Prevalence and indicators of cure of Italian women with vulvar squamous cell carcinoma: A population-based study

OBJECTIVE

Five-year net survival and conditional survival from vulvar squamous cell carcinoma (VSCC) patients in Italy have shown no progress during the past three decades. This study aims to estimate the complete prevalence and multiple indicators of cure.

METHODS

Observed prevalence was estimated using 31 Italian cancer registries covering 47 % of Italian women. A subset of 22 cancer registries was used to estimate model-based long-term survival and indicators of cure, i.e., complete prevalence, cure fraction (CF), time to cure (TTC), proportion of 'already cured' patients, and cure prevalence.

RESULTS

In 2018, VSCC patients alive in Italy (complete prevalence) were 6620 or 22 per 100,000 women. The cure fraction (the proportion of newly diagnosed patients who will not die of VSCC) did not change between 2000 and 2010 both for all patients (32 %) and in each age group. The time to cure (5-year conditional net survival >95 %) was 11 years for patients aged ≥44 years, but excess mortality remained for >15 years in the other age groups. This led to a negligible (5 %) proportion of 'already cured' patients (living longer than time to cure). The proportion of patients alive <2 years (21 %) was the same as that of patients surviving ≥15 years. The cure prevalence (patients who will not die of VSCC) was 64 %. A considerable proportion of patients will not be cured even among those who survived ≥5 years.

CONCLUSION

There is an urgent need to reshape the current vulvar care model in Italy.

Patients with cancer who will be cured and projections of complete prevalence in Italy from 2018 to 2030

BACKGROUND

The number and projections of cancer survivors are necessary to meet the healthcare needs of patients, while data on cure prevalence, that is, the percentage of patients who will not die of cancer by time since diagnosis, are lacking.

MATERIALS AND METHODS

Data from Italian cancer registries (duration of registration ranged from 9 to 40 years, with a median of 22 years) covering 47% of the population were used to calculate the limited-duration prevalence, the complete prevalence in 2018, projections to 2030, and cure prevalence, by cancer type, sex, age, and time since diagnosis.

RESULTS

A total of 3 347 809 people were alive in Italy in 2018 after a cancer diagnosis, corresponding to 5.6% of the resident population. They will increase by 1.5% per year to 4 012 376 in 2030, corresponding to 6.9% of the resident population, 7.6% of women and ∼22% after age 75 years. In 2030, more than one-half of all prevalent cases (2 million) will have been diagnosed by ≥10 years. Those with breast (1.05 million), prostate (0.56 million), or colorectal cancers (0.47 million) will be 52% of all prevalent patients. Cure prevalence was 86% for all patients alive in 2018 (87% for patients with breast cancer and 99% for patients with thyroid or testicular cancer), increasing with time since diagnosis to 93% for patients alive after 5 years and 96% after 10 years. Among patients who survived at least 5 years, the excess risk of death (1 - cure prevalence) was <5% for patients with most cancer types except for those with cancers of the breast (8.3%), lung (11.1%), kidney (13.2%), and bladder (15.5%).

CONCLUSIONS

Study findings encourage the implementation of evidence-based policies aimed at improving long-term clinical follow-up and rehabilitation of people living after cancer diagnosis throughout the course of the disease. Updated estimates of complete prevalence are important to enhance data-driven cancer control planning.

The descriptive epidemiology of melanoma in Italy has changed - for the better

A recent research project using data from a total of 40 cancer registries has provided new epidemiologic insights into the results of efforts for melanoma control in Italy between the 1990s and the last decade. In this article, the authors present a summary and a commentary of their findings. Incidence increased significantly throughout the study period in both sexes. However, the rates showed a stabilization or a decrease in men and women aged below 35 years. The risk of disease increased for successive cohorts born until 1973 (women) and 1975 (men) while subsequently tending to decline. The trend towards decreasing tumor thickness and increasing survival has continued, but a novel favorable prognostic factor has emerged since 2013 for patients - particularly for males - with thick melanoma, most likely represented by molecular targeted therapies and immune checkpoint inhibitors. Due to this, the survival gap between males and females has been filled out. In the meanwhile, and despite the incidence increase, dermatologists have not lowered their threshold to perform skin biopsy. Skin biopsy rate has increased because of the increasingly greater volume of dermatologic office visits, but the proportion of skin biopsies out of dermatologic office visits has remained constant. In summary, an important breakthrough in melanoma control in Italy has taken place. Effective interventions have been implemented across the full scope of care, which involve many large local populations - virtually the whole national population. The strategies adopted during the last three decades represent a valuable basis for further steps ahead in melanoma control in Italy.

Breast cancer deaths attributable to alcohol consumption: Italy, 2015-2019

A study was conducted to assess the fraction of female breast cancer (BC) deaths attributable to alcohol consumption in Italy. National mortality data for the period 2015-2019 were used along with national estimates of women from the general population exposed to moderate (11-20 gr/day) or heavy (>20 gr/day) alcohol consumption. From 2015 to 2019, 2918 (4.6%) out of 63,428 BC| deaths were attributable to alcohol consumption, including 1269 deaths (2.0%) caused by moderate consumption. Study findings could help stakeholders to prioritize programs aimed at reducing alcohol consumption, and to improve ways to effectively communicate alcohol-related health risks, including moderate consumption.

Complete prevalence and indicators of cancer cure: enhanced methods and validation in Italian population-based cancer registries

Objectives

To describe the procedures to derive complete prevalence and several indicators of cancer cure from population-based cancer registries.

Materials and methods

Cancer registry data (47% of the Italian population) were used to calculate limited duration prevalence for 62 cancer types by sex and registry. The incidence and survival models, needed to calculate the completeness index (R) and complete prevalence, were evaluated by likelihood ratio tests and by visual comparison. A sensitivity analysis was conducted to explore the effect on the complete prevalence of using different R indexes. Mixture cure models were used to estimate net survival (NS); life expectancy of fatal (LEF) cases; cure fraction (CF); time to cure (TTC); cure prevalence, prevalent patients who were not at risk of dying as a result of cancer; and already cured patients, those living longer than TTC at a specific point in time. CF was also compared with long-term NS since, for patients diagnosed after a certain age, CF (representing asymptotical values of NS) is reached far beyond the patient's life expectancy.

Results

For the most frequent cancer types, the Weibull survival model stratified by sex and age showed a very good fit with observed survival. For men diagnosed with any cancer type at age 65-74 years, CF was 41%, while the NS was 49% until age 100 and 50% until age 90. In women, similar differences emerged for patients with any cancer type or with breast cancer. Among patients alive in 2018 with colorectal cancer at age 55-64 years, 48% were already cured (had reached their specific TTC), while the cure prevalence (lifelong probability to be cured from cancer) was 89%. Cure prevalence became 97.5% (2.5% will die because of their neoplasm) for patients alive >5 years after diagnosis.

Conclusions

This study represents an addition to the current knowledge on the topic providing a detailed description of available indicators of prevalence and cancer cure, highlighting the links among them, and illustrating their interpretation. Indicators may be relevant for patients and clinical practice; they are unambiguously defined, measurable, and reproducible in different countries where population-based cancer registries are active.

Comparison between two cancer registry quality check systems: functional features and differences in an Italian network of cancer registries dataset

Purpose

The aim of this study was to compare the functional characteristics of two computer-based systems for quality control of cancer registry data through analysis of their output differences.

Methods

The study used cancer incidence data from 22 of the 49 registries of the Italian Network of Cancer Registries registered between 1986 and 2017. Two different data checking systems developed by the WHO International Agency for Research on Cancer (IARC) and the Joint Research Center (JRC) with the European Network of Cancer Registries (ENCR) and routinely used by registrars were used to check the quality of the data. The outputs generated by the two systems on the same dataset of each registry were analyzed and compared.

Results

The study included a total of 1,305,689 cancer cases. The overall quality of the dataset was high, with 86% (81.7-94.1) microscopically verified cases and only 1.3% (0.03-3.06) cases with a diagnosis by death certificate only. The two check systems identified a low percentage of errors (JRC-ENCR 0.17% and IARC 0.003%) and about the same proportion of warnings (JRC-ENCR 2.79% and IARC 2.42%) in the dataset. Forty-two cases (2% of errors) and 7067 cases (11.5% of warnings) were identified by both systems in equivalent categories. 11.7% of warnings related to TNM staging were identified by the JRC-ENCR system only. The IARC system identified mainly incorrect combination of tumor grade and morphology (72.5% of warnings).

Conclusion

Both systems apply checks on a common set of variables, but some variables are checked by only one of the systems (for example, checks on patient follow-up and tumor stage at diagnosis are included by the JRC-ENCR system only). Most errors and warnings were categorized differently by the two systems, but usually described the same issues, with warnings related to "morphology" (JRC-ENCR) and "histology" (IARC) being the most frequent. It is important to find the right balance between the need to maintain high standards of data quality and the workability of such systems in the daily routine of the cancer registry.

The use of PSA testing over more than 20-years: A population-based study in North-Eastern Italy

OBJECTIVE

To describe the practice of prostate-specific antigen (PSA) testing over more than 20 years in Friuli Venezia Giulia (FVG), North-Eastern Italy.

METHODS

A population-based, ecological study was conducted using information derived from regional administrative health-related databases. Data on PSA and prostate biopsies performed on resident men aged ⩾45 years from 1998 to 2019 were retrieved. PSA and biopsy rates were calculated as the number of men who had at least one such procedure in each calendar year over the mean resident male population of the same year. Temporal trends were analyzed using joinpoint regression (annual percentage change -APC).

RESULTS

A total of 2,502,670 PSA were made between 1998 to 2019 in men aged ⩾45 years. The number of PSA steadily increased from 51,055 in 1998-1999 to 134,504 in 2010-2011, then dropped to 122,080 in 2018-2019. Significant changes in the slopes of PSA rates emerged in 2002 and 2009: the largest increase occurred during 1998-2002 (APC 18.4), followed by a smaller increase in 2002-2009 (APC 3.4) and a subsequent reduction (APC -2.5). Similar patterns emerged for all ages, but the decrease since 2009 was smaller for men aged ⩾65 years. An upward trend emerged in biopsy rate from 1998 to 2001 (APC 13.0), followed by a smaller increase until 2007 (APC 5.7) and a subsequent decrease. Biopsies as percentage of PSA decreased from 3.2% to 2.2%, particularly in those aged ⩾75 years.

CONCLUSIONS

Although overall declining PSA rates have been observed in FVG since 2009, rates remained higher in the ⩾65-year-old group than in the 45-64-year-old group.

The puzzling clinical presentation of fluoropyrimidines cardiotoxicity

The cardiotoxicity of fluoropyrimidines (FP) [5-Fluorouracil and Capecitabine] is often reported as acute cardiac ischemia with rest typical angina, signs of ischemia at electrocardiogram (ECG), and ventricular kinetics abnormalities. However, silent ischemia, effort-related toxicity, and ventricular arrhythmias (VA) have been also described. The aim of this study is to report a consecutive series of 115 patients with FP cardiotoxicity observed in a single center both within clinical prospective studies and during the clinical routine. The clinical presentation widely varied as regards symptoms, ECG abnormalities, and clinical outcomes. We report also the strategies used to prevent cardiotoxicity in a subgroup of 35 patients who continued o rechallenged FP therapy after cardiotoxicity. In nearly half of the patients, the cardiotoxicity was triggered by physical effort. Typical angina was rare: the symptoms were absent in 51% of cases and were atypical in half of the other cases. ST-segment elevation and VA were the most frequent ECG abnormality; however, ST segment depression or negative T waves were the only abnormalities in 1/3 of the cases. Troponins essays were often within the normal limits, even in presence of extensive signs of ischemia. The most effective strategy to prevent cardiotoxicity at rechallenge was reducing FP dosage and avoiding physical effort. Anti-ischemic therapies were not always effective. Raltitrexed was a safe alternative to FP. Fluoropyrimidine cardiotoxicity shows a wide variety of clinical presentations in real life, from silent ischemia to atypical symptoms, acute coronary syndrome, left ventricular dysfunction (LVD), VA, or complete atrio-ventricular block. Physical effort is the trigger of cardiotoxicity in nearly half of the cases. The recognition of cardiotoxicity cannot rely on symptoms only but requires an active screening with ECG and stress test in selected cases.

Cardiotoxicity from Capecitabine Chemotherapy: Prospective Study of Incidence at Rest and During Physical Exercise

BACKGROUND

Physical activity may increase the risk of cardiotoxicity (myocardial ischemia, major arrhythmias) of 5-Fluorouracil, but this risk has never been investigated for its prodrug capecitabine.

PATIENTS AND METHODS

One hundred and ninety-two consecutive patients undergoing capecitabine chemotherapy from December 1, 2010 through July 31, 2016 were prospectively evaluated. The baseline evaluation included electrocardiography (ECG) and echocardiography (2DE); a follow-up evaluation, including ECG and exercise stress testing (2DE in case of ECG abnormalities), was done after ≥10 days of treatment. Cardiotoxicity was suspected from ischemic ECG changes, new kinetic abnormalities at 2DE, Lown classification ≥2 ventricular arrhythmia, symptomatic arrhythmias, or positive stress test, and confirmed by a negative stress test after capecitabine washout.

RESULTS

Cardiotoxicity was diagnosed in 32 patients (16.7%): six at rest and 26 during exercise. All 32 patients had ECG abnormalities: ST-segment changes (24 patients), negative T-waves (2) and/or arrhythmias: ventricular arrhythmias (14 cases), supraventricular tachycardia (2), complete heart block (1). Eight patients had typical symptoms, 6 had atypical symptoms, 1 had syncope, 17 (53%) were asymptomatic. Cardiotoxicity was more common in patients with atypical symptoms during daily life (OR = 15.7) and in those on a therapeutic schedule of 5 days/week (OR = 9.44).

CONCLUSION

Capecitabine cardiotoxicity is frequent, and often elicited by physical effort. Oncologists, cardiologists, and general practitioners should be aware of this risk. Active cardiotoxicity surveillance with ECG (and echocardiogram and/or stress testing in suspected cases) during therapy is recommended.

CLINICAL TRIALS REGISTRATION NUMBER

CRO-2010-17.

Biological Predictors of De Novo Tumors in Solid Organ Transplanted Patients During Oncological Surveillance: Potential Role of Circulating TERT mRNA

Background

De novo tumors are a major cause of morbidity and mortality after long-term solid organ transplantation. Chronic immunosuppression strongly affects solid organ transplanted (SOT) patients' immune system by promoting immune evasion strategies and reactivations of viruses with oncogenic potential, ultimately leading to cancer onset. In this scenario, an oncological Surveillance Protocol integrated with biobanking of peripheral blood samples and evaluation of immunovirological and molecular parameters was activated for SOT patients at CRO-IRCCS Aviano, with the aim of identifying suitable biomarkers of cancer development.

Methods

An exploratory longitudinal study was designed based on two serial peripheral blood samples collected at least three months apart. Forty nine SOT patients were selected and stratified by tumor onset during follow-up. Spontaneous T-cell responses to EBV, CMV and tumor associated antigens, EBV-DNA and CMV-DNA loads, and circulating TERT mRNA levels were investigated.

Results

Significantly higher levels of circulating TERT mRNA were observed 3.5-23.5 months before and close to the diagnosis of cancer as compared to tumor-free patients. Plasmatic TERT mRNA levels >97.73 copies/mL at baseline were significantly associated with the risk of developing de novo tumors (HR=4.0, 95%C.I. = 1.4-11.5, p=0.01). In particular, the risk significantly increased by 4% with every ten-unit increment in TERT mRNA (HR=1.04, 95%C.I. = 1.01-1.07, p=0.01).

Conclusions

Although obtained in an exploratory study, our data support the importance of identifying early biomarkers of tumor onset in SOT patients useful to modulate the pace of surveillance visits.

Linearity of Age at Cancer Onset Worldwide: 25-Year Population-Based Cancer Registry Study

Background The linear association between median age at cancer onset and median age of the underlying population has been described only for breast cancer. We quantified the shape and strength of such association for 20 cancer types using data from all population-based cancer registries (CRs) worldwide. Methods The patients' median age at cancer onset and of the underlying population were extracted from all CRs listed in volumes VI (1983-1987 years) and XI (2008-2012 years) of Cancer Incidence in Five Continents. The association was assessed at cross-sectional level by linear regression models and longitudinally considering only the long-standing CRs active throughout the study period (i.e., 25-year span). Results During 2008-2012, each one-year increase in median population ageing was associated in men with a nearly half year increase of median age at onset of all cancers, but skin; and a 2/3 year increase in women. Variance explained by linear model was around 60%. In long-standing CRs a decrease in median age at cancer onset was observed for prostate and cervical cancers throughout the 25-year span. Conclusions Population ageing reflected 60% of the median age at cancer onset. Misinterpretation of peaks of cancer incidence in specific age groups may be avoided by examining population pyramids.

[Mortality Atlas of the Campania Region. All-cause and cause-specific mortality at municipal level, 2006-2014]

OBJECTIVES

This Monograph aims to provide the scientific community and the Regional Healthcare Service an up-to-date Atlas of mortality for the Campania Region (Southern Italy). The Atlas shows an overview of mortality through comparisons with national data and with intraregional macroareas. Maps presenting risk measures with municipal details are also provided.

MATERIALS AND METHODS

Both overall and cause-specific mortality data for the period 2006-2014 referred to people residing in Campania Region are analysed in this Atlas. Twenty-nine death causes (major causes and specific cancers) are studied; for each of them, it has been provided: • direct standardised rates (standard population EU 2013) referred to Italy, Campania Region, and the seven regional Local Health Units (LHUs); • standardised mortality ratios (SMRs), estimated on a regional basis, referred to every LHU; • years of life lost (number and rate) both on a regional and on LHU basis; • mortality rate trends for the period 2006-2014, including annual percentage changes (APCs) for Italy, Campania Region, and every LHU; • for every death cause, regional maps are provided also with municipal details for Relative Risks (RRs) and risk posterior probabilities (PPs) estimated through a Bayesian hierarchical model. Risk estimates are presented both crude and adjusted by socioeconomic deprivation index resulted from the 2011 Census of the Italian National Institute fo Statistics.

RESULTS

In Campania Region, standardised mortality ratios (per 100,000; IC95%) higher than the national average have been recorded for the following causes: all causes of death: M: 1,233.3 (IC95% 1,227.9-1,238.9) vs 1,093.8 (IC95% 1,092.5-1,095.1); F: 826.1 (IC95% 822.6-829.7) vs 722.8 (IC95% 721.9-732.6); digestive system diseases: M: 51.2 (IC95% 50.2-52.3) vs 44.2 (IC95% 44.0-44.5); F: 35.8 (IC95% 35.1-36.6) vs 29,2 (IC95% 29.0-29.4); circulatory system diseases: M: 493.1 (IC95% 489.6-496.8) vs 404.3 (IC95% 403.5-405.1); F: 388.5 (IC95% 386.1-390.9) vs 296.5 (IC95% 295.9-297.0); genitourinary system diseases: M: 27.2 (IC95% 26.4-28.1) vs 21.9- (IC95% 21.7-22.1); F: 18.2 (IC95% 17.7-18.7) vs 13.7- (IC95% 13.5-13.8); endocrine and metabolic diseases: M: 60.0 (IC95% 58.8-61.2) vs 43.8 (IC95% 43.5-44.0); F: 60.7 (IC95% 59.8-61.7) vs 36.6 (IC95% 36.4-36.8); myocardial infarction: M: 71.1 (IC95% 69.8-72.4) vs 60.9 (IC95% 60.6-61.2); F: 38.2 (IC95% 37.4-39.0) vs 30.2-(IC95% 30.0-30.4); diabetes: M: 52.6 (IC95% 51.5-53.8) vs 35.1 (IC95% 34.9-35.3); F: 53.8 (IC95% 52.9-54.7) vs 28.6 (IC95% 28.4-28.8). On the other hand, mortality rates comparable to or lower than the national average are observed for the remaining causes of death, with different differences for gender. Mortality for cancer causes in Campania Region presents rates higher than the rates observed at national level in males for the following causes: all cancers: 380.4 (IC95% 377.5-383.3) vs 356.5 (IC95% 355.8-357.2); lung cancer: 112.5 (IC95% 110.9/114.0) vs 93.0 (IC95% 92.6-93.3);larynx cancer: 7.6 (IC95% 7.2-8.0) vs 5.5 (IC95% 5.4-5.6);bladder cancer: 25.1 (IC95% 24.4-25.9) vs 17.3 (IC95% 17.1-17.4); in females for the following causes: liver cancer: 3.8 (IC95% 3.6-4.1) vs 3.3 (IC95% 3.2-3.4);bladder cancer:: 3.5 (IC95% 3.3-3.7) vs 3.0 (IC95% 2.9-3.0). In Campania Region, mortality rates comparable to or lower than the national average are observed for the remaining cancer causes both in females and in males. For almost all the death causes, the highest mortality rates are observed in the three LHUs of Naples (Naples centre, Naples 2 North, Naples 3 South); for some death causes, also the Province of Caserta presents the highest mortality rates. It is worth noting that these areas are characterised by the highest urbanisation and regional population density, and by exposures to possible environmental risks. Time trend analyses highlight that regional and national trends are similar for almost all the examined death causes. In Campania Region, males present decreasing trends for all-cause mortality; for respiratory system, circulatory system, and digestive system diseases; for all malignant cancers; for lung, prostate, and stomach cancers; for leukaemias. On the other hand, an increasing trend is shown for liver cancer. Trends for genitourinary system and nervous system diseases are almost unchanged; the same is for blood diseases and haemolymphopoietic system cancers. In females, there is a decreasing mortality trend for all causes, for circulatory system and digestive system diseases; for haemolymphopoietic system and stomach cancers; on the contrary, an increasing trend is highlighted for communicable diseases and lung and liver cancer, mirroring the national situation. Trends for respiratory system, genitourinary system, nervous system diseases; blood diseases; all malignant cancers; kidney and breast cancers; leukaemias are almost unchanged. The analysis of mortality data on municipal basis reported that the most excesses in mortality risk occur in the municipalities included in the area with the highest urban development of Naples and, partly, in the municipalities of the Caserta Province. The distribution of the excesses at municipal level is not homogeneous in Campania Region, but there are relevant intermunicipal differences related to the considered causes of death. This heterogeneity in the distribution of excess risk is a characteristic also of the area called Terra di fuochi (Land of fires), both for overall mortality and for mortality by gender.

CONCLUSIONS

Mortality data are a valuable support to the analysis of the population health conditions. Excesses in general mortality and for some specific causes found in Campania Region vs Italy in 2006-2014 suggest that in this region there is a need to implement more strict intervention in terms both of primary prevention (for individuals and the environment) and of management of the whole care and clinical pathway of some pathologies, bearing in mind the burden of regional structural and economic factors on these excesses. The highest excesses in mortality in Campania Region have been found in the areas with the highest degree of urbanisation: this confirms the national data of a different distribution of diseases - and mortality - in the areas characterised by high urban development compared to rural areas. Finally, cause-specific mortality maps at municipal level, extended to the whole region, could enable to identify possible critical issues which may need epidemiological studies focused on possible local factors of environmental pressure.

Sociodemographic and Reproductive Risk Factors for Breast Cancer: A Case-Control Study in the Setif Province, Northern Algeria

Background:

The age-standardized rate of breast cancer (BC) increased nearly nine-fold in the last 30 years in Setif, Algeria. A case-control study was carried out to investigate the role of sociodemographic characteristics and reproductive factors in the etiology of BC in this young Arab/Berber population of Setif.

Methods:

Cases were 612 women with incident BC admitted to major teaching and general hospitals of Setif during 2012–2017. Controls were 615 women admitted for acute, non-neoplastic conditions to the same hospital network of cases. Information was elicited using a standardized questionnaire. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed after allowance for age and education.

Results:

Significant associations with BC risk emerged for family history of BC (OR= 4.15 for yes vs. no; 95%CI: 2.22-7.77), for the generation of oral contraceptive used (OR=1.57 for II-generation vs. III-generation; 95%CI:1.01-2.44), and education (OR=0.63 for >11 years vs. no schooling; 95%CI: 0.46-0.86). Conversely, parity and body mass index were not associated with BC risk, whereas a late age at menarche was linked with a non statistically significant BC risk (OR=1.20 for >15 vs. <13 years; 95%CI:0.86-1.66). These results were consistent in strata of menopausal status.

Conclusion(s):

Some of the expected risk factors (e.g., low education levels and type of oral contraceptives) were associated with elevated BC risks also in Setif, and these findings offer further support to primary preventive efforts already carried on in Algeria. Conversely, no association emerged for other well established risk factors (e.g., body mass index).

Hospital Anxiety and Depression Scale (HADS) accuracy in cancer patients

PURPOSE

The Hospital Anxiety and Depression Scale (HADS) is a self-report questionnaire designed to screen anxious and depressive states in patients in non-psychiatric settings. In spite of its large use, no agreement exists in literature on HADS accuracy in case finding. The present research addresses the issue of HADS accuracy in cancer patients, comparing its two subscales (HADS-A and HADS-D) against tools not in use in psychiatry, which are able to detect prolonged negative emotional states.

METHODS

2121 consecutive adult cancer inpatients were administered the HADS together with the State Anxiety subscale of State-Trait Anxiety Inventory and the Center for Epidemiologic Studies Scale on Depression. Receiver operating characteristic (ROC) curves were computed to identify a cut-off for anxious and depressive states in cancer patients. All indicators were computed together with their corresponding 95% confidence interval (95% CI).

RESULTS

Data of 1628 and 1035 participants were used to assess the accuracy in case finding of HADS-A and HADS-D, respectively. According to the ROC analysis, the optimal cut-off was > 9 units for the HADS-A and > 7 units for the HADS-D. The area under the ROC curve was 0.90 for HADS-A (95% CI 0.88-0.91) and 0.84 for HADS-D (95% CI 0.81-0.86).

CONCLUSIONS

This study suggested that risk scores of anxious and depressive states above specific HADS cut-offs are useful in identifying anxious and depressive states in cancer patients, and they may thus be applicable in clinical practice.

Thyroid cancer in Friuli Venezia Giulia, northeastern Italy: incidence, overdiagnosis, and impact of type of surgery on survival

BACKGROUND

Incidence rates of thyroid cancer (TC) increased in the last decades worldwide. This study aimed to describe TC incidence in the Friuli Venezia Giulia (FVG) region, to estimate the quota of overdiagnosis, and to investigate the impact of surgery on long-term survival after TC diagnosis.

METHODS

TC cases reported to the FVG population-based cancer registry during 2002-2013, aged <85 years, were included. Age standardized rates (ASR) on the European population were computed, while proportion of TC overdiagnosis was estimated in comparison with expected age-specific incidence rates from published time series. Adjusted hazard ratios of death, with 95% confidence intervals, were also estimated.

RESULTS

During 2002-2013, 1701 TC cases were reported to the FVG cancer registry, with papillary TC (78.2%) as the most frequent histologic type. ASR increased from 12.4 to 16.5 in women and from 4.3 to 6.2 in men (+33.1% and +44.2%, respectively). Overdiagnosis was estimated as 79% of TC cases in women and 64% in men. Almost all TC cases (97.1%) underwent surgery, including 84.6% of women and 78.9% of men who underwent total thyroidectomy. Up to 10 years after TC diagnosis, the type of surgery did not appear to influence survival.

CONCLUSIONS

This study documented an increase in TC incidence in FVG in the last decade, with overdiagnosis accounting for a large proportion of TC diagnoses and total thyroidectomy in more than 80% of cases. These findings suggest reconsidering thyroid screening practice and aggressive therapeutic strategies, as recommended by new TC guidelines.

Adjuvant Treatment of High-risk Adult Soft Tissue Sarcomas: A Survey by the Italian Sarcoma Group

Aims and Background

After the first adjuvant study on adult soft tissue sarcomas was concluded, the participating institutions continued to select and treat patients according to that protocol. The aim of this study was to test the protocol reproducibility when applied as a standard practice.

Methods

A call for retrospective data was launched in June 1999 (self-referral of consecutive unregistered patients); thereafter, a prospective follow-up was performed. The treatment regimen consisted of epirubicin (60 mg/m2 days 1 and 2), ifosfamide (3 g/m2/die for 3 days) and equimolar doses of 6-mercapto-ethansulfonate (MESNA), with 300 μg G-CSF administered subcutaneously from day +8 until recovery, every 3 weeks for a total of 5 cycles.

Results

From November 1996 to June 1999, 55 high-risk, adult patients were treated. The average median dose intensity was 89% of the planned program. Grade 3-4 toxicities were leukopenia (49%), thrombocytopenia (14%), transfusion requiring anemia in 7 patients (16%), and alopecia in all patients (100%). After a median follow-up of 70 months, 23 patients (41.8%) relapsed and 19 died. Median disease-free, local disease-free and overall survival rates have not yet been reached. The disease-free survival rates at 2 and 4 years were 73% and 57%, respectively; the corresponding overall survival rates were 91% and 70%, respectively.

Conclusions

The feasibility and reproducibility of the original protocol were confirmed, since disease-specific overall survival and disease-free survival rates at the same period of observation and with the same prolonged follow-up did not differ.

Patients and caregivers' unmet information needs in the field of patient education: results from an Italian multicenter exploratory survey

Patient education and empowerment (PEE) is aimed at improving competence of patients during their clinical path and enabling healthcare providers with specific communication strategies. We investigated the interest of Italian Cancer Research & Care Centers (CRCI) users (patients and caregivers) in being involved in PEE activities. An anonymous questionnaire addressed to users was distributed between June 2013 and February 2014. The questionnaire gathered information on the following: health-related topics; 13 different PEE initiatives/modalities of learning already active at CRCI; personal demographic data; the willingness to be more involved in the organization of health services provided and in which context; and five preferred info-educational activities. Frequency distribution and chi-square analysis were computed. Statistical significance (p value) was set at < 0.05. A total of 875 (29%) users responded to the 3000 distributed questionnaires. The first three priorities of interest were “early diagnosis” (18%), “prevention” (17%), and “diagnosis explanation” (13%). The first three priorities on informational activity were as follows: “classes on cancer-related topics with healthcare professionals” (28%); “cancer information service” (22%); “drug information point” (7%). Forty-nine percent of the respondents stated that they would like to be involved in the organization of PEE activities, particularly caregivers and users older than 55 years of age. The preferred educational activities were “classes on cancer-related topics with healthcare professionals” and “cancer information service” on a face-to-face modality. Patients were more interested than caregivers in “prevention.” The extension of PEE programs to all CRCI users into routine care will be the next step of the present research.

Sensitivity and specificity of breast cancer ICD-9-CM codes in three Italian administrative healthcare databases: a diagnostic accuracy study

OBJECTIVES

To assess the accuracy of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes in identifying patients diagnosed with incident carcinoma in situ and invasive breast cancer in three Italian administrative databases.

DESIGN

A diagnostic accuracy study comparing ICD-9-CM codes for carcinoma in situ (233.0) and for invasive breast cancer (174.x) with medical chart (as a reference standard). Case definition: (1) presence of a primary nodular lesion in the breast and (2) cytological or histological documentation of cancer from a primary or metastatic site.

SETTING

Administrative databases from Umbria Region, Azienda Sanitaria Locale (ASL) Napoli 3 Sud (NA) and Friuli VeneziaGiulia (FVG) Region.

PARTICIPANTS

Women with breast carcinoma in situ (n=246) or invasive breast cancer (n=384) diagnosed (in primary position) between 2012 and 2014.

OUTCOME MEASURES

Sensitivity and specificity for codes 233.0 and 174.x.

RESULTS

For invasive breast cancer the sensitivities were 98% (95% CI 93% to 99%) for Umbria, 96% (95% CI 91% to 99%) for NA and 100% (95% CI 97% to 100%) for FVG. Specificities were 90% (95% CI 82% to 95%) for Umbria, 91% (95% CI 83% to 96%) for NA and 91% (95% CI 84% to 96%) for FVG.For carcinoma in situ the sensitivities were 100% (95% CI 93% to 100%) for Umbria, 100% (95% CI 95% to 100%) for NA and 100% (95% CI 96% to 100%) for FVG. Specificities were 98% (95% CI 93% to 100%) for Umbria, 86% (95% CI 78% to 92%) for NA and 90% (95% CI 82% to 95%) for FVG.

CONCLUSIONS

Administrative healthcare databases from Umbria, NA and FVG are accurate in identifying hospitalised news cases of carcinoma of the breast. The proposed case definition is a powerful tool to perform research on large populations of newly diagnosed patients with breast cancer.

Accuracy of administrative databases in detecting primary breast cancer diagnoses: a systematic review

OBJECTIVE

To define the accuracy of administrative datasets to identify primary diagnoses of breast cancer based on the International Classification of Diseases (ICD) 9th or 10th revision codes.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, Web of Science and the Cochrane Library (April 2017).

ELIGIBILITY CRITERIA

The inclusion criteria were: (a) the presence of a reference standard; (b) the presence of at least one accuracy test measure (eg, sensitivity) and (c) the use of an administrative database.

DATA EXTRACTION

Eligible studies were selected and data extracted independently by two reviewers; quality was assessed using the Standards for Reporting of Diagnostic accuracy criteria.

DATA ANALYSIS

Extracted data were synthesised using a narrative approach.

RESULTS

From 2929 records screened 21 studies were included (data collection period between 1977 and 2011). Eighteen studies evaluated ICD-9 codes (11 of which assessed both invasive breast cancer (code 174.x) and carcinoma in situ (ICD-9 233.0)); three studies evaluated invasive breast cancer-related ICD-10 codes. All studies except one considered incident cases.The initial algorithm results were: sensitivity ≥80% in 11 of 17 studies (range 57%-99%); positive predictive value was ≥83% in 14 of 19 studies (range 15%-98%) and specificity ≥98% in 8 studies. The combination of the breast cancer diagnosis with surgical procedures, chemoradiation or radiation therapy, outpatient data or physician claim may enhance the accuracy of the algorithms in some but not all circumstances. Accuracy for breast cancer based on outpatient or physician's data only or breast cancer diagnosis in secondary position diagnosis resulted low.

CONCLUSION

Based on the retrieved evidence, administrative databases can be employed to identify primary breast cancer. The best algorithm suggested is ICD-9 or ICD-10 codes located in primary position.

TRIAL REGISTRATION NUMBER

CRD42015026881.

Accuracy of colorectal cancer ICD-9-CM codes in Italian administrative healthcare databases: a cross-sectional diagnostic study

Objectives To assess the accuracy of International Classification of Diseases, Ninth Revision - Clinical Modification (ICD-9-CM) codes in identifying subjects with colorectal cancer.

DESIGN

A diagnostic accuracy study comparing ICD-9-CM codes (index test) for colorectal cancers with medical chart (as a reference standard). Case ascertainment based on neoplastic lesion(s) within the colon/rectum and histological documentation from a primary or metastatic site positive for colorectal cancer.

SETTING

Administrative databases from the Umbria region, Azienda Sanitaria Locale (ASL) Napoli 3 Sud (NA) region and Friuli Venezia Giulia (FVG) region.

PARTICIPANTS

We randomly selected 130 incident patients from each hospital discharge database, admitted between 2012 and 2014, having colorectal cancer ICD-9 codes located in primary position, and 94 non-cases, that is, patients having a diagnosis of cancer (ICD-9 140-239) other than colorectal cancer in primary position.

OUTCOME MEASURES

Sensitivity, specificity and predictive values for 153.x code (colon cancer) and for 154.x code (rectal cancer).

RESULTS

The positive predictive value (PPV) for colon cancer diagnoses was 80% for Umbria (95% CI 73% to 87%), 81% for NA (95% CI 73% to 88%) and 80% for FVG (95% CI 72% to 87%).The sensitivity ranged from 98% to 99%, while the specificity ranged from 78% to 80% in the three units.For rectal cancer, the PPV was 84% for Umbria (95% CI 77% to 90%), 80% for NA (95% CI 72% to 87%) and 81% for FVG (95% CI 73% to 87%). The sensitivities ranged from 98% to 100%, while the specificity estimates from 79% to 82%.

CONCLUSIONS

Administrative databases in Italy can be a valuable tool for cancer surveillance as well as monitoring geographical and temporal variation of cancer practice.

Molecular and Pathological Features of Gastric Cancer in Lynch Syndrome and Familial Adenomatous Polyposis

Lynch syndrome (LS) and familial adenomatous polyposis (FAP) are autosomal dominant hereditary diseases caused by germline mutations leading to the development of colorectal cancer. Moreover, these mutations result in the development of a spectrum of different tumors, including gastric cancers (GCs). Since the clinical characteristics of GCs associated with LS and FAP are not well known, we investigated clinical and molecular features of GCs occurring in patients with LS and FAP attending our Institution. The Hereditary Tumor Registry was established in 1994 at the Department of Oncologic Gastroenterology, CRO Aviano National Cancer Institute, Italy. It includes 139 patients with LS and 86 patients with FAP. Patients were recruited locally for prospective surveillance. Out of 139 LS patients, 4 developed GC—3 in the presence of helicobacter pylori infection and 1 on the background of autoimmune diseases. All GCs displayed a high microsatellite instability (MSI-H) and loss of related mismatch repair (MMR) protein. One of the FAP patients developed a flat adenoma, displaying low-grade dysplasia at the gastric body, and another poorly differentiated adenocarcinoma with signet ring cells like Krukenberg without HP infection. LS carriers displayed a risk of GC. The recognition of HP infection and autoimmune diseases would indicate those at higher risk for an endoscopic surveillance. Regarding FAP, the data suggested the need of suitable endoscopic surveillance in long survivals with diffuse fundic gland polyps.