Anthropogenic climate change impacts exacerbate summer forest fires in California.

Record-breaking summer forest fires have become a regular occurrence in California. Observations indicate a fivefold increase in summer burned area (BA) in forests in northern and central California during 1996 to 2021 relative to 1971 to 1995. While the higher temperature and increased dryness have been suggested to be the leading causes of increased BA, the extent to which BA changes are due to natural variability or anthropogenic climate change remains unresolved. Here, we develop a climate-driven model of summer BA evolution in California and combine it with natural-only and historical climate simulations to assess the importance of anthropogenic climate change on increased BA. Our results indicate that nearly all the observed increase in BA is due to anthropogenic climate change as historical model simulations accounting for anthropogenic forcing yield 172% (range 84 to 310%) more area burned than simulations with natural forcing only. We detect the signal of combined historical forcing on the observed BA emerging in 2001 with no detectable influence of the natural forcing alone. In addition, even when considering fuel limitations from fire-fuel feedbacks, a 3 to 52% increase in BA relative to the last decades is expected in the next decades (2031 to 2050), highlighting the need for proactive adaptations.

Which Factors Are Associated With Comorbid Psychiatric Conditions in Patients Affected by Substance Use Disorders? The Impact of COVID-19 Pandemic on Dual-Diagnosis Subjects.

OBJECTIVE: To investigate demographic/cinical variables associated to dual diagnosis and the psychological reaction of dual-diagnosis patients to COVID-19 pandemic. METHODS: Information was collected at the Addiction Service of Monza, Italy. The Impact of Event Scale-Revised (IES-R), a self-report questionnaire measuring the subjective response to a traumatic event, was administered. Univariate analyses and binary logistic regression were performed. IES-R scores were compared between groups defined by qualitative variables through one-way analyses of variance (ANOVA). RESULTS: 118 outpatients were included, 48.3% with dual diagnosis. Alcohol use disorder and being female were associated to dual diagnosis. IES-R scores were significantly higher in the dual-diagnosis group, especially for personality disorders (PDs). IES-R scores were higher in patients taking treatment for substance use disorder (SUD). CONCLUSIONS: Females and alcohol abusers were at-risk subjects for dual diagnosis. Patients with SUD and PDs may benefit from additional support, especially when traumatic life events occur. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04694482.

The association between reasons for first using cannabis, later pattern of use, and risk of first-episode psychosis: the EU-GEI case-control study.

BACKGROUND: While cannabis use is a well-established risk factor for psychosis, little is known about any association between reasons for first using cannabis (RFUC) and later patterns of use and risk of psychosis. METHODS: We used data from 11 sites of the multicentre European Gene-Environment Interaction (EU-GEI) case-control study. 558 first-episode psychosis patients (FEPp) and 567 population controls who had used cannabis and reported their RFUC.We ran logistic regressions to examine whether RFUC were associated with first-episode psychosis (FEP) case-control status. Path analysis then examined the relationship between RFUC, subsequent patterns of cannabis use, and case-control status. RESULTS: Controls (86.1%) and FEPp (75.63%) were most likely to report 'because of friends' as their most common RFUC. However, 20.1% of FEPp compared to 5.8% of controls reported: 'to feel better' as their RFUC (χ2 = 50.97; p < 0.001). RFUC 'to feel better' was associated with being a FEPp (OR 1.74; 95% CI 1.03-2.95) while RFUC 'with friends' was associated with being a control (OR 0.56; 95% CI 0.37-0.83). The path model indicated an association between RFUC 'to feel better' with heavy cannabis use and with FEPp-control status. CONCLUSIONS: Both FEPp and controls usually started using cannabis with their friends, but more patients than controls had begun to use 'to feel better'. People who reported their reason for first using cannabis to 'feel better' were more likely to progress to heavy use and develop a psychotic disorder than those reporting 'because of friends'.

Spatial patterns and broad-scale weather cues of beech mast seeding in Europe.

Mast seeding is a crucial population process in many tree species, but its spatio-temporal patterns and drivers at the continental scale remain unknown . Using a large dataset (8000 masting observations across Europe for years 1950-2014) we analysed the spatial pattern of masting across the entire geographical range of European beech, how it is influenced by precipitation, temperature and drought, and the temporal and spatial stability of masting-weather correlations. Beech masting exhibited a general distance-dependent synchronicity and a pattern structured in three broad geographical groups consistent with continental climate regimes. Spearman's correlations and logistic regression revealed a general pattern of beech masting correlating negatively with temperature in the summer 2 yr before masting, and positively with summer temperature 1 yr before masting (i.e. 2T model). The temperature difference between the two previous summers (DeltaT model) was also a good predictor. Moving correlation analysis applied to the longest eight chronologies (74-114 yr) revealed stable correlations between temperature and masting, confirming consistency in weather cues across space and time. These results confirm widespread dependency of masting on temperature and lend robustness to the attempts to reconstruct and predict mast years using temperature data.

Linking crop yield anomalies to large-scale atmospheric circulation in Europe.

Understanding the effects of climate variability and extremes on crop growth and development represents a necessary step to assess the resilience of agricultural systems to changing climate conditions. This study investigates the links between the large-scale atmospheric circulation and crop yields in Europe, providing the basis to develop seasonal crop yield forecasting and thus enabling a more effective and dynamic adaptation to climate variability and change. Four dominant modes of large-scale atmospheric variability have been used: North Atlantic Oscillation, Eastern Atlantic, Scandinavian and Eastern Atlantic-Western Russia patterns. Large-scale atmospheric circulation explains on average 43% of inter-annual winter wheat yield variability, ranging between 20% and 70% across countries. As for grain maize, the average explained variability is 38%, ranging between 20% and 58%. Spatially, the skill of the developed statistical models strongly depends on the large-scale atmospheric variability impact on weather at the regional level, especially during the most sensitive growth stages of flowering and grain filling. Our results also suggest that preceding atmospheric conditions might provide an important source of predictability especially for maize yields in south-eastern Europe. Since the seasonal predictability of large-scale atmospheric patterns is generally higher than the one of surface weather variables (e.g. precipitation) in Europe, seasonal crop yield prediction could benefit from the integration of derived statistical models exploiting the dynamical seasonal forecast of large-scale atmospheric circulation.

Determinants of extinction-colonization dynamics in Mediterranean butterflies: the role of landscape, climate and local habitat features.

Many species are found today in the form of fragmented populations occupying patches of remnant habitat in human-altered landscapes. The persistence of these population networks requires a balance between extinction and colonization events assumed to be primarily related to patch area and isolation, but the contribution of factors such as the characteristics of patch and matrix habitats, the species' traits (habitat specialization and dispersal capabilities) and variation in climatic conditions have seldom been evaluated simultaneously. The identification of environmental variables associated with patch occupancy and turnover may be especially useful to enhance the persistence of multiple species under current global change. However, for robust inference on occupancy and related parameters, we must account for detection errors, a commonly overlooked problem that leads to biased estimates and misleading conclusions about population dynamics. Here, we provide direct empirical evidence of the effects of different environmental variables on the extinction and colonization rates of a rich butterfly community in the western Mediterranean. The analysis was based on a 17-year data set containing detection/nondetection data on 73 butterfly species for 26 sites in north-eastern Spain. Using multiseason occupancy models, which take into account species' detectability, we were able to obtain robust estimates of local extinction and colonization probabilities for each species and test the potential effects of site covariates such as the area of suitable habitat, topographic variability, landscape permeability around the site and climatic variability in aridity conditions. Results revealed a general pattern across species with local habitat composition and landscape features as stronger predictors of occupancy dynamics compared with topography and local aridity. Increasing area of suitable habitat in a site strongly decreased local extinction risks and, for a number of species, both higher amounts of suitable habitat and more permeable landscapes increased colonization rates. Nevertheless, increased topographic variability decreased the extinction risk of bad dispersers, a group of species with significantly lower colonization rates. Our models predicted higher sensitivity of the butterfly assemblages to deterministic changes in habitat features rather than to stochastic weather patterns, with some relationships being clearly dependent on the species' traits.

A monthly gridded burned area database of national wildland fire data.

We assembled the first gridded burned area (BA) database of national wildfire data (ONFIRE), a comprehensive and integrated resource for researchers, non-government organisations, and government agencies analysing wildfires in various regions of the Earth. We extracted and harmonised records from different regions and sources using open and reproducible methods, providing data in a common framework for the whole period available (starting from 1950 in Australia, 1959 in Canada, 1985 in Chile, 1980 in Europe, and 1984 in the United States) up to 2021 on a common 1° × 1° grid. The data originate from national agencies (often, ground mapping), thus representing the best local expert knowledge. Key opportunities and limits in using this dataset are discussed as well as possible future expansions of this open-source approach that should be explored. This dataset complements existing gridded BA data based on remote sensing and offers a valuable opportunity to better understand and assess fire regime changes, and their drivers, in these regions. The ONFIRE database can be freely accessed at https://zenodo.org/record/8289245 .

Fluctuating mastectomy rates across time and geography.

In 2009, 2 single-institution studies from the United States reported increasing mastectomy rates during the last decade. We have recently reported unilateral mastectomy trends from a European database and demonstrated a significant trend of decreasing mastectomy rates from 38.1 % in 2005 to 13.1 % in 2010. A recent study from the SEER registry in the United States confirmed a previously reported decrease in mastectomy rates from 40.1 % in year 2000 to 35.6 % in 2005, but showed a statistically significant increase in mastectomy rates up to 38.4 % in 2008. This report provides evidence that mastectomy trends may be in opposite directions in different geographical areas. The sharpest increase in mastectomy rates across all ages in the recent SEER study occurs right after year 2005, which interestingly corresponds with the time of publication of the meta-analysis by the EBCTCG that highlighted the importance of local control in breast cancer. The coincident timing raises the question of whether this evidence may have indirectly triggered an increase in mastectomy rates in the United States that would partially explain the observed trend, and more importantly, of whether an increase would be justified on this basis. Multiple factors influence the proportion between mastectomy and breast conservation, so it may be unreasonable to think of an optimal cutoff. There is not necessarily a right or wrong direction for mastectomy trends, but aiming to determine explanations for these differences may help provide a clearer insight of the decision-making process involved in the surgical management of breast cancer.

The impact of different communication and organizational strategies on mammography screening uptake in women aged 40-45 years.

BACKGROUND: Several factors can influence access to population breast cancer screening. The aim of the study was to evaluate the impact of different information approaches, women's socio-demographic characteristics and organizational factors on mammography screening uptake. METHODS: We selected 5744 women aged 40-45 years who were randomly assigned to be given letters with: (i) a pre-fixed appointment plus standard leaflet (Group 1); (ii) a pre-fixed appointment plus a more comprehensive booklet (Group 2); (iii) point (ii) plus the offer of a counselling session (Group 3); and (iv) an invitation to contact the centre to get information and arrange participation (Group 4). RESULTS: Ninety-five women were excluded before the invitation and 5649 were randomized. After excluding undelivered letters (n = 41) and women reporting an exclusion criterion following our invitation (n = 248), the final eligible population was 5360 women. Participation rates following the first contact were 36.5, 39.9, 35.8 and 16.5% for Groups 1-4, respectively. The rates increased to 40.9, 43.6, 40.1 and 35.1% after the reminder letters. Women receiving more complete information had a higher uptake (Group 2), although not statistically significant. Differences among the four groups were maintained by controlling the effect of socio-demographic and attendance determinants. Regardless of intervention, participation was higher among married, higher educated, white-collared women, those born in northern Italy, living closer to the screening unit and with a female-collaborative doctor. CONCLUSION: Invitation letters with a fixed appointment correlate with a higher attendance rate. Providing women with more information on procedures, risks and benefits of mammography screening does not modify their participation.

The psychopathological impact of the SARS-CoV-2 epidemic on subjects suffering from different mental disorders: An observational retrospective study.

SARS-CoV-2 infection causes a pulmonary disease (COVID-19) which spread worldwide generating fear, anxiety, depression in the general population as well as among subjects affected by mental disorders. Little is known about which different psychopathological changes the pandemic caused among individuals affected by different psychiatric disorders, which represents the aim of the present study. Specific psychometric scales were administered at three time points: T0 as outbreak of pandemic, T1 as lockdown period, T2 as reopening. Descriptive analyses and linear regression models were performed. A total of 166 outpatients were included. Overall, psychometric scores showed a significant worsening at T1 with a mild improvement at T2. Only psychopathology in schizophrenia (SKZ) patients and obsessive-compulsive (OC) symptoms did not significantly improve at T2. Subjects affected by personality disorders (PDs) resulted to be more compromised in terms of general psychopathology than depressed and anxiety/OC ones, and showed more severe anxiety symptoms than SKZ patients. In conclusion, subjects affected by PDs require specific clinical attention during COVID-19 pandemic. Moreover, the worsening of SKZ and OC symptoms should be strictly monitored by clinicians, as these aspects did not improve with the end of lockdown measures. Further studies on larger samples are needed to confirm our results. ClinicalTrials.gov Identifier: NCT04694482.

Human and climate drivers of global biomass burning variability.

Biomass burning is one of the most critical factors impacting vegetation and atmospheric trends, with important societal implications, particularly when extreme weather conditions occur. Trends and factors of burned area (BA) have been analysed at regional and global scales, but little effort has been dedicated to study the interannual variability. This paper aimed to better understand factors explaining this variation, under the assumption that the more human control of fires the more frequently they occur, as burnings will be less dependent of weather cycles. Interannual variability of BA was estimated from the coefficient of variation of the annual BA (BA_CV) estimated from satellite data at 250 m, covering the period from 2001 to 2018. These data and the explanatory variables were resampled at 0.25-degree resolution for global analysis. Relations between this variable and explanatory factors, including human and climate drivers, were estimated using Random Forest (RF) and generalized additive models (GAM). BA_CV was negatively related to BA_Mean, implying that areas with higher average BA have lower variability as well. Interannual BA variability decreased when maximum temperature (TMAX) and actual and potential evapotranspiration (AET, PET) increased, cropland and livestock density increased and the human development index (HDI) values decreased. GAM models indicated interesting links with AET, PET and precipitation, with negative relation with BA_CV for the lower ranges and positive for the higher ones, the former indicating fuel limitations of fire activity, and the latter climate constrains. For the global RF model, TMAX, AET and HDI were the main drivers of interannual variability. As originally hypothesised, BA_CV was more dependent on human factors (HDI) in those areas with medium to large BA occurrence, particularly in tropical Africa and Central Asia, while climatic factors were more important in boreal regions, but also in the tropical regions of Australia and South America.

Population exposure to particulate-matter and related mortality due to the Portuguese wildfires in October 2017 driven by storm Ophelia.

In October 2017, hundreds of wildfires ravaged the forests of the north and centre of Portugal. The fires were fanned by strong winds as tropical storm Ophelia swept the Iberian coast, dragging up smoke (together with Saharan dust from north-western Africa) into higher western European latitudes. Here we analyse the long-range transport of particulate matter (PM10) and study associations between PM10 and short-term mortality in the Portuguese population exposed to PM10 due to the October 2017 wildfires, the worst fire sequence in the country over the last decades. We analysed space- and ground-level observations to track the smoke plume and dust trajectory over Portugal and Europe, and to access PM10 concentrations during the wildfires. The effects of PM10 on mortality were evaluated using satellite data for exposure and Poisson regression models. The smoke plume covered most western European countries (including Spain, France, Belgium and the Netherlands), and reached the United Kingdom, where the population was exposed in average to an additional PM10 level of 11.7 µg/m3 during seven smoky days (three with dust) in relation to the reference days (days without smoke or dust), revealing the impact of the wildfires on distant populations. In Portugal, the population was exposed in average to additional PM10 levels that varied from 16.2 to 120.6 µg/m3 in smoky days with dust and from 6.1 to 20.9 µg/m3 in dust-free smoky days. Results suggest that PM10 had a significant effect on the same day natural and cardiorespiratory mortalities during the month of October 2017. For every additional 10 µg/m3 of PM10, there was a 0.89% (95% confidence interval, CI, 0-1.77%) increase in the number of natural deaths and a 2.34% (95% CI, 0.99-3.66%) increase in the number of cardiorespiratory-related deaths. With rising temperatures and a higher frequency of storms due to climate change, PM from Iberian wildfires together with NW African dust will tend to be more often transported into Northern European countries, which may carry health threats to areas far from the ignition sites.

The requirements of a specialist breast centre.

This article is an update of the requirements of a specialist breast centre, produced by EUSOMA and endorsed by ECCO as part of Essential Requirements for Quality Cancer Care (ERQCC) programme, and ESMO. To meet aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this article, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

Physical activity and mammographic breast density in a Mediterranean population: the EPIC Florence longitudinal study.

A protective effect of physical activity (PA) on breast cancer (BC) risk has been suggested. Few studies have examined the influence of PA on mammographic breast density (MBD), a strong risk factor for BC. In a prospective study in Florence, Italy, we identified 2,000 healthy women with a mammogram taken 5 years after enrollment. Individual mammograms were retrieved (83%) and MBD assessed according to Wolfe's classification. Detailed information on PA at work and during leisure time, reproductive history, lifestyle and anthropometric measurements at enrollment were available for 1,666 women. Information on hormone replacement therapy (HRT) was also obtained at mammogram. Women with high-MBD (P2 + DY Wolfe's patterns) were compared with women with low-MBD (N1 + P1) by multivariate logistic models. Overall, high-MBD was inversely associated with increasing levels of leisure time PA (p for trend = 0.04) and among peri-/postmenopausal women, also with increasing levels of recreational activities (p for trend = 0.02). An interaction between PA and HRT emerged, with a stronger inverse association of highest level of recreational activity with MBD among HRT nonusers (p for interaction = 0.02). A modifying effect by body mass index (BMI) was evident among 1,025 peri-/postmenopausal women who did not use HRT at the time of mammogram, with a stronger inverse association between recreational PA and MBD in the highest BMI tertile (OR = 0.34; 95% CI 0.20-0.57; p for interaction = 0.03). This large study carried out in Mediterranean women suggests that leisure time PA may play a role in modulating MBD, particularly in overweight/obese peri-/postmenopausal women.

Founder mutations account for the majority of BRCA1-attributable hereditary breast/ovarian cancer cases in a population from Tuscany, Central Italy.

BACKGROUND: Germline mutations in the BRCA1 and BRCA2 tumour-suppressor genes predispose to early-onset breast and ovarian cancer. Although both genes display a highly heterogeneous mutation spectrum, a number of alterations recur in some populations. Only a limited number of founder mutations have been identified in the Italian population so far. OBJECTIVE: To investigate the spectrum of BRCA1/BRCA2 mutations in a set of families originary from the Central-Eastern part of Tuscany and to ascertain the presence of founder effects. We also wanted to approximate the age of the most frequent BRCA1 founder mutation. RESULTS: Overall, four distinct BRCA1 mutations accounted for a large fraction (72.7%) of BRCA1-attributable hereditary breast/ovarian cancer in families originary from this area. We identified common haplotypes for two newly recognised recurrent BRCA1 mutations, c.3228_3229delAG and c.3285delA. The c.3228_3229delAG mutation was estimated to have originated about 129 generations ago. Interestingly, male breast cancer cases were present in 3 out of 11 families with the c.3228_3229delAG mutation. CONCLUSIONS: The observation that a high proportion of families with BRCA1 alterations from Central-Eastern Tuscany harbours a limited number of founder mutations can have significant impact on clinical management of at risk subjects from this area. In addition, the identification of a large set of families carrying an identical mutation that predisposes to breast and ovarian cancer provides unique opportunities to study the effect of other genetic and environmental factors on penetrance and disease phenotype.

Audit system on Quality of breast cancer diagnosis and Treatment (QT): results of quality indicators on screen-detected lesions in Italy for 2006 and preliminary results for 2007.

Within this survey, conducted by the Italian Breast Screening Network (Gruppo Italiano per lo Screening Mammografico, GISMa), individual data are collected yearly on more than 50% of all screen-detected operated lesions in Italy. In 2006, results showed overall good diagnosis and treatment quality and an improving trend over time. Critical issues were identified in waiting times, compliance with recommendations on not performing frozen section examination on small lesions and on performing specimen X-ray. Pre-operative diagnosis reached the acceptable target, but there is a large variation between Regions and programmes. The sentinel lymph node technique (SLN) was performed on the axilla in more than 70% of screen-detected invasive cancers, avoiding a large number of potentially harmful dissections. On the other hand, potential overuse of SLN in ductal carcinoma in situ deserves further investigation. The detailed results have been distributed to regional and local screening programmes, also by means of an online database, in order to allow multidisciplinary discussion and the identification of appropriate solutions to any problems documented by the data. Specialist Breast Units with adequate case volume and enough resources would provide the best setting for making audit effective in producing quality improvement with a shortening of waiting times.

Seasonal prediction of climate-driven fire risk for decision-making and operational applications in a Mediterranean region.

In this paper, we assess and develop a climate service focused on the production of seasonal predictions for summer wildfires in a Mediterranean region through a participatory approach with end-users. We start by building a data-driven model that links a drought indicator (Standardised Precipitation Evapotranspiration Index; SPEI) with a series of burned areas in Catalonia (northeastern Spain). Afterwards, we feed this model with SPEI forecasts obtained through a combination of the antecedent observed conditions and climatology. Finally, we assess the forecasting skill of the system by using cross-validation to evaluate the predictions as if they had been made operationally. Our fire forecasting system reveals an untapped and useful burned area predictive ability. We argue that this source of predictability is mostly attributable to the effect of observed initial conditions on summer drought conditions. This system was conceived with the stakeholders, merging climate-driven predictions with information that is of interests to the users, including the identification of climate variables, thresholds and models. The co-production of this customized system allows fire-risk outlooks to be translated into usable information for fire management. This fire forecasting ability plays a crucial role in developing proactive fire management practices such as long-term fuel assessment and other fire-risk planning, thus minimising the impact of adverse climate conditions on summer burned area.

Climate drivers of the 2017 devastating fires in Portugal.

A record 500,000 hectares burned in Portugal during the extreme wildfire season of 2017, with more than 120 human lives lost. Here we analyse the climatic factors responsible for the burned area (BA) from June to October series in Portugal for the period 1980-2017. Superposed onto a substantially stationary trend on BA data, strong oscillations on shorter time scales were detected. Here we show that they are significantly affected by the compound effect of summer (June-July-August) drought and high temperature conditions during the fire season. Drought conditions were calculated using the Standardized Precipitation Evapotranspiration Index (SPEI), the Standardized Precipitation Index (SPI) and the Standardized Soil Moisture Index (SSI). Then the extent to which the burned area has diverged from climate-expected trends was assessed. Our results indicate that in the absence of other drivers, climate change would have led to higher BA values. In addition, the 2017 extreme fire season is well captured with the model forced with climate drivers only, suggesting that the extreme fire season of 2017 could be a prelude to future conditions and likewise events. Indeed, the expected further increase of drought and high temperature conditions in forthcoming decades, point at a potential increase of fire risk in this region. The climate-fire model developed in this study could be useful to develop more skilled seasonal predictions capable of anticipating potentially hazardous conditions.

Microinvasive breast carcinoma: An analysis from ten Senonetwork Italia breast centres.

BACKGROUND AND OBJECTIVES: We studied a large series of ductal carcinoma in situ with microinvasion (MIDC) an infrequent disease whose diagnosis and management are not well defined. METHODS: 17,431 cases of breast carcinoma were treated between 2011 and 2016 by ten Italian Breast Units. Our analysis included diagnostic and clinic-pathological characteristics, surgical management, and the use of adjuvant therapies. RESULTS: 15,091 cases (86.6%) were infiltrating carcinomas (IC), 2107 (12.1%) ductal carcinoma in situ (DCIS), and 233 (1.3%) MIDC. Age at diagnosis did not differ between DCIS and MIDC. MIDC were usually larger and expressed more frequently biologically aggressive features (higher Ki67 values, hormone receptor negativity and HER2/neu over-expression) (p < 0.01). Axillary lymph nodes were involved in 25 MIDC cases (12%), but >3 lymph nodes were involved in two cases only (1%). At multivariable analysis, only lymphovascular invasion (LVI) was associated with lymph node status (p < 0.01). Hormone therapy was prescribed in 388/1462 DCIS cases (26.5%), in 84/200 MIDC cases (42%), and in 11,086/14,188 IC cases (84.7%) (p < 0.01). Chemotherapy was administered in 28/190 MIDC cases (14.7%), and in 4080/11,548 IC cases (35.3%) (p < 0.001). CONCLUSIONS: This is one of the largest studies of MIDC reported in the literature. Approximately 10% of DCIS harbor one or more foci of MIDC, and the latter often expresses aggressive biological features. LVI is a predictor of axillary node involvement, but this is infrequent and usually limited. Conservative surgery is performed less often than in DCIS, and adjuvant chemotherapy is less frequently utilized compared to IC.

[Interval cancers as indicators of performance in screening programmes]. / I carcinomi di intervallo quali indicatori di performance di un programma di screening.

GISMa analyses the interval cancer (IS) topic providing guidelines and reference standards in addition to CE recommendations. IC identification is based on Cancer Registries (CR), if existing, or on hospital discharge records, in alternative. The optimal measure of IC frequency (inversely correlated with sensitivity) is the IC proportional incidence (observed IC/carcinomas expected in absence of screening). Other formulas (IC/IC + screen detected cancers; IC rate per 1000 negative screens) look less reliable. IC stage at diagnosis (if available through CR) must be compared with screen detected cancer and cancer detected in non-attenders. Review of mammograms preceding the IC (coded as screening error, minimal signs, or occult) should be done mainly with a blind procedure (IC mixed with negative controls), as this procedure is more representative of the original scenario and more respectful of radiologist's rights.