Cardio-metabolic risk modeling and assessment through sensor-based measurements.

OBJECTIVE: Cardio-metabolic risk assessment in the general population is of paramount importance to reduce diseases burdened by high morbility and mortality. The present paper defines a strategy for out-of-hospital cardio-metabolic risk assessment, based on data acquired from contact-less sensors. METHODS: We employ Structural Equation Modeling to identify latent clinical variables of cardio-metabolic risk, related to anthropometric, glycolipidic and vascular function factors. Then, we define a set of sensor-based measurements that correlate with the clinical latent variables. RESULTS: Our measurements identify subjects with one or more risk factors in a population of 68 healthy volunteers from the EU-funded SEMEOTICONS project with accuracy 82.4%, sensitivity 82.5%, and specificity 82.1%. CONCLUSIONS: Our preliminary results strengthen the role of self-monitoring systems for cardio-metabolic risk prevention.

The professional quality criteria of Italian breast screening radiologists: results from a national survey comparing the programmes started in 2000-2012 versus the ones started in 1990-1999.

INTRODUCTION: In Italy, due to increasing healthcare budget and staff shortages, the recently created regional mammography screening programmes were established under worse radiology practice quality criteria than the previously created programmes. METHODS: Using available data from a national questionnaire survey conducted at the end of 2013 and involving 222 responder radiologists, we compared the main professional quality standards of radiologists working in the screening programmes established during the period 2000-2012 with those working in the screening programmes created from 1990 to 1999. RESULTS: The former reported more years of clinical experience in breast imaging and a greater clinical mammogram reading volume than the latter. Conversely, they dedicated less working time to breast imaging, were less likely to participate in the diagnostic assessment of screen-detected lesions, to work in large-staffed screening centres, and to have a screening and a total mammogram reading volume (SMRV and TMRV) ≥ 5000 per year. CONCLUSIONS: The level of most professional quality criteria of Italian mammography screening radiologists has decreased over time. As SMRV and TMRV are important predictors of diagnostic accuracy, we can expect a lower interpretation performance of radiologists working in the recently created screening programmes.

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.

Cervical cancer screening in immigrant women in Italy: a survey on participation, cytology and histology results.

Cervical cancer screening programmes in Italy actively invite all 25-64-year-old resident women for the Pap test every 3 years irrespective of their citizenship. Immigrant women come from countries where screening is absent or poorly implemented and the prevalence of human papillomavirus is often high. These women therefore have significant risk factors for cervical cancer. The Italian Group for Cervical Cancer Screening promoted a survey of all the screening programmes on the participation and the positivity and detection rates in Italian and foreign women in 2009-2011. Aggregated data for participation, cytology results, compliance with colposcopy and histology results were collected, distinguishing between women born in Italy and abroad. All comparisons were age adjusted. Forty-eight programmes out of 120 participated in the immigrant survey, with 3 147 428 invited and 1 427 412 screened Italian women and 516 291 invited and 205 948 screened foreign women. Foreign women had a slightly lower participation rate compared with Italians (39.9 vs. 45.4%), whereas compliance with colposcopy was similar (90%). Foreigners showed a higher risk of pathological findings than Italians: cytology positivity [relative risk (RR)=1.25, 95% confidence interval (CI) 1.24-1.27] and detection rate for cervical intraepithelial neoplasia grade 2 (CIN2) (RR=1.39, 95% CI 1.31-1.47), CIN3 (RR=2.07, 95% CI 1.96-2.18) and cancer (RR=2.68, 95% CI 2.24-3.22). The ratio between cancer and CIN was higher in immigrants (0.06 vs. 0.04, P<0.01). Foreign women had a higher risk of cervical precancer and cancer. Because of their high risk and because opportunistic screening does not cover this often disadvantaged group, achieving high participation in screening programmes for foreigners is critical to further reducing the cervical cancer burden in Italy.

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.

Problems, solutions, and perspectives in the evaluation of interval cancers in Italian mammography screening programmes: a position paper from the Italian group for mammography screening (GISMa).

In this position paper, a self-convened team of experts from the Italian Group for Mammography Screening (Gruppo italiano screening mammografico, GISMa) pointed out the problems that increasingly hamper the feasibility and validity of the estimate of the proportional incidence of interval breast cancer (IBC) in Italy, suggested potential solutions and an agenda for research, and proposed that the question of the sensitivity of mammography be viewed in a larger perspective, with a greater attention to radiological review activities and breast radiology quality assurance programmes. The main problems are as follows: the coverage of cancer registration is incomplete; the robustness of using the pre-screening incidence rates as underlying rates decreases with time since the start of screening; the intermediate mammograms performed for early detection purposes may cause an overrepresentation of IBCs; the classification of many borderline screening histories is prone to subjectivity; and, finally, the composition of cohorts of women with negative screening results is uncertain, because several mammography reports are neither clearly negative nor clearly positive, and because of the limitations and instability of the electronic mammography records. Several possibilities can be considered to cope with these issues: standard methods for using the hospital discharge records in the identification of IBCs should be established; for the calculation of regional estimates of the underlying incidence, a suitable mathematical model should be identified; the definition of IBC according to the 2008 GISMa guidelines needs to be updated, especially with respect to in situ cancers and to invasive cancers with borderline screening histories; a closer adherence to standard screening protocols, with a simplified patient management, would make it easier to objectively identify IBCs; alternative methods for estimating the sensitivity of mammography should be taken into consideration; and, finally, analysis could be restricted to the absolute incidence rate of IBC, which would make comparison of the risk between neighbouring populations possible. Epidemiologists must extend their attention to the prevention of the risk of IBC and the implementation of breast radiology quality assurance practices. Epidemiologists and radiologists can share common objectives: it is necessary to promote the idea that the availability of a registry-based series of IBCs is not a prerequisite for their radiological review; radiological review of breast cancers greater than 20mm in size detected at second and subsequent screens, that are potential substitutes for IBCs, needs radiological and epidemiological validation studies; the advent of digital mammography brings about the possibility to create libraries of mammograms accessible online, which enables the conduct of large studies of the diagnostic variability of radiologists; and, finally, epidemiologists and radiologists have the responsibility to monitor the effects that a loss of cumulative professional experience in screening centres, due to the imminent retirement of a substantial proportion of healthcare workforce, could cause on their performance.

A wize mirror for lifestyle improvement.

This paper discusses the problem of fostering lifestyle changes towards healthier habits via tailored user guidance. We present a novel multisensory device, the Wize Mirror, which will be able to detect semeiotic face signs related to cardio-metabolic risk, and encourage users to reduce their risk by improving their lifestyle. Offering a proper user guidance requires solving three main issues: user profiling, definition of a wellness index based on biophysical data, and personalized guidance by means of coaching and supportive messages. For each of these issues, the solutions proposed in the EU FP7 Project SEMEOTICONS are presented, highlighting their advantages with respect to the state-of-the-art.

A comparison of different strategies used to invite subjects with a positive faecal occult blood test to a colonoscopy assessment. A randomised controlled trial in population-based screening programmes.

OBJECTIVE: The purpose of this parallel randomised controlled trial was to compare compliance with different modalities used to invite patients with a positive immunochemical faecal occult blood test (FIT+) for a total colonoscopy (TC). METHOD: FIT+ patients from nine Italian colorectal cancer screening programmes were randomised to be invited for a TC initially by mail or by phone and, for non-compliers, to be recalled by mail, for counselling with a general practitioner, or to meet with a specialist screening practitioner (nurse or healthcare assistant). RESULTS: In all, 3777 patients were randomised to different invitation strategies. Compliance with an initial invitation by mail and by phone was similar (86.0% vs. 84.0%, relative risk - RR: 1.02; 95%CI 0.97-1.08). Among non-responders to the initial invitation, compliance with a recall by appointment with a specialist practitioner was 50.4%, significantly higher than with a mail recall (38.1%; RR:1.33; 95%CI 1.01-1.76) or with a face-to-face counselling with the GP (30.8%; RR:1.45;95%CI 1.14-1.87). CONCLUSION: Compliance with an initial invitation for a TC by mail and by phone was similar. A personal meeting with a specialist screening practitioner was associated with the highest compliance among non-compliers with initial invitations, while the involvement of GPs in this particular activity seemed less effective.

[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.

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.

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.

Time trends of process and impact indicators in Italian breast screening programmes: 1998-2007.

Since its establishment in 1990, one of the main tasks of the Italian Group for Mammography Screening (GISMa) has been that of collecting, as systematically and thoroughly as possible, data on the activity of the Italian mammography screening programmes. Data are collected in an aggregated way and gathered through a standardised form to calculate process and impact parameters. Analysis of data referring to the period 1998-2007 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 of about 4-9%. The time trends of the other parameters included in the analysis showed a good average performance. For example, benign/malignant surgical biopsy ratio (B/M ratio) continued to progressively decrease, reaching 0.20 at first screening and 0.10 at subsequent screening in 2007; overall detection rate, detection rate for in situ and small cancers (< or =10 mm) showed a good trend, reaching 5.4 per thousand, 0.9 per thousand, and 1.6 per thousand, respectively, for fi rst screening, and 4.8 o/oo, 0.8 o/oo, and 1.2 o/oo for subsequent screening in 2007. On the contrary, excess referral rate at first screening persists over time. Data comparing activity volume and programme duration were also considered. In programmes with greater activity volume (average test number: 24,596) the referral rate for first screening was higher if compared with programmes with lower activity volume, but still within acceptable standards. Nevertheless, this performance is compensated by better specificity and sensitivity. An improvement in quality with the increase of programmes experience continues to be evident: compared with new programmes, programmes with more than 6 years of activity showed lower recall rates, higher positive predictive values and higher overall detection rates in the first screening round. Outcomes related to subsequent screening rounds present analogous performances. These results continue to be consistent with those achieved by other European programmes and reassuring for all Italian mammography screening professionals.

Mammography screening in Italy: 2007 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. In 2007, screening activity also started in Puglia, so today all Italian Regions have implemented screening programmes. In 2007, almost 2,210,000 women aged 50-69 years were invited to have a screening mammogram, and over 1,225,000 were screened. Theoretical extension was 81.4%, while actual extension increased from 57.2% in 2006 to 62.3% in 2007, finally rising over the critical value of about 50% registered during the last years. An imbalance in coverage is still present when comparing Northern and Central Italy to Southern Italy, which only has a 52% coverage by organised screening. The percentage of women screened during 2007 accounted for 33.3% of the national target population. During the last few years (2004-2007), 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 no regional mean value surpassed the desirable level of at least 20,000 examinations for each programme. Referral rates of 7.9% at first screening and 4.0% at repeat screening were recorded. Direct standardised detection rate was 6.5x1,000 at first test and 3.8 at repeat test, while benign to malignant ratio for first and repeat screening was 0.21 and 0.14, respectively. Detection rate of invasive cancers

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.

Mammography screening in Italy: 2005 survey and 2006 preliminary data.

Mammography screening programmes in Italy have been implemented since the early 90's. Over the last ten years, national and international institutions have strongly supported screening programme implementation with several laws. Since 2004, the Italian Ministry of Health, together with the Commission of Regions and Self-governing Provinces Health Officials, has officially entrusted the ONS (Osservatorio Nazionale Screening, National Centre for Screening Monitoring) with monitoring and promoting nationwide screening programmes. Previously, for several years, GISMa (Gruppo Italiano per lo Screening Mammografico) carried out a yearly survey to collect process indicators of mammography screening and compare them, using national and international standard values as reference. In 2006, an updated version of the operative report of process indicators was published by GISMa, and in November 2006 the updated national screening guidelines, prepared by the workgroups on oncological screening set up by the Ministry, was published. This report is an update of similar previous papers published by the ONS 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 2005, an increase in screening activity was recorded with the inclusion of all Northern and Central Italian Regions, and 2006 showed a further development n the Southern Regions and Islands. Only one Region is missing (Puglia), but it started its activity in 2007; so starting from 2007, all Italian Regions have implemented screening programmes. In 2006, more than 2 million women aged 50-69 years were invited to have a screening mammogram, and over 1,150,000 were screened. Theoretical extension was 76.4% in 2005 and 78.2% in 2006. This year shows an important increase in actual extension, improving from 50.3% in 2005 to 57.2% in 2006 and finally rising over the critical value of about 50% registered during the last years. An imbalance in coverage is still present when comparing Northern and Central Italy (more than 90%) to Southern Italy, which only has a 46% coverage by organised screening. The percentage of women screened during 2005 accounted for 28.6% of the national target population, and increased up to 31.8% in 2006. During the three-year period 2004-2006, participation rates were substantially stable around 55-57% for crude rate, and 59-60% for adjusted rate, respectively. A decreasing trend towards the South of Italy is evident for this parameter, too, but in 2005-2006 the Central Regions registered the highest increase in attendance: crude and adjusted participations rose from 52-54% in 2004 to 56-58% in 2005-2006. Many programmes work with low volumes of activity (below 10,000 or even 5,000 examinations per year), and no regional mean value surpassed the desirable level of at least 20,000 examinations for each programme. Referral rates of 8.3% at first screening and 4.5% at repeat screening were recorded. Direct standardised detection rate was 5.7 x 1,000 at first test and 4.6 at repeat test, while benign to malignant ratio for first and repeat screening was 0.28 and 0.21, respectively. Detection rate of invasive cancers < or =10 mm was 1.44 x 1,000 at first test and 1.58 at repeat test; the proportion of in situ carcinomas was 12.9% and 14.7% 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--1996-2005.

Since its establishment in 1990, one of the main tasks of the Italian Group for Mammography Screening (GISMa) has been that of collecting, as systematically and thoroughly as possible, data on the activity of the various 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. Analysis of data collected in the period 1996-2006 shows that the number of Italian women involved in mammography screening has constantly increased over time. In 2006, almost 8 out of 10 Italian women in the 50-69 year age range lived in areas where an organised screening activity had been implemented. The geographical distribution of the screening activity in Italy continues to present differences between Northern and Central Italy, where the coverage ranges from 95.7% to 89.6%, and Southern Italy and the Islands, where this value is still lower (45.9%). The discrepancy between annual theoretical coverage and actual coverage still persists (21%). Throughout the period, crude attendance rate reached the acceptable 50% standard, presenting the same North-South trend as the coverage rate distribution. In areas where the centralised management is more established or complete, the participation rate was higher compared with areas without such characteristics, with differences of about 4-9%. The time trends of the other parameters included in the analysis showed a good average performance. For example, benignant/malignant surgical biopsy ratio (B/M ratio) continued to progressively decrease, reaching 0.24 at first screening and 0.14 at subsequent screening in 2005; overall detection rate, detection rate for in situ and small cancers (< or =10 mm) showed a good trend, reaching 6.0 per thousand, 0.7 per thousand, and 1.3 per thousand, respectively, for first screening, and 5.2 per thousand, 0.8 per thousand, and 1.6 per thousand for subsequent screening in 2005. On the contrary, excess referral rate at first screening persists over time. Data comparing activity volume and programme duration were also considered. In programmes with greater activity volume (average test number: 24,596) the referral rate for first screening was higher if compared with programmes with lower activity volume, but still within acceptable standards. Nevertheless, this performance is compensated by better specificity and sensitivity. An improvement in quality with the increase of programmes experience continues to be evident: compared with new programmes, programmes with more than 6 years of activity showed lower recall rates and higher positive predictive values and overall detection rates in first screening. Outcomes related to subsequent screening present analogous performances. These results continue to be consistent with those achieved by other European programmes and reassuring for all Italian mammography screening professionals.