Extension of organised cervical cancer screening programmes in Italy and their process indicators.

Since 1996, Italian national guidelines recommend that Regions implement organised screening programmes for cervical cancer. As in previous years since 1998, we have collected from Italian organised cervical screening programmes aggregated tables of data in order to centrally compute process indicators. In 2006, the target population of Italian organised screening programmes included 11,362,580 women, corresponding to 69% of Italian women aged 25-64 years. However, taking into account the proportion of women invited, the actual extension was 52.9%. Compliance to invitation was 38.5%, with a clear North-South decreasing trend. It should, however, be considered that many women are screened outside the organised programmes. The remaining process indicators deal with women invited during 2005 and screened up to April 2006 Of these, 6.1% were recommended to repeat cytology and 57% of them complied; 2.3% of screened women were referred to colposcopy. Compliance to colposcopy was 84.7% among women referred because of ASCUS or more severe cytology and 90% among those referred because of HSIL or more severe cytology. The positive predictive value (PPV) of referral because of ASCUS or more severe cytology for CIN2 or more severe histology was 16.8%. There was a relevant variability of both referral rate and PPV that were inversely related. The unadjusted detection rate of histologically confirmed CIN2 or more severe was 2.7 per 1,000 screened women (2.6 standardised on the Italian population, truncated 25-64).

Extension of organised cervical cancer screening programmes in Italy and their process indicators.

Since 1996, Italian national guidelines have recommended to regions the implementation of organised screening programmes for cervical cancer. As in the previous years, starting from 1998, we collected aggregated tables of data from Italian organised cervical screening programmes in order to centrally compute process indicators. In 2005, the target population of Italian organised screening programmes included 10,969,571 women, corresponding to 66.7% of Italian women aged 25-64 years. However, these programmes invited only 24.8% of their target population in 2005, vs. 33.3% expected in order to invite the entire target population in the 3-year recommended interval. Compliance to invitation was 36.7%, with a clear North-South decreasing trend. It must however be considered that many women are screened outside the organised programmes. The remaining process indicators deal with women invited during 2004 and screened up to April 2005. Unsatisfactory smears were 3.1%. It was recommended to 6.1% of women to repeat cytology, and 61% of them complied. Some (2.5%) of screened women were referred to colposcopy. Compliance to colposcopy was 84.7% among women referred because of ASCUS or more severe cytology and 88.2% among those referred because of HSIL or more severe cytology. The Positive Predictive Value (PPV) of referral because of ASCUS or more severe cytology for CIN2 or more severe histology was 15.5%. There was a relevant variability of both referral rate and PPV, that were inversely related, and 10 % ofprogrammes referred > 5% of women, suggesting too broad criteria of interpretation of cytology. The unadjusted detection rate ofhistologically confirmed CIN2 or more severe was 2.7 per 1000 screened women (3.0 per 1000, standardised on the Italian population, truncated 25-64).

Activity level and process indicators of organised programmes for cervical cancer screening in Italy.

The target population of Italian organised cervical screening programmes that were active (that invited at least 1000 women) in 2004 was 10,206,741 women, corresponding to 64% of the Italian female population in the 25-64 year age range. This proportion was 66%, 83% and 49% in Northern, Central, and Southern Italy respectively. Some 27% of this target population was invited during 2004. Among women invited in 2004, 37.7% had cytology within organised programmes up to April 2005 (46.2%, 36.0% and 26.2% in Northern, Central, and Southern Italy respectively). It must be kept in mind that many women have spontaneous tests that are not registered in organised programmes. Further data on women invited in 2003 were collected as aggregated tables, provided by the local screening registration systems. We obtained data from 99 programmes with an overall target population of 8,698,480 women. At least 70% of programmes could provide data for most indicators. Overall, 3.2% of smears were classified as unsatisfactory. At a national level 6.6% of women was advised to repeat cytology and 62.2% of them actually did. However 13/71 programmes recommended repeat cytology to > 10% of screened women. Nationwide, 2.6% of screened women were referred to colposcopy. The Positive Predictive Value (PPV) of detecting a biopsy-proven Cervical Intraepithelial Neoplasia grade 2 (CIN2) or more severe among women referred because of cytology "Atypical Squamous Cells of Undetermined Significance" or more severe was 15.0%. There was however a relevant variability: 9/90 programmes had a referral rate >5%. There was an inverse correlation between referral rate and PPV. Compliance with recommended colposcopy was 86% (91% among women with high-grade cytology). The raw detection rate of biopsy-proven CIN2+ was 2.7 per 1000 screened women (2.8 per 1000 when standardised on the Italian population). In conclusion, during 2004 there was a further increase of active organised programmes, especially in Southern Italy. This is important, as spontaneous activity is known to be low there. Despite this rise, quality indicators were stable. However, in a few programmes, the use of excessively broad criteria in the interpretation of cytology decides an excessively high rate of referrals to colposcopy.

Gynaecological cancers in Umbria (Italy): trends of incidence, mortality and survival, 1978-1998.

OBJECTIVE: For the period 1978-1998 incidence, mortality and survival from gynaecological cancers in the Umbria region (Central Italy) were examined. STUDY DESIGN: Mortality data were derived from the National Institute of Statistics while incidence and survival data were provided by an ad hoc survey carried out over the period 1978-1982 and by the Umbrian Population-Based Cancer Registry operating since 1994. Age-standardised mortality and incidence rates were calculated. Survival was assessed using the Estève method. Mortality trends were analysed by joinpoint regression model. RESULTS: In the Umbria Region, over the period 1978-1998, the incidence rate of cervical cancer decreased, while those for endometrial and ovarian cancers rose. By contrast, the mortality rates from ovarian and endometrial cancers decreased, while that for cervical cancer rose slightly. Comparing relative survival rates, at 5 years an increase in survival was reported for ovarian cancer, cervical cancer remained constant and endometrial cancer slightly decreased; at 1 year only the ovarian cancer survival improved. Nevertheless, age-standardised survival rates showed that survival improved in all examined sites. CONCLUSIONS: The improvement in diagnosis and in data coding could have determined an increase in endometrial and ovarian cancer incidence, while the dramatic decrease in cervical cancer incidence is probably due to the effectiveness of cervical screening.