Biomedical subjects
Marcello Vettorazzi
Publications and source records attributed to Marcello Vettorazzi.
Stage-specific incidence of breast cancer before the beginning of organized screening programs in Italy.
OBJECTIVE: To measure stage-specific geographic and time variability of breast cancer in seven Italian areas before the onset of organized screening programs. METHODS: All invasive cancers (8689 cases) arising in women aged 40-79 years during the pre-screening period 1985-1997, were considered. Multiple Poisson regression analysis was performed. RESULTS: About 39% of the cases were classified as "early," 52% as "advanced," and 9% as "unspecified" stage. Age-adjusted incidence rates showed a significant geographic variation for early but not for advanced cancers (range: 58-103 cases/100,000 and 104-125 cases/100,000, respectively). The result was confirmed in the multiple regression analysis after adjustment for year of diagnosis and age. Early breast cancer risk adjusted for age and registry showed a significant increase over time (+3.9% per year for all ages, and +6.2% per year for age category 50-79). In contrast, a decreasing time trend was observed for advanced cancer of 3 cm or over in women aged less than 60. CONCLUSIONS: In our study, early breast cancer incidence varied both by geographic area and time before the commencement of screening. The differences in early-stage incidence may well be related to differences in availability of "spontaneous" mammography. Late-stage incidence decreased over time in younger women and for very advanced cases, but not in the older ones, nor for cancers less than 3 cm. Early detection outside organized screening was only partially efficient in reducing advanced breast cancer incidence. The trend of incidence of advanced disease, as previously proposed, is confirmed to be a valid early indicator of effectiveness of screening.
Quality control of mammography screening in the Veneto Region. Evaluation of four programs at a local health unit level--analysis of the frequency and diagnostic pattern of interval cancers.
AIMS AND BACKGROUND: Service mammography screening has been reported to have suboptimal performance compared to controlled trials. The aim of this study was to evaluate the sensitivity of the mammography screening program in four Local Health Units (ASL) and the possible causes of diagnostic error in cases further surfacing as interval cancers. MATERIAL AND METHODS: Interval cancers were identified by cross checking of screened women databases with hospital discharge records reporting breast cancer. Proportional interval cancer incidence (observed interval cancers/expected invasive cancers) was determined by matching the database of women screened during 1999-2002 to the hospital discharge records databases during 1999-2003. The ratio of observed interval cancer rate to underlying incidence was compared to international standards and with literature data. Screening mammograms reported as negative and followed by interval cancers were randomly mixed with true-negative controls, and the resulting set underwent blind review by an external radiologist who applied the conventional criteria recommended for the classification of the type of diagnostic error (occult, minimal signs, screening error). RESULTS: Matching of screening archives with the hospital discharge records databases allowed for the identification of 154 invasive interval cancers compared to 480 expected. The proportional observed/expected interval cancer incidence in the first and second year of the interval was 21% and 46%, respectively (ASL 1 = 14% or 38%, ASL 2 = 19% or 48%, ASL 3 = 30% or 53%, ASL 4 = 25% or 49%). Radiological review included 38 further interval cancer cases, identified after the time limits defined for proportional interval cancer incidence assessment, and could not include 18 interval cancers, not retrieved from ASL 4 archives: overall, 174 interval cancers were reviewed, of which 135 were classified as occult (77.3%) (ASL 1 = 83.3%, ASL 2 = 71.1%, ASL 3 = 78.6%, ASL 4 = 75%), 12 (6.9%) as minimal signs (ASL 1 = 6.6%, ASL 2 = 11.5%, ASL 3 = 2.4%, ASL 4 = 5%), and 27 (15.5%) as screening error (ASL 1 = 8.3%, ASL 2 = 17.3%, ASL 3 = 19.0%, ASL 4 = 25%). CONCLUSIONS: Observed proportional interval cancer incidence was lower than commonly reported for service screening programs and currently recommended (< 30% in the first, < 50% in the second year of the interval). The analysis of interval cancer causes showed a screening error rate below the maximum acceptable standard (< 20% of interval cancers should be classified as screening error) in three of four programs and in average figures. Substantial differences observed among single programs (one did not comply to recommended standards) suggest that space is available for the improvement of overall performance by optimizing program organization and by further training of radiologists. Overall, the analysis showed a good sensitivity of the screening program in the Veneto Region, although the performance was inferior to that of excellence centers, and further action to improve it is possible. Assessment and review of interval cancers is an early indicator of screening efficacy which has not yet been fully adopted in Italian screening programs. Although using hospital discharge records to identify interval cancers may be affected by limited errors, such a procedure is particularly convenient, as data from hospital discharge records are available much in advance compared to cancer registries and are the most reliable source of information for areas uncovered by a cancer registry. Hospital discharge records-based procedures for interval cancers assessment should be employed routinely in screening programs.
Screening for colorectal cancer in Italy: 2004 survey.
We present the main results of the first national survey of organised screening programmes, conducted by the Italian Group for Colorectal Cancer Screening (GISCoR). During 2004, 18 programs, adopting faecal occult blood testing (FOBT), sigmoidoscopy (FS), or a combination of both, were active in Italy. Overall, 331,333 subjects were invited to undergo FOBT and 165,480 were screened; the attendance rate (51.3%) equals the best performances reported in the literature. Positivity rate was 5.4% at first and 3.9% at repeat screening: it increased with age and was higher among men than among women in all age groups. The average attendance rate at colonoscopy (TC) was 83% (range: 70%-100%; median: 85%). Completion rate of TC was 92%, with higher rates among males. At first screening, the detection rate (DR) per 1000 screened subjects was 2.8 and 11.6 for cancer (CRC) and "high-risk" adenomas (HRA) (> or =3 adenomas, 1 adenoma > or =1 cm, or with villous component >20%, or with high grade dysplasia) respectively; the corresponding figures at repeat screening were 1.2 for CRC and 4.9 for HRA. The DR of CRC and adenomas increased with age and it was higher among men than among women; 51% of screen-detected CRCs were at TNM stage 1. The positive predictive value (PPV) was 6.3% for CRC and 25.8% for HRA at first screening, and 3.6% for CRC and 15.1% for HRA at repeat screening. Given this high PPV of positive FOBT, to obtain a high attendance at TC is crucial. In the three FS programmes 15,688 subjects were invited and 4884 were screened (attendance rate: 31.9%). TC referral rates ranged between 7.6% and 14.0%, due to different referral criteria. Among subjects referred to colonoscopy the prevalence of HRA and CRC ranged from 7.9 to 9.9%. The overall DR (subjects with at least one advanced lesion) ranged from 5.5 to 7.0%. Comparing the DR at FS and FOBT in the same age range. FS showed a higher sensitivity both for HRA (DR was four times higher) and for CRC. In conclusion, colorectal cancer screening looks feasible. The reported experiences showed good results in terms of attendance and DR, although some critical aspects need to be carefully addressed when planning and implementing screening activity.
Audit system on Quality of breast cancer diagnosis and Treatment (QT): results from the survey on screen-detected lesions in Italy, 2003-2004.
Within the Italian Breast Screening Network, individual data are collected yearly on about 50% of all screen-detected operated lesions. In 2003 results showed a good overall quality of diagnosis and treatment, and an improving trend over time. Critical issues were identified in the number of cancers diagnosed pre-operatively, which is still below standards, and in the waiting times for surgery. Compliance with recommendations as to not performing frozen section on small lesions and unnecessary axillary dissection for ductal carcinoma in situ still have not reached the target. The sentinel lymph node technique was performed on the axilla in more than 60% of screen-detected invasive cancers, avoiding a large number of potentially harmful dissections. Preliminary data for 2004 show further progress towards better quality, particularly in pre-operative diagnosis and in the avoidance of frozen section. The detailed results of this survey have been distributed to local and regional screening programmes in order to allow multidisciplinary discussion and the identification of appropriate solutions to any problems documented by the data. Specialist Breast Units with adequate case volume would provide the best setting for making audit effective in producing quality improvement.