Complete cancer prevalence in Europe in 2020 by disease duration and country (EUROCARE-6): a population-based study.

BACKGROUND: Cancer survivors-people living with and beyond cancer-are a growing population with different health needs depending on prognosis and time since diagnosis. Despite being increasingly necessary, complete information on cancer prevalence is not systematically available in all European countries. We aimed to fill this gap by analysing population-based cancer registry data from the EUROCARE-6 study. METHODS: In this population-based study, using incidence and follow-up data up to Jan 1, 2013, from 61 cancer registries, complete and limited-duration prevalence by cancer type, sex, and age were estimated for 29 European countries and the 27 countries in the EU (EU27; represented by 22 member states that contributed registry data) using the completeness index method. We focused on 32 malignant cancers defined according to the third edition of the International Classification of Diseases for Oncology, and only the first primary tumour was considered when estimating the prevalence. Prevalence measures are expressed in terms of absolute number of prevalent cases, crude prevalence proportion (reported as percentage or cases per 100 000 resident people), and age-standardised prevalence proportion based on the European Standard Population 2013. We made projections of cancer prevalence proportions up to Jan 1, 2020, using linear regression. FINDINGS: In 2020, 23 711 thousand (95% CI 23 565-23 857) people (5·0% of the population) were estimated to be alive after a cancer diagnosis in Europe, and 22 347 thousand (95% CI 22 210-22 483) in EU27. Cancer survivors were more frequently female (12 818 thousand [95% CI 12 720-12 917]) than male (10 892 thousand [10 785-11 000]). The five leading tumours in female survivors were breast cancer, colorectal cancer, corpus uterine cancer, skin melanoma, and thyroid cancer (crude prevalence proportion from 2270 [95%CI 2248-2292] per 100 000 to 301 [297-305] per 100 000). Prostate cancer, colorectal cancer, urinary bladder cancer, skin melanoma, and kidney cancer were the most common tumours in male survivors (from 1714 [95% CI 1686-1741] per 100 000 to 255 [249-260] per 100 000). The differences in prevalence between countries were large (from 2 to 10 times depending on cancer type), in line with the demographic structure, incidence, and survival patterns. Between 2010 and 2020, the number of prevalent cases increased by 3·5% per year (41% overall), partly due to an ageing population. In 2020, 14 850 thousand (95% CI 14 681-15 018) people were estimated to be alive more than 5 years after diagnosis and 9099 thousand (8909-9288) people were estimated to be alive more than 10 years after diagnosis, representing an increasing proportion of the cancer survivor population. INTERPRETATION: Our findings are useful at the country level in Europe to support evidence-based policies to improve the quality of life, care, and rehabilitation of patients with cancer throughout the disease pathway. Future work includes estimating time to cure by stage at diagnosis in prevalent cases. FUNDING: European Commission.

[Oncological organized screening programmes in the COVID-19 era: an Italian survey on accrued delays, reboot velocity, and diagnostic delay estimates]. / Ritardi maturati dai programmi di screening oncologici ai tempi del COVID-19 in Italia, velocità della ripartenza e stima dei possibili ritardi diagnostici.

OBJECTIVES: to describe the course of Italian organized cancer screening programmes during the COVID-19 emergency; to provide estimates of the diagnosis of malignant or pre-malignant lesions that will face a diagnostic delay due to the slowing down of screening activities. DESIGN: quantitative survey of aggregated data for each Region and overall for Italy relating to screening tests carried out in the period January-May 2020 compared to those of the same period of 2019; estimate of diagnostic delays starting from the calculation of the average detection rate of the last 3 years available (specific by Region). SETTING AND PARTICIPANTS: Italian mass screening programmes. Data on the tests carried out in the target population of the breast (women 50-69 years old), cervix (women 25-64 years old), and colorectal (women and men 50-69 years old) cancer screening. MAIN OUTCOME MEASURES: the cumulative delay (in absolute numbers and as a percentage) in the period January-May 2020 compared to the same period of 2019, by Region; the difference of screening tests (in absolute number and in percentage) performed in May 2020 compared to May 2019; the estimate of the fewer lesions diagnosed in 2020 compared with 2019 with relative 95% confidence intervals (95%CI); the 'standard months' of delay (proportion of fewer tests carried out from January to May 2020 for the corresponding number of months). RESULTS: 20 Regions out of 21 participated. In the period January-May 2020, the fewer screening tests performed in comparison with the same period of 2019 were: 472,389 (equal to 53.8%) with an average delay of standard months of 2.7 for mammography screening; 585,287 (equal to 54.9%) with an average delay of standard months of 2.7 for colorectal screening; 371,273 (equal to 55.3%) with an average delay of 2.8 standard months for cervical screening. The estimated number of undiagnosed lesions is 2,201 (95%CI 2,173-2,220) breast cancers; 645 (95%CI 632-661) colorectal carcinomas; 3,890 (95%CI 3,855-3,924) advanced colorectal adenomas and 1,497 (95%CI 1,413-1,586) CIN2 or more serious lesions. CONCLUSIONS: mass screenings need to be restarted as quickly as possible. In order to make up for the delay that is accumulating, it is necessary to provide for wider delivery times, greater resources, and new organizational approaches. It will also be essential to develop communication strategies suitable for promoting participation during this emergency.

Patients' experience of screening CT colonography with reduced and full bowel preparation in a randomised trial.

OBJECTIVES: To assess patients' experience of bowel preparation and procedure for screening CT colonography with reduced (r-CTC) and full cathartic preparation (f-CTC) that showed similar detection rate for advanced neoplasia in a randomised trial. METHODS: Six hundred seventy-four subjects undergoing r-CTC and 612 undergoing f-CTC in the SAVE trial were asked to complete two pre-examination questionnaires-(1) Life Orientation Test - Revised (LOT-R) assessing optimism and (2) bowel preparation questionnaire-and a post-examination questionnaire evaluating overall experience of CTC screening test. Items were analysed with chi-square and t test separately and pooled. RESULTS: LOT-R was completed by 529 (78%) of r-CTC and by 462 (75%) of f-CTC participants and bowel preparation questionnaire by 531 (79%) subjects in the r-CTC group and by 465 (76%) in the f-CTC group. Post-examination questionnaire was completed by 525 (78%) subjects in the r-CTC group and by 453 (74%) in the f-CTC group. LOT-R average score was not different between r-CTC (14.27 ± 3.66) and f-CTC (14.54 ± 3.35) (p = 0.22). In bowel preparation questionnaire, 88% of r-CTC subjects reported no preparation-related symptoms as compared to 70% of f-CTC subjects (p < 0.001). No interference of bowel preparation with daily activities was reported in 80% of subjects in the r-CTC group as compared to 53% of subjects in the f-CTC group (p < 0.001). In post-examination questionnaire, average scores for discomfort of the procedure were not significantly different between r-CTC (3.53 ± 0.04) and f-CTC (3.59 ± 0.04) groups (p = 0.84). CONCLUSIONS: Reduced bowel preparation is better tolerated than full preparation for screening CT colonography. KEY POINTS: • Reduced bowel preparation is better tolerated than full preparation for screening CT colonography. • Procedure-related discomfort of screening CT colonography is not influenced by bowel preparation. • Males tolerate bowel preparation and CT colonography screening procedure better than females.

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.

Factors associated with breast screening radiologists' annual mammogram reading volume in Italy.

PURPOSE: Screening mammogram reading volume (SMRV) and total (screening and clinical) mammogram reading volume (TMRV) per year are strongly associated with the radiologist's diagnostic performance in breast cancer screening. The current article reports the prevalence and correlates of a SMRV and a TMRV ≥5000 among Italian breast screening radiologists. MATERIALS AND METHODS: A questionnaire survey was carried out in 2013-2014 by the Italian Group for Mammography Screening (GISMa). The questionnaire included items of information for radiologist's experience-related characteristics and for facility-level factors supposedly associated with SMRV and TMRV. Multivariate analysis was performed using backward stepwise multiple logistic regression models. RESULTS: Data for 235 radiologists from 51 local screening programmes were received. Of the 222 radiologists who were eligible, 133 (59.9 %) reported a SMRV ≥5000 and 163 (73.4 %) a TMRV ≥5000. Multivariate factors positively associated with both characteristics included: the number of years of experience reading mammograms; the percentage of total working time dedicated to breast imaging and breast care; the participation in diagnostic assessment; and the availability of digital tomosynthesis at facility. Full-time dedication to breast imaging and breast care was associated with the highest odds ratio for a SMRV and a TMRV ≥5000, i.e. 11.80 and 46.74, respectively, versus a percentage of time ≤50 %. An early (<2000) year of implementation of the screening programme and the availability of vacuum-assisted biopsy at facility were associated with a SMRV and, respectively, a TMRV ≥5000. CONCLUSIONS: Increasing the proportion of radiologists with full-time dedication to breast imaging and breast care qualified as the most effective approach to improve SMRV and TMRV.

Mammographic breast cancer screening in Italy: 2011-2012 survey.

This report is an update of a number of papers that have been published by the ONS (Osservatorio nazionale screening, National centre for screening monitoring) since 2002. Data for the survey come from several programmes that may have changed over time, and may have different settings of organization and management. During 2011-2012, a slight increase in actual extension was recorded compared to the previous years. Currently, all Italian regions have implemented screening programmes. In 2011-2012, almost 5,300,000 women aged 50-69 years were invited to have a screening mammogram, and almost 3,000,000 were screened.While potential extension was 94.4%, actual extension was 73.3%. An imbalance in extension is still present when comparing northern and central Italy, that have an actual screening extension of 94% and 86% respectively, to southern Italy, that has less than 40%. During the last few years, participation rates have been substantially stable, at around 56%for crude rate, and 60% for adjusted rate, respectively. Women actually screened during 2011-2012 were 38.9%of the national target population. Referral rates of 9.2%at first screening and 4.7%at repeat screening were recorded, showing an increasing trend in recent years. Detection rate was 4.8x1,000 at first screening and 4.4x1,000 at repeat screening, while benign to malignant surgical biopsy ratio for first and repeat screening was 0.2 and 0.1, respectively. Detection rate of small (≤10 mm) invasive cancers was 1.3x1,000 at first screening and 1.4x1,000 at repeat screening; the proportion of in situ carcinomas was 13.3%and 12.0%for first and repeat screening, respectively. Indicators by 5-year age group confirm greater diagnostic problems at younger ages (50-54 years), with higher referral rates and a substantially lower detection rate as compared to older age groups.

Breast cancer screening in Italy: evaluating key performance indicators for time trends and activity volumes.

Together with the National centre for screening monitoring (ONS), GISMa supports annual collection of data on national breast screening activities. Aggregated data on implementation and performance are gathered through a standardized form to calculate process and impact indicators. Analyzed data belong to 153 local programmes in the period 2006-2011 (2006-2012 for participation rate only). During the whole period, Italian crude participation rate exceeded GISMa's acceptable standard (50%), even though a higher participation in northern and central Italy compared to southern Italy and Islands was observed. Time trend analysis of diagnostic indicators confirmed in 2011 an adequate quality of breast screening performance, especially at subsequent screening. Recall rate at initial screening did not reach the acceptable standard (<7%) and rose slightly over the period. On the contrary, a good performance was achieved at subsequent screening. The same trend was followed by the overall detection rate and positive predictive value. They both showed a progressive reduction (from 6.2‰ in 2006 to 4.5‰ in 2011 for DR and from 8.0% in 2006 to 5.2% in 2011 for PPV, respectively) at initial screening and a good, stable trend at subsequent screening. Activity volume analysis shows that in programmes with greater activity (test/year ≥10,000) RR at both initial and subsequent screening has a better performance. This is also true for DR and PPV where programmes with high volumes of activity do better, especially when compared with those that interpret fewer than 5,000 mammograms per year. In spite of a few limits, these results are reassuring, and they reward the efforts made by screening professionals. It is therefore important to continue to monitor screening indicators and suggest, test, and evaluate new strategies for continuous improvement.

Estimating cancer incidence using a Bayesian back-calculation approach.

We propose a Bayesian hierarchical model for the calculation of incidence counts from mortality data by a convolution equation that expresses mortality through its relationship with incidence and the survival probability density. The basic idea is to use mortality data together with an estimate of the survival distribution from cancer incidence to cancer mortality to reconstruct the numbers of individuals who constitute previously incident cases that give rise to the observed pattern of cancer mortality. This model is novel because it takes into account the uncertainty from the survival distribution; thus, a Bayesian-mixture cure model for survival is introduced. Furthermore, projections are obtained starting from a Bayesian age-period-cohort model. The main advantage of the proposed approach is its consideration of the three components of the model: the convolution equation, the survival mixture cure model and the age-period-cohort projection within a directed acyclic graph model. Furthermore, the estimation are obtained through the Gibbs sampler. We applied the model to cases of women with stomach cancer using six age classes [15-45], [45-55], [55-65], [65-75], [75-85] and [85-95] and validated it by using data from the Tuscany Cancer Registry. The model proposed and the program implemented are convenient because they allow different cancer disease to be analysed because the survival time is modelled by flexible distributions that are able to describe different trends.

Toward Self-Powered Sensing and Thermal Energy Harvesting in High-Performance Composites via Self-Folded Carbon Nanotube Honeycomb Structures.

The development of high-performance self-powered sensors in advanced composites addresses the increasing demands of various fields such as aerospace, wearable electronics, healthcare devices, and the Internet-of-Things. Among different energy sources, the thermoelectric (TE) effect which converts ambient temperature gradients to electric energy is of particular interest. However, challenges remain on how to increase the power output as well as how to harvest thermal energy at the out-of-plane direction in high-performance fiber-reinforced composite laminates, greatly limiting the pace of advance in this evolving field. Herein, we utilize a temperature-induced self-folding process together with continuous carbon nanotube veils to overcome these two challenges simultaneously, achieving a high TE output (21 mV and 812 nW at a temperature difference of 17 °C only) in structural composites with the capability to harvest the thermal energy from out-of-plane direction. Real-time self-powered deformation and damage sensing is achieved in fabricated composite laminates based on a thermal gradient of 17 °C only, without the need of any external power supply, opening up new areas of autonomous self-powered sensing in high-performance applications based on TE materials.

Estimating complete cancer prevalence in Europe: validity of alternative vs standard completeness indexes.

Introduction: Comparable indicators on complete cancer prevalence are increasingly needed in Europe to support survivorship care planning. Direct measures can be biased by limited registration time and estimates are needed to recover long term survivors. The completeness index method, based on incidence and survival modelling, is the standard most validated approach. Methods: Within this framework, we consider two alternative approaches that do not require any direct modelling activity: i) empirical indices derived from long established European registries; ii) pre-calculated indices derived from US-SEER cancer registries. Relying on the EUROCARE-6 study dataset we compare standard vs alternative complete prevalence estimates using data from 62 registries in 27 countries by sex, cancer type and registration time. Results: For tumours mostly diagnosed in the elderly the empirical estimates differ little from standard estimates (on average less than 5% after 10-15 years of registration), especially for low prognosis cancers. For early-onset cancers (bone, brain, cervix uteri, testis, Hodgkin disease, soft tissues) the empirical method may produce substantial underestimations of complete prevalence (up to 20%) even when based on 35-year observations. SEER estimates are comparable to the standard ones for most cancers, including many early-onset tumours, even when derived from short time series (10-15 years). Longer observations are however needed when cancer-specific incidence and prognosis differ remarkably between US and European populations (endometrium, thyroid or stomach). Discussion: These results may facilitate the dissemination of complete prevalence estimates across Europe and help bridge the current information gaps.

[Mammography breast cancer screening in Italy: 2010 survey]. / Lo screening mammografico in Italia: survey 2010.

This report is an update of similar previous papers that have been published by the ONS (Osservatorio nazionale screening, National Centre for Screening Monitoring) since 2002. Data for the survey come from several different programmes that may have changed over time, and may have different settings of organisation and management. During 2010, the first slight decrease in theoretical extension was recorded. Currently, all Italian regions have implemented screening programmes. In 2010, almost 2,496,000 women aged 50-69 years were invited to have a screening mammogram, and more than 1,382,000 were screened. Theoretical extension was 91.7%, while actual extension was 69.1%. An imbalance in extension is still present when comparing northern and central Italy to southern Italy, which only has a 75% coverage by organised screening. The Italian mean value (69%) of two-year extension (period 2009-2010) suggests that, at full capacity, Italian programmes are able to invite only three quarters of the target population. The percentage of women screened during 2010 was 36.7% of the national target population. During the last few years, participation rates were substantially stable, around 55-57% for crude rate, and 59-61% for adjusted rate, respectively. A decreasing trend towards the South of Italy is evident for this parameter, too. Many programmes work with low volumes of activity (below 10,000 or even 5,000 examinations per year), and only one region surpassed the desirable level of at least 20,000 examinations for each programme. Referral rates of 8.8% at first screening and 4.6% at repeat screening were recorded. Direct standardised detection rate was 6.2x1,000 at first screening and 4.3x1,000 at repeat screening, while benign to malignant ratio for first and repeat screening was 0.26 and 0.12, respectively. Detection rate of invasive cancers ≤10 mm was 1.36x1,000 at first screening and 1.49x1,000 at repeat screening; the proportion of in situ carcinomas was 13.9% and 13.4% for first and repeat screening, respectively. Indicators by 5-year age group confirm greater diagnostic problems at younger ages (50-54 years), with higher referral rates, higher frequency of surgical procedures with benign outcome (B/M ratio), and a substantially lower detection rate as compared to older age groups.

[Time trends of process and impact indicators in Italian breast screening programmes (2000-2010)]. / Trend temporali di alcuni indicatori dello screening mammografico (2000-2010).

Since its establishment in 1990, one of the main tasks of the Italian group for breast cancer screening (GISMa) is the systematic data collection on the activity of the organised breast cancer screening programmes implemented in Italy. Data are collected in an aggregated way and gathered through a standardised form to calculate process and impact parameters. Data analysis from 2000-2010 shows that crude attendance rate reached the acceptable 50% standard, presenting a higher level of participation in Northern and Central Italy compared to Southern Italy/Islands, where attendance rates are still inadequate and do not reach the acceptable standard. In areas where a more complete regional extension (referring frequently to a more centralised management) exists, the participation rate was higher compared to those with partial regional extension and no centralised management. The differences range from 5% in 2005 to 22% in 2010. The time trends of the other analysed parameters showed, in 2010, a good overall quality of the performance. For example, benign/malignant surgical biopsy ratio (B/M ratio) reached 0.19 at first screening and 0.11 at subsequent screening; detection rate for in situ and small cancers (≤10 mm) showed a good trend, reaching 0.9‰ and 1.2‰, respectively, at first screening, and 0.6‰, and 1.5‰ for subsequent screening, respectively. On the contrary, excess referral rate at first screening persisted (9.2%) in the year 2010, while RR is improved at subsequent screening (from 4.2% in 2009 to 3.9% in 2010). The overall detection rate is improved both at first and subsequent screening (5.2‰ in 2010 vs. 5.7‰ in 2009 and 4.7‰ in 2010 vs. 5.7‰ in 2009, respectively). Although further analyses are needed to better interpret these trends, results continue to be consistent with those achieved by other European programmes, and they are reassuring for all Italian breast cancer screening professionals.

Key performance indicators of breast cancer screening programmes in Italy, 2011-2019.

INTRODUCTION: Performance indicators for organised breast cancer screening programmes in Italy, 2011-2019, were evaluated. MATERIALS AND METHODS: Aggregated data were gathered by the National Centre for Screening Monitoring from over 150 regional or sub-regional screening programmes in Italy. Invitation and examination coverage, participation rate (PR), recall rate (RR), detection rate, positive predictive value (PPV) for the target population as a whole (women aged 50-69), by 5-year age-class, geographical macro-area (North, Centre, South-Islands with the exception of three Regions for missing/uncomplete data) and Region were estimated. RESULTS: Coverage showed an increasing positive trend, especially in the South-Islands, and PR was stable all over Italy. On the other hand, an increasing RR and decreasing PPV were recorded, especially at the first screening test and in some regions. DISCUSSION AND CONCLUSIONS: The positive increase in coverage is accompanied by a worsening of some performance indicators for which a better resource allocation and staff training are required. For this reason, further and continuous monitoring is mandatory.

Single CT colonography versus three rounds of faecal immunochemical test for population-based screening of colorectal cancer (SAVE): a randomised controlled trial.

BACKGROUND: Colorectal cancer screening is recommended for people aged 50-75 years, but the optimal screening test and strategy are not established. We aimed to compare single CT colonography versus three faecal immunochemical test (FIT) rounds for population-based screening of colorectal cancer. METHODS: This randomised controlled trial was done in Florence, Italy. Adults aged 54-65 years, never screened for colorectal cancer, were randomly assigned (1:2) by simple randomisation and invited by post to either a single CT colonography (CT colonography group) or three FIT rounds (FIT group; each round was done 2 years apart). Exclusion criteria included previous colorectal cancer, advanced adenoma, or inflammatory bowel disease, colonoscopy within the last 5 years or FIT within the last 2 years, and severe medical conditions. Participants who had a colonic mass or at least one polyp of 6 mm or more in diameter in the CT colonography group and those who had at least 20 µg haemoglobin per g faeces in the FIT group were referred for work-up optical colonoscopy. The primary outcome was detection rate for advanced neoplasia. Outcomes were assessed in the modified intention-to-screen and per-protocol populations. The trial is registered with ClinicalTrials.gov, NCT01651624. FINDINGS: From Dec 12, 2012, to March 5, 2018, 14 981 adults were randomised and invited to screening interventions. 5242 (35·0%) individuals (2809 [53·6%] women and 2433 [46·4%] men) were assigned to the CT colonography group and 9739 (65·0%) individuals (5208 [53·5%] women and 4531 [46·5%] men) were assigned to the FIT group. Participation in the screening intervention was lower in the CT colonography group (1286 [26·7%] of the 4825 eligible invitees) than it was for the FIT group (6027 [64·9%] of the 9288 eligible invitees took part in at least one screening round, 4573 [49·2%] in at least two rounds, and 3105 [33·4%] in all three rounds). The detection rate for advanced neoplasia of CT colonography was significantly lower than the detection rate after three FIT rounds (1·4% [95% CI 1·1-1·8] vs 2·0% [1·7-2·3]; p=0·0094) in the modified intention-to-screen analysis, but the detection rate was significantly higher in the CT colonography group than in the FIT group (5·2% [95% CI 4·1-6·6] vs 3·1% [2·7-3·6]; p=0·0002]) in the per-protocol analysis. Referral rate to work-up optical colonoscopy (the secondary outcome of the trial) was significantly lower for the CT colonography group than for the FIT group after three FIT rounds (2·7% [95% CI 2·2-3·1] vs 7·5% [7·0-8·1]; p<0·0001) in the modified intention-to-screen analysis, whereas no significant difference was observed in the per-protocol analysis (10·0% [8·4-11·8] vs 11·6% [10·8-12·4]). No major complications were observed in the CT colonography group after screening and work-up optical colonoscopy, whereas three cases of bleeding were reported in the FIT group after work-up optical colonoscopy (two after the first FIT and one after the second FIT). INTERPRETATION: Greater participation makes FIT more efficient than single CT colonography for detection of advanced neoplasia in population screening for colorectal cancer. Nonetheless, higher detection rate in participants and fewer work-up colonoscopies are possible advantages of CT colonography as a screening tool, which might deserve consideration in future trials. FUNDING: Government of Tuscany and Cassa di Risparmio di Firenze Foundation. TRANSLATION: For the Italian translation of the abstract see Supplementary Materials section.

Mammography screening in Italy: 2009 survey.

This report is an update of similar previous papers that have been published by the ONS (Osservatorio nazionale screening, National Centre for Screening Monitoring) since 2002. Data for the survey come from several different programmes that may have changed over time, and may have different settings of organisation and management. During 2009, an increase in theoretical extension was recorded; however, this was not followed by an increase in actual extension, which remained stable. Currently, all Italian regions have implemented screening programmes. In 2009, almost 2,522,000 women aged 50-69 years were invited to have a screening mammogram, and more than 1,362,000 were screened. Theoretical extension was 93.8%, while actual extension was 69.5%. An imbalance in coverage is still present when comparing northern and central Italy to southern Italy, which only has a 78% coverage by organised screening. The Italian mean value (78.5%) of two-year extension (period 2008-2009) suggests that, at full capacity, Italian programmes are able to invite only three quarters of the target population. The percentage of women screened during 2009 accounted for 36.5% of the national target population. During the last few years, participation rates were substantially stable, around 55-57%for crude rate, and 59-61%for adjusted rate, respectively. A decreasing trend towards the South of Italy is evident for this parameter, too. Many programmes work with low volumes of activity (below 10,000 or even 5,000 examinations per year), and only one region surpassed the desirable level of at least 20 000 examinations for each programme. Referral rates of 8% at first screening and 4.6% at repeat screening were recorded. Direct standardised detection rate was 6.2 x 1,000 at first screening and 4.4 x 1,000 at repeat screening, while benign to malignant ratio for first and repeat screening was 0.25 and 0.12, respectively. Detection rate of invasive cancers ≤ 10 mm was 1.34 x 1,000 at first screening and 1.51 x 1.000 at repeat screening; the proportion of in situ carcinomas was 14.1% and 14.4% for first and repeat screening, respectively. Indicators by 5-year age group confirm greater diagnostic problems at younger ages (50-54 years), with higher referral rates, higher frequency of surgical procedures with benign outcome (B/M ratio), and a substantially lower detection rate as compared to older age groups.

Time trends of process and impact indicators in Italian breast screening programmes (1999-2009).

Since its establishment in 1990, one of the main tasks of the Italian group for mammography screening (GISMa) is the systematic data collection on the activity of the organised mammography screening programmes implemented in Italy. Data are collected in an aggregated way and gathered through a standardised form to calculate process and impact parameters. Data analysis from 1999-2009 shows that crude attendance rate reached the acceptable 50% standard, presenting a higher level of participation in northern and central Italy compared to southern Italy/Islands, where attendance rates are still inadequate and do not reach the acceptable standard. In areas where centralised management is more established or complete, the participation rate was higher compared to areas without such characteristics, with differences from 5% in 2005 (reaching 22% in 2008) to 10% in 2009. The time trends of the other parameters included in the analysis showed, in 2009, a good average performance. For example, benign/malignant surgical biopsy ratio (B/M ratio) reached 0.21 at first screening and 0.08 at subsequent screening; detection rate for in situ and small cancers (≤10 mm) showed a good trend, reaching 0.9‰, and 1.5‰, respectively, for first screening, and 0.9‰, and 1.4‰ for subsequent screening. On the contrary, excess referral rate at first screening persisted, and the overall detection rate presented a negative trend in the last period (8.9% and 5.7‰, respectively). Although further analyses are needed to better interpret these trends, results continue to be consistent with those achieved by other European programmes, and are reassuring for all Italian mammography screening professionals.

Influence of seasonal variations in ambient temperatures on performance of immunochemical faecal occult blood test for colorectal cancer screening: observational study from the Florence district.

BACKGROUND: Faecal occult blood testing (FOBT) in population screening has proved to be effective in reducing mortality from colorectal cancer. In Italy a latex agglutination FOBT has been adopted for a single-sample screening programme. The aim of this study was to examine the performance of FOBTs in the Florence screening programme over several seasons to evaluate the impact of variations in ambient temperature on the performance of the screening test. METHODS: Measured haemoglobin (Hb) concentrations were aggregated into seasons with their average ambient temperature (AAT). Using logistic regression, the AAT over the period preceding the test measurement was analysed. This period included the time between faecal sampling and return of the test sample (mean 7days) and the time in the laboratory refrigerator before analysis (mean 4days). The AAT from days 5-11 before analysis of the test sample was considered a determinant of test positivity. The Kruskal-Wallis rank test was used to evaluate the significance of seasonal and/or AAT-related differences in Hb concentration. A logistic regression model adjusted for sex, age, season and screening episode (first or repeated examination) was constructed. RESULTS: 199 654 FOBT results were examined. Mean FOBT seasonal Hb concentrations (ng/ml) were: spring 27.6 (95% CI 26.2 to 29.1); summer 25.2 (95% CI 23.1 to 27.3); autumn 29.2 (95% CI 27.7 to 30.6); winter 29.5 (95% CI 27.9 to 31.1). Logistic regression showed that there was a 17% lower probability of the FOBT being positive in summer than in winter. The results of the logistic regression showed that an increase in temperature of 1°C produced a 0.7% reduction in probability of a FOBT being positive. In the summer the probability of detecting a cancer or an advanced adenoma was about 13% lower than in the winter. CONCLUSIONS: This study showed that there is a significant fall in Hb concentration at higher ambient temperatures. These results will have important implications for the organisation of immunochemical FOBT-based screening programmes, particularly in countries with high ambient temperatures.

Human papillomavirus infection and risk factors in a cohort of Tuscan women aged 18-24: results at recruitment.

BACKGROUND: There is conclusive evidence that human papillomavirus (HPV) infections of the cervix are a necessary cause of cervical cancer. In Italy there are consistent data of HPV prevalence in women aged 25 - 64 years, but there is limited data for younger women. The objective of this on-going 3-year prospective cohort study is to investigate the prevalence, acquisition, clearance and persistence of HPV infections in young Tuscan women and the risk factors correlated with such events. METHODS: One thousand and sixty-six women aged between 18 and 24 years were enrolled and received an initial HPV test. They were asked to return to the clinic over the study period for further tests every 12 months, if their HPV HR result was negative, or every 6 months, if positive. Additionally, women with an HPV positive result were given a cytological examination and if the cytological diagnosis was ASC-US or more severe, only women with HPV HR, were referred for colposcopy. RESULTS: We present here data for the enrollment phase of the study. At baseline, within the study sample, just under 30% of women were infected by HPV and 19.3% of women were infected with oncogenic types. A relationship was highlighted between HPV infection, number of sexual partners (in particularly in the last 3 years) and the lifetime number of partner's partners. Condom use showed a slight protective effect in univariate analysis but these data were not statistically significant in multivariate analysis. The association between HPV infection and demographic and behavioural variables were tested by crude odds ratio (OR). Multivariate logistic regression was applied to compute the adjusted odds ratios. CONCLUSIONS: The prevalence of oncogenic HPV types was high in young Tuscan women. The 3-year follow-up of this cohort may provide a better understanding of the processes of acquisition, clearance and persistence of infection and the correlated risk factors.

Mammography screening in Italy: 2008 survey.

This report is an update of similar previous papers that have been published by the ONS (Osservatorio Nazionale Screening, National Centre for Screening Monitoring) since 2002. Data for the survey come from several different programmes that may have changed over time, and may have different settings of organisation and management. During 2007, a further increase in screening activity was recorded, with the inclusion of all Northern and Central Italian Regions, and a further development in the Southern Regions and Islands, so today all Italian Regions have implemented screening programmes. In 2008, almost 2,509,000 women aged 50-69 years were invited to have a screening mammogram, and more than 1,361,000 were screened. Theoretical extension was 89.9%, while actual extension increased from 62.3% in 2007 to 69.4%in 2008. An imbalance in coverage is still present when comparing Northern and Central Italy to Southern Italy, which only has a 69% coverage by organised screening. The Italian mean value (72.8%) of two-year extension (period 2007-2008) suggests that, at full capacity, Italian programmes are able to invite only two thirds of the target population. The percentage of women screened during 2008 accounted for 36.7% of the national target population. During the last few years, participation rates were substantially stable around 55-57% for crude rate, and 59-61% for adjusted rate, respectively. A decreasing trend towards the South of Italy is evident for this parameter, too. Many programmes work with low volumes of activity (below 10,000 or even 5,000 examinations per year), and only one Region surpassed the desirable level of at least 20,000 examinations for each programme. Referral rates of 7.5% at first screening and 4.4% at repeat screening were recorded. Direct standardised detection rate was 6.2x1,000 at first test and 4.2 at repeat test, while benign to malignant ratio for first and repeat screening was 0.25 and 0.15, respectively. Detection rate of invasive cancers ≤10 mm was 1.39x1,000 at first test and 1.44 at repeat test; the proportion of in situ carcinomas was 12.5% and 14.2% for first and repeat test, respectively. Indicators by 5-year age group confirm greater diagnostic problems at younger ages, with higher referral rates, higher frequency of surgical procedures with benign outcome (B/M ratio), and a substantially lower detection rate as compared to older age groups.

Time trends of process and impact indicators in Italian breast screening programmes: 1998-2008.

Since its establishment in 1990, one of the main tasks of the Italian Group for Mammography Screening (GISMa) is the systematic data collection on the activity of the organised mammography screening programmes implemented in Italy. Data are collected in an aggregated way and gathered through a standardised form to calculate process and impact parameters. Data analysis referring to the period 1998-2008 shows that crude attendance rate reached the acceptable 50% standard, presenting a higher level of participation in Northern and Central Italy compared to Southern Italy/Islands, where attendance rates are still inadequate and do not reach the acceptable standard. In areas where the centralised management is more established or complete, the participation rate was higher compared with areas without such characteristics, with differences from 5% to 22% (in 2008). The time trends of the other parameters included in the analysis showed, in 2008, a good average performance. For example, benign/malignant surgical biopsy ratio (B/M ratio) reached 0.21 at first screening and 0.11 at subsequent screening; overall detection rate, detection rate for in situ and small cancers (≤10 mm) showed a good trend, reaching 5.7‰, 1.1‰, and 1.4‰, respectively, for first screening, and 5.0‰, 0.7‰, and 1.4‰ for subsequent screening. On the contrary, excess referral rate at first screening persists over time. These results continue to be consistent with those achieved by other European programmes and reassuring for all Italian mammography screening professionals.