How a faecal immunochemical test screening programme changes annual colorectal cancer incidence rates: an Italian intention-to-screen study.

BACKGROUND: This study aimed to evaluate the effectiveness of a biennial faecal immunochemical test (FIT) screening programme in reducing annual colorectal cancer (CRC) incidence in its dynamic target population. METHODS: The target population included over 1,000,000 persons aged 50-69 living in a region of northern Italy. The average annual response rate to invitation was 51.4%. Each observed annual age-standardised (Europe) rate per 100,000 persons between 2005, the year of introduction of the programme, and 2016 was compared with each expected annual rate as estimated with age-period-cohort (men) and age-period (women) models. RESULTS: For both sexes, the rates observed in 1997-2004 and those expected in 2005-2016 were stable. Observed rates increased in 2005, peaked in 2006 (the first full year of screening), dropped significantly below the expected level in 2009, and continued to decrease until 2013 (the eighth full year), after which no further significant changes occurred. In the pooled years 2013-2016, the observed incidence rate per 100,000 persons was 102.2 [95% CI: 97.4, 107.1] for men, 75.6 [95% CI: 71.6, 79.7] for women and 88.4 [95% CI: 85.3, 91.5] for both sexes combined, with an observed:expected incidence rate ratio of 0.68 [95% CI: 0.65, 0.71], 0.79 [95% CI: 0.76, 0.82] and 0.72 [95% CI: 0.66, 0.81], respectively. DISCUSSION: The study provided multiple consistent proofs of a causal relationship between the introduction of screening and a stable 28% decrease in annual CRC incidence after eight years.

Five-year annual incidence and clinico-molecular features of breast cancer after the last negative screening mammography at age 68-69.

OBJECTIVE: The European Commission Initiative on Breast Cancer recommendation for triennial screening of women aged 70-74 is based on very weak evidence. A cohort of Italian women who had their last biennial screening mammography at age 68-69 was followed up for 5 years, assumed to represent the interval to another hypothetical screening mammography, in order to determine the annual proportional incidence of interval breast cancer. METHODS: The cohort included 118,370 women. They had their last mammography between 1997 and 2008. Incident breast cancers were identified by record-linking the cohort with the regional breast cancer registry. The expected incidence in the age range 65-74 was estimated with an age-period-cohort model. The number of interval cancers was divided by the expected number to obtain their proportional incidence. RESULTS: Overall, there were 298,658 woman-years at risk with 371 interval cancers versus 988.8 expected. In the first, second, third, fourth, and fifth interval year, the proportional incidence was 0.09 (95% confidence interval, 0.06-0.13), 0.32 (0.25-0.39), 0.60 (0.49-0.73), 0.75 (0.60-0.92), and 0.81 (0.60-1.07), respectively. Between the second and the fifth year, tumour stage and molecular subtype did not change significantly. CONCLUSION: Though not supported by these findings, the proposal of triennial screening for women aged 70-74 merits further research, because the 95% confidence interval of the third-year proportional incidence of interval cancer included 0.50-the maximum limit considered acceptable for women aged 50-69. KEY POINTS: • The third-year incidence of breast cancer relative to the expected one was 0.60 (95% confidence interval, 0.49-0.73). • Between the second and the fifth year, tumour stage and molecular subtype did not change significantly (p >0.10). • The proposal of a 3-year screening interval at age 70-74 merits further evaluation.

Estimating the impact of an organised screening programme on cervical cancer incidence: A 26-year study from northern Italy.

The impact of the organised cervical cancer (CC) screening programmes implemented in Europe since the 1990s has been insufficiently evaluated. We investigated the changes in CC incidence following the introduction of a screening programme in the Emilia-Romagna Region (northern Italy). The study period was 1988-2013. The programme, targeting women aged 25-64 years (1,219,000 in 2018), started in 1998. The annual incidence rates that would be expected in 1998-2013 in the absence of screening were estimated, first, by analysing the annual rates in 1988-1997 with a log-linear model and, second, by analysing the annual rates in 1988-2013 with an age-period model in which the period effect was enforced to be linear. Cervical adenocarcinoma incidence trend over the entire period was used to validate both estimates. Observed annual rates were compared to the two series of expected ones with the incidence rate ratio (IRR). Incidence remained stable during 1988-1997, peaked in 1998 and then decreased until 2007, when it stabilised. The two series of expected rates were virtually coincident and their trends roughly paralleled the stable adenocarcinoma incidence trend. After 2007, the median IRR was 0.60 (95% confidence interval, 0.45-0.81) based on the log-linear model and 0.58 (95% confidence interval, 0.34-0.97) based on the age-period model. Thirty-six to seventy-five CC cases were prevented annually for an average annual frequency of 6.5 per 100,000 women in the target population. In summary, consistent circumstantial evidences were obtained that the organised screening programme brought about a 40% reduction in annual CC incidence after 10 years.

Annual mammography at age 45-49 years and biennial mammography at age 50-69 years: comparing performance measures in an organised screening setting.

OBJECTIVE: To compare the results of 5 years of annual mammography screening at age 45-49 with the results of 5 years of biennial screening at age 50-54 and 55-69. METHODS: In an Italian screening programme, data from 1,465,335 mammograms were analysed. Recall rates, invasive assessment rates, surgical biopsy (including excisional biopsy and definitive surgical treatment) rates, and cancer detection rates were calculated for the first screen (first) and, cumulatively, for the second and subsequent screens (second+). RESULTS: The rate ratios between younger women and the two groups of older ones were (in parentheses, original figures per 1000 mammograms if not otherwise specified): recall rate: first 1.11 (103.6 vs. 93.5) and 1.11 (vs. 93.2), second+ 2.10 (208.9 vs. 99.7) and 2.77 (vs. 75.5); invasive assessment rate: first 0.94 (23.0 vs. 24.5) and 0.94 (vs. 24.6), second+ 1.63 (35.8 vs. 22.0) and 1.56 (vs. 23.0); surgical biopsy rate: first 0.68 (5.9 vs. 8.6) and 0.45 (vs. 13.2), second+ 1.35 (11.5 vs. 8.5) and 0.88 (vs. 13.0); total detection rate: first 0.63 (4.3 vs. 6.7) and 0.37 (vs. 11.7), second+ 1.30 (8.9 vs. 6.8) and 0.74 (vs. 12.0); total positive predictive value of surgical biopsy: first 0.93 (72.8% vs. 78.0%) and 0.82 (vs. 88.9%), second+ 0.96 (77.2% vs. 80.5%) and 0.83 (vs. 92.7%). CONCLUSION: Younger women experienced two to threefold higher cumulative recall rates at second+ screens and limited differences in surgical biopsy rate. Albeit encouraging, these results must be completed with further investigation, especially on interval cancer incidence. KEY POINTS: • At repeated screens, cumulative recall rate was two- to threefold higher for younger women. • Differences in cumulative surgical referral and surgical biopsy rates were moderate. • Differences in positive predictive value of surgical biopsy were particularly small.

The perception of the relationship between environment and health according to data from Italian Behavioural Risk Factor Surveillance System (PASSI). / La percezione del rapporto ambiente-salute secondo i dati della sorveglianza Progressi delle aziende sanitarie per la salute in Italia (PASSI).

"OBJECTIVES: to identify groups of people in relation to the perception of environmental risk and to assess the main characteristics using data collected in the environmental module of the surveillance network Italian Behavioral Risk Factor Surveillance System (PASSI). METHODS: perceptive profiles were identified using a latent class analysis; later they were included as outcome in multinomial logistic regression models to assess the association between environmental risk perception and demographic, health, socio-economic and behavioural variables. RESULTS: the latent class analysis allowed to split the sample in "worried", "indifferent", and "positive" people. The multinomial logistic regression model showed that the "worried" profile typically includes people of Italian nationality, living in highly urbanized areas, with a high level of education, and with economic difficulties; they pay special attention to their own health and fitness, but they have a negative perception of their own psychophysical state. CONCLUSIONS: the application of advanced statistical analysis enable to appraise PASSI data in order to characterize the perception of environmental risk, making the planning of interventions related to risk communication possible. ".

Cancer screening uptake: association with individual characteristics, geographic distribution, and time trends in Italy.

BACKGROUND: In Italy, organized screening programmes invite the vast majority of the population for cervical and breast cancer, and about one half of the population for colorectal cancer. Programme activity and quality are closely monitored. Nevertheless, there is a vast spontaneous activity, both public and private, for which information on service and coverage is missing. To estimate actual population coverage for the three types of screening the extent of spontaneous screening needs to be known. METHODS: PASSI is a national telephone-interview surveillance system that continuously collects information about behavioural health risk factors and the diffusion of preventive health interventions. From 2010 to 2013, more than 151,000 18- to 69-year-olds were interviewed. During 2013, 136 out of 147 Italian local health authorities participated in the survey. Information about screening includes: test uptake (Pap smear, HPV, mammography, faecal occult blood test, colonoscopy), date of the last test, provider of the last test (whether paid or for free, proxy of the organized screening programme), reason for not participating in screening, and screening promotion/recommendation received. Individual information on socio-economic characteristics is available. RESULTS: Seventy-seven percent of the 25-64 year-old women interviewed said they had undergone a Pap smear or HPV test in the three years before the interview, 40%within the screening programme, 37% spontaneously and paying. Seventy percent of the 50-69 year-old women interviewed reported having had a mammography in the two years before the interview, 51% within the screening programme, 19% spontaneously and paying. Thirty-eight percent of the 50-69 year olds interviewed reported having undergone colorectal screening in the two years before the interview, 31% within the screening programme, 7% spontaneously and paying. All three screening programmes showed a decreasing North-South trend in coverage. From 2010 to 2013, coverage increased for all types of screening; the trend was stronger in the South; the increase was mostly due to the tests performed within the organized programmes. People with low education, economic problems, and immigrants from high migration pressure countries had lower coverage levels. In regions with well-implemented organized screening programmes, test coverage was higher and differences for socio-economic factors were smaller than in regions with incomplete programme activation.

The two behavioural risk factor surveillances on the adult and elderly populations as information systems for leveraging data on health-related sustainable development goals in Italy.

INTRODUCTION: Current lengthening of average life and constant increase of population ageing associated to forces that include rapid unplanned urbanisation and globalisation of unhealthy behaviours have determined the huge relevance of noncommunicable diseases (NCDs). Monitoring key modifiable behavioural risk factors has resulted to be crucial both in spatial terms and as per temporal trends in order to allow comparisons between different geographic areas or levels and over time. MATERIALS AND METHODS: In Italy, PASSI (Progressi delle Aziende Sanitarie per la Salute in Italia) and Passi d'Argento are the ongoing Behavioural Risk Factor Surveillance Systems (BRFSSs), respectively, on adults (people aged 18-69) and elderly (65 and older). RESULTS: The two Italian surveillances are information systems providing data not only on the third Sustainable Development Goal (SDG) that explicitly addresses ensuring healthy lives and promoting well-being for all, but on a total of nine health-related SDGs (HRSDGs) and 19 HRSDG targets/indicators. We describe these pairs more in detail specifying where in case of BRFSS core indicators (N = 14 HRSDG targets/indicators) concerning six HRSDGs or, on the other hand, as per BRFSS further in-depth analysis (N = five HRSDG targets/indicators) in regard of four different HRSDGs. About the HRSDG 3, HRSDG target 3.4, HRSDG indicator 3.4.1, from the PASSI and Passi d'Argento data it is possible not only to detect the prevalence of NCDs in adults and elderly living in Italy, but also to evaluate the social determinants of health, such as gender, age group, educational level, economic difficulties, as well as the associations with modifiable lifestyle risk factors. CONCLUSIONS: The two Italian BRFSSs generate accurate data, which are highly relevant to design, implement, monitor, and evaluate programs and policies at different levels (local, regional, national) for NCD prevention and health promotion. They provide numbers which can also serve as propaedeutic or, in some cases, complementary ground to address a robust measurement of several HRSDG patterns.

[Prevalence of and risk factors for functional dependence in the non-institutionalised elderly population of 11 Italian Regions: results of the Argento Study, 2002.]. / La prevalenza e i fattori di rischio per la non autosufficienza nella popolazione anziana non istituzionalizzata in 11 Regioni italiane: risultati dello Studio Argento, 2002.

INTRODUCTION: Elderly people who are not capable of performing the basic activities of daily living (ADL) represent a fragile population at greater risk for morbidity and mortality. In order to better describe the size and characteristics of the non self-sufficient population in Italy, we evaluated data from the Argento Study, a survey conducted in 2002 in 11 Italian regions. MATERIALS AND METHODS: A sample of 210 non-institutionalised elderly individuals aged >65 years was selected in each region (310 in the Campania region) by the cluster sampling technique. Home interviews were performed using a standardised questionnaire which included 6 questions on ADL. Participants were considered to have a severe level of dependence if unable to perform any of the 6 activities of daily living independently, partially dependent if able to perform only 1-5 activities independently, and self-sufficient if able to perform all of the activities. A multivariate analysis was performed to evaluate risk factors associated with functional dependence. RESULTS: Complete information regarding ADLs was available for 2,355 (99%) of the interviewed subjects. Of these, 78% (95% CI 76-80%) were found to be self-sufficient, 19% (95% CI 18-22%) partially dependent and 3% (95% CI 1.9-3.2%) severely dependent. Twenty percent of self sufficient subjects and 18% of partially dependent subjects lived alone. Multivariate analysis showed a statistically significant association between being either partially or severely dependent and the following factors: age >75 years (OR 2.8), female sex (OR 1.5), having >2 chronic disorders, (OR 2.8), history of ictus (OR 2.8), having a cognitive disorder (OR 2.6), vision problems (OR 2.3) and hearing problems (OR 1.9). DISCUSSION: These results highlight the presence of a substantial number of partially dependent elderly people that live in the community and that have numerous medical problems and a high frequency of cognitive disorders. It is essential that these fragile elderly subjects be identified, through the active involvement of general practitioners, so that the necessary measures may be undertaken to improve quality of life and of emergency interventions (for example, during heat waves).

["Quality of life" of the elderly population: a survey to evaluate elderly people's self -perceived health in 11 Italian regions (Argento Study, 2002).]. / La "Qualità di vita" nella popolazione anziana: indagine sulla percezione dello stato di salute in 11 regioni italiane (Studio Argento, 2002).

Self-perception of health influences the quality of life of the elderly. In order to identify the more vulnerable elderly and guide interventions to improve health in this population group, we evaluated self-perceived health of elderly people through a set of 4 questions called the "Healthy Days Measures", which were incorporated into the Argento Study. The latter is a study performed to evaluate the health status of the elderly population in 11 Italian regions (2002). Methods. Following cluster sampling, 2,369 elderly subjects (>64 years) were interviewed at home, by trained personnel, through a standardized questionnaire. Self-rated health (on a scale from poor to excellent) was estimated, as well as the average number of days during the previous month when physical or mental health was not good and the number of activity limitation days. Multivariate analysis was performed using Sudaan software and by considering the following outcomes: self-perceived health, physical or mental problems or activity limitations for more than 1 day. Prevalence rates by gender, age, civil status, education level, home situation, place of residence, chronic diseases, dependence on a caregiver, sedentariness and social isolation, were calculated. Results. 34.7% of interviewed subjects rated their health as good to excellent. A significantly lower proportion of women, older subjects (>75 years), those with a lower education level, those residing in southern Italy, those suffering from chronic illnesses, those dependent on a caregiver, and socially isolated or sedentary subjects rated their health favorably. The mean number of physically and mentally unhealthy days (summary index) was estimated to be 11.3 per month. Multivariate analysis showed that female gender was significantly associated with all outcomes considered; age and education level did not show any significant associations with the outcomes considered; depression was significantly associated with self-rated health and with number of mentally unhealthy days; physical dependence and sedentariness were associated with an increased risk for all outcomes, especially activity limitation days. Conclusions. These results suggest that depression, physical dependence and sedentariness influence self-perceived health more so than socio-demographic characteristics. Public Health may have a relevant role in promoting and guiding interventions to prevent these factors in the elderly. The introduction of Healthy Days measures in health surveillance systems may be an important public health tool for monitoring perceived health status and in intervention planning and evaluation at both the national and local levels.

[Design and implementation of evidence-based measures for the prevention and treatment of tobacco use disorder: the experience of the Public Health Department of the Cesena Local Health Authority]. / Progettazione e realizzazione di interventi basati su prove di efficacia nella prevenzione e cura del tabagismo: l'esperienza del Dipartimento di Sanità Pubblica dell'Azienda Sanitaria di Cesena.

Tobacco smoke is the main cause of preventable death in Italy. It is important therefore to develop evidence-based measures aimed at preventing and treating tobacco addiction. This article describes the "Smoke-free" community project, implemented in the territory of the Cesena Local Health Authority. The success of the project shows that it is possible to carry out inter-sectorial and evidence-based prevention. It also leads to considerations about the role of Prevention Services in the fight against tobacco smoke.