A First Survey of Organized Cervical Cancer Screening Programs in Italy

In Italy, where no national screening program for cervical cancer exists, organized programs have developed on a local basis. We performed the first survey of existing organized programs by mailing a standard questionnaire to a large network of possibly involved services. For the present survey, a program was defined as organized if personal invitations were sent. We identified 29 already active organized programs and 4 others in a starting phase. The target population of active programs included 2,074,820 women in the age range 25-64 years, corresponding to 13.5% of the Italian female population of the same age. The situation is rapidly evolving since many regional programs are being implemented. Most programs followed Italian and European recommendations as regards the age limits, interval between screening rounds, presence of a fail-safe system for women referred for colposcopy, presence of protocols for diagnostic workup and treatment, and presence of referral centers for such phases. However, many programs did not meet national guidelines as regards the size of laboratories interpreting smears, which were frequently small. Second-level referral centers also frequently had a very small activity. The average (weighted for size of the invited population) compliance to invitation and coverage (proportion of women with at least one test in the last 3 years) was 32.6% and 66.0%, respectively, therefore needing to be improved. Compliance to colposcopy (weighted for number of referred women) was 81.4%. We found a very high variability in the proportion of women referred for colposcopy that could only be partly explained by different referral protocols and could depend on different criteria of smear interpretation: the average (weighted for number of tested women) was 2.01%. A need for improvement in the process of evaluation and for homogenization of criteria of cytology interpretation was identified: work in this regard is on-going.

[Audit of histopathology activities at the pathology departments of 7 general hospitals. 2. Response time]

A retrospective analysis of 1,000 consecutive cases was conducted in each histopathology lab of seven general hospitals. The collected information included the date of specimen withdrawal (six labs only), receipt in the laboratory, and reporting. Time intervals between withdrawal and receipt. Two labs, received 3/4 of cases the same day, while the others had a very low prevalence of receipt. All labs but one, received 80-90% of cases within 48 hours. In one lab, 17% of cases arrived five days after from the withdrawal. Time intervals between receipt and reporting. The mean observed in the seven labs ranged from 3.1 to 6.1 days. Two labs were able to report within 24 hours, but this occurred only in 6% of their cases. The reporting prevalence within three days ranged between 5 and 64%, with a mean for the seven labs of 37%. The reporting prevalence within 6 days was about 95% (four labs), 60-70% (two labs) and 20% (one lab). All labs but one reported 95-100% of cases within ten days. Time intervals between withdrawal and reporting. Our labs were not able to report within 24 hours from the withdrawal (frozen sections excluded). The reporting prevalence within 2-3 days was about 35-40% (three labs), 16% (one lab), 2% (two labs), and within six days it was about 90% (three labs), and 61%, 38% and 14% (the remaining). These latter reported 95% of their cases within twenty days. The turnaround times we found are unsatisfactory. Probably, there are many sources of delay, and these are multifactorial. However, a major factor involved in these delays seems to be related to poor arrangements in the allocation and managing of human resources.

[Audit of histopathological activities in the laboratories of 7 general hospitals. 1. Types of resources and quantitative aspects of the workload]

Following a major reorganization of the National Health Service, competition for resources will depend to a great extent on the quality of the service offered, and audit will be of increasing importance. The present investigation deals with the quantitative aspects of the histopathology workload. A retrospective analysis of the biopsy handling of 1,000 consecutive cases was conducted in each histopathology lab of seven general hospitals. The data collected included information on specimen type, diagnosis, block/section/stain details for each specimen, as well as information about human resources, total workload and technical equipment. Among the seven labs, the histopathology workload ranged between 6,600 and 15,600 cases/year. The workload per person/year ranged between 1,400 and 2,600 (mean 1,900) for pathologists, between 800 and 3,000 (mean 1,500) for technicians, and between 2,200 and 8,300 (mean 4,400) for secretarial staff. The prevalence of biopsy fragments (endoscopic, endometrial curettage , etc.), "small" surgery (skin, appendix, gallbladder, etc.) and surgery was, respectively, between 42 and 50%, 34 and 47%, 9 and 21%. In all labs but one, 80% of cases were within 1-3 blocks; the seven labs had a mean of blocks/case ranging from 1.8 to 4.0 (total mean = 2.8). Differences in performing special stains were astonishing: one lab performed special stains in about 40%, and another in only 0.6% of cases (mean of the seven labs = 15%). Finally, the labs performed immunohistochemical stains within a range of 2.7-8% of cases (mean of the seven labs = 4.6%). The data we have collected provided baseline information on the laboratory running, and this is likely to be an integral part of laboratory administration in the near future.

Neoadjuvant chemotherapy or chemotherapy and endocrine therapy in locally advanced breast carcinoma. A prospective, randomized study

Forty-nine patients with locally advanced breast carcinoma were prospectively randomized to be treated with either CMF or CMF plus T for four courses, both before and after mastectomy. The overall clinical objective remission rate for induction treatment was similar (71% with CMF and 64% with CMF + T). The time to progression or recurrence of the disease was also not significantly different between the two groups. Overall survival was shorter after CMF + T treatment (median value of 41.5 months) than after CMF treatment alone (median value of 79.7 months; p = 0.05). Even after progression or recurrence, survival was shorter for patients receiving CMF + T than those receiving CMF (median values of 7.5 and 17.3 months, respectively; p = 0.09). These results show that the addition of T to CMF in the treatment of locally advanced breast carcinoma, before and after mastectomy, offers no advantage for improving the overall response rate. Moreover, this addition may have an adverse impact on survival in this disease setting.