Mortality from Skin Melanoma in Italy and Friuli-Venezia Giulia Region, 1970-1989

Aims and background

Substantial upward trends for skin cancer mortality have been observed in most European countries in the last two decades. The distinction, however, between cutaneous malignant melanoma (CMM) and non-melanomatous skin cancers on the basis of death certification is unreliable

Methods

In order to assess the trends of CMM, analysis of the specific code for CMM (International Classification of Disease VIII and IX:172) was coupled with analysis of total skin cancer mortality rates, standardized on the 1981 Italian Census population, at all ages and in selected age groups (15-44, 45-64 and 65-84 years). The analyses were carried out for the whole of Italy and for Friuli-Venezia Giulia (FVG), a region in North-East Italy with a high proportion of fair-complexioned individuals, elevated frequency of sunbathing, and especially good diagnostic standards.

Results

In 1985-89 skin cancer mortality rates in men at all ages, as compared to 1970-74, were 33% higher in Italy and 46% higher in FVG. In women, there was a rise of 22% in Italy and 94% in FVG. More marked upward trends were observed in young and middle aged adults, especially among women in FVG (over 300% increase). In absolute terms, approximately 3000 more Italians died from skin cancers in 1985-89 as compared to 1970-74, about half of them prematurely (i.e., < 65 years). CMM was mentioned in death certifications for skin cancer increasingly often in all age groups, particularly in FVG.

Conclusions

The analysis of mortality trends from skin cancer is consistent with a substantial rise of CMM-related deaths. The sensitivity of death certification with respect to CMM diagnosis is also increasing, especially in FVG. A public health strategy with the aim of reducing intermittent intense exposure to ultraviolet light, especially in children, is urgent in Italy as CMM represents one of the few causes of premature death with unfavorable trends.

Diet and Epithelial Cancer of the Thyroid Gland

Enhanced secretion of thyroid stimulating hormone (TSH) has been linked with increased risk of thyroid carcinoma. Diet can increase TSH secretion in various ways: 1) low iodine intake, 2) high goitrogen intake, especially in subjects living in iodine-deficiency areas and 3) direct stimulation of anterior pituitary gland. Excessive iodine intake, however, has also been shown to increase risk of goitre and, perhaps, also thyroid carcinoma. Epidemiological evidence on the role of diet in the etiology of thyroid carcinoma is reviewed here. Ad hoc studies in affluent countries are few and often conflicting. A case-control study conducted in the North of Italy suggests that perhaps dietary aspects other than iodine or goitrogens (i.e. fresh fruit and vegetables and animal fat) may be involved.

Does the Information Level of Cancer Patients Correlate with Quality of Life? A Prospective Study

AIMS AND BACKGROUND

The aim of the study was to evaluate the impact of information level on quality of life in cancer patients previously studied for their information level.

PATIENTS AND METHODS

The information level was determined by means of a questionnaire that explored the degree of information on diagnosis and status of disease, the patient's interpretation of his/her disease status, and his/her satisfaction with the information received. Quality of life was evaluated, some months after evaluation of the information level, by means of the Functional Living Index for Cancer (FLIC) and the State-Trait Anxiety Inventory (STAI 1-2).

RESULTS

A total of 175 patients were studied. Information was adequate in 53.7% of patients. An adequate level of information was present more frequently among patients aged < or = 65 years and in those patients followed at a cancer institute. There was no difference in the quality of life of adequately versus inadequately informed patients. Satisfaction with the information received influenced quality of life in both age groups. Objective clinical variables (active disease present and ongoing treatment) negatively affected quality of life in patients <65 years, whereas the subjective perception of the presence of disease was associated with a worse quality of life in older patients.

CONCLUSIONS

In the study, although the level of information did not affect the quality of life, satisfaction with the information was associated with a better quality of life. The finding stresses the importance of a sensible disclosure of diagnosis and prognosis.

Cancer Mortality by Urbanization and Proximity to the Sea Coast in Campania Region, Southern Italy

Aims and background

The risk for several cancers is higher in urban than in rural areas. The gradient has seldom been studied in southern Europe.

Patients and methods

The geographical pattern of mortality for different cancers and all causes was studied in the Campania Region (about 5.6 million inhabitants), whose largest town is Naples. The key variables were residence in urban/rural and coastal/inland municipalities. Relative risks of death and corresponding 95% confidence intervals by residence were evaluated by means of Poisson log-linear regression models.

Results

Significantly increased mortality rates in urban compared to rural municipalities were found for several cancer causes of death. In particular, in both sexes, excesses in the order of 30-50% were observed for tobacco-related neoplasms (i.e., larynx, lung, and bladder) and cancers of the intestine, liver, brain, multiple myeloma and non-Hodgkin's lymphoma, in addition to all-cancer, and all-cause mortality. In females, specific excesses were also noticed for cancer of the gallbladder, pancreas, breast and uterus (corpus and cervix). Conversely, significantly decreased mortality rates in urban with respect to rural municipalities were observed for cancer of the oral cavity and pharynx in males. Coastal location and degree of urbanization were strongly correlated, thus showing similar associations with most causes of death. However, a significant excess of cancer of the pleura in males was restricted to coastal municipalities.

Conclusions

Anti-smoking campaigns, sanitation improvements, hepatitis B vaccination, and a decrease in obesity emerge as high priorities with respect to cancer control strategies in the Campania Region, particularly in overpopu-lated, underprivileged urban areas.

Mediterranean diet and risk of endometrial cancer: a pooled analysis of three Italian case-control studies

Background:

Some components of the Mediterranean diet have favourable effects on endometrial cancer, and the Mediterranean diet as a whole has been shown to have a beneficial role on various neoplasms.

Methods:

We analysed this issue pooling data from three case-control studies carried out between 1983 and 2006 in various Italian areas and in the Swiss Canton of Vaud. Cases were 1411 women with incident, histologically confirmed endometrial cancer, and controls were 3668 patients in hospital for acute diseases. We measured the adherence to the Mediterranean diet using a Mediterranean Diet Score (MDS), based on the nine dietary components characteristics of this diet, that is, high intake of vegetables, fruits/nuts, cereals, legumes, fish; low intake of dairy products and meat; high monounsaturated to saturated fatty acid ratio; and moderate alcohol intake. We estimated the odds ratios (OR) and the corresponding 95% confidence intervals (CI) for increasing levels of the MDS (varying from 0, no adherence, to 9, maximum adherence) using multiple logistic regression models, adjusted for major confounding factors.

Results:

The adjusted OR for a 6–9 components of the MDS (high adherence) compared with 0–3 (low adherence) was 0.43 (95% CI 0.34–0.56). The OR for an increment of one component of MDS diet was 0.84 (95% CI 0.80–0.88). The association was consistent in strata of various covariates, although somewhat stronger in older women, in never oral contraceptive users and in hormone-replacement therapy users.

Conclusions:

Our study provides evidence for a beneficial role of the Mediterranean diet on endometrial cancer risk, suggesting a favourable effect of a combination of foods rich in antioxidants, fibres, phytochemicals, and unsaturated fatty acids.

Nutrient-based dietary patterns and nasopharyngeal cancer: evidence from an exploratory factor analysis

BACKGROUND

To our knowledge, no study assessed the association between dietary patterns and nasopharyngeal carcinoma (NPC) in low-incidence areas.

METHODS

We examined this association in a hospital-based case-control study carried out in Italy between 1992 and 2008, including 198 incident NPC cases and 594 controls. A posteriori dietary patterns were identified through principal component factor analysis performed on 28 nutrients and minerals derived from a 78-item food-frequency questionnaire. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using unconditional multiple logistic regression models on tertiles of factor scores.

RESULTS

We identified five dietary patterns named Animal products, Starch-rich, Vitamins and fibre, Animal unsaturated fatty acids (AUFAs), and Vegetable unsaturated fatty acids (VUFAs). The Animal product (OR=2.62, 95% CI=1.67-4.13, for the highest vs lowest score tertile), Starch-rich (OR=2.05, 95% CI=1.27-3.33), and VUFA (OR=1.90, 95% CI=1.22-2.96) patterns were positively associated with NPC. The AUFA pattern showed a positive association of borderline significance, whereas the Vitamins and fibre pattern was nonsignificantly but inversely associated with NPC.

CONCLUSIONS

These findings suggest that diets rich in animal products, starch, and fats are positively related to NPC risk in this low-incidence country.

Long-term survival, prevalence, and cure of cancer: a population-based estimation for 818 902 Italian patients and 26 cancer types

Original, population-based estimates of indicators of long-term survival and cure in cancer patients are provided. More than a quarter of cancer patients in Italy have reached death rates similar to those of the general population. Nearly three quarters of them will not die as a result of cancer. These estimates are potentially helpful to health-care planners, clinicians, and patients.

Background

Persons living after a cancer diagnosis represent 4% of the whole population in high-income countries. The aim of the study was to provide estimates of indicators of long-term survival and cure for 26 cancer types, presently lacking.

Patients and methods

Data on 818 902 Italian cancer patients diagnosed at age 15–74 years in 1985–2005 were included. Proportions of patients with the same death rates of the general population (cure fractions) and those of prevalent patients who were not at risk of dying as a result of cancer (cure prevalence) were calculated, using validated mixture cure models, by cancer type, sex, and age group. We also estimated complete prevalence, conditional relative survival (CRS), time to reach 5- and 10-year CRS >95%, and proportion of patients living longer than those thresholds.

Results

The cure fractions ranged from >90% for patients aged <45 years with thyroid and testis cancers to <10% for liver and pancreatic cancers of all ages. Five- or 10-year CRS >95% were both reached in <10 years by patients with cancers of the stomach, colon–rectum, pancreas, corpus and cervix uteri, brain, and Hodgkin lymphoma. For breast cancer patients, 5- and 10-year CRSs reached >95% after 19 and 25 years, respectively, and in 15 and 18 years for prostate cancer patients. Five-year CRS remained <95% for >25 years after cancer diagnosis in patients with liver and larynx cancers, non-Hodgkin lymphoma, myeloma, and leukaemia. Overall, the cure prevalence was 67% for men and 77% for women. Therefore, 21% of male and 31% of female patients had already reached 5-year CRS >95%, whereas 18% and 25% had reached 10-year CRS >95%.

Conclusions

A quarter of Italian cancer patients can be considered cured. This observation has a high potential impact on health planning, clinical practice, and patients' perspective.

Fiber intake and pancreatic cancer risk: a case-control study

BACKGROUND

Scanty and inconsistent studies are available on the relation between dietary fiber intake and pancreatic cancer. A case-control study was carried out in northern Italy to further investigate the role of various types of dietary fibers in the etiology of pancreatic cancer.

PATIENTS AND METHODS

Cases were 326 patients with incident pancreatic cancer, excluding neuroendocrine tumors, admitted to major teaching and general hospitals during 1991-2008. Controls were 652 patients admitted for acute, nonneoplastic conditions to the same hospital network of cases. Information was elicited using a validated food frequency questionnaire. Odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) were estimated for intake quintiles of different types of fiber after allowance for total energy intake and other potential confounding factors.

RESULTS

Total fiber intake was inversely related to risk of pancreatic cancer (OR=0.4 for highest versus lowest quintile of intake; 95% CI 0.2-0.7). An inverse association emerged between pancreatic cancer and both soluble (OR=0.4; 95% CI 0.2-0.7) and total insoluble fiber (OR=0.5; 95% CI 0.3-0.8), particularly cellulose (OR=0.4; 95% CI 0.3-0.7) and lignin (OR=0.5; 95% CI 0.3-0.9). Fruit fiber intake was inversely associated with pancreatic cancer (OR=0.5; 95% CI 0.3-0.8), whereas grain fiber was not (OR=1.2; 95% CI 0.7-2.0).

CONCLUSIONS

This study suggests that selected types of fiber and total fiber are inversely related to pancreatic cancer.

Early and short-term acenocumarine or dalteparin for the prevention of central vein catheter-related thrombosis in cancer patients: a randomized controlled study based on serial venographies

BACKGROUND

We evaluated efficacy and safety of early and short-term prophylaxis with acenocumarine or dalteparin in the prevention of non-occlusive or occlusive central vein catheter-related thrombosis (CVCrT).

PATIENTS AND METHODS

Consecutive cancer patients scheduled for chemotherapy randomly received: acenocumarine 1 mg/day for 3 days before and 8 days after central vein catheter (CVC) insertion; dalteparin 5000 IU 2 h before and daily for 8 days after CVC insertion; no anticoagulant treatment (NT). All patients underwent venography on days 8 and 30, some of them on days 90, 150 and 210 after CVC.

RESULTS

A total of 450 patients were randomized, 348 underwent at least two venography. Both acenocumarine and dalteparin reduced venography-detected CVCrT rate [21.9% acenocumarine versus 52.6% NT, odds ratio (OR) 0.3, P < 0.01; 40% dalteparin versus 52.6% NT, OR 0.6, P = 0.05]. Acenocumarine was more effective than dalteparin (OR 0.4, P = 0.01). The rate of occlusive CVCrT was not different in the three groups (0.9% acenocumarine, 3.3% dalteparin, 1.8% NT; P = 0.40). Most CVCrTs (95.6%) were observed on day 8 after CVC insertion and were non-occlusive.

CONCLUSIONS

In this study of early and short-term prophylaxis, acenocumarine was more effective than dalteparin on non-occlusive and asymptomatic CVCrT events. The first days following CVC insertion represent the highest risk for CVCrT.

Treatment of liver toxicity in women undergoing adjuvant chemotherapy for breast cancer: A phase III, monocentric, prospective, randomised trial of ursodeoxycolic acid (UDCA) vs no treatment

9060

Background: Liver toxicity during adjuvant chemotherapy (CT) represents one of the causes of treatment delay and dose reduction, with impairment of dose intensity and of final results. UDCA, a hydrophilic bile acid, has been reported to be effective in cholestasis. Aim: to evaluate the efficacy of UDCA (12 mg/kg/die) plus CT discontinuation vs CT discontinuation alone in the treatment of liver toxicity. Methods: The study provided two arms of randomization: discontinuation of CT and administration of UDCA at the dosage of 12 mg/kg/day or discontinuation of CT. CT was resumed at normalization of liver tests. Pts with liver metastases, acute or chronic hepatopathy, heart or kidney failure, or PS<70 were excluded. During a 3 year period, 118/305 pts developed CT-induced hepatotoxicity and were enrolled into the study. Logistic multiple models and Fisher test or χ2 test and the Mann-Whitney test were used. Results: Out the 118 pts, 66% were treated with CMF, 29% with Anthracyclines alone or in sequence with CMF and 5% with Anthracyclines and Taxanes. Liver toxicity occurred respectively in 37 pts after the 1st cycle, in 35 after the 2nd, in 15 after the 3rd, in 19 after the 4th, in 9 after the 5th and in 3 after the 6th. CT was definitely stopped in 8% of pts. CT was delayed of 1 week in 53%, of 2 wks in 31% and of 3 or more in 16%. 95% of pts had a hepatocytolitic damage and nobody purely cholestatic. G1 toxicity was observed in 34%, G2 in 57%, G3 in 9%. Pts were randomized in two groups of 59 pts each. UDCA group: 3 pts (5%) stopped CT and 11 (19%) had dose reduction. Control group: 6 pts (10%) stopped CT and 7 (12%) had dose reduction. No statistically significant difference between UDCA group and control group was noted both for dose reduction (p = 0.31) and for CT stop (p = 0.30), even if twice as many pts of the control group had to stop CT (6/59). No correlation between alcohol use and liver damage was noted. Conclusions: Most cases of liver toxicity are of low or intermediate grade. No statistically significant difference was found between UDCA and control, even if there was a positive trend in reducing liver toxicity, that can have a positive impact on the final results of adjuvant CT.

No significant financial relationships to disclose.

Epidemiological and ethical aspects of multiplex autoantibody testing

Arrays are one of the technologies able to detect autoantibodies by measuring simultaneously many thousands of markers from a unique biological sample. The main purpose of a diagnostic test is making an early and accurate diagnosis. From a statistical point of view, multiple testing increases the probability of false positive and false negative results. Some correction methods are available to account for this problem for instance family-wise error rate or false discovery rate. From an ethical point of view, the decision to accept or decline a test not requested has to be made autonomously. Some people may seek clarification about tests and implications of their choices. A scarcity of proven measures to reduce mortality has to be considered too. Reasons may also include avoidance of psychological harm or anxiety. Moreover, protection of confidentiality and privacy has to be respected. In conclusion, the fact that testing is optional and that surveillance advice can be offered on the basis of risk alone without a test should be discussed in the consultation. The implication of a positive test result should be discussed to make a decision about the degree to which early treatment of the condition is better than late (or no) treatment.

Pre-storage leucocyte depletion and transfusion reaction rates in cancer patients

Passenger leucocytes transfused with allogenic blood are responsible for potential adverse effects. The impact of pre-storage leucodepletion (in-line filtration) of all whole blood units on transfusion reaction rate among patients suffering from cancer was retrospectively studied, comparing all reactions following red blood cell (RBC) transfusions during 2 years of pre-storage vs. 2 years of selective (bedside) leucodepletion. During selective leucodepletion, 5165 RBC units - of which 2745 were bedside filtered units- were transfused to 866 patients. Twenty-eight reactions were recorded: 22 (15 in the bedside group) febrile non-haemolytic transfusion reactions (FNHTR) and six allergic reactions (five in the bedside group). The overall percentage of reactions was 0.54 (0.76 for bedside) and 0.42 for FNHTR (0.54 for bedside). During pre-storage leucodepletion, 4116 RBC units were transfused to 841 patients. Eleven reactions were recorded: four FNHTR and seven allergic reactions (urticaria). The percentage of reactions for transfused RBC units was 0.26 (0.09 for FNHTR). Comparison between pre-storage filtration and bedside filtration with regard to FNHTR showed an odds ratio of 2.80 (95% confidence interval = 0.83-14.87) for bedside filtration. The study suggests that, for transfused patients affected by cancer, pre-storage leucodepletion is more effective than selective (bedside) filtration in reducing the incidence of transfusion reactions (FNHTR).

Macronutrients, fatty acids, cholesterol and prostate cancer risk

BACKGROUND

The role of selected macronutrients, fatty acids and cholesterol in the etiology of prostate cancer was analyzed using data from a case-control study carried out in five Italian areas between 1991 and 2002.

PATIENTS AND METHODS

Cases were 1294 men with incident, histologically confirmed prostate cancer, and admitted to the major teaching and general hospitals of study areas. Controls were 1451 men admitted for acute, non-neoplastic conditions to the same hospital network. Information on dietary habits was elicited using a validated food frequency questionnaire including 78 food groups and recipes. Odds ratios (OR) and 95% confidence intervals (CI) were estimated for increasing levels of nutrient intake.

RESULTS

A direct association with prostate cancer was found for starch intake (OR = 1.4 in the highest versus the lowest quintile of intake; 95% CI: 1.1-1.8), whereas an inverse association emerged for polyunsaturated fatty acids (OR = 0.8; 95% CI: 0.6-1.0). Among polyunsaturated fatty acids, linolenic acid (OR = 0.7; 95% CI: 0.6-0.9) and linoleic acid (OR = 0.8; 95% CI: 0.6-1.0) were inversely related to prostate cancer. When the six major macronutrients were included in the same model, the adverse effect of high intake of starch and monounsaturated fatty acids was statistically significant together with the protective effect of polyunsaturated fatty acids. Results were consistent in separate strata of age, body mass index and family history of prostate cancer.

CONCLUSIONS

Starch and monounsaturated fatty acids were directly associated with prostate cancer risk and polyunsaturated fatty acids were inversely associated.

[Analysis of infectious disease mortality in Italy]

Our research aimed to describe infectious disease mortality in Italy between 1969 and 1999, with particular emphasis on sex, age, and geographic differences. Using mortality data provided by the Italian Central Institute for Statistics (ISTAT), we evaluated all codes of the ICD8 and ICD9 classifications to identify each cause of death attributable to infectious agents. Deaths for HIV/AIDS were excluded. Infectious diseases accounted for 1.7% of overall mortality between 1969-1999, and our approach identified 57.5% of all deaths from infections not included in the ICD8 and ICD9 infectious disease codes. Up to 1994, the mortality for all infectious diseases showed a very strong downward trend, with a 6-fold decline. This trend levelled off in 1995-1999, mainly due to increasing deaths due to septicaemias, heart infections and hepatitis. An increasing proportion of deaths due to infectious diseases occurred in the elderly, from 48.1% in 1969-1979 to 77.3% in 1990-1999. Mortality rates were consistently higher in men than in women and showed a substantial geographic heterogeneity. In the newborn, mortality rates declined 10-fold and an inverse north-south geographic gradient persisted during the study period. This exhaustive methodological approach to identifying infectious causes of deaths allows us to better define the burden of infections on mortality and register downward trends similar to those found in other industrialized countries.

Ifosfamide in the Adjuvant Therapy of Soft Tissue Sarcomas

Ifosfamide and anthracyclines are the only active agents in advanced soft tissue sarcomas. Doxorubicin was always used in sarcomas, whereas ifosfamide was reintroduced in the clinic after the discovery of mesna which prevents its typical dose-limiting toxicity: hemorrhagic cystitis. In the adjuvant setting, doxorubicin was used alone or in combination in the first-generation trials, whereas its parent compounds epirubicin and ifosfamide were employed in the second-generation adjuvant trials, which started in the early 90s. Other relevant aspects of the second-generation trials are the use of the hematopoietic growth factors and the increase of the dose intensity, the introduction of more restrictive selection criteria and the use of the two most active agents, ifosfamide and anthracyclines. Only the Italian cooperative trial has been concluded, and the results reported and updated. After a median follow-up of 89.6 months (range 56-119), the intention-to-treat analysis still reveals a difference in overall survival which, however, is not statistically significant. However, the 5-year overall survival estimate, which is a reasonable end point for the survival analysis of adjuvant treatment in soft tissue sarcomas, was 66.0 and 46.1% for the treatment and the control groups, respectively (p = 0.04).

Combined effect of tobacco and alcohol on laryngeal cancer risk: a case-control study

OBJECTIVE

To provide information on the effects of alcohol and tobacco on laryngeal cancer and its subsites.

METHODS

This was a case-control study conducted between 1992 and 2000 in northern Italy and Switzerland. A total of 527 cases of incident squamous-cell carcinoma of the larynx and 1297 hospital controls frequency-matched with cases on age, sex, and area of residence were included. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were estimated using multiple logistic regression.

RESULTS

In comparison with never smokers, ORs were 19.8 for current smokers and 7.0 for ex-smokers. The risk increased in relation to the number of cigarettes (OR = 42.9 for > or = 25 cigarettes/day) and for duration of smoking (OR = 37.2 for > or = 40 years). For alcohol, the risk increased in relation to number of drinks (OR = 5.9 for > or = 56 drinks per week). Combined alcohol and tobacco consumption showed a multiplicative (OR = 177) rather than an additive risk. For current smokers and current drinkers the risk was higher for supraglottis (ORs 54.9 and 2.6, respectively) than for glottis (ORs 7.4 and 1.8) and others subsites (ORs 10.9 and 1.9).

CONCLUSIONS

Our study shows that both cigarette smoking and alcohol drinking are independent risk factors for laryngeal cancer. Heavy consumption of alcohol and cigarettes determined a multiplicative risk increase, possibly suggesting biological synergy.

Prognostic factors in soft tissue sarcomas: a study of 395 patients

AIMS

The aim of this study was to report prognostic factors, end-points of local recurrence, distant recurrence, post-metastasis survival, and overall survival in a cohort of patients with soft tissue sarcomas.

METHODS

We analysed a database of 395 patients affected by primary soft tissue sarcomas of various primary sites, treated and followed up at the Centro di Riferimento Oncologico, Aviano, Italy from January 1985 to January 1997.

RESULTS

Grade, size, stage, surgical margins, distant metastasis, age, sex, performance status, and haemoglobin value were significant for overall survival. Histology, grade, stage, and surgical margins were significant for local recurrence. Grade, size, and stage, were significant for distant recurrence; and surgical margin was significant variable for post-metastasis survival.

CONCLUSIONS

Grade, size, and TNM stage (UICC/AJCC) have stronger prognostic significance for overall survival and distant recurrence than for local relapse. Positive surgical margins are the main predictors for local relapse. Age was the most consistent adverse independent prognostic factor for survival.

Viral load of human herpesvirus 8 in peripheral blood of human immunodeficiency virus-infected patients with Kaposi's sarcoma

Viral load is an important marker of activity of viral diseases for a number of viruses. We wished to evaluate whether the viral load of human herpesvirus 8 (HHV-8) in peripheral blood was a consistent feature of Kaposi's sarcoma (KS) patients and whether the viral load correlated with human immunodeficiency virus (HIV) RNA levels, CD4 counts, and/or the HHV-8 seroreactivity. Fifty-four consecutive plasma samples from 14 patients with KS were evaluated for HHV-8 viral load by quantitative real-time PCR. Samples were analyzed at the start of highly active antiretroviral therapy (HAART) and at different intervals during treatments. The median HHV-8 DNA load before HAART treatment was 8,998 (ranging from 170 to 40,100) copies/ml and 12,270 (ranging from 40 to 142,575) copies/ml during HAART. There were both increasing and decreasing trends. There was an association between HHV-8 DNA and HIV RNA viral loads (odds ratio [OR] = 5.40; 95% confidence interval [95% CI], 1.54 to 18.98) and between HHV-8 viral load and CD4 cell counts (OR = 7.24; 95% CI, 1.30 to 40.35). High HHV-8 viral load was also correlated with the titers of antibodies to the lytic HHV-8 antigen detected with immunofluorescence (P < 0.01), but not with antibodies to the latent HHV-8 antigen. In conclusion, we found that HHV-8 viremia in KS is associated with HIV viral load, CD4 cell counts, and lytic HHV-8 serological reactivity. HHV-8 viral load monitored by real time PCR might be useful for determination HHV-8 viral load during the follow-up of KS patients.

Micronutrients and ovarian cancer: a case-control study in Italy

BACKGROUND

The role of selected micronutrients, vitamins and minerals in the aetiology of epithelial ovarian cancer was investigated using data from a case-control study conducted between 1992 and 1999 in five Italian areas.

PATIENTS AND METHODS

Cases were 1,031 patients with histologically confirmed incident epithelial ovarian cancer. Controls were 2,411 subjects admitted for acute, non-neoplastic diseases to major hospitals in the same catchment areas. Dietary habits were elicited using a validated food frequency questionnaire including 78 food groups and recipes. Odds ratios (OR) and 95% confidence intervals (95% CI) were computed by quintiles of intake of nutrients.

RESULTS

Inverse associations emerged for vitamin E (OR = 0.6; 95% CI: 0.5-0.8), beta-carotene (OR = 0.8; 95% CI: 0.6-1.0), lutein/zeaxanthin (OR = 0.6; 95% CI: 0.5-0.8 for the highest vs. the lowest quintile of intake), and calcium intake (OR = 0.7; 95% CI: 0.6-1.0). When the combined effect of calcium and vitamin E was considered, the OR reached 0.4 (95% CI: 0.3-0.7) for subjects in the highest compared to those in the lowest intake tertile of both micronutrients. Results were consistent across strata of menopausal status, parity and family history of ovarian or breast cancer.

CONCLUSIONS

The intake of selected micronutrients, which were positively correlated to a diet rich in vegetables and fruits, was inversely associated with ovarian cancer.

Role of macronutrients, vitamins and minerals in the aetiology of squamous-cell carcinoma of the oesophagus

Between 1992 and 1997 we conducted a case-control study of oesophageal cancer in 3 areas of northern Italy. Cases were 304 patients (29 women), ages 39-77 years (median age 60 years), with a first incident squamous-cell carcinoma (SCC) of the oesophagus. Controls were 743 patients (150 women), ages 35-77 years (median age 60 years), admitted for acute illnesses, unrelated to tobacco and alcohol, to major hospitals of the areas under surveillance. We derived estimates of daily dietary intake of 6 macronutrients, cholesterol, and 20 micronutrients or minerals from a validated food-frequency questionnaire, including 78 food groups and recipes and 15 questions on individual eating patterns. After allowance for age, gender, area of residence, education, body mass index, physical activity, smoking habit, alcohol consumption and energy intake, most micronutrients were inversely associated with oesophageal SCC risk. Highly significant associations emerged for monounsaturated fatty acids [odds ratio (OR) in highest vs. lowest intake quintile = 0.5]; carotene (OR = 0.3); lutein + zeaxanthin (OR = 0.4); vitamin C (OR = 0.4); and niacin (OR = 0.5). Only retinol appeared to be positively related to risk (OR = 1.9). The effect of the above nutrients, expressed as ORs, appeared to be similar in non-smokers and smokers, and non/light drinkers and heavy drinkers.

Role of macronutrients, vitamins and minerals in the aetiology of squamous-cell carcinoma of the oesophagus

Between 1992 and 1997 we conducted a case-control study of oesophageal cancer in 3 areas of northern Italy. Cases were 304 patients (29 women), ages 39-77 years (median age 60 years), with a first incident squamous-cell carcinoma (SCC) of the oesophagus. Controls were 743 patients (150 women), ages 35-77 years (median age 60 years), admitted for acute illnesses, unrelated to tobacco and alcohol, to major hospitals of the areas under surveillance. We derived estimates of daily dietary intake of 6 macronutrients, cholesterol, and 20 micronutrients or minerals from a validated food-frequency questionnaire, including 78 food groups and recipes and 15 questions on individual eating patterns. After allowance for age, gender, area of residence, education, body mass index, physical activity, smoking habit, alcohol consumption and energy intake, most micronutrients were inversely associated with oesophageal SCC risk. Highly significant associations emerged for monounsaturated fatty acids [odds ratio (OR) in highest vs. lowest intake quintile = 0.5]; carotene (OR = 0.3); lutein + zeaxanthin (OR = 0.4); vitamin C (OR = 0.4); and niacin (OR = 0.5). Only retinol appeared to be positively related to risk (OR = 1.9). The effect of the above nutrients, expressed as ORs, appeared to be similar in non-smokers and smokers, and non/light drinkers and heavy drinkers.

Comparison of cancers of the oral cavity and pharynx worldwide: etiological clues

We assessed separate and combined sex-specific incidence rates of oral and pharyngeal cancer for 1988-92 and oral/pharyngeal ratios from 49 different cancer registries in five continents. Incidence trends over a period of approximately 30 years were evaluated in 16 long active registries for men and four for women. Cancers of the lip, salivary glands, and nasopharynx were excluded. The incidence of both oral and pharyngeal cancer among men is highest in northern France, southern India, a few areas of central and eastern Europe, and Latin America. Among women, the highest incidence is observed in India. Oral/pharyngeal ratio is everywhere systematically lower in men compared to women. Recent trends for oral cancer are more favourable than those for pharyngeal cancer in developing countries. In developed countries, trends in oral cancer appears to be more closely correlated to changes in alcohol consumption than those of pharyngeal cancer.

Risk of invasive cervical cancer among women with, or at risk for, HIV infection

Although invasive cervical cancer (ICC) has been included among the AIDS-defining conditions since 1993, it remains controversial whether HIV infection increases the risk of developing such neoplasm. In this study, ICC risk was longitudinally investigated among 1,340 HIV-positive intravenous drug user (IDU), 811 HIV-negative IDU, and 801 HIV-positive heterosexual women. These women, aged 15-49 years, were followed up at the Italian HIV Seroconverter Study, at the San Patrignano Community (Rimini, North Italy), and in South-eastern France (the DMI-2 study). The number of observed cases of ICC was compared with the expected one, based on ICC incidence rates among women of the same age in the general population of Italy or France, and standardized incidence ratios (SIR) were computed; 9,070 person-years of observation were accumulated among HIV-positive women and 2,310 among HIV-negative ones. Ten cases of ICC were diagnosed among HIV-positive women (SIR = 12.8): ICC risk was apparently higher among HIV-positive IDU (SIR = 16.7) than among heterosexual women (SIR = 6.7). No cases of ICC were diagnosed among HIV-negative IDU women admitted to the San Patrignano Community (0.15 cases were expected). Our findings confirm previous suggestions showing an increased risk of ICC among HIV-infected women and have important implications at the individual and public health levels.

A computer program to calculate indicators of descriptive epidemiology

Comparison of incidence and mortality data between areas is useful for monitoring the health status of a population, for exploring quality of health care, and for planning studies on determinant(s) of heterogeneous patterns. Common statistical indicators involved, together with their confidence intervals, are age-specific and cumulative rates, age-standardized rates and ratios, and expected numbers. The data required for calculations include information of event distribution according to age and residence, and corresponding population at risk. The calculations of these indicators, although conceptually simple, can be a cumbersome task to carry out with available statistical packages; lack of flexibility to suit the need of specific researches represents another problem. In order to facilitate descriptive epidemiological studies, we developed a set of Statistical Analysis System macros to compute indicators but, also, to read and write data from/to some standard file formats. Important features of these macros are their flexibility, expandability, and ability to be transferred to various computer platforms. Moreover, macros give an added value to raw data. The method is illustrated using published incidence data from Italy.

Reirradiation and lomustine in patients with relapsed high-grade gliomas

PURPOSE

The aim of this study was to evaluate the toxicity, response, and survival of patients with relapsed high-grade gliomas after radiation therapy (RT) combined with lomustine (CCNU).

METHODS AND MATERIALS

Thirty-one patients with relapsed gliomas at least 6 months after completion of RT were reirradiated. Twenty-four patients had a pathological diagnosis of high-grade gliomas, whereas 7 had a radiological diagnosis of relapsed malignant gliomas. The study focused on patients with high-grade relapsed gliomas. A total dose of 34.5 Gy was delivered in 23 fractions over 4.5 weeks. Oral administration of CCNU (130 mg/m2) was begun at the same time as RT, and was repeated every 6 weeks until disease progression, or up to 12 courses.

RESULTS

Twelve of 24 patients had surgery before RT plus CCNU treatment. Median interval between RT courses was 14 months (range 6-73). All patients received a complete course of RT, and 22 of 24 patients received at least one course of CCNU. Objective responses were seen in 14 evaluable patients: 3 with partial response, 5 with stable disease, and 6 with progressive disease. Duration of partial response was 20, 9, and 8 months. Median time to progression and overall survival from the onset of retreatment were 8.4 months (range 1-22) and 13.7 months (range 1-63+), respectively. One case of G4 thrombocytopenia was observed. Five patients had G1 or G2 leucopenia and 3 patients had G3 leucopenia. Moderate nausea and vomiting were reported in 4 patients. One patient, after one course of CCNU, refused further chemotherapy. No significant difference in survival from relapse was found between patients who underwent surgery before RT plus CCNU and those who received only RT plus CCNU (p = 0.74).

CONCLUSION

Overall, the acute toxicity was moderate, and patient compliance was good. Reirradiation of high-grade glioma was associated with modest subjective and objective response rates. It is remarkable that median overall survival from relapse was 13.7 months.

The epidemiology of lung cancer

Lung cancer is the most frequent cancer worldwide, accounting for about 12% of all new cancer diagnoses in the two sexes combined. During the 1950s and 1960s clear evidence emerged that smoking was the cause of striking lung cancer increases. Risk of lung cancer increases approximately with the fourth power of duration of smoking and the square of the number of cigarettes smoked daily. Between 1990 and 1994, lung cancer mortality rates showed first decreases in the US and several European countries, including Italy, in men although not in women. Marked shifts are, however, taking place in the incidence of different histologic types. Adenocarcinoma, which had always been the predominant type in women and non-smokers, is increasingly associated with tobacco smoking. Since the 1950s steady rises in the incidence of adenocarcinoma of the lung have been observed in many developed countries. Increases are similar in the two sexes and have followed a clear cohort pattern, paralleling changes in smoking habits and cigarette design more than diagnostic advances. Low-yield filter cigarettes tend to be inhaled more deeply than high-yield cigarettes in order to satisfy a craving for nicotine. The peripheral part of the lung, where most adenocarcinomas arise, is thus exposed to a disproportionately higher amount of smoke carcinogens. The hazards of light and ultra-light cigarettes tend to be underestimated, whereas the only safe cigarette is the non-smoked one.

Evaluation of the risk for metachronous colorectal neoplasms following intestinal polypectomy: a clinical, endoscopic and pathological study

BACKGROUND/AIMS

Surveillance programs are recommended for patients with previous intestinal polypectomy because of the high rate of adenomatous recurrences and risk of subsequent colorectal cancer. The parameters to identify patients at higher risk and the length and schedules of follow-up have not yet been established. We considered some clinical, endoscopic and pathological parameters in order to assess the probability of developing new colorectal neoplasms and eventually to schedule proper surveillance programs.

METHODOLOGY

Patients with removed adenomas were enrolled into a clinico-endoscopic follow-up, comprehensive of two colonoscopies the first at 1 year and the second at 3 years. We evaluated the risk of new neoplasms dividing the patients into four groups according to the number and size of the adenomas removed and the parameters considered.

RESULTS

Of 164 patients enrolled 156 completed the study. We had an overall 21.3% of adenomatous recurrences at 1 year and 12.8% at 3 years. Most of the adenomas removed were tubular and small in size (< 1 cm). The percentage of patients who had adenomas with advanced pathological features was 1.82% at 1 year and 0.64% at 3 years. The increase in number and size of the adenomas removed on the initial colonoscopic examination was the only one parameter statistically significant, X(2)1 (trend) 5.11; p<0.05 at the first follow-up and X(2)1 (trend) 4.87; p<0.05 at the second follow-up.

CONCLUSIONS

Patients with previous single adenoma showed few recurrences of extremely benign histological features. Since they do not require short-term endoscopic examination, it would be reasonable to defer the next colonoscopy for at least another 5 years. During follow-up, patients with multiple polyps had adenomas with advanced pathological features so it was useful to follow-up at 1 year. The tendency for advanced pathological features of removed polyps was not seen at 3 years, suggesting the importance of long-term follow-up, but with longer intervals.

Physical activity and bone mineral density in Italian middle-aged women

Osteoporosis is a major health issue in post-menopausal women on account of the association between low bone mineral density and fractures. A role of physical activity in the prevention and treatment of low bone mineral density is possible but still unclear. The relationship between low spine bone mineral density measured by means of dual photon absorptiometry at lumbar spines, and levels of past and recent physical activity has been assessed by means of a population-based screening study carried out on 1373 women (age 40-64 years) in the North-East of Italy. Physical activity at work and in leisure time was investigated for three specific periods of life: at age 12, between 15 and 19 years (during bone formative years), and in the recent years prior to the interview (30-39 or 50-59 years). Data were analysed comparing low versus high bone mineral density tertile (i.e., 458 and 461 women, respectively), after controlling for other known contributory factors in the development of osteoporosis. A positive association emerged with leisure time physical activity, with significant trends at age 15-19 (odds ratio (OR) for low versus high tertile of leisure time activity: 1.4, 95% confidence interval (CI): 0.8-2.4) and at most recent age (OR: 1.7, 95% CI: 1.1-2.6). Risk trends with occupational physical activity were less clear and non-statistically significant. The present Southern European cross-sectional study lends further support to the possibility that past and recent physical activity helps increasing bone mineral density in middle-aged women. Although the most beneficial type and intensity level of exercise has yet to be determined, the present results provide further evidence that participation in even moderate exercise programs should be encouraged.

High mortality rates from liver cancer in the urban area of Campania Region: prevalence of hepatitis and sociodemographic factors

The incidence of liver cancer appears lower in Europe and the USA and it is often looked upon as a problem in developing countries. Liver cancer has two main risk factors: the abuse of alcohol and the elevated prevalence of hepatitis B and C viruses. In Italy the first one is mainly present in the North and the second one in Southern less developed areas. Our study evaluates the relationship between living in urban and suburban zones in South of Italy in conditions of overcrowding, poor health services and high incidence of hepatitis and liver cancer.

High-Dose Epirubicin in Locally Advanced Operable Noninflammatory Breast Cancer: A Feasibility Trial

Aims and background

Anthracyclines are among the most active agents for the treatment of patients with locally advanced breast cancer. The aim of our study was to evaluate the feasibility and activity of a relatively high-dose regimen with 4-epirubicin plus normal doses of cyclophosphamide over a short period of time without the use of hematologic growth factors as adjuvant in resected locally advanced breast cancer.

Methods.

Between January 1990 and June 1992, 43 consecutive patients, premenopausal or postmenopausal «60 yrs, were surgically resected and then treated with epirubicin plus cyclophosphamide for at least 4 cycles (maximum 6). Electron beam (6–10 MeV energy) radiotherapy was delivered on the chest wall in patients with pathological skin infiltration (pT4b).

Results

Median age was 46 years (range, 27–59); 37 were premenopausal and 6 postmenopausal. The total number of administered cycles was 202 (6 in 15 patients and 4 in 28 patients); 195/202 (96.5%) were administered at full dose, and 7 (3.5%) were reduced to 75% of the planned dosage. The three-year disease-free survival was 67% for stage IlIa and 61% for stage IIIb patients. The three-year overall survival was 88% and 79%, respectively. Local relapse only was reported in one patient (2%), distant relapse in 11 patients (25%), and local and distant relapse in four patients (9%). Toxicity was acceptable and mainly hematologic.

Conclusions.

Our trial showed that the regimen is feasible without the use of hematologic growth factors. In this era of cost containment, the use of this short-term, high-dose induction course instead of repetitive courses of conventional dose regimens merits further evaluation, possibly in a large randomized trial.