

CONCLUSION

In the Florence area the CIS incidence trend, showing a marked increase beginning in 1991, was mainly explained by the spread of the mammographic screening by personal invitation. The period during which mammographic screening became widespread coincided with a change in the treatment policy of breast cancer, with a high proportion of breast conserving surgery also for CIS. Therefore, the rise in CIS incidence rates correlated with the widespread use of mammographic screening did not substantially increase the number of women treated by mastectomy.

Fibrinogen and mortality in chronic critical limb ischaemia

OBJECTIVE

Plasma fibrinogen predicts cardiovascular events in patients with stable peripheral arterial occlusive disease, but its predictive value in patients with chronic critical limb ischaemia, a condition associated with a high risk of death, is unknown.

DESIGN

A prospective cohort study.

SETTING

Determination of fibrinogen and other potential predictors during clinic-based work-up of patients admitted for diagnostic and therapeutic evaluation.

SUBJECTS

A total of 108 patients (72 +/- 10 years, 78 males) with atherosclerotic occlusive disease and critical limb ischaemia (pain at rest and/or trophic lesions) followed up for a median period of 1.6 years). (range: 8 days-5.5 years; 218 patient-years).

MAIN OUTCOME MEASURES

Total mortality.

RESULTS

Forty-five deaths (71% cardiovascular) occurred during the follow-up. Baseline fibrinogen was higher in those who died in the early follow-up period (first 6 months), as were white cell count and serum creatinine, while haematocrit was lower. Plasma fibrinogen values correlated positively with white cell count, and negatively with haematocrit; other cardiovascular prognostic factors did not differ. Only plasma fibrinogen predicted survival independently in multivariate age-corrected Cox regression analysis. Relative risk of death doubled for each standard deviation above the mean and increased with each tertile increase in fibrinogen.

CONCLUSIONS

Fibrinogen predicted death in these elderly arteriopaths with critical limb ischaemia, particularly those who died in the first months following critical ischaemia. Inflammatory stimuli secondary to severely defective tissue oxygenation and possibly sepsis and necrosis, might have stimulated fibrinogen, an acute-phase reactant, thereby compromising organ perfusion through increased blood viscosity and/or promoting thrombosis.

[The mortality due to pulmonary silicosis in the Tuscany region in the last decade demonstrates that the health effects of work exposure to silica are still marked]

An analysis of death certificates from 1987 to 1996 among residents of the Tuscany Region identified 1518 deaths from pneumoconiosis, the large majority from silicosis, a disease explained by occupational exposure to silica dust. A dozen of deaths are from asbestosis, occurred at younger ages and are concentrated in a restricted area where a cement-asbestos factory was active. Deaths from pneumoconiosis occurred mainly among males, and the rates of the disease are decreasing only in the latest years. About 10% of deaths from silicosis are among subjects dying before 65 years of age. Mortality rates are very high in several areas of the Region, approximating those from lung cancer and ischaemic heart disease. For the above reasons the disease is still of concern from the point of view of public health and actions are suggested to obtain a description of prevalence and incidence of the disease.

Risk of cancer other than Kaposi's sarcoma and non-Hodgkin's lymphoma in persons with AIDS in Italy. Cancer and AIDS Registry Linkage Study

Record linkage was carried out between the national Registry of AIDS and 13 Cancer Registries (CRs) covering, in 1991, about 15% of the Italian population. Observed and expected numbers of cancers and standardized incidence ratios (SIRs) were assessed in 6067 persons with AIDS, for a total of 25,759 person-years. Significantly increased SIRs were found for Hodgkin's disease [8.9, 95% confidence interval (CI) 4.4-16.0], in which seven of 11 cases were of mixed cellularity type; invasive carcinoma of the cervix uteri (15.5; 95% CI 4.0-40.1); and non-melanomatous skin cancer (3.0, 95% CI 1.3-5.9), in which five of eight cases were basal cell carcinoma. An excess was also seen for brain tumours, but this may be partly due to misdiagnosis of brain non-Hodgkin's lymphoma or other brain diseases occurring near the time of the AIDS diagnosis. The risk for all cancer types, after exclusion of Kaposi's sarcoma (KS) and non-Hodgkin's lymphoma (NHL), was approximately twice the general population risk. An increased SIR for Hodgkin's disease in persons with AIDS is thus confirmed, though it is many times smaller than that for NHL. An association with invasive carcinoma of the cervix is also shown at a population level. The excess of non-melanomatous skin cancer seems to be lower than in transplant recipients.

High suicide mortality soon after diagnosis among cancer patients in central Italy

A high suicide mortality risk has been documented among a population-based cohort of 27 123 cancer patients resident in central Italy where the general suicide rate is low. Forty-one suicides were observed (SMR = 2.36) which were only 0.2% of all deaths. However, the highest risk (SMR = 27.7) during the first 6 months after diagnosis, represents a greater contrast with the general population than has been observed in other studies.

Linkage of AIDS and cancer registries in Italy

We report the first results of a comparison between the Italian Registry on AIDS (RAIDS) and 13 population-based cancer registries (about 8 million population in 1991) with respect to the notification of Kaposi's sarcoma and non-Hodgkin's lymphoma. Routine indicators of data quality and completeness have been found in both types of registry, consistent with the best international standards. A linkage process was carried out on about 339,000 cancer notifications and 3,134 AIDS notifications and was herein restricted to individuals under the age of 50. Out of 243 Kaposi's sarcomas at either type of registry, 90 (37%) were reported as such by both; 68% of individuals with Kaposi's sarcoma at cancer registries could be identified at the AIDS registry, including AIDS-defining illnesses other than Kaposi's sarcoma; 62% of individuals with Kaposi's sarcoma at RAIDS could be found at cancer registries. Of 2,104 non-Hodgkin's lymphomas at either type of registry, 55 were reported as such by both; 65% of individuals reported as having non-Hodgkin's lymphoma at the AIDS registry were found at cancer registries. Our present results indicate the scope for improving cancer assessment in individuals with HIV infection and AIDS and the potential of AIDS and cancer registries for such a purpose.

[Survival for digestive system tumors: Italian population-based data and international comparisons]

Survival for malignant tumour of the upper digestive tract, oesophagus, stomach and pancreas are analysed from the data of 5042 cases observed during the period 1976-1985 by the Italian cancer registries (CRs) of Varese, Latina, Ragusa and Florence. Three-year relative survival rates were 42% for patients with tumours of the upper digestive tract and 7% for those tumour of the oesophagus. Five-year relative survival for patients with stomach cancer was 20%. A worse prognosis was found for cases from the Latina and Ragusa CRs. One-year relative survival for patients with pancreatitic cancer was 17%. Younger age, histologic confirmation, period of diagnosis (for upper tract, stomach and pancreatitic cancers), and female gender (for tumours of the upper tract) resulted as positively associated to survival.

[Use of mortality statistics for the study of the distribution of digestive system tumors: characteristics and quality of the data]

We present an evaluation of the accuracy of death certificates in Italy for patients with cancers of the digestive apparatus in Italy: oral cavity and pharynx, oesophagus, stomach, colon rectum, liver, bilious ducts, pancreas. The diagnosis reported on death certificates is compared to post mortem examinations, diagnoses histologically confirmed, clinical and cancer registry records. For oropharynx cancer mortality data available from official statistics are underreported when compared to cancer registry data. The oesophagus presents misclassification problems with gastric cancer. Mortality data of stomach cancer show a good agreement with incidence and mortality data from cancer registries. No major differences are revealed among the various sources for colorectal cancer mortality. On the contrary the separate analysis of colon and rectum evidentiates diagnostical difficulties in identifying the primary site of intestinal cancers. Cancers of liver, bilious ducts and pancreas have a low percentage of cases with histological confirm and a high frequency of death certificate only (DCO) due to diagnostical difficulties.

[Mortality in population migrated from other Italian regions to the Tuscany region in 1989-94]

In the period 1989-94, mortality rates for the most important causes of death in people migrated to the Tuscany from other Italian regions were analysed. The area of birth was assessed according to the information on province of birth recorded on death certificates. For this analysis we classified Italy into Tuscany and five broad areas, each including a number of political regions: North-West, North-East, Centre, South and Islands. The number of person-years for calculation of the mortality risks was based on 1991 census data, which also included information on place of birth and on current residence. The risks of death of subjects born in other Italian areas and resident in Tuscany ("migrated populations") in comparison to Tuscany born population were assessed by means of Poisson multivariate regression models. For most sites (particularly for lung and breast), cancer mortality rates were higher among North-West and North-East born people and lower among Centre, South and Islands born people. Gastric cancer mortality was higher in Tuscany born subjects. Cardiovascular diseases mortality was generally lower among people born outside of the Tuscany, with the exception of ischaemic heart disease (higher in North-West and Islands born people). Liver cirrhosis mortality was generally higher in North-West, North-East, South and Islands born subjects (with some differences between males and females). Diabetes mellitus mortality was higher in South and Islands born people. AIDS and opioids overdose mortality was higher in North-West born subjects. Mortality for external causes was higher in people born outside of the Tuscany. Both in males and females, overall mortality was higher in North-West and lower in South born people and lower in Centre and Islands born males.

[Hospital admissions, diagnostic and therapeutic procedures of patients with colorectal cancer during 5 years after diagnosis: population-based study]

This research evaluated basic parameters of care, also in the terms of costs. The study examined a sample of colorectal cancer cases incident in 1987 in the population of Florence's municipality, taken from the data base of Tuscany Cancer Registry (RTT). We collected, for 71 patients, all clinical records, for the five follow-up years and evaluated the diagnostic and therapeutic procedures (blood tests, histologic examination, instrumental investigation and surgical intervention) and the duration of all hospitalisations. Besides, on the basis of the diagnostic and therapeutic procedures and of the discharge diagnosis, each hospitalisation was coded following the DRG system and the economic cost of hospital care was analysed. The average number of hospitalisations and the average length of stay for patient in five follow-up years are respectively 1.9 (SD = 1.3) and 41.3 (SD = 25.8); the length of stay resulted highly correlated with the stage of disease. The mean hospital cost per patient (about ItL 18.000.000 overall) was higher in patients with more advanced disease at diagnosis. In the period of study an average 125.9 blood tests (SD = 110.7), 1.2 histologic examinations (SD = 0.9) and 10.3 instrumental investigations (SD = 9.0) were performed for each patient; 61 subjects (86%) were submitted to surgical intervention, of which 4 had a second intervention, and 1 subject was submitted to surgical intervention for liver's metastases.

Survival after AIDS diagnosis in Tuscany (Italy), 1985-1992

The study evaluated the overall survival after AIDS diagnosis of 1,014 patients reported to the Italian AIDS Registry as resident in Tuscany, stratified by age, gender, year of diagnosis, HIV transmission category, initial AIDS-defining disease and CD4+ cells count. The study was a population-based survival analysis, carried out through Kaplan-Meier method (mean survival times-MST-, 1, 2 and 3-year observed survival) and Cox models (crude and adjusted relative risk-RR). The MST was 12.4 months for all cases, increasing from 4-7 months in 1985-1987 to 14 months in 1991-1992. The observed survival was 51.4% at the first year of follow-up, 28.4% at the second year and 14.5% at the third year. The multivariate analysis showed an independent prognostic effect of age, year of diagnosis, initial AIDS-defining disease and CD4+ cells count. The prognosis was worse in cases aged over 44 (reference: 25-29), diagnosed before 1988 (reference: 1991) and with wasting syndrome, toxoplasmosis, HIV encephalopathy or multiple diseases (reference: PCP alone); and better in cases with more than 100 CD4+ cells/mm3 (reference: < or = 50 cells/mm3). The differences in gender and among HIV transmission categories disappeared after age-adjustment. The study confirmed, in an European population-based series, the poor long-term AIDS prognosis and, once AIDS has became clinically manifest, the prognostic value of some clinical and demographic variables.

Changing trends in the incidence of non-Hodgkin's lymphoma in Europe. Biomed Study Group

Non-Hodgkin's lymphoma (NHL) is not a uniform disease entity, and in order to investigate the reported changes in incidence we have set up a study in seven population-based cancer registries in Europe. The study is designed to look at changes in the incidence of total NHL and disease subgroups using standard definitions and methodology. The registries are based in Leeds, Dijon, Kuopio, Odense, Florence, Eindhoven, and Ragussa. The classification system we have used is based on the REAL classification and has utility for epidemiological studies. We have used it to convert data sets which have utilized both local cases and the ICD-O classification. In order to improve data reproducibility, CLL/LL, myeloma/MGUS, lymphoblastic disease, and Hodgkin's disease have been excluded because of the difficulty in defining incident cases accurately. The preliminary results of this study show that there is still an upward trend in incidence rate and that in Yorkshire this is 3% per annum in total NHL. The subgroups which are increasing are extranodal and nodal peripheral T-cell lymphoma. Similar increases in incidence have been reported for the other registries. We conclude that there is a continued upward trend in incidence of NHL, the causes of which are uncertain.

[Avoidable mortality in the Italian regions, 1980-1990]

In Italy, between 1890-85 and 1986-90, rates for most "avoidable deaths" decreased: the decline ranged between 20% and 50%. For ages 5-64 years, total "avoidable mortality" declined in both sexes at a greater percentage (-26/27%) than mortality for all causes (-12%). In both periods, often the higher mortality rates (for causes of death selected as "avoidable" and for total avoidable mortality") were observed in the regions of Southern Italy. The "avoidable mortality" summary score showed higher values in 5 regions of Southern Italy (Compania, Sicily, Puglia, Calabria and Basilicata, the last in the period 1986-90, and in 2 regions of Northern Italy (Piedmont and Valle d'Aosta). The regions with higher values of the "avoidable mortality" summary score had also SMRs for total "avoidable mortality" significantly higher than the standard population (whole Italy of the same period). Hypertensive and cerebrovascular diseases, all respiratory diseases (age 1.4 years), perinatal mortality, and, only in the first period, the chronic rheumatic heart disease and all respiratory diseases (age 5-14 years) showed the highest degree of regional variations. The SMRs significantly higher than the standard population were more frequent in females (also after exclusion of sex-specific causes of death). The number of SMRs significantly higher than the standard population and the range of the "avoidable mortality" summary scores were smaller in the second period.

Colorectal cancer survival--population-based rates in the province of Florence

This study aimed to evaluate survival in 2,339 colorectal cancer patients diagnosed in 1985-87 in the province of Florence, where the Tuscany Tumour Registry is active. The effect of sex, site (colon, rectum), sub-site, disease diffusion (localized, regional, distant, unspecified), year of diagnosis, place of residence (municipalities involved in the screening programme, Florence, others) and source of diagnosis (Center for the Study and Prevention of Cancer-CSPO, others) were evaluated. Five-year observed and relative survivals were 37.9 and 48.1% respectively. Five-year prognosis was worse in men, in older age groups, in advanced stages and in patients not diagnosed at the CSPO. No differences were shown in residents of municipalities involved in the screening programme. Relative 5-year survival in Florence was among the highest in Europe for cancers of both the colon and the rectum. Sex, age, disease diffusion and source of diagnosis showed an independent prognostic effect. The effect of screening was not evident, probably due to the low compliance during the period under study and to the use of a low sensitivity test.

Colorectal, lung, and breast cancer care during the three years following the diagnosis: a population-based study

AIMS

We evaluated a number of basic parameters of care during hospitalization that contribute to the total cost of therapy during the 3 years after the first diagnosis of cancer.

METHODS

The study examined a sample of cases of cancer of the colon-rectum (164 cases), lung (160 cases) and breast (144 cases) diagnosed in 1987, taken from the data base of the Tuscany Cancer Registry. All the information collected by the Registry was examined and the sample was further validated by reviewing original clinical records. The agreement between the two sources was very high, confirming the adequacy of the Registry as a source of information. The parameters evaluated for each patient were the number of cytohistologic examinations, surgery, hospital admissions and days spent in hospital during the 3 follow-up years.

RESULTS

The average number of admittances in 3 years was 1.93 for colorectal, 3.39 for lung and 2.15 for breast cancer. The mean number of days spent in hospital in the 3 follow-up years was 39.9 for colorectal, 50.1 for lung and 21.1 for breast cancer. The parameters differed among subjects still alive, those deceased and those in various stages of the illness.

CONCLUSIONS

The costs of the time spent in hospital, based on the number of days during the first 3 years of the illness, were higher in cases of lung cancer than of the other sites, and more so for patients diagnosed in an advanced phase of the disease.

Completeness of AIDS reporting and quality of AIDS death certification in Tuscany (Italy): a linkage study between surveillance system of cases and death certificates

In Italy, the AIDS cases defined according to the CDC criteria are reported to the National AIDS Registry (RAIDS, compulsory surveillance system). The aim of the present study is to evaluate the completeness of AIDS cases reported and the quality of AIDS death certification in an Italian Region (Tuscany, about 3,500,000 inhabitants). The 737 AIDS cases reported to RAIDS as residents in Tuscany (1987-91) were cross-linked (key link: name and date of birth) with the data of the Mortality Registration system of the Region (RMR). For the residents in Tuscany decreased with a 279.1 death diagnosis (the code for AIDS deaths stated by the Italian Census Bureau) and not reported to RAIDS as AIDS cases, the clinical records were reviewed to check whether the diagnosis fitted the 1987-CDC diagnostic criteria. This study shows that there is a high completeness (97-98%) of the AIDS cases resident in Tuscany, reported to the RAIDS. The quality of RAIDS data is not as good with regard to life status assessment (23% of under-reporting of death). In Tuscany, the death certification for AIDS (code 279.1 of ICD IX) has a sensitivity of 88% and a specificity around 100% in comparison to RAIDS. About 50% of 'false negatives' in death certification are due to causes of death presumably unrelated to HIV infection. The evaluation of the quality of AIDS surveillance and mortality data is important in the assessment of the impact for AIDS epidemic in a target population.