The Burden of Thin Melanomas in Tuscany, Italy, 1985-2017: Age- and Sex-Specific Temporal Trends in Incidence and Mortality

A steady increase in the incidence and mortality burden correlated to thin melanomas (≤1 mm) has been reported in recent years in some international studies, but there is currently a paucity of data from the Mediterranean area. We aimed to describe the epidemiological characteristics of thin melanoma in Tuscany, Central Italy. A total of 6002 first cutaneous invasive melanomas occurring from 1985 to 2017 were selected for analysis; data were retrieved from the local population-based cancer registry. The standardized incidence rate was 15.0 per 100,000 in the population, higher among men than women (16.5 vs. 14.1). Incidence rates tended to increase over time across all age group-specific population strata, with annual percent changes moderately higher among men (+8.0%) than women (+6.9%), especially among the elderly. Among both sexes and in each age group, the trend toward increasing incidence rates was particularly strong for thin melanomas. Survival was better among women than men across all categories of thickness. Approximately 15% of deaths occurred among patients with thin lesions, with no major temporal changes in recent years. This study contributes to an improved understanding of melanoma epidemiology in Tuscany and underscores the need for primary prevention strategies tackling the growing burden of thin melanomas.

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.

10-year survival in female breast cancer patients according to ER, PR and HER2 expression: a cancer registry population-based analysis

INTRODUCTION

Invasive breast cancer prognosis has significantly improved over time; however, there are few data about the long-term survival.

MATERIALS AND METHODS

We analysed the data on female breast cancer incident during 2004-2005 in the area of the Tuscan Cancer Registry, distinguishing them in five subtypes, according to ER, PgR, HER2, and Ki67 expression: luminal A, luminal B, luminal B/HER2 + , triple-negative, and HER2 + . Effects of subtypes and age on 10 years breast cancer specific survival were analysed by Kaplan-Meier and multivariate Cox analysis.

RESULTS

The majority of breast cancer were luminal B (57%), and 45% of them were diagnosed at pathological stage I. The 10-year survival rates (p < 0.001) were higher among luminal A (90.2%) and lower among HER-2 + patients (70.3%). Prognostic effect of age was statistically significant (p < 0.0004): the 10-year cancer specific survival rates were higher among 40-59 years of age patients (88.5%), lower among 0-39 (75.8%). Luminal A breast cancer patients had a constant low risk throughout 10 years of follow up, while luminal B/HER2 + and triple negative tumours showed a peak 5 years after the diagnosis and then declined.

DISCUSSION

Our study confirmed the prognostic effect of biological subtype also in a long term follow up study; moreover, age at diagnosis showed to influence the outcome, other than stage at diagnosis and treatment. The long term follow up showed a constant risk of death for luminal A and B tumours, whereas for non-luminal cancer a peak 5 years after the diagnosis was found.

Excess risk of subsequent malignant neoplasms in adolescent and young adult cancer survivors: Results from the first Italian population-based cohort

BACKGROUND

Evidence about late effects in adolescent and young adult (AYA) cancer survivors is scarce. This study assessed the risk of subsequent malignant neoplasms (SMNs) to identify the most common SMNs to be considered in follow-up care.

METHODS

Population-based cancer registries retrospectively identified first primary tumors (between 1976 and 2013) and SMNs in AYAs (15-39 years old at their cancer diagnosis). AYA cancer survivors were those alive at least 5 years after their first cancer diagnosis. The excess risk of SMNs was measured as standardized incidence ratios (SIRs) and absolute excess risk together with the cumulative incidence of SMNs.

RESULTS

The cohort included 67,692 AYA cancer survivors. The excess risk of developing any SMN (SIR, 1.6; 95% confidence interval, 1.5-1.7) was 60%. The excess risk of SMNs was significantly high for survivors of lymphomas; cancers of the breast, thyroid, female genital tract, digestive organs, gonads, and urinary tract; and melanomas. The cumulative incidence of all SMNs in AYA cancer survivors within 25 years of their first cancer diagnosis was approximately 10%. Subsequent tumors contributing to approximately 60% of all SMNs were breast cancer, colorectal cancer, corpus uteri cancer, and ovarian cancer in females and colorectal cancer, bladder cancer, prostate cancer, lung cancer, and lymphomas in males.

CONCLUSIONS

These results highlight the need to personalize follow-up strategies for AYA cancer survivors.

Nonthyroidal second primary malignancies in differentiated thyroid cancer patients: Is the incidence increased comparing to the general population and could it be a radioiodine therapy consequence?

The long-term survival of differentiated thyroid cancer (DTC) patients and the need to perform several treatments with radioiodine (131-I) lead to the question if the lifetime risk of developing a nonthyroidal second primary cancer (NTSPC) is increased in these patients. In our study, we assessed the prevalence of NTSPCs in thyroid cancer population and evaluated the possible causative role of 131-I treatment. We analyzed 1096 consecutive patients followed at our institution from 1964 to 1998. A total of 101 NTSPCs were observed in 92/1096 patients (8.4%) among which 17/101 (16.8%) diagnosed before DTC and 84/101 (83.2%) diagnosed after. The most frequent tumor sites observed were breast and bladder/urinary tract in the post-DTC group and breast and hematological system in the pre-DTC group. Regarding 131-I treatment, we did not observe any significant differences regarding either the number of treatments or the cumulative activity. The only significant parameter associated with an increased incidence of NTSPC was follow-up (P = .02): a longer follow-up period was associated with a higher number of NTSPCs. The mean latency between 131-I and NTSPC was 10.52 ± 7.69 years. Comparing with the general Italian population, independent of radioiodine treatment, the standard incidence ratio in our cohort was similar to that of the general population (SIR 1.07) and this result was confirmed by analyzing only the treated group. In conclusion, these results show that the risk of NTSPCs in the DTC patients' population is similar to that in the general population and 131-I treatment was not associated with an increased risk.

Adolescent and Young Adult Cancer Survivors: Design and Characteristics of the First Nationwide Population-Based Cohort in Italy

Purpose: Adolescent and young adult (AYA, 15-39 years) cancer survivors (alive at least 5 years after cancer diagnosis) are less studied than younger and older cancer survivors and research on their late effects is limited. To facilitate research on long-term outcomes of AYA cancer survivors, we established, in Italy, a population-based AYA cancer survivors' cohort. This article describes the study design and main characteristics of this cohort. Methods: The cohort derives from population-based cancer registries (CRs). Each CR identified AYA cancer patients retrospectively. Treatment for first primary cancer and all health events from diagnosis to death can be traced through linkage with available health databases, such as hospital discharge records (HDRs), mortality files, and outpatient and pharmaceutical databases. Results: Thirty-four CRs participated to the cohort which overall includes 93,291 AYAs with cancer and 67,692 cancer survivors. First primary cancer distribution in AYA cancer survivors differs by sex and age groups because of the different cancer types diagnosed in AYAs. Almost 78% of AYA cancer survivors have HDRs and 14.8% also pharmaceutical and outpatient databases. Conclusion: This cohort will be used to study, for the first time in Italy, the pattern and excess risk of late effects in AYA cancer survivors. HDRs, outpatient and pharmaceutical databases will be used to define primary treatment to assess its impact on AYA cancer survivors' late effects. This cohort exploiting data sources already available at CRs, minimize the data collection effort and it will contribute to assess the feasibility of using administrative database to study cancer survivors' late effects.

Impact of screening programme using the faecal immunochemical test on stage of colorectal cancer: Results from the IMPATTO study

To evaluate the impact of faecal immunochemical test (FIT) screening on stage distribution at diagnosis, and to estimate relative incidence rates by stage in screened at first and subsequent rounds vs. unscreened. We included all incident cases occurring in 2000-2008 in 50- to 71-year-olds residing in areas with an FIT-screening programme. Multinomial logistic models were computed to estimate the relative risk ratio (RRR) of stages I and IV, compared to stage II + III, adjusting for age, sex, geographical area, and incidence year. Proportions were then used to estimate incidence rate ratios (IRR) by stage for screened subjects at the first and at subsequent rounds vs. unscreened subjects, applying the expected changes in overall incidence during screening phases. 11,663 cancers were included: 5965 in not-invited and 5,698 in invited subjects, 3,425 of whom attendees. Compared to not-invited, invited subjects had RRR 2.04 (95% CI: 1.84; 2.46) of stage I and RRR 0.77 (95% CI: 0.69; 0.87) of stage IV. Differences were stronger comparing attendees vs. nonattendees. Interval cancers were more frequently stage I compared to non-invited (RRR 1.54; 95% CI: 1.15; 2.04), but there was no difference for stage IV. IRRs in screened at first round vs. unscreened were 4.6 (95% CI: 4.2; 5.1), 1.4 (95% CI: 1.3; 1.5) and 0.7 (95% CI: 0.6; 0.9) for stages I, II + III and IV, respectively; in the following rounds the IRRs of screened vs. unscreened were 1.4 (95% CI: 1.2; 1.6), 0.8 (95% CI: 0.7; 0.9) and 0.3 (95% CI: 0.1; 0.4) for stages I, II + III and IV, respectively. FIT screening reduces the incidence of metastatic cancers by about 70% after the first round.

Smoking Cessation in the ITALUNG Lung Cancer Screening: What Does “Teachable Moment” Mean?

Background

Changes in smoking habits and predictors of smoking cessation were examined in the randomized ITALUNG lung cancer screening trial.

Methods

In three centers, eligible smokers or ex-smokers (55–69 years, ≥20 pack-years in the last 10 years) were randomized to receive annual invitation for low-dose computed tomography for 4 years or usual care. At invitation, subjects received written information for a free smoking cessation program. Quitting outcome was assessed at year 4.

Results

Among participants who completed baseline assessments and year 4 screening, higher quitting (20.8% vs. 16.7%, p = .029) and lower relapse (6.41% vs. 7.56%, p = .50) rates were observed in the active screening group as compared to the usual-care control group. Corresponding figures in the intention-to-treat analysis were as follows: 16.04% versus 14.64% (p = .059) and 4.88% versus 6.43% (p = .26). Quitting smoking was significantly associated to male gender, lower pack-years, and having pulmonary nodules at baseline. Center-specific analyses showed a threefold statistically significant higher probability to quit associated with participating in the smoking cessation program. A subsample of smokers of the scan group from one center showed higher quitting rates over 12-month follow-up as compared to matched controls from the general population who underwent the same smoking cessation program.

Conclusions

Consistently with previous reports, in the ITALUNG trial, screened subjects showed significantly higher quit rates than controls, and higher quit rates were associated with both the presence of pulmonary nodules and participating in a smoking cessation program. Maximal effect on quitting outcome was observed with the participation in the smoking cessation program.

Implications

Participating in lung cancer screening promotes smoking cessation. An effective “teachable moment” may be achieved when the smoking cessation intervention is structured as integral part of the screening clinical visits and conducted by a dedicated team of health care professionals. Standardized guidelines for smoking cessation interventions in lung cancer screening are needed.

[Reporting a cluster of lymphohaematopoietic cancers and management of the communication process with the community: the experience of a Local health Authority in Tuscany, Italy]

In 2008, some general practitioners (GPs) in the area of Empoli (Tuscany Region, Central Italy), reported to the Local Health Authority (LHA), an unusually high frequency of leukemia deaths among their patients residing in a one of the municipalities of the area. The LHA decided to carry out an epidemiological investigation. An interdepartmental working group was set up, led by the Department of Prevention of the LHA, and made up of representatives of the Institute for Study, Prevention and Cancer Network (ISPRO, Florence), the G. Monasterio Foundation/ Institute of Clinical Physiology of the National Council for Research (CNR) of Pisa, the University of Pisa, the Regional Environmental Protection Agency and community members. Several epidemiological analyses were carried out (namely incidence and mortality analysis, assessment of the residential history of all cases and micro-geographical incidence evaluation, assessment and quantification of local environmental pressures, evaluation of congenital abnormalities). The investigation took over two years to be completed. The work agenda was shared with community members, who contributed to decision-making, study design and the communication plan. Thanks to the interaction with community members, researchers had the chance to become aware of their information needs and of local knowledge concerning the research issues. The final report was published online and presented to citizens in several public meetings. Direct involvement of the local community during project development was found to be useful to reduce the perceived distance between public authorities and the local population, as highlighted in the guidelines on cancer cluster investigations.

Volumetric breast density and risk of advanced cancers after a negative screening episode: a cohort study

BACKGROUND

We evaluated the association between volumetric breast density (BD) and risk of advanced cancers after a negative screening episode.

METHODS

A cohort of 16,752 women aged 49-54 years at their first screening mammography in the Florence screening programme was followed for breast cancer (BC) incidence until the second screening round. Volumetric BD was measured using fully automated software. The cumulative incidence of advanced cancer after a negative screening episode (including stage II or more severe cancer during the screening interval - on average 28 months - and at the subsequent round) was calculated separately for Volpara density grade (VDG) categories.

RESULTS

BC incidence gradually increased with the increas in BD: 3.7‰, 5.1‰, 5.4‰ and 9.1‰ in the VDG categories 1-4, respectively (p trend < 0.001). The risk of advanced cancers after a negative screening episode was 1.0‰, 1.3‰, 1.1‰, and 4.2‰ (p trend = 0.003). The highest BD category, compared with the other three together, has double the invasive BC risk (RR = 2.0; 95% CI 1.5-2.8) and almost fourfold risk of advanced cancer (RR = 3.8; 95% CI 1.8-8.0).

CONCLUSION

BD has a strong impact on the risk of advanced cancers after a negative screening episode, the best early surrogate of BC mortality. Therefore, our results suggest that screening effectiveness is quite different among BD categories.

Melanoma survival: sex does matter, but we do not know how

The objective of this study was to provide further insights into the prognostic role of female sex in skin melanoma. The prognostic effect of sex in a population-based case series of 3900 skin melanomas in central Italy has been evaluated considering the possible confounding role of many demographic and clinical variables (age, period of diagnosis, Breslow's thickness, Clark level, ulceration, lymph node status, metastasis, histological type, skin site, and pathological T and N). Multiple imputations, according to chained equations, have been used for imputing incomplete values. A Cox proportional hazards model on the risk of death caused by melanoma was fitted. Univariate and multivariate effects of sex and of other variables were computed. The 5-year cause-specific survival was 87% (95% confidence interval: 86-89%) for women and 80% (78-82%) for men. Women had higher rates at any time since diagnosis. After adjustment for other confounders, women had a 34% reduced risk compared with men of dying from skin melanoma (hazard ratio=0.66, 95% confidence interval: 0.56-0.79). The present study confirmed a strong protective effect of female sex on skin melanoma mortality. The protective factor is still unknown.

How staging of thin melanoma is changed after the introduction of TNM 7th edition: a population-based analysis

INTRODUCTION

In 2009, the American Joint Committee on Cancer (AJCC) incorporated the tumor mitotic rate in the melanoma pathological TNM staging system. To investigate the effect of this change on the pT1 substaging of primary cutaneous melanomas, we reclassified the cases collected by a cancer registry according to the 6th and the 7th editions of AJCC melanoma staging.

METHODS

Patients with pathological T1 melanoma diagnosed in the period 2000-2008 were selected from Tuscan Cancer Registry. The histological reports were reviewed and pT1 melanomas classified according to both the 6th and the 7th editions of the AJCC staging system. The shift of melanomas between pT1 substages was analyzed.

RESULTS

Among the 242 pT1 melanomas collected in the study period and with mitotic index available, there were 202 (83 % of all pT1) and 175 (72 %) pT1a, according to the 6th and the 7th editions of the AJCC melanoma staging, respectively. When the 7th edition was used, 20 % of all pT1a melanomas shifted to pT1b, and 32 % of all pT1b melanomas shifted to pT1a. A poor level agreement between the two TNM staging systems, measured by the Cohen's kappa coefficient, was found (K = 0.37).

CONCLUSIONS

The addition of mitotic activity to the pathological staging resulted in an increase in pT1b proportion and in a change in the classification of some cases. This modification could influence the clinical approach, with a different use of the sentinel lymph node biopsy, and underlines the role of mitosis evaluation in the management of thin melanoma patients.

[Suicide mortality among cancer patients]

OBJECTIVE

to evaluate the excess risk in the deaths due to suicide in a huge case-series of cancer patients and in particular in a group with recent diagnosis.

DESIGN

observational cohort.

SETTING AND PARTICIPANTS

population-based study based on 136,105 patients of the cancer registry of Tuscany Region, incident during 1985-2005, 42,321 of whom diagnosed during 2000-2005.

MAIN OUTCOME MEASURES

standardised mortality ratio (SMR) of suicide by sex, age, prognosis, time since diagnosis and period of incidence.

RESULTS

deaths due to suicide were 0.2% of all the deaths observed in the cohort of patients. Overall cases, 1985-2005, showed a SMR of 1.47 (p<0.05), it was higher than expected for men (SMR =1.50), for subjects older that 54 years, especially for cancers with poor prognosis (SMR=2.27), particularly during the first year after diagnosis (SMR=2.87) but also in the following years. Cases diagnosed in 2000-2005 had a SMR=1.19 (n.s.), confirmed the high risk for the age 55-64 years (SMR=2.27), for cancers with worse prognosis (SMR=3.23) and during the first year after diagnosis (SMR=2.64). Trend analysis showed that the excess in the risk of suicide death among cancer patients decreased over time (p=0.042).

CONCLUSION

although suicide is not one of the major cause of death among cancer patients, we confirmed that those patients had a higher risk than the general population. SMR higher than expected were documented for the age 55-64 years, for cancers with poor prognosis and during the first year after diagnosis. Trend analysis shows that excess in the risk of suicide death among cancer patients is decreasing over time. This may be due, among other possible explanations, to the relevant development of the palliative care system in the area based both on hospices and on home care. Although suicide deaths are rather rare, their prevention among cancer patients is still a priority, due to its likely depressive etiology and to the effects on the family and on the health system.

Balancing harms and benefits of service mammography screening programs: a cohort study

INTRODUCTION

The use of screening mammography is still under debate within the medical community. The aim of this study is to define a balance sheet of benefits (breast cancer mortality reduction) and harms (overdiagnosis) for mammography screening programs.

METHODS

We compared breast cancer incidence and mortality in two cohorts of women, defined as 'attenders' or 'non-attenders' on the basis of the individual attitudes towards screening, who were invited to the first round of the Florentine screening program. The effects of screening exposure on breast cancer incidence and mortality were evaluated by fitting Poisson regression models adjusted for age at entry, marital status and deprivation index. We performed a sensitivity analysis excluding 34 women not responding to the invitation with a breast cancer diagnosis in the following six months.

RESULTS

In total, we included 51,096 women aged 50 to 69 years invited at the first screening round (1991 to 1993) and followed-up for breast cancer incidence and mortality until 31 December 2007 and 31 December 2008, respectively The estimate of mortality reduction varies from 45% among 50 to 59 year-old women up to 51% among 60 to 69 year-old women. The estimate of overdiagnosis, according to the cumulative-incidence method, is an additional 10% of all breast cancer cases among 60 to 69 year-old women screened.

CONCLUSIONS

Comparing the breast cancer mortality and breast cancer incidence between attenders and non-attenders, we have determined that the overall cost to save one life corresponds to no more than one over-diagnosed tumor (from 0.6 to 1 depending on the selection criteria of the cohort), even if a residual self-selection bias cannot be excluded.

[Socio-economic determinants of cancer survival in the municipality of Florence]

OBJECTIVE

The aim of the present paper is to evaluate cancer survival in patients resident in the municipality of Florence according to different deprivation levels.

DESIGN

We used data from the Tuscan Cancer Registry and data from the national census 2001. We used a deprivation index, measured as a continue variable, classified in tertiles according to the distribution of the resident population. We compared more deprived patients (category 3) vs less deprived ones (category 1-2).

MAIN OUTCOME MEASURES

10-year relative survival has been computed for patients diagnosed with 27 different cancer sites during 1997-2002, for different deprivation categories. Cancer sites were split into three groups of the same dimension, on the basis of 10-year survival (bad, intermediate and good prognosis). For each category the relative excess risk of death (RER) for most deprived patients has been computed using a Generalized Liner Model. We evaluated also the effect of marital status, classified as married and non-married.

RESULTS

We analysed 14 549 invasive cancer cases (out of skin epithelioma). Overall bad prognosis cancers did not show any RER of dying for most deprived patients. For intermediate prognosis cancers RER was 1.13 (1.02 ; 1.24). A excess occurs in the most disadvantaged tertile for tumors diagnosed under 50 years. For good prognosis cancers the RER was 1.06 (0.89 ; 1.26). We found a relative excess of mortality for non-married vs married.

CONCLUSIONS

In the area of Florence there is an effect of deprivation level of survival for median-better prognosis cancers, for tumours diagnosed under 50 years and for unmarried people compared to unmarried ones.

[Cancer incidence in Italian natives and in first-generation immigrants to Italy]

OBJECTIVE

The aim of this study was to evaluate differences in cancer incidence in populations born in different countries in the area covered by the Tuscan Cancer Registry.

SETTING

We selected cancer cases diagnosed during the period 1998-2005 in the population resident in the provinces of Firenze and Prato. Each case was classified according to the place of birth: a) born in Italy, b) born in countries with high migration (PFPM), born in other highly developed countries (PSA).To compute incidence rates we used as denominator the health regional registry.

MAIN OUTCOME MEASURES

We used the European standard population in computing standardized incidence rates (restricted to the age group 20-59 years) and the standardized rate ratio (SRR) in order to compare subjects born in different countries.

RESULTS

During the period 1998-2005, 14 791 invasive cancers were diagnosed (non-melanoma skin excluded) in subjects aged 20-59 years old, 4.2% in subjects born in countries outside Italy (1.2% in other PSA e 3.0% in PFPM). Incidence in subjects born in PSA did not differ significantly from incidence in subjects born in Italy. Incidence rates among subjects born in PFPM were statistically lower, both in men (151.2 per 100 000) and women (199.3 per 100 000), than in subjects born in Italy (243.5 men e 337.5 women). On the contrary, liver and cervix uteri cancer incidence showed higher rates among subjects born in PFPM (liver: SRR=2.13, p=0.007; cervix uteri: SRR=1.88, p=0.0095).

CONCLUSION

Subjects born in countries with high migration showed a level of incidence lower than subjects born in Italy (healthy migration effect). Incidence was higher among subjects born in PFPM only for liver and cervix uteri, cancers with a virological aetiology. The migration phenomena open new study prospectives, but also methodological questions (definition of immigrants and of reference populations).

Risk of invasive cervical cancer and cervical intraepithelial neoplasia grade III in central Italy by area of birth

OBJECTIVES

To evaluate cervical cancer incidence among women born in different countries but residing in Italy.

SETTING

Women aged 25-59 from a central Italian population-based cancer registry.

METHODS

Invasive and in situ cervical cancer incidence rates from 2000-2004 were calculated. Standardized incidence rates were based on the European standard population. Places of birth were categorized by nine different areas.

RESULTS

Within the resident population aged 25-59, there were 148 invasive cervical cancers (17.6% in women born outside Italy) and 501 (14.2% in women born outside Italy) cervical intraepithelial neoplasia grade III (CIN III) diagnoses. The incidence of invasive cervical cancer for women born in 'Central & South America and the Caribbean' was 60.5 per 100,000 and in 'Central and Eastern Europe' it was 38.3, statistically significantly higher than for women born in Italy (9.5 per 100,000). The CIN III rate was 35.0 per 100,000 for women born in Italy. The ratio between standardized rates for CIN III and invasive cancers was around 4 for women born in Italy and the 'extended European Union', and around 6 for those born in 'Asia'. It was 1.64 for women born in 'Africa', 1.31 in 'Central & South America and the Caribbean' and 0.69 for those born in 'Eastern Europe'.

CONCLUSIONS

Women who reside in Italy but were born in 'Central & South America and the Caribbean' or in 'Central and Eastern Europe' are at high risk for invasive cervical cancer. These groups are less inclined to participate in screening, and appropriate preventive strategies should be planned accordingly.

[Cancer incidence estimation by hospital discharge flow as compared with cancer registries data]

OBJECTIVE

the study evaluates the accuracy of an algorithm based on hospital discharge data (HDD) in order to estimate breast cancer incidence in three italian regions (Emilia-Romagna, Toscana and Veneto) covered by cancer registries (CR). The evolution of computer-based information systems in health organization suggests automatic processing of HDD as a possible alternative to the time-consuming methods of CR. The study intends to verify whether HDD quickly provides reliable cancer incidence estimates for diagnosis and therapy evaluations.

DESIGN AND SETTING

an algorithm based on discharge diagnosis and surgical therapy of hospitalized breast cancer patients was developed in order to provide breast cancer incidence. Results were compared with the corresponding incidence data of cancer registries. The accuracy of the automatic method was also verified by a direct record-linkage between HDD output and registries' files. The overall survival of cases lost to "HDD method" was analyzed.

RESULTS

in the period covered by the study (3,125,425 person/year) CR enrolled 6,079 incident cases, compared to 6,000 cases recorded through the HDD flow. Incidence rates of the two methods (CR 194.5; HDD 192.0 x 100.000) showed no statistical differences. However, matched cases by the two methods were only 5,038. The sensitivity of the HDD algorithm was 82.9% and its predictive positive value (PPV) was 84.0%. False positive cases were 9.9%. On the other hand, 12.3% CR incident cases were not identified by the algorithm: these were mainly made up of older women, not eligible for surgical therapy. Their three-years survival was 62.0% vs 88.8% of the whole incidence group.

CONCLUSION

HDD flow performance was similar to observations reported in the literature. The agreement between HDD and CR incidence rates is a result of a cross effect of both sensitivity and specificity limitations of the HDD algorithm. This can seriously impair the reliability of the latter method with regard to the evaluation of diagnostic and therapeutic strategies in cohort studies (i.e. the most effective approach to health setting in oncology).s.