Reply to the Letter of Terracini B. et al. "Comment on Piscitelli et al. Hospitalizations in Pediatric and Adult Patients for All Cancer Type in Italy: The EPIKIT Study under the E.U. COHEIRS Project on Environment and Health". Int. J. Environ. Res. Public Health 2017, 14, 495.

A letter to the IJERPH Editor was submitted by Terracini B. et al. as a comment to our latest paper "Hospitalizations in Pediatric and Adult Patients for all Cancer Type in Italy:[...].

Hospitalizations in Pediatric and Adult Patients for All Cancer Type in Italy: The EPIKIT Study under the E.U. COHEIRS Project on Environment and Health.

Background: Cancer Registries (CRs) remain the gold standard for providing official epidemiological estimations. However, due to CRs' partial population coverage, hospitalization records might represent a valuable tool to provide additional information on cancer occurrence and expenditures at national/regional level for research purposes. The Epidemiology of Cancer in Italy (EPIKIT) study group has been built up, within the framework of the Civic Observers for Health and Environment: Initiative of Responsibility and Sustainability (COHEIRS) project under the auspices of the Europe for Citizens Program, to assess population health indicators. Objective: To assess the burden of all cancers in Italian children and adults. Methods: We analyzed National Hospitalization Records from 2001 to 2011. Based on social security numbers (anonymously treated), we have excluded from our analyses all re-hospitalizations of the same patients (n = 1,878,109) over the entire 11-year period in order to minimize the overlap between prevalent and incident cancer cases. To be more conservative, only data concerning the last five years (2007-2011) have been taken into account for final analyses. The absolute number of hospitalizations and standardized hospitalization rates (SHR) were computed for each Italian province by sex and age-groups (0-19 and 20-49). Results: The EPIKIT database included a total of 4,113,169 first hospital admissions due to main diagnoses of all tumors. The annual average number of hospital admissions due to cancer in Italy has been computed in 2362 and 43,141 hospitalizations in pediatric patients (0-19 years old) and adults (20-49 years old), respectively. Women accounted for the majority of cancer cases in adults aged 20-49. As expected, the big city of Rome presented the highest average annual number of pediatric cancers (n = 392, SHR = 9.9), followed by Naples (n = 378; SHR = 9.9) and Milan (n = 212; SHR = 7.3). However, when we look at SHR, minor cities (i.e., Imperia, Isernia and others) presented values >10 per 100,000, with only 10 or 20 cases per year. Similar figures are shown also for young adults aged 20-49. Conclusions: In addition to SHR, the absolute number of incident cancer cases represents a crucial piece of information for planning adequate healthcare services and assessing social alarm phenomena. Our findings call for specific risk assessment programs at local level (involving CRs) to search for causal relations with environmental exposures.

Dioxins levels in breast milk of women living in Caserta and Naples: assessment of environmental risk factors.

Naples and Caserta provinces are extensively affected by the illegal dumping of hazardous and urban wastes, which were periodically set to fire. Several studies were made on the possible health impact of this illegal waste management. The aim of the study was to detect dioxins levels in breast milk of volunteer primiparae and to assess the possible source of dioxins in the affected areas. The authors determined dioxins levels in breast milk from 100 primiparae from the study area and collected anamnestic information on donors. We determined dioxins levels in breast milk from 100 primiparae from the study area and collected anamnestic information on donors. As a measure of environmental risk of dioxins (EDR) we used the interpolated values of dioxins concentration in buffalo milk samples collected in the study area. Correlations between the EDR, age of the mother, smoking habit, cheese consumption, occupation in activity at risk, presence of plants for the disposal of toxic waste or illegal burning of solid waste near the residence of the donor and dioxin level in breast milk were investigated. The dioxin level in breast milk is significantly correlated to the EDR, the age of the sampled women and the presence of illegal burning of solid waste.

A general model of dioxin contamination in breast milk: results from a study on 94 women from the Caserta and Naples areas in Italy.

BACKGROUND: The Caserta and Naples areas in Campania Region experience heavy environmental contamination due to illegal waste disposal and burns, thus representing a valuable setting to develop a general model of human contamination with dioxins (PCDDs-PCDFs) and dioxin-like-PCBs (dl-PCBs). METHODS: 94 breastfeeding women (aged 19-32 years; mean age 27.9 ± 3.0) were recruited to determine concentrations of PCDDs-PCDFs and dl-PCBs in their milk. Individual milk samples were collected and analyzed according to standard international procedures. A generalized linear model was used to test potential predictors of pollutant concentration in breast milk: age, exposure to waste fires, cigarette smoking, diet, and residence in high/low risk area (defined at high/low environmental pressure by a specific 2007 WHO report). A Structural Equation Model (SEM) analysis was carried out by taking into account PCDDs-PCDFs and dl-PCBs as endogenous variables and age, waste fires, risk area and smoking as exogenous variables. RESULTS: All milk samples were contaminated by PCDDs-PCDFs (8.6 pg WHO-TEQ/98g fat ± 2.7; range 3.8-19) and dl-PCBs (8.0 pg WHO-TEQ/98g fat ± 3.7; range 2.5-24), with their concentrations being associated with age and exposure to waste fires (p < 0.01). Exposure to fires resulted in larger increases of dioxins concentrations in people living in low risk areas than those from high risk areas (p < 0.01). CONCLUSIONS: A diffuse human exposure to persistent organic pollutants was observed in the Caserta and Naples areas. Dioxins concentration in women living in areas classified at low environmental pressure in 2007 WHO report was significantly influenced by exposure to burns.