The impact of mammography screening programmes on incidence of advanced breast cancer in Europe: a literature review

Background

Observational studies have reported conflicting results on the impact of mammography service screening programmes on the advanced breast cancer rate (ABCR), a correlation that was firmly established in randomized controlled trials. We reviewed and summarized studies of the effect of service screening programmes in the European Union on ABCR and discussed their limitations.

Methods

The PubMed database was searched for English language studies published between 01-01-2000 and 01–06-2018. After inspection of titles and abstracts, 220 of the 8644 potentially eligible papers were considered relevant. Their abstracts were reviewed by groups of two authors using predefined criteria. Fifty studies were selected for full paper review, and 22 of these were eligible. A theoretical framework for their review was developed. Review was performed using a ten-point checklist of the methodological caveats in the analysis of studies of ABCR and a standardised assessment form designed to extract quantitative and qualitative information.

Results

Most of the evaluable studies support a reduction in ABCR following the introduction of screening. However, all studies were challenged by issues of design and analysis which could at least potentially cause bias, and showed considerable variation in the estimated effect. Problems were observed in duration of follow-up time, availability of reliable reference ABCR, definition of advanced stage, temporal variation in the proportion of unknown-stage cancers, and statistical approach.

Conclusions

We conclude that much of the current controversy on the impact of service screening programmes on ABCR is due to observational data that were gathered and/or analysed with methodological approaches which could not capture stage effects in full. Future research on this important early indicator of screening effectiveness should focus on establishing consensus in the correct methodology.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4666-1) contains supplementary material, which is available to authorized users.

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.

What Do Italian Hospital Physicians Know about Quality of Life Assessment in Oncology?

Aims

To assess the current level of information and use of quality of life assessment instruments by Italian physicians involved in oncologic patient care.

Methods

Specifically trained scientific representatives of a pharmaceutical company interviewed 2237 hospital physicians all over Italy.

Results

A total of 1390 physicians (62.1%) had some knowledge of quality of life assessment tools in oncology, but 364 of them (26.2%) were unable to recall the name of any instruments. The one that was most frequently recalled by the 1026 physicians who knew of the existence of one or more instruments was the Karnofsky Performance Status (KPS) (91%) followed by the Eastern Cooperative Oncology Group performance scale (ECOG) (35.5%) whereas the Quality of Life Index and Visual Analogue Scale were at the very bottom of the list (5.9% and 3.7%, respectively). Physician age and type of department were found to be strong predictors of knowledge of the instruments, which was greater among young physicians and those working in oncological departments. Of the physicians aware of the KPS, 56.6% used it, whereas the percentage of physicians using ECOG was higher (69.5%).

Conclusions

The collected data indicate a poor knowledge of quality of life assessment instruments in Italian physicians. Most physicians tend to use so-called «objective» instruments where the assessment is made by the physician and not by the patient (KPS, ECOG Quality of Life index), are practically unaware of the new generation of «subjective» self-rating instruments. The use of such instruments in particular might provide greater insights into the impact of the disease and related treatments on the quality of life of cancer patients.

First Results of a Mammographic Screening Program in Two Municipalities of Massa-Carrara Province (Italy)

Aims and Background

A mammographic screening for breast cancer was started in 1989 in two municipalities of Massa-Carrara province. This paper describes the results of the first two years and evaluates the quality of the program via early indicators.

Methods

We calculated the attendance rate at first screening, the proportion of women recalled for further examinations (recall rate), the ratio between benign lesions and carcinomas detected by screening, the staging of the screen detected cancers and the ratio between detection rate and expected incidence (P/l ratio).

Results

Out of 14826 invited women 10407 (70.2 %) attended the first screening; 266 (2.6%) of them were referred for further investigations but only 63 (0.6%) required surgical biopsy. A histological confirmed malignancy was found in 39 women corresponding to a detection rate of 3.7/1000. According to pTNM classification 89.1 % of all cancers were either Tis or in stage T1; and in two third of the cases there was no nodes involvment.

Conclusion

The results achieved so far, evaluated via early indicators, show a good start of the program.

Selection of High-Risk Groups for Breast Cancer Screening. Evidence from an Italian Multicentric Case Control Study

In recent years techniques for the selection of risk groups for high priority breast screening have been evaluated (7, 11). We used data from a large multicentric case control study in Italy, recently published (12), to fit a reduced logistic model for predictive purposes, using variables which are easily collected. The predicted probability of being a case obtained through the logistic analysis was then used to classify the same set of data by calculating values of sensitivity and specificity at different cutoff points of the predicted probability. The results showed the low predictive power of the model. The selection of higher risk groups in a screening population program is discussed.

Association of exposure to benzene and smoking with oxidative damage to nucleic acids by means of biological monitoring of general population volunteers

In this study, the validation of liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) isotopic dilution method for the determination of benzene and nicotine metabolites in urine was carried out. Limit of detection are 0.026 μg/L for S-phenylmercapturic acid (SPMA), 0.55 μg/L for t,t-muconic acid (t,t-MA), and 12.41 μg/L for the cotinine, and the relative combined uncertainty was also calculated. The study involves 446 healthy volunteer residents since at least 10 years in an area of central Italy. SPMA resulted to be strongly correlated with cotinine (p = 0.75), its concentration in smokers (93) being about ten times than in non/ex-smokers (197/156), while the t,t-MA of smokers is about twice the non/ex-smokers value. A cutoff value for the definition of smoker is set at 100 μg/g creat. Oxidative stress was studied in smokers and non- and ex-smokers by means of the determination of the biomarkers 8-Oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodGuo), 8-Oxo-7,8-dihydroguanosine (8-oxoGuo), and 8-Oxo-7,8-dihydroguanine (8-oxoGua): no significant differences were found between smokers and non/ex-smokers, but when subjects are classified according to the cotinine cutoff value, a correlation in smokers' urinary 8-oxodGuo is found with SPMA and cotinine (p = 0.60 and p = 0.57). Results were confirmed by chemometric analysis that also identified the experimental variables most contributing the discrimination as cotinine and t,t-MA.

Oxidative stress biomarkers and otoacoustic emissions in humans exposed to styrene and noise

OBJECTIVE

Evaluating the correlation between otoacoustic emission levels, styrene exposure, and oxidative stress biomarkers concentration in styrene-exposed subjects, to investigate the role of oxidative stress in outer hair cell damage.

DESIGN

Distortion product otoacoustic emissions were measured in the exposed workers and in a control group. Separation between the distortion and reflection otoacoustic components was performed by time-frequency-domain filtering. The urinary concentration of the DNA and RNA oxidation products, namely 8-oxo-7,8-dihydroguanine (oxoGua), 8-oxo-7,8-dihydro-2'-deoxyguanosine (oxodGuo), and 8-oxo-7,8-dihydroguanosine (oxoGuo), were evaluated.

STUDY SAMPLE

Nine subjects exposed to styrene in a fiberglass factory, eight control subjects. The two groups were statistically equivalent in mean age.

RESULTS

Statistically significant differences were found in the distortion component levels between the exposed and the control group. High levels of the oxidative damage biomarkers were found in the workers exposed to high levels of styrene. Significant negative correlation was found between the otoacoustic emission distortion component levels and the concentration of the oxoGuo biomarker.

CONCLUSIONS

Exposure-induced damage of the cochlear amplifier is shown in the mid-frequency range, confirming animal experiments, in which hair cells in the cochlear middle turn were damaged. Hearing damage is consistent with the outer hair cell apoptosis pathway associated with oxidative stress.

Sex differences in the outcome of juvenile social isolation on HPA axis function in rats

Women are more likely than men to suffer from anxiety disorders and major depression. These disorders share hyperresponsiveness to stress as an etiological factor. Thus, sex differences in brain arousal systems and their regulation by chronic stress may account for the increased vulnerability to these disorders in women. Social isolation is a model of early life stress that results in neurobiological alterations leading to increased anxiety-like and depressive-like behaviors. Here we investigated the sex difference in the effects of post-weaning social isolation on acute stress sensitivity and behavior in rats. In both sexes, social isolation at weaning reduced basal levels of the neuroactive steroid allopregnanolone in the brain and of corticosterone in plasma. Moreover, acute stress increased plasma corticosterone levels in both group-housed and socially isolated male and female rats; however this effect was greater in male than female rats subjected to social isolation. Intriguingly, group-housed female rats showed no change in plasma and brain levels of allopregnanolone after acute foot-shock stress. The absence of stress-induced effects on allopregnanolone synthesis might be due to the physiologically higher levels of this hormone in females vs. males. Accordingly, increasing allopregnanolone levels in male rats blunted the response to foot-shock stress in these animals. Socially isolated male, but not female, rats also display depressive-like behavior and increased hippocampal brain-derived neurotrophic factor (BDNF). The ovarian steroids could "buffer" the effect of this adverse experience in females on these parameters. Finally, the dexamethasone (DEX) suppression test indicated that the chronic stress associated with social isolation impairs feedback inhibition in both sexes in which an increase in the abundance of glucocorticoid receptors (GRs) in the hippocampus was found. Altogether, these results demonstrate that social isolation affects neuroendocrine reactivity to stress, plasticity and emotionality in a sexually dimorphic manner.

Careful monitoring of the use of sedative drugs at the end of life: the role of Epidemiology. The ITAELD study

BACKGROUND

Sedative drugs are often used at the end of life for different clinical indications, and sometimes sedation is not interrupted until the patient dies. The aim of this study was to estimate the prevalence of patients who died while deeply sedated in Italy in 2007.

METHODS

Cross-sectional survey which asked physicians about the last death that occurred among their assisted patients during the last year, and about their attitudes towards end-of-life decisions. All general practitioners (N=5,710) and a random sample of hospital physicians (N=8,950) from 14 Italian provinces were invited to participate.

RESULTS

The response rate was 20%. Among 1855 reported deaths, 1466 (79.2%) were classified by physicians as expected or non-sudden; 18.2% of these expected or non-sudden deaths occurred while the patient was deeply sedated. GPs were the least likely to report deep sedation, whereas anesthetists were the most likely. In 8% of cases, sedation occurred along with an abrupt increase in the dosage of opioids during the last day of life, reaching a dosage considered higher than necessary by the doctor. No association with positive attitudes of the physician towards physician assisted death was found, whereas reporting sedation was associated with a positive attitude towards respecting the choice of relatives to forgo life-sustaining treatment in the case of an incompetent patient.

CONCLUSION

Our study confirms the high prevalence of patients in Italy who die while being deeply sedated and shows that different practices may converge under the same label. Careful descriptive language is needed.

Otoacoustic emission sensitivity to exposure to styrene and noise

The ototoxic effect of the exposure to styrene is evaluated, also in the presence of simultaneous exposure to noise, using otoacoustic emissions as biomarkers of mild cochlear damage. Transient-evoked and distortion product otoacoustic emissions were recorded and analyzed in a sample of workers (15 subjects) exposed to styrene and noise in a fiberglass manufacturing facility and in a control group of 13 non-exposed subjects. Individual exposure monitoring of the airborne styrene concentrations was performed, as well as biological monitoring, based on the urinary concentration of two styrene metabolites, the Mandelic and Phenylglyoxylic acids. Noise exposure was evaluated using wearable phonometers, and hearing loss with pure tone audiometry. Due to their different job tasks, one group of workers was exposed to high noise and low styrene levels, another group to higher styrene levels, close to the limit of 20 ppm, and to low noise levels. A significant negative correlation was found between the otoacoustic emission levels and the concentration of the styrene urinary metabolites. Otoacoustic emissions, and particularly distortion products, were able to discriminate the exposed workers from the controls, providing also a rough estimate of the slope of the dose-response relation between otoacoustic levels and styrene exposure.

Trends in colorectal incidence by anatomic subsite from 1985 to 2005: a population-based study

BACKGROUND

Conflicting results on the shift of right-left ratio in colon cancer incidence have been reported. We examine incidence trends by subsite in a population-based study.

MATERIALS AND METHODS

Colorectal cancer cases diagnosed in the 1985-2005 period were identified through the Tuscany Cancer Registry. Colon subsite was defined as proximal and distal; gender, age at diagnosis, histology, and stage were analyzed. Average annual incidence and age-specific rates according to subsite were calculated.

RESULTS

A total of 21,160 colorectal cancer cases were extracted; in 18,311 cases, the subsite was identified: 6,916 rectal, 5,239 proximal, and 6,156 distal. A larger proportion of distal colon cancers presented as early stage when compared with proximal. Incidence of rectal and distal colon cancer remained stable, while proximal colon cancer incidence increased.

CONCLUSIONS

Proximal colon cancer incidence rate increased through the period. Temporal variations in the incidence rate by subsite could suggest different carcinogenic pathways of right- and left-sided colon cancer.

Invasive breast cancer: a significant correlation between histological types and molecular subgroups

INTRODUCTION

The special types of breast cancer seem to have not only distinct morphological features but also distinct biological features.

MATERIALS AND METHODS

Women diagnosed with a first primary invasive breast cancer in the 2004-2005 period were identified through Tuscan Cancer Registry. Information on age, tumor size, lymph node status, histological type and grade, hormonal receptors, HER2 immunohistochemical expression were collected. Five subtypes were defined: luminal A, luminal B HER2+, luminal B HER2-, triple negative, and HER2 positive. The association between the histological type and molecular subgroups was assessed by a Fisher's exact test, and a multinomial logistic regression model was used.

RESULTS

Out of 1,487 patients, 34 % were luminal A subtype, 25 % luminal B HER2-, 11 % luminal B HER2+, 19 % triple negative, and 10.2 % HER2+; 58.5 % of cancers were ductal NOS types. With luminal A as reference, histological types distribution was significantly different between the subgroups. Mucinous, tubular, and cribriform histotypes were found among luminal A cancers more than in other subgroups; all medullary carcinomas were triple negative cancers. Pathological stage at diagnosis was more advanced, and histological grade was lower among subgroups other than luminal A.

CONCLUSIONS

Significant association between breast cancer histotypes and molecular subgroups was found.

Occupational exposure to styrene in the fibreglass reinforced plastic industry: comparison between two different manufacturing processes

BACKGROUND

Styrene is used in manufacturing fiberglass reinforced plastics: and occupational exposure was related to neurotoxicology and genotoxicity. The sum of the metabolites mandelic and phenylglyoxylic acids is the ACGIH biomarker for occupational exposure with a BEI of 400 mg/g of creatinine in end shift urine corresponding to a airborne styrene concentration of 85 mg/m3. There are two main molding processes, open and closed, the last more effective at controlling worker's styrene exposure.

OBJECTIVES

To compare the open molding process to the compression of fiber reinforced resin foils, a kind of closed molding, monitoring the styrene exposure of workers in two production sites (A and B).

METHODS

Environmental Monitoring was carried out by Radiello samplers and Biological Monitoring by means of the determination of MA and PGA with HPLC/MS/MS in 10 workers at Site A and 14 at Site B.

RESULTS

The median values for styrene exposure resulted 31.1 mg/m3 for Site A and 24.4 mg/m for Site B, while the medians for the sum of the two metabolites in the end shift urine were 86.7 e 33.8 mg/g creatinine respectively. There is a significant linear correlation between personal styrene exposure and the excretion of styrene metabolites (R = 0.74).

CONCLUSIONS

As expected the exposure markers of the workers of the two production sites resulted higher in the open process. The analytical results of both environmental and biological monitoring were all below the occupational exposure limits, confirming the efficacy of the protective devices.

Dose exposure in the ITALUNG trial of lung cancer screening with low-dose CT

Few data are available on the effective dose received by participants in lung cancer screening programmes with low-dose CT (LDCT). We report the collective effective dose delivered to 1406 current or former smokers enrolled in the ITALUNG trial who completed 4 annual LDCT examinations and related further investigations including follow-up LDCT, 2-[(18)F]flu-2-deoxy-d-glucose positron emission tomography (FDG-PET) or CT-guided fine needle aspiration biopsy (FNAB). Using the air CT dose index and Monte Carlo simulations on an anthropomorphic phantom, the whole-body effective dose associated with LDCT was determined for the eight CT scanners used in the trial. A value of 7 mSv was assigned to FDG-PET while the measured mean effective dose of CT-guided FNAB was 1.5 mSv. The mean collective effective dose in the 1406 subjects ranged between 8.75 and 9.36 Sv and the mean effective dose to the single subject over 4 years was between 6.2 and 6.8 mSv (range 1.7-21.5 mSv) according to the cranial-caudal length of the LDCT volume. 77.4% of the dose was owing to annual LDCT and 22.6% to further investigations. Considering the nominal risk coefficients for stochastic effects after exposure to low-dose radiation according to the National Radiological Protection Board, International Commission on Radiological Protection (ICRP) 60, ICRP103 and Biological Effects of Ionizing Radiation VII, the mean number of radiation-induced cancers ranged between 0.12 and 0.33 per 1000 subjects. The individual effective dose to participants in a 4-year lung cancer screening programme with annual LDCT is very low and about one-third of the effective dose that is associated with natural background radiation and diagnostic radiology in the same time period.

[Synergistic exposure to noise and styrene and cochlear functionality in a sample of exposed workers: preliminary results]

This study is aimed at testing the cochlear functionality using otoacoustic emissions, analyzing the synergistic effects of simultaneous exposure to noise and organic solvents EBTx on workers of a glass-reinforced plastic products factory. Exposure to organic solvents was assessed using ambiental measurements and evaluation of the salivary concentration. Biological monitoring was performed evaluating the urinary concentration of the styrene metabolites. Statistical analysis shows that otoacoustic tests can discriminate between different exposure groups. Significant differences were found between controls and subjects exposed to high styrene and low noise levels, showing the ototoxic effect (at sub-clinical level) of the styrene exposure.

[Biological monitoring of the PAH exposure in the hardening of metals]

The hardening of metals involves the immersion of hot components in mineral oil with production of aerosols containing PAHs, to wich workers can be exposed. The determination of airborne PAHs and urinary 1-hydroxypyrene (1-OHPy) was performed for a group of workers and the latter resulted within the reference values. However, the average 1-OHPy concentration on metal workers (0.07 microg/g creatinine) was statistically different from the average value obtained for a group of employees (0.03 microg/g creatinine), highlighting the risk of exposure to PAHs. Therefore, being these potentially carcinogenic compounds, interventions were prescribed in order to reduce the risk of occupational exposure.

The major determinant of exendin-4/glucagon-like peptide 1 differential affinity at the rat glucagon-like peptide 1 receptor N-terminal domain is a hydrogen bond from SER-32 of exendin-4

BACKGROUND AND PURPOSE

Exendin-4 (exenatide, Ex4) is a high-affinity peptide agonist at the glucagon-like peptide-1 receptor (GLP-1R), which has been approved as a treatment for type 2 diabetes. Part of the drug/hormone binding site was described in the crystal structures of both GLP-1 and Ex4 bound to the isolated N-terminal domain (NTD) of GLP-1R. However, these structures do not account for the large difference in affinity between GLP-1 and Ex4 at this isolated domain, or for the published role of the C-terminal extension of Ex4. Our aim was to clarify the pharmacology of GLP-1R in the context of these new structural data.

EXPERIMENTAL APPROACH

The affinities of GLP-1, Ex4 and various analogues were measured at human and rat GLP-1R (hGLP-1R and rGLP-1R, respectively) and various receptor variants. Molecular dynamics coupled with in silico mutagenesis were used to model and interpret the data.

KEY RESULTS

The membrane-tethered NTD of hGLP-1R displayed similar affinity for GLP-1 and Ex4 in sharp contrast to previous studies using the soluble isolated domain. The selectivity at rGLP-1R for Ex4(9-39) over Ex4(9-30) was due to Ser-32 in the ligand. While this selectivity was not observed at hGLP-1R, it was regained when Glu-68 of hGLP-1R was mutated to Asp.

CONCLUSIONS AND IMPLICATIONS

GLP-1 and Ex4 bind to the NTD of hGLP-1R with similar affinity. A hydrogen bond between Ser32 of Ex4 and Asp-68 of rGLP-1R, which is not formed with Glu-68 of hGLP-1R, is responsible for the improved affinity of Ex4 at the rat receptor.

CHARMM: the biomolecular simulation program

CHARMM (Chemistry at HARvard Molecular Mechanics) is a highly versatile and widely used molecular simulation program. It has been developed over the last three decades with a primary focus on molecules of biological interest, including proteins, peptides, lipids, nucleic acids, carbohydrates, and small molecule ligands, as they occur in solution, crystals, and membrane environments. For the study of such systems, the program provides a large suite of computational tools that include numerous conformational and path sampling methods, free energy estimators, molecular minimization, dynamics, and analysis techniques, and model-building capabilities. The CHARMM program is applicable to problems involving a much broader class of many-particle systems. Calculations with CHARMM can be performed using a number of different energy functions and models, from mixed quantum mechanical-molecular mechanical force fields, to all-atom classical potential energy functions with explicit solvent and various boundary conditions, to implicit solvent and membrane models. The program has been ported to numerous platforms in both serial and parallel architectures. This article provides an overview of the program as it exists today with an emphasis on developments since the publication of the original CHARMM article in 1983.

Determination of free and totalS-phenylmercapturic acid by HPLC/MS/MS in the biological monitoring of benzene exposure

Urinary S-phenylmercapturic acid (SPMA) is a biomarker suggested by the American Conference of Governmental Industrial Hygienists (ACGIH) for assessing occupational exposure to benzene. A possible cause of the miscorrelation between environmental monitoring and biological monitoring for benzene exposure, which many authors complain about, is the existence of a urinary metabolite that turns into SPMA by acid hydrolysis. Forty urine samples were tested to determine which concentration value would correspond to the ACGIH Biological Exposure Index (BEI) of 25 microg g(-1) creatinine if exposure assessment was based on the determination of SPMA after quantitative hydrolysis of its precursor. An aliquot of each sample was hydrolysed with 9 M H2SO4, a second one was brought to pH 2 and a third one was used as it was (free SPMA). SPMA was determined by high-performance liquid chromatography/tandem mass spectrometric technique (HPLC/MS/MS) using an internal standard. The analytical method was validated in the range 0.5-50 microg 1(-1). The average SPMA in pH 2 samples is 45-60% of the total, while free SPMA varies from 1% to 66%. The hydrolysis of pre-SPMA reduces the likelihood of variability in the results by reducing pH differences in urine samples and increasing the amount of measured SPMA. The BEI limit value would be about 50 microg g(-1) creatinine.

Effectiveness of service screening: a case-control study to assess breast cancer mortality reduction

The aim of this study was the evaluation of the impact of service screening programmes on breast cancer mortality in five regions of Italy. We conducted a matched case-control study with four controls for each case. Cases were defined as breast cancer deaths occurred not later than 31 December 2002. Controls were sampled from the local municipality list and matched by date of birth. Screening histories were assessed by the local, computerised, screening database and subjects were classified as either invited or not-yet-invited and as either screened or unscreened. There were a total of 1750 breast cancer deaths within the 50 to 74-year-old breast cancer cases and a total of 7000 controls. The logistic conditional estimate of the cumulative odds ratios comparing invited with not-yet-invited women was 0.75 (95% CI: 0.62-0.92). Restricting the analyses to invited women, the odds ratio of screened to never-respondent women corrected for self-selection bias was 0.55 (95% CI: 0.36-0.85). The introduction of breast cancer screening programmes in Italy is associated with a reduction in breast cancer mortality attributable to the additional impact of service screening over and above the background access to mammography.

[Occupational exposure to hexavalent chromium during aircraft painting]

Hygienists are interested in hexavalent chromium due to its genotoxic and carcinogenic effect on humans. The use of products containing hexavalent chromium is decreasing in many industrial fields because of the substitution with less-toxic compounds. In the aeronautical industry, however, the chromate are added to primer paint as a corrosion inhibitor of aircrafts surfaces: so hexavalent chromium compounds are available in many primers with a composition ranging from 10% to 13%. The application of these primers by using electrostatic guns potentially exposes painting and coating workers at high concentrations of aerosols containing Cr(VI). The aim of the present study is the evaluation of professional exposure to hexavalent chromium during aircraft painting, by adopting both environmental personal sampling and biological monitoring. To valuate workers exposure levels the personal measurements results have been compared with the exposure limit values (TLV-TWA) and the urinary chromium contents with the biological exposure indices (IBE). Moreover the strategy of coupling environmental sampling with biological monitoring seems to be a useful instrument to measure the validity of the individual protection devices.

[Isotopic dilution HPLC/MS/MS urinary trans, trans-muconic quantitative analysis among refinery workers]

The determination of trans, trans muconic acid (t,t-MA) in human urine, a biomarker suggested by the American Conference of Governmental Industrial Hygienists for occupational benzene exposure, with a limit value of 500 microg/g creatinine, is usually performed by means of gas or liquid chromatographic methods. Almost all the HPLC methods make use of strong ionic exchange cartridges for sample cleaning, reverse phase separation and detection either by UV at lambda = 259 nm or; more recently, by electrospray tandem mass spectrometry: yet, not all of these methods have been validated for quantitative analysis considering also the matrix effect. This paper presents the quantitative analysis of t,t-MA in 94 end-shift urine samples from workers of an oil refinery performed by means of an HPLC/MS/MS analytical method that uses a commercially available deuterium labeled isotope as internal standard, that during the validation has highlited the problem of interferences due to urine ion suppression effect and to the interference from isobaric ions both for the analyte and the internal standared. The following mean values have been obtained: 47.37 microg/g creatinine for non smokers non occupationally exposed to benzene, 97.40 microg/g creatinine for non smokers exposed to benzene, 142.38 microg/g creatinine for smokers non occupationally exposed and 149.08 microg/g creatinine for smokers occupationally exposed to benzene. The results obtained demonstrate that using this analytical method for urinary t,t,MA it is possible to discriminate among groups with different levels of benzene exposure, due to all the possible benzenene sources: environmetal, occupational, due to smoking, and their possible combinations.

Continuous deep sedation in home palliative care units: case studies in the Florence area in 2000 and in 2003-2004

AIM

The aim of this paper was to describe the frequency and the characteristics of continuous deep sedation in terminally ill patients.

METHODS

All patients who died in home palliative care units in the Florence area between March 1-December 31, 2000 and July 1, 2003-June 30, 2004 were prospectively analysed with regard to social, demographic, and clinical characteristics.

RESULTS

The data presented refer to 1075 patients (331 in 2000 and 744 in 2003-2004). Continuous deep sedation was applied in 14.2% and in 12% of patients, respectively. At baseline, patients who were sedated during the final stages of their life were more likely to be younger in age, to have poorer quality of life and better performance status. Such characteristics did not differ between the two periods. Hydration was not performed in 65% of all patients who finally received sedation in the period 2003-2004 versus 33% in those who did in 2000. In 2003-2004, the decision to use sedation was discussed with patients in 39% of those who were sedated. In 2003-2004, we noticed an increase in the use of benzodiazepines for continuous deep sedation from 43% to 87%. The increase in opioid average dosage from the onset of sedation until the last 24 h of their life was about seven-fold in 2000 and almost twice that amount in 2003-2004 in those patients who were not undergoing treatment with opioids when sedation started.

CONCLUSION

The monitoring of end-of-life decision making and of medical practices involved in continuous deep sedation contributes to an enhancement in the quality of caring for terminally ill patients.

Gastric cancer after positive screening faecal occult blood testing and negative assessment

BACKGROUND

Gastric cancer may be suspected with otherwise unexplained positive faecal occult blood testing.

AIMS

To assess the frequency of gastric cancer following positive faecal occult blood testing and negative colonoscopy.

SUBJECTS

Age 40-74 cohort at first screening (1985-2001) with (a) faecal occult blood testing- (83,489), (b) faecal occult blood testing +/colonoscopy+ (2025), or faecal occult blood testing+/colonoscopy- (3555).

METHODS

Gastric cancer incidence in faecal occult blood testing subsets, compared with expected standardized incidence rates.

RESULTS

Gastric cancer risk was increased (standardized incidence rate=146.7; 95% confidence interval: 105.8-203.4) in faecal occult blood testing+/colonoscopy- subjects. A four-fold excess incidence occurred during first year (observed cases=10, standardized incidence rate=408.3; 95% confidence interval: 219.7-758.8), irrespective of faecal occult blood testing type (guaiac, immunological). No excess risk occurred in faecal occult blood testing- (observed cases=53, standardized incidence rate=91.2; 95% confidence interval: 84.1-98.8) or in faecal occult blood testing+/colonoscopy+ subjects (observed cases=2, standardized incidence rate=101.9; 95% confidence interval: 25.5-407.4). Assuming a 100% 3-year study sensitivity for gastric cancer, faecal occult blood testing positive predictive value would be 0.4% (40-74 years) or 0.7% (> or =60 years) in faecal occult blood testing+/colonoscopy- subjects.

CONCLUSIONS

Data suggest an association of faecal occult blood testing+/colonoscopy- and excess gastric cancer incidence in the following year. Due to low faecal occult blood testing+ positive predictive value, routine upper digestive tract endoscopy in these subjects is questionable.

Gender differences in non-small cell lung cancer: a population-based study

BACKGROUND

A retrospective study including all patients with non-small cell lung cancer carcinoma in a population-based registry was performed to characterize gender differences in lung cancer and to analyze the factors influencing prognosis in women.

METHODS

We retrieved through the Tuscan Cancer Registry (RTT) archive 2,523 lung tumor cases diagnosed during the period 1996-1998 in the provinces of Florence and Prato, central Italy. We compared the prognosis within 464 non-small lung cancer women and 1,798 men in a population-based case series. The influence of the following variables on postoperative survival were analyzed: age, cell type, pathologic T and N status, site of tumor and type of surgical resection.

RESULTS

The age at diagnosis was similar in women and in men. Women were significantly more likely to have adenocarcinoma but less likely to have squamous cell carcinoma compared with men. Fewer pneumonectomies were performed in women than in men. Nevertheless, prognosis was similar in both sexes and type of surgical resection was significant prognostic factor.

CONCLUSIONS

Lung cancer was more frequent in men than in women, but overall survival is similar. Differences in lung cancer histology and rate of pneumonectomies were found between men and women.

Mastectomy rates are decreasing in the era of service screening: a population-based study in Italy (1997-2001)

We enrolled all 2162 in situ and 21 148 invasive cases of breast cancer in 17 areas of Italy, diagnosed in 1997–2001. Rates of early cancer increased by 13.7% in the screening age group (50–69 years), and breast conserving surgery by 24.6%. Advanced cancer rates decreased by 19.4%, and mastectomy rates by 24.2%. Service screening did not increase mastectomy rates in the study population.

The Liverpool Statement 2005: priorities for the European Union/United States spiral computed tomography collaborative group

The Liverpool Statement 2005 was developed at the Fourth International Lung Cancer Molecular Biomarkers Workshop in Liverpool (October 27-29, 2005) and focused on the priorities for the European Union/United States (EU-US) Spiral Computed Tomography (CT) Collaborative Group. The application of spiral CT technology for early lung cancer screening has gained enormous momentum in the past 5 years. The EU-US Spiral CT Collaboration was initiated in 2001 in Liverpool, and subsequent meetings throughout Europe have resulted in the development of collaborative protocols and minimal data sets that provide a mechanism for the different trial groups to work together, with the ultimate aim to pool results. Considerable progress has been made with major national screening trials in the U.S. and Europe, which include IELCAP, NLST, and NELSON. The major objective of this international collaboration is the planned cross-analysis of the individual studies after they are reported. The EU-US researchers have agreed to a number of long-term objectives and to explore strategic areas for harmonization of complementary investigations.

[Determination of free and total S-phenylmercapturic acid in the biologic monitoring of exposure to benzene]

One of the biomarkers suggested by the ACGIH to assess the professional exposure to benzene is the S-phenylmercapturic acid in the end-shift urine. The existence in the urine of N-acetyl-S(1,2-dihydro-2hydroxypHenyl)-L-Cysteine, a precursor of SPMA that can be turned into it by acid hydrolysis, is a possible cause of miscorrelation between environmental and biological monitoring. The amount of measured SPMA depends on the degree of hydrolysis and therefore it is a function both of the urine PH and of the storage conditions of the sample. 40 urine samples have been collected from workers exposed to benzene, both smokers and not smokers, and for each sample the percentage of SPMA measurable at pH 2 and without pH correction (free SPMA) has been calculated with respect to the SPMA measured after quantitative hydrolysis, with the objectives to determine if a correct assessment of the exposure requires the determination of total SPMA and which concentration value could correspond to the BEI of 25 microg/g of creatinine established by the ACGIH. An aliquot of the urine samples has been treated with 9M H2SO4, a second one is brought to pH 2 and a third one is analyzed as it is. All samples are analyzed by HPLC/MS/MS in negative ions/MRM mode, and quantitative analysis is performed using the internal standard method. The percentage found in samples treated at pH 2 is on average 45% of the total SPMA for smokers and 60% for non smokers, while the free SPMA varies from 1% to 66% due to the urine pH variability and to the lower concentrations detected. The determination of total SPMA allows the standardization of the preanalyticalfactors and the dosage with analytical methods less sensitive than HPLC/MS/MS.

Hepatic portal venous gas in a patient with enterovascular fistula

Hepatic portal venous gas is an uncommon clinical condition that is often characterized by acute onset of abdominal pain and is associated with a high rate of mortality despite clinical and/or surgical treatment. Radiologic diagnosis is important and usually includes abdominal radiography, ultrasound, and computed tomography. We describe the clinical, computed tomographic, and angiographic data of a patient with sigmoid diverticulitis who developed a massive embolism of the intra- and extrahepatic portal systems due to an enterovascular fistula and was treated with fistula embolization and subsequent sigmoidectomy.

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.

Screening of lung cancer with low dose spiral CT: results of a three year pilot study and design of the randomised controlled trial ''Italung-CT''

PURPOSE

To report the results of a three-year observational pilot study of lung cancer screening with low dose computed tomography (CT) and to present the study design of a randomised clinical trial named as ''Italung-CT''.

MATERIALS AND METHODS

Sixty (47 males and 13 females, mean age 64+/-4.5 years) heavy smokers (at least 20 packs-year) underwent three low-dose spiral CT screening tests one year apart on a single slice or multislice CT scanner. Indeterminate nodules were managed according to the recommendations of the Early Lung Cancer Action Project.

RESULTS

and Indeterminate nodules were observed in 33 (55%) of the subjects (60% at the baseline screening test, 24% at the first annual test and 16% at the second annual test). The size of the largest indeterminate nodule was <5 mm in diameter in 20 subjects, 10 of whom showed the nodule at the baseline test. Forty-five subjects (75%) completed the first annual test and 42 (70%) the second annual test. One (1.6%) prevalent lung cancer (adenosquamous carcinoma) and one (2.2%) incident lung cancer (small cell cancer at the first annual examination) were observed, as well as a pulmonary localisation of Hodgkin's lymphoma (at the second annual test). In addition, one subject underwent lung surgery for a chondromatous hamartoma.

CONCLUSIONS

The results of the pilot study are substantially in line with those of other observational studies of greater sample size. This justifies optimism about the reliability of the results in the screened arm of the ''Italung CT'' trial which has just begun.

Overdiagnosis in screening: is the increase in breast cancer incidence rates a cause for concern?

OBJECTIVES

To estimate the degree of overdiagnosis of breast cancer in a mammographic screening programme.

SETTING

A mammography service screening programme in Florence, Italy.

METHODS

We studied the incidence of breast cancer in Florence between 1990 and 1999, following the introduction of screening in 1990. Incidence of breast cancer in this period was compared with incidence between 1985 and 1989, before the introduction of screening. It was necessary to estimate the number of cancers that would have arisen in the absence of screening, but after the end of followup (31 December 1999), so that these were not misclassified as overdiagnosed tumours. Around 60,000 women aged 50-69 were invited for screening during the period of study.

RESULTS

There were 2780 breast cancers diagnosed during the period of study (2626 were invasive). There was no significant evidence of overdiagnosis of invasive cancers. When invasive and in situ cancers were considered together, around 5% of cases were overdiagnosed.

CONCLUSIONS

There is a small amount of overdiagnosis of ductal carcinoma in situ in mammography screening; however, this should not deter women from being screened. Training and practice in mammographic screening should emphasise detection of small, invasive lesions. Research into the natural history and treatment of the disease should aim at minimising overtreatment of those in situ lesions that are less likely to progress to invasive disease.

Prognostic value of morphology and hormone receptor status in breast cancer - a population-based study

We analysed the 5-year relative survival among 4473 breast cancer cases diagnosed in 1990–1992 from cancer registries in Estonia, France, Italy, Spain, the Netherlands and the UK. Among eight categories based on ICD-O codes (infiltrating ductal carcinoma, lobular plus mixed carcinoma, comedocarcinoma, ‘special types’, medullary carcinoma, not otherwise specified (NOS) carcinoma, other carcinoma and cancer without microscopic confirmation), the 5-year relative survival ranged from 66% (95% CI 61–71) for NOS carcinoma to 95% (95% CI 90–100) for special types (tubular, apocrine, cribriform, papillary, mucinous and signet ring cell); 27% (95% CI 18–36) for cases without microscopic confirmation. Differences in 5-year relative survival by tumor morphology and hormone receptor status were modelled using a multiple regression approach based on generalised linear models. Morphology and hormone receptor status were confirmed as significant survival predictors in this population-based study, even after adjusting for age and stage at diagnosis.

Lower protection of cytological screening for adenocarcinomas and shorter protection for younger women: the results of a case-control study in Florence

The efficacy of cytological screening in preventing adenocarcinoma of cervix uteri as compared to squamous cell cancer has been evaluated by means of a case-control study in the province of Florence. The odds ratios of women who had a Pap test within the 3 years before the index date was 0.65 (95% confidence interval (CI) 0.26-1.64) and 0.15 (95% CI 0.07-0.31), for adenocarcinoma and squamous cancer, respectively. The duration of the protective effect was shorter in women below the age of 40 years than in older women.

Breast cancer mortality trends in two areas of the province of Florence, Italy, where screening programmes started in the 1970s and 1990s

We compared breast cancer mortality rates in the period 1985-2000 in two areas of the province of Florence, Italy, where breast cancer screening programmes started in the 1970s (early screening (ES) area) and in 1990s (late screening (LS) area). The overall age-standardised mortality decreased in the whole period by 40.9% in the ES area (P<0.001), and by 11.3% in the LS area (P=0.030). Significant decreases in the ES area were detected in groups aged 45-54 years (61.1%; P= 0.018) and 65-74 years (44.7%; P= 0.049), whereas in the LS area no significant decrease was detected in any age group. The relatively low compliance in the first years of the programme in both areas, and the long enrollment period in the LS area could have reduced the effect on mortality. Our findings suggest that the drop in mortality in the ES area (41%) could be explained by both service screening and better care. The slight decrease in mortality in the LS area (11%) could be mainly due to better care. A reduction of about 30% is attributable to screening in the ES area over the period 1985-2000.

Suicide mortality is decreasing among cancer patients in Central Italy

The objective of this study was to discover whether suicide mortality among patients diagnosed with cancer during the period 1985-1999 had decreased with calendar time in comparison to the rate in the general population. 90?197 cancer patients resident in Tuscany, Central Italy and incident during the period 1985-1999 were followed up for life status to 31 December 2000. The mortality codes for suicide were considered (E950-E959). Time trends for suicide rates were assessed by using Kernel smoothing estimators, standardised mortality ratios and Poisson analysis of the observed/expected ratios. The standardised mortality ratios were 324, 224, and 185 for cancer patients diagnosed during the periods 1985-1989, 1990-1994, and 1995-1999, respectively. Tests for linear trends were borderline significant (P=0.053). Suicide mortality among cancer patients in central Italy had decreased with calendar time relative to the suicide trend in the general population. Improved treatment options and better communication of diagnosis are possible explanations of this finding.

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.