Methods to increase participation in organised screening programs: a systematic review.

BACKGROUND: The European Community recommends the implementation of population-based screening programmes for cervical, breast, and colorectal cancers. This recommendation is supported by many observational studies showing that organised programmes effectively reduce mortality and control the inappropriate use of screening tests. We conducted a systematic review of studies assessing the efficacy of interventions to increase participation in organised population-based screening programs. METHODS: We included all studies on interventions aimed at increasing screening participation published between 1/1999 and 7/2012. For those published before 1999, we considered the Jepson et al. (2000) review (Health Technol Assess 4:1-133, 2000). RESULTS: Including studies from the Jepson review, we found 69 with quantitative information on interventions in organised screening: 19 for cervical, 26 for breast, 20 colorectal cancers, and 4 for cervical and breast cancer together.Effective interventions were: postal (breast RR = 1,37 95% Confidence Interval (95% CI): 1.25-1.51; cervical RR = 1.71 95% CI: 1.60-1.83; colorectal RR = 1.33 95% CI: 1.17-1.51) and telephone reminders (with heterogeneous methods for implementation); GP's signature on invitation letter (breast RR = 1.13 95% CI: 1.11-1.16; cervical RR = 1.20 95% CI: 1.10-1.30; colorectal RR = 1.15 95% CI: 1.07-1.24); scheduled appointment instead of open appointment (breast RR = 1.26 95% CI: 1.02-1.55; cervical RR = 1.49 95% CI: 1.27-1.75; colorectal RR = 1.79 95% CI: 1.65-1.93). Mailing a kit for self-sampling cervical specimens increased participation in non-responders (RR = 2.37 95% CI: 1.44-3.90). CONCLUSION: Although some interventions did prove to be effective, some specific variables may influence their effectiveness in and applicability to organised population-based screening programs.

The effect of physician's recommendation on seasonal influenza immunization in children with chronic diseases.

BACKGROUND: Despite recommendations by Health Authorities, influenza immunization coverage remains low in children with chronic diseases. Different medical providers involved in the management of children with chronic conditions may affect the pattern of influenza vaccine recommendations and coverage. The likelihood of vaccination by type of provider in children with chronic conditions is poorly understood. Therefore, the objectives of this study were to analyze the pattern and the effect of recommendations for seasonal influenza immunization provided by different physician profiles to families of children with chronic diseases and to measure the frequency of immunization in the study population. METHODS: We recruited children with chronic diseases aged 6 months-18 years who subsequently presented to specialty clinics for routine follow-up visits, during spring 2009, in three Italian Regions Families of children with chronic diseases were interviewed during routine visits at reference centers through a face-to-face interview. We analyzed the following immunization predictors: having received a recommendation toward influenza immunization by a health provider; child's sex and age; mothers and fathers' age; parental education and employment; underlying child's disease; number of contacts with health providers in the previous year. Influenza immunization coverage was calculated as the proportion of children who received at least one dose of seasonal influenza vaccine in the previous season. We calculated prevalence ratios and we used a generalized linear model with Poisson family, log link and robust error variance to assess the effect of socio-demographic variables, underlying diseases, and recommendations provided by physicians on influenza immunization. RESULTS: We enrolled 275 families of children with chronic diseases. Overall influenza coverage was 57.5%, with a low of 25% in children with neurological diseases and a high of 91.2% in those with cystic fibrosis. While 10.6% of children who did not receive any recommendation toward influenza immunization were immunized, among those who received a recommendation 87.5-94.7% did, depending on the health professional providing the recommendation. Receiving a recommendation by any provider is a strong predictor of immunization (PR = 8.5 95% CI 4.6;15.6) Most children received an immunization recommendation by a specialty (25.8%) or a family pediatrician (23.3%) and were immunized by a family pediatrician (58.7%) or a community vaccinator (55.2%). CONCLUSIONS: Receiving a specific recommendation by a physician is a strong determinant of being immunized against seasonal influenza in children with chronic diseases independently of other factors. Heterogeneity exists among children with different chronic diseases regarding influenza recommendation despite international guidelines. Increasing the frequency of appropriate recommendations toward influenza immunization by physicians is a single powerful intervention that may increase coverage in children with chronic conditions.

[Human Papilloma Virus (HPV), cervical cancer incidence and screening uptake: differences among Northern, Central and Southern Italy]. / Epidemiologia del Papilloma virus umano (HPV), incidenza del cancro della cervice uterina e diffusione dello screening: differenze fra macroaree in Italia.

OBJECTIVE: this article presents a review of evidences about Human Papillomavirus (HPV) and cervical cancer in Italy, highlighting geographical differences. DESIGN: two systematic reviews recently published were updated, one collecting studies on the prevalence of HPV types in Italy in the general population and the other collecting prevalence of HPV types in cervical pathologic samples.The search was updated to 31.10.2010 and performed exclusively in MedLine and references in retrieved papers. MAIN OUTCOME MEASURES: the prevalence of HPV types has been related with the incidence of cervical cancer and the spread of Pap tests and screening programs. RESULTS: the prevalence high risk HPV types is 8%in studies with population-based random sample, with no significant difference between Centre-North and South-Islands, however, the prevalence is slightly higher in the South than the Centre-North for women up to 54 years of age, whereas in older women the ratio is reversed. HPV 16 is the most common type, while HPV 18 is less frequent, 5% and 1% respectively. The average of HPV 16 positivity is 64% and 68% in CIN2/3 and invasive cancer respectively, while the average of HPV 18 is 7% and 11% in CIN2/3 and invasive cancer respectively. There are no significant differences by geographical area.The incidence of invasive cervical cancer in Italy has been decreasing in recent years changing from 9.2 to 7.7 per 100,000 inhabitants in 10 years. The incidence is lower in South-Islands. Pap test coverage is over 80% in Centre-North and less than 60%in South-Islands. CONCLUSIONS: cervical cancer incidence is lower in Southern Italy, while the Pap test coverage is much higher in Centre-Northern Italy. This paradox, until now, has been interpreted as a consequence of a lower HPV prevalence in Southern than Northern regions. Recent studies on HPV prevalence do not confirm this hypothesis. Our interpretation is that in Southern Italy we are facing an epidemiologic scenario in transition where the low cancer incidence is the consequence of a low HPV prevalence in the previous decades, but new generations are experiencing a higher prevalence of HPV and will probably have higher risk of cervical cancer. The consequence may be an epidemic of cervical cancer in the next decades, if adequate screening programs are not implemented.

[Methods to increase participation in cancer screening programmes]. / Metodi per aumentare la partecipazione ai programmi di screening oncologici.

OBJECTIVE: to synthesize scientific evidences about methods to increase cervical, breast and colorectal cancer screening participation. METHODS: a multidisciplinary working group has been set up to define the scope of the report and to conduct the evaluation. The scope and the final evaluation have been submitted to a stakeholder committee, including the Ministry of Health, the National Screening Observatory, regional screening program coordinators, scientific societies, and Lega Italiana Lotta ai Tumori, for comments and integrations. A systematic review of the principal biomedical and social literature databases was conducted to identify experimental and observational studies, updating the existing review by Jepson and coll. (Health Technol Assess. 2000;4(14):i-vii, 1-133). RESULTS: 5900 have been identified, 900 relevant for the topic.Among those, 148 reported quantitative information on intervention efficacy, other 90 came from the previous review. Organised screening programmes, based on invitation letter or on GP involvement,were consistently effective in increasing participation compared to spontaneous screening. Interventions are classified according to their target: individual, community, test simplification, health operators, health service organization. The report presents meta-analyses on efficacy, analyses of cost-effectiveness, impact on organisation and social inequality, and ethical and legal issues, of all the intervention reported in the literature. CONCLUSIONS: there are several interventions consistently effective in any context, some of them have minimal impact on costs and health service resources.

The combination of depressive symptoms and smoking shorten life expectancy among the aged.

BACKGROUND: Depression is a potential risk factor for mortality among the aged and it is also associated with other chronic diseases and unhealthy lifestyles that may also affect mortality. The purpose of this study was to investigate the association between depressive symptoms and mortality, controlling for health, nutritional status, and life-style factors. METHODS: A cohort of elderly people (N = 167) was followed-up for ten years. Information on socio-demographic characteristics, medical history, smoking, and alcohol consumption was collected. The primary outcome was all-cause mortality; the secondary outcome was cancer-specific mortality. The Geriatric Depression Scale (GDS-15) was used to assess depression. Using a multivariable Cox proportional hazards regression, we examined the association between depressive symptoms and mortality. RESULTS: Elderly people with depression (scoring above the depression cut-off of 7) had a 53% increased risk of mortality (relative risk (RR) 1.53; 95%CI: 1.05-2.24) compared to non-depressed subjects. The combination of depressive symptoms with smoking was associated with a particularly higher risk of mortality (RR: 2.61; 95%CI: 1.28-5.31), after controlling for potential confounders. CONCLUSIONS: Depressive symptoms are associated with a significantly increased risk of all-cause mortality. The combination of depressive symptoms and smoking shorten life expectancy among the aged.

Can we use the pharmacy data to estimate the prevalence of chronic conditions? a comparison of multiple data sources.

BACKGROUND: The estimate of the prevalence of the most common chronic conditions (CCs) is calculated using direct methods such as prevalence surveys but also indirect methods using health administrative databases.The aim of this study is to provide estimates prevalence of CCs in Lazio region of Italy (including Rome), using the drug prescription's database and to compare these estimates with those obtained using other health administrative databases. METHODS: Prevalence of CCs was estimated using pharmacy data (PD) using the Anathomical Therapeutic Chemical Classification System (ATC).Prevalences estimate were compared with those estimated by hospital information system (HIS) using list of ICD9-CM diagnosis coding, registry of exempt patients from health care cost for pathology (REP) and national health survey performed by the Italian bureau of census (ISTAT). RESULTS: From the PD we identified 20 CCs. About one fourth of the population received a drug for treating a cardiovascular disease, 9% for treating a rheumatologic conditions.The estimated prevalences using the PD were usually higher that those obtained with one of the other sources. Regarding the comparison with the ISTAT survey there was a good agreement for cardiovascular disease, diabetes and thyroid disorder whereas for rheumatologic conditions, chronic respiratory illnesses, migraine and Alzheimer's disease, the prevalence estimates were lower than those estimated by ISTAT survey. Estimates of prevalences derived by the HIS and by the REP were usually lower than those of the PD (but malignancies, chronic renal diseases). CONCLUSION: Our study showed that PD can be used to provide reliable prevalence estimates of several CCs in the general population.

Risk factors for sporadic pancreatic endocrine tumors: a case-control study of prospectively evaluated patients.

OBJECTIVES: Pancreatic endocrine tumors (PETs) are heterogeneous tumors with increasing prevalence. Little is known about the molecular pathogenesis and risk factors for the occurrence of sporadic PETs. The aim of this study was to identify the risk factors associated with the occurrence of sporadic PETs. METHODS: A case-control study comprising 162 sporadic PETs and 648 controls was undertaken. Subjects were interviewed using a specific questionnaire on demographics and potential risk factors, including smoking, alcohol, height, weight, medical history, and family history of cancer. A multiple hierarchical logistic regression analysis was performed with a stepwise variable- selection procedure. RESULTS: A first-degree family history of any cancer was a significant risk factor (odds ratio (OR) 2.2; 95% confidence interval (CI): 1.5-3.2). Among the different cancer sites, first-degree family history of pancreatic adenocarcinoma was more frequent in PETs than in controls (4.3 vs. 1.2%; P=0.01). A high alcohol intake (OR 4.8; 95% CI: 2.4-9.5), history of chronic pancreatitis (CP) (OR 8.6; 95% CI: 1.4-51), and recent-onset diabetes (OR 40.1; 95% CI: 4.8-328.9) were all independent risk factors. The history of diabetes was also associated with metastatic disease at the time of diagnosis. CONCLUSIONS: This case-control study identified family history of any cancer (and to a less extent of pancreatic adenocarcinoma), CP, high alcohol intake, and recent-onset diabetes as risk factors for PET, thus suggesting a possible partial overlap with risk factors for exocrine pancreatic carcinogenesis.

Morbidity experience in populations residentially exposed to 50 hz magnetic fields: methodology and preliminary findings of a cohort study.

A morbidity study of the population of a district of Rome built in part under a 60 kV electric distribution line, included 345 subjects resident in the study area in any period between 1954 and 2003, excluding those deceased before 1998. Residential magnetic field levels were estimated based on current load, line characteristics, and distance of the dwellings from the power line, and the study area was divided into sub-areas with differing magnetic field levels. Standardized morbidity ratios were computed from hospital discharge records dated 1998-2003. Non statistically significant increases were observed for all and primary cancers; primary cancers were significantly increased among subjects with > 30 years' residence and latency. A significant increase for all, primary, and secondary cancers, and a two-fold increase for ischaemic diseases, was observed in subjects in the sub-area with the highest exposure. No increase was seen in neoplastic haematological diseases.

Validating regional Hospital Information System data through comparison with a local cancer register to identify interval cancers of a breast screening program.

The objective of this study was to evaluate the accuracy of the Hospital Information System (HIS) in monitoring the breast cancer incidence and interval cancers compared with the cancer registry (CR). The HIS data linked with CR and Mammographic Screening Information System data for breast cancer cases diagnosed in the period 1999-2003. The sensitivity and positive predictive value of the HIS data were calculated using the CR as a gold standard. One thousand two hundred and thirty-six breast cancers were registered by the CR and 1028 were reported in the HIS. The sensitivity rate was 83.2% and the positive predictive value was 83.0%; similar results were obtained in the screening target population (50-69 years old). Fifteen invasive breast cancers occurred among screened women identified by HIS (four interval cancers and 11 screen-detected), two were registered as in situ in the CR. The HIS seems to have the potential to identify interval breast cancers, but the low accuracy of information does not permit an exact measure of the incidence.

Can colorectal cancer mass-screening organization be evidence-based? Lessons from failures: the experimental and pilot phases of the Lazio program.

BACKGROUND: Screening programmes should be organized to translate theoretical efficacy into effectiveness. An evidence-based organizational model of colorectal cancer screening (CRCS) should assure feasibility and high compliance. METHODS: A multidisciplinary Working Group (WG), reviewed literature and guidelines to define evidence-based recommendations. The WG identified the need for further local studies: physicians' CRCS attitudes, the effect of test type and provider on compliance, and individual reasons for non-compliance. A survey of digestive endoscopy services was conducted. A feasibility study on a target population of 300.000 has begun. RESULTS: Based on the results of population trials and on literature review the screening strategy adopted was Faecal Occult Blood Test (FOBT) every two years for 50-74 year olds and, for positives, colonoscopy. The immunochemical test was chosen because it has 20% higher compliance than the Guaiac. GPs were chosen as the preferred provider also for higher compliance. Since we observed that distance is the major determinant of non-compliance, we choose GPs because they are the closest providers, both geographically and emotionally, to the public. The feasibility study showed several barriers: GP participation was low, there were administrative problems to involve GPs; opportunistic testing by the GPs; difficulties in access to Gastroenterology centres; difficulties in gathering colonoscopy results; little time given to screening activity by the gastroenterology centre. CONCLUSION: The feasibility study highlighted several limits of the model. Most of the barriers that emerged were consequences of organisational choices not supported by evidence. The principal limit was a lack of accountability by the participating centres.

Efficacy of disease management profiles. The mammographic screening program of Lazio.

BACKGROUND: Screening programs are considered disease management profiles. The aim of the present study was to evaluate the efficacy of screening programs compared to regularly offered health care services, using early outcomes and process indicators. METHOD: In the study period (1/7/99-30/6/01), six breast cancer screening programs were active in 12 health districts in the Lazio region of Italy. Screening histories of all the incident cases of women surgically treated for a breast neoplasm were reconstructed (not contacted, contacted, non-participants, participants). The subpopulations were then compared for the appropriateness of treatments received. RESULTS: We identified 3251 women who were treated for malignant neoplasms of the breast and 1562 treated for benign neoplasms. The incidence of malignant neoplasms was higher in the women contacted for screening (incidence rate ratio, 1.45; 95% CI, 1.32-1.60), and the incidence of treatment for non-malignancies was similar in the two populations (incidence rate ratio, 1.00: 95% CI, 0.86-1.16). The percentage of surgery for non-malignancies detected by screening was 16.7%, whereas among the cases diagnosed outside a screening program it was 33.8%. Of malignancies detected outside of screening, 16.6% had a surgical treatment that was too invasive, among the screen-detected malignancies the percentage fell to 11% (prevalence rate ratio, 0.66; 95% CI, 0.48-0.91). Women contacted for screening showed a higher incidence of localized and in situ tumors, whereas the incidence of non-localized and metastatic tumors was basically the same in the two groups. CONCLUSIONS: The first round of screening programs led to more surgical interventions, a similar incidence of mastectomy and of interventions for benign neoplasm, but a lower incidence of unnecessary treatment.

[Screening and vaccine: toward an integrated cervical cancer prevention programme]. / Screening e vaccini: verso un programma integrato di prevenzione del cervicocarcinoma.

The identification of the human papilloma virus (HPV) as the necessary cause of cervical cancer introduced two new tools for prevention: HPV DNA test and vaccine. In this paper we analyse the plausible changes that will happens in the cervical cancer prevention in Italy and what we will need to have a governance of these changes. From a public health point of view, screening and vaccination are interventions directed to the whole community and their goal is to reach high coverage of the target population. The vaccinated women should be screened with different algorithms from the non-vaccinated ones, consequently we need individual information about the vaccination status of the women that we are going to invite for screening. Vaccine and screening interventions must be integrated in a unique public health program and screening should use less aggressive protocols, to be less expensive and more sustainable and efficient. The challenge for the Health Service is to integrate the primary and secondary prevention avoiding that one will diminish the benefits of the other and that the introduction of new technologies will be only the opportunity to double the costs with minimal health benefits.

Breast cancer diagnostic methods: screen-detected and clinical cases. An Italian survey of women's experiences.

AIMS AND BACKGROUND: The real practice of breast cancer diagnosis and treatment is often very different from guideline recommendations. Screening programs should minimize deviations from "best practice". The aim of the study was to compare cases detected by screening programs with cases that were not part of the public screening program, analyzing the diagnostic pathways from the first suspected breast problem to therapeutic intervention for breast cancer. METHODS: We interviewed a random sample of 268 women aged 49-70 years in three Italian regions (Lazio, Tuscany, Basilicata) who were treated for breast cancer, stratified by screening participation. RESULTS: In the nonscreened group, 48% of women were symptomatic and 50% were diagnosed by preventive tests. The proportion of women treated within 30 days of diagnosis was significantly lower in the screened group, 21.3% vs 35.8% (P = 0.0003). The mean number of tests (mammography, ultrasonography, cytology and histology) performed in the screened group was significantly higher than in the nonscreened group, 3.7 vs 2.8 (P = 0.001). The percentage of women treated without a preoperative histological or cytological diagnosis was lower in the screened group than in the nonscreened group, 14% vs 25% (P = 0.024). CONCLUSION: Participation in screening programs seems to lead to more appropriate disease management even for breast cancer cases treated at the same hospital.

[Socio-economic status and family profile indicators: methodological issues in studying the burden of caregiving for terminally ill cancer patients]. / Indicatori di stato socio-economico e profili familiari: problemi metodologici nello studio dell'impatto sulle famiglie della fase terminale della malattia oncologica.

INTRODUCTION: The quality of care received by terminally ill cancer patients depends heavily on socio-economic conditions and family resources, especially because of the current increase in home care assistance. OBJECTIVE: To validate the demographic information on educational level which is recorded in the registries of residents in Italian towns; to compare simple indicators of socio-economic status and family profiles with composite indicators in their ability to predict the economic and social impact of the disease. DESIGN: A two-level probabilistic sample of cancer deaths from the Italian Survey on Dying Of Cancer. PARTICIPANTS: 2000 deaths were sampled; caregivers were identified and interviewed between 4 and 12 months after the patient's death. METHODS: We calculated Cohens kappa for educational level as reported in the registry, and in the questionnaire. We constructed a composite indicator of socio-economic status and family profile using a cluster analysis; its association with the impact on finances and quality of daily life was compared with that from the educational level reported in the questionnaire and with a previously derived indicator of family profile. RESULTS: The weighted kappa of the two sources used for educational level was 0.60 (CI 95% 0.55-0.64). Of the two indicators, educational level and socio-economic status (6 groups), only the later showed a significant association with the outcomes "difficulties" in sustaining the costs of treatment" and "use of entire savings for the illness". The composite indicator of family profile (7 groups) was significantly associated with all outcomes considered. Log-likelihood was significantly better with model using the composite and the prior indicators of family profile than in models without them. Models that included educational level and prior indicator of family profile (7 groups) were more adaptable than models with the composite indicators. CONCLUSIONS: The good level of agreement between the two sources regarding educational level suggests that the registry is an adequate data source, when other information is lacking. Our study did not reveal which of the indicators we used is the best, at least with regard to the outcomes we considered.

Dying of cancer in Italy: impact on family and caregiver. The Italian Survey of Dying of Cancer.

OBJECTIVE: To describe the effect of terminal cancer on the patient's family, finances and daily life. METHODS: A cluster sample of 2000 adults (> or = 18 years old) who had died from cancer, and who were representative of Italy, was studied. 1900 caregivers were identified and 68% responded to a post-bereavement survey. Caregivers included the patient's child (46%), his/her spouse (31%), other relatives or friends (20%) or a health professional (3%). The median age of a caregiver was 54 years and 69% were females. During the last 3 months of the patient's life, 44% of caregivers reported difficulties in their regular employment. RESULTS: Of the 68% of families who had to pay for some of the care, 37% had to pay for drugs, 36% for nursing and assistance and 22% for physicians. Paying for care was more frequent in the south of Italy (OR 2.5; 95% CI 1.0 to 6.3) and when the patient was a housewife (OR for unit increase 2.7; 95% CI 1.6 to 6.1). To cover the costs of patient care, 26% of families used all or most of their savings. Economic difficulties were greater in the south of Italy (OR 3; 95% CI 1.8 to 5.1), for female caregivers (OR 1.4; 95% CI 1.0 to 1.9) and for disadvantaged patients. The duration of time the patient was completely dependent strongly determined the effect caregiving had on their regular employment and on the family's financial situation. CONCLUSIONS: Although in Italy families are responsible for a small percentage of the overall costs of patient care, the effect of cancer on savings and daily life can be substantial. Strong geographical and gender differences emerged from this study.

The effect of screening programmes on the treatment of benign breast neoplasms: observations from current practice in Italy.

PURPOSE: In the Lazio region, Italy, mammographic screening programmes were gradually activated from 1999 to 2003, providing an opportunity to compare two unselected populations in the same time period: women who were contacted in writing, and those who had not been contacted. In this study, we compare the incidences of treatments for benign and malignant neoplasms in the two groups. METHODS: The target population was women aged 50-69 years. We linked all incident cases of surgery for benign and malignant breast neoplasms, from the Hospital Information System (1999-2003) to the Mammographic Screening Information System (1999-2001). We calculated incidence, adjusted for age and standardized breast cancer mortality ratio in each area of residence, for benign and malignant neoplasms surgery in non-yet-contacted and contacted woman. Incidence for contacted women was calculated for the two years following initial contact. RESULTS: The target population in Lazio is 681,000; 116,000 women were contacted during the study period and 3252 malignant and 1566 benign neoplasms were surgically treated. Annual incidence was, respectively, 2.0/1000 and 1.1/1000 for malignant and benign neoplasms in women not contacted, and, respectively, 2.9/1000 and 1.1/1000 in the contacted population. Among the contacted group, annual incidence was 4.3/1000 and 1.5/1000 in compliant women, and 2.0/1000 and 0.9/1000 in non-compliant women. About one-half of the surgeries for benign neoplasms in compliant women were treated against the recommendation of the screening programme. CONCLUSIONS: The implementation of the screening programme did not increase the incidence of treatment for benign neoplasms, and detected 50% more malignant neoplasms.

Is the type of test used for mass colorectal cancer screening a determinant of compliance? A cluster-randomized controlled trial comparing fecal occult blood testing with flexible sigmoidoscopy.

BACKGROUND: The efficacy of colorectal cancer screening has been proved, and three different screening tests are recommended by international guidelines: the faecal occult blood test, flexible sigmoidoscopy and colonoscopy. While the effectiveness of a screening program depends on the compliance obtained, the role of the type of test on compliance has not yet been sufficiently studied. AIMS: To measure the effect of the type of screening test used, i.e. faecal occult blood test or flexible sigmoidoscopy, on the compliance to colorectal cancer screening programs. SUBJECTS AND METHODS: A cluster-randomized two-arm trial was conducted. We randomly assigned 20 GP's practices that had an average of 150 patients between 50 and 74 years old. RESULTS: 1449 individuals were referred to faecal occult blood test and 1538 to flexible sigmoidoscopy. The faecal occult blood test obtained higher compliance: 17.2% (95%CI 12.5-25.7) versus 7.0% (95%CI 5.7-9.0). The socio-economic status was an effect modifier of the test type: the effect of the type of test was smaller in low socioeconomic classes. CONCLUSIONS: The type of screening test used for colorectal cancer is a determinant of participation. In a low compliance area, better compliance will result from offering the faecal occult blood test than from the flexible sigmoidoscopy.

Colorectal cancer screening: recommendations and guideline adherence by physicians from digestive endoscopy centers in the Lazio region, Italy.

INTRODUCTION: Endoscopy plays a key role in colorectal cancer screening; at the beginning of a mass screening campaign, it is important for public health officials to assess physicians' attitudes and adherence to guidelines regarding colorectal cancer screening. METHODS: In April 2004, a questionnaire was sent to all 80 digestive endoscopy centers in the Lazio region, identified by the annual census of the Italian Society of Digestive Endoscopy. The results were compared to those from a similar survey of general practitioners (GPs). RESULTS: Seventy-one centers (89%) returned the questionnaire. Only 3% of physicians said they did not recommend any colorectal cancer screening test. Colonoscopy was perceived as the most effective screening test and was the most recommended (80%). Fecal occult blood test was recommended by 61% of physicians and flexosigmoidoscopy by 11%. Endoscopy centers' physicians recommend screening more than GPs (96.9% vs. 78.3%), while they have a similar level of over-recommending (50.8% vs. 47.2%). Almost 95% of endoscopy physicians properly recommended colonoscopy after positive FOBT. CONCLUSIONS: Neither physicians at endoscopy centers nor GPs tend to follow screening guidelines. Screening programmes should not rely on a single medical specialist, but on interdisciplinary management of the disease to strengthen adherence to existing guidelines.

Indicators of breast cancer severity and appropriateness of surgery based on hospital administrative data in the Lazio Region, Italy.

BACKGROUND: Administrative data can serve as an easily available source for epidemiological and evaluation studies. The aim of this study is to evaluate the use of hospital administrative data to determine breast cancer severity and the appropriateness of surgical treatment. METHODS: the study population consisted of 398 patients randomly selected from a cohort of women hospitalized for first-time breast cancer surgery in the Lazio Region, Italy. Tumor severity was defined in three different ways: 1) tumor size; 2) clinical stage (TNM); 3) severity indicator based on HIS data (SI). Sensitivity, specificity, and positive predictive value (PPV) of the severity indicator in evaluating appropriateness of surgery were calculated. The accuracy of HIS data was measured using Kappa statistic. RESULTS: Most of 387 cases were classified as T1 and T2 (tumor size), more than 70% were in stage I or II and the SI classified 60% of cases in medium-low category. Variation from guidelines indications identified under and over treatments. The accuracy of the SI to predict under-treatment was relatively good (58% of all procedures classified as under-treatment using pT where also classified as such using SI), and even greater predicting over-treatment (88.2% of all procedures classified as over treatment using pT where also classified as such using SI). Agreement between clinical chart and hospital discharge reports was K = 0.35. CONCLUSION: Our findings suggest that administrative data need to be used with caution when evaluating surgical appropriateness, mainly because of the limited ability of SI to predict tumor size and the questionable quality of HIS data as observed in other studies.

The role of GPs in increasing compliance to colorectal cancer screening: a randomised controlled trial (Italy).

AIMS: To assess the effect of the provider (GPs versus hospital) on the compliance in returning the faecal occult blood test. To analyse the characteristics of the GP associated with high compliance among his beneficiaries. METHODS: A questionnaire about screening attitudes was mailed to the 1192 GPs working in 13 districts of the Lazio region. We asked the GPs to participate in a randomised trial, we sampled 130 GPs and about 1/10 of the GPs' 50-75 year old beneficiaries (n = 3657) were invited to be screened at the GP office and 1/10 (3675) at the nearest gastroenterology centre. RESULTS: 58.5% of the GPs completed the questionnaire and 22.7% agreed to participate in the trial. The compliance in the GP arm was 50%, in the hospital arm 16% (RR 3.4; 95% CI: 3.13-3.70). There was a high variability in the compliance obtained by the GPs. GPs with more than 25 patients visited/day and those incorrectly recommended screening of colorectal cancer obtained a lower compliance (OR 0.74, 95% CI: 0.57-0.95 and OR 0.76, 95% CI: 0.59-0.97, respectively). CONCLUSIONS: The involvement of GPs in colorectal cancer screening can be very effective to enhance the compliance, but the effectiveness is dependent on their willingness to be involved.