[Analysis of predictive factors for non-adherence to organized screening for colorectal and breast cancers in the pre-pandemic period (2018-2019) in Lombardy Region (Northern Italy)]. / Analisi dei fattori predittivi della mancata adesione allo screening organizzato per i tumori del colon retto e della mammella nel periodo pre-pandemico (2018-2019) in Lombardia.

BACKGROUND: according to the International Agency for Cancer Research on Cancer, in 2022, breast cancer is the most common cancer in the Italian population, followed by colorectal cancer. Oncological screenings represent an effective secondary prevention strategy to counteract colorectal and breast cancers, significantly reducing mortality. In Lombardy Region (Northern Italy), screening programmes have been active since 2007, but adherence, especially in specific population subgroups, remains lower than expected. OBJECTIVES: to analyse potential predictors of non-adherence to colorectal and breast cancer screening in the Lombardy Region during the pre-pandemic period of 2018-2019. DESIGN: a retrospective cohort study aimed at investigating the role of sociodemographic variables, health status, and access to the healthcare system on non-adherence to colorectal and breast cancer screening. Statistical analyses were conducted separately by each Agency for Health Protection (ATS). The results of the models were synthesized across the Lombardy region through random-effects meta-analysis. SETTING AND PARTICIPANTS: residents within the territory of each ATS in Lombardy as of 01.01.2018 and aged between 49 and 69 years at the beginning of the follow-up. MAIN OUTCOMES MEASURES: adherence to colorectal and breast cancer screenings. RESULTS: during the study period, across the Lombardy Region, 2,820,138 individuals were eligible to participate in colorectal cancer screening, and 1,357,344 women were eligible to participate in breast cancer screening, with an invitation coverage of 87% and 86%, respectively.For breast cancer screening, older age, cardiopathy, chronic obstructive pulmonary disease (COPD), inflammatory bowel diseases (IBD), autoimmune diseases, and presence of a rare disease are associated with a reduced risk of non-adherence. Conversely, foreign citizenship, oncological diagnosis, transplant, chronic kidney disease/dialysis, diabetes, heart failure, arterial or cerebral vasculopathy, and presence of a neurological diagnosis are associated with significant excess risks of non-participation. For colorectal cancer screening, factors favouring adherence include female gender, older age, cardiopathy, COPD, autoimmune diseases, and having access/utilization of primary care. Non-adherence is associated with foreign citizenship, transplant, chronic kidney disease/dialysis, diabetes, heart failure, arterial or cerebral vasculopathy, IBD, neurological diseases, residence in assisted living facilities, use of integrated home care, and presence of disability. CONCLUSIONS: this is the first study conducted in the Lombardy Region which explores the theme of equity of access to organized screenings. This analysis highlights how sociodemographic determinants, chronic conditions, and access to the healthcare and social healthcare system constitute significant risk factors for non-adherence to screening programmes. Based on the results of this analysis, communication and/or organizational change interventions will be developed to counteract inequalities in access to effective prevention procedures.

Indicators of cure for women living after uterine and ovarian cancers: a population-based study.

This study aims to estimate long-term survival, cancer prevalence, and several cure indicators for Italian women with gynaecological cancers. Thirty-one cancer registries, representing 47% of the Italian female population, were included. Mixture cure models were used to estimate Net Survival (NS), Cure Fraction, Time To Cure (5-year conditional NS>95%), Cure Prevalence (women who will not die of cancer), and Already Cured (living longer than Time to Cure). In 2018, 0.4% (121,704) of Italian women were alive after corpus uteri cancer, 0.2% (52,551) after cervical, and 0.2% (52,153) after ovarian cancer. More than 90% of patients with uterine cancers and 83% with ovarian cancer will not die from their neoplasm (Cure Prevalence). Women with gynaecological cancers have a residual excess risk of death <5% after 5 years since diagnosis. The Cure Fraction was 69% for corpus uteri, 32% for ovarian, and 58% for cervical cancer patients. Time To Cure was ≤10 years for women with gynaecological cancers aged <55 years. 74% of patients with cervical cancer, 63% with corpus uteri cancer, and 55% with ovarian cancer were Already Cured. These results will contribute to improving follow-up programs for women with gynaecological cancers and supporting efforts against discrimination of already cured ones.

Cure indicators and prevalence by stage at diagnosis for breast and colorectal cancer patients: A population-based study in Italy.

People alive many years after breast (BC) or colorectal cancer (CRC) diagnoses are increasing. This paper aimed to estimate the indicators of cancer cure and complete prevalence for Italian patients with BC and CRC by stage and age. A total of 31 Italian Cancer Registries (47% of the population) data until 2017 were included. Mixture cure models allowed estimation of net survival (NS); cure fraction (CF); time to cure (TTC, 5-year conditional NS >95%); cure prevalence (who will not die of cancer); and already cured (prevalent patients living longer than TTC). 2.6% of all Italian women (806,410) were alive in 2018 after BC and 88% will not die of BC. For those diagnosed in 2010, CF was 73%, 99% when diagnosed at stage I, 81% at stage II, and 36% at stages III-IV. For all stages combined, TTC was >10 years under 45 and over 65 years and for women with advanced stages, but ≤1 year for all BC patients at stage I. The proportion of already cured prevalent BC women was 75% (94% at stage I). Prevalent CRC cases were 422,407 (0.7% of the Italian population), 90% will not die of CRC. For CRC patients, CF was 56%, 92% at stage I, 71% at stage II, and 35% at stages III-IV. TTC was ≤10 years for all age groups and stages. Already cured were 59% of all prevalent CRC patients (93% at stage I). Cancer cure indicators by stage may contribute to appropriate follow-up in the years after diagnosis, thus avoiding patients' discrimination.

Complete prevalence and indicators of cancer cure: enhanced methods and validation in Italian population-based cancer registries.

Objectives: To describe the procedures to derive complete prevalence and several indicators of cancer cure from population-based cancer registries. Materials and methods: Cancer registry data (47% of the Italian population) were used to calculate limited duration prevalence for 62 cancer types by sex and registry. The incidence and survival models, needed to calculate the completeness index (R) and complete prevalence, were evaluated by likelihood ratio tests and by visual comparison. A sensitivity analysis was conducted to explore the effect on the complete prevalence of using different R indexes. Mixture cure models were used to estimate net survival (NS); life expectancy of fatal (LEF) cases; cure fraction (CF); time to cure (TTC); cure prevalence, prevalent patients who were not at risk of dying as a result of cancer; and already cured patients, those living longer than TTC at a specific point in time. CF was also compared with long-term NS since, for patients diagnosed after a certain age, CF (representing asymptotical values of NS) is reached far beyond the patient's life expectancy. Results: For the most frequent cancer types, the Weibull survival model stratified by sex and age showed a very good fit with observed survival. For men diagnosed with any cancer type at age 65-74 years, CF was 41%, while the NS was 49% until age 100 and 50% until age 90. In women, similar differences emerged for patients with any cancer type or with breast cancer. Among patients alive in 2018 with colorectal cancer at age 55-64 years, 48% were already cured (had reached their specific TTC), while the cure prevalence (lifelong probability to be cured from cancer) was 89%. Cure prevalence became 97.5% (2.5% will die because of their neoplasm) for patients alive >5 years after diagnosis. Conclusions: This study represents an addition to the current knowledge on the topic providing a detailed description of available indicators of prevalence and cancer cure, highlighting the links among them, and illustrating their interpretation. Indicators may be relevant for patients and clinical practice; they are unambiguously defined, measurable, and reproducible in different countries where population-based cancer registries are active.

[A method for identifying people with a high level of frailty by using a population database, Varese, Italy]. / Un metodo per identificare pazienti ad alto grado di fragilità a partire dalla Banca Dati Assistiti nell'ASL di Varese.

Since over 10 years, the Lombardy Region (Italy) has developed a system for classifying all persons registered with the healthcare system (database of persons registered with a general practitioner), according to their use of major healthcare services (hospitalizations, outpatient consultations, pharmaceutical) and whether they are exempt from copayment fees for disease-specific medications and healthcare services. The present study was conducted by the local health authorities of the province of Varese (Lombardy region, Italy) with 894.039 persons registered in the database of whom 258.770 (28.9%) with at least one chronic condition, 104.731 (11.7%) with multiple chronic conditions and 195.296 (21.8%) elderly persons. The aim was to evaluate death rates in different subgroups of patients entered in the database, including persons with chronic diseases and elderly persons. Standardized mortality rates were calculated for the year 2012. Compared with the general population, relative risk for mortality was 4,1 (95% confidence Intervals 4,0-4,2) in the elderly and 1,3 (95% confidence intervals 1,3-1,4) in chronic patients. This confirms that elderly persons have a higher level of frailty with respect to patients with chronic conditions. Mortality was found to be 28 times higher in elderly persons over 74 years of age, affected by high cost conditions such as cancer and cardiac disease, with respect to the general population.

Sex differences and the interaction of age and sleep issues in neuropsychological testing performance across the lifespan in an ADD/ADHD sample from the years 1989 to 2009.

Chart review of population (9 to 80 years) neuropsychological test battery for ADHD diagnosis, questionnaires with multiple responders were evaluated in outpatient setting from 1989-2009. The focus was gender differences across age, diagnostic group (ADHD-Inattentive/ADHD plus), neuropsychological test performance, and reported sleep symptoms over the lifespan. Individuals were assigned to ADHD-I group or ADHD plus group (based upon secondary diagnosis of sleep, behavioral, emotional disturbance); ADHD not primary was excluded (brain insult, psychosis). Among these were 1,828 children (ages 9 to 14), adolescents (ages 15 to 17), and adults (ages 18 and above); 446 children (312 diagnosed ADHD-I), 218 adolescents (163 diagnosed ADHD-I), and 1,163 adults (877 ADHD-I). Sleep was problematic regardless of age, ADHD subtype, and gender. The type and number of sleep problems and fatigue were age dependent. ADHD subtype, gender, fatigue, age, and sleep (sleep onset, unrefreshing sleep, sleep maintenance) were significant variables affecting neuropsychological test performance (sequencing, cognitive flexibility, slow- and fast-paced input, divided attention, whole brain functioning). Findings suggest that ADHD involves numerous factors and symptoms beyond attention, such as sleep which interacts differently dependent upon age.

Assessment of mortality risk in elderly patients after proximal femoral fracture.

Mortality after hip fracture is a major problem in the Western world, but its mechanisms remain uncertain. This study assessed the 2-year mortality rate after hip fracture in elderly patients by including hospital factors (eg, intervention type, surgical delay), underlying health conditions, and, for a subset, lifestyle factors (eg, body mass index, smoking, alcohol). A total of 828 patients (183 men) 70 to 99 years old experiencing a hip fracture in 2009 in the province of Varese were included in the study. The risk factors for death were assessed through Kaplan-Meier analysis and Cox proportional hazards analysis. Hip fracture incidence per 1000 persons was higher in women (8.4 vs 3.7 in men) and in elderly patients (12.4 for 85-99 years vs 4.4 for 70-84 years). The mortality rate after 1, 6, 12, and 24 months was 4.7%, 16%, 20.7%, and 30.4%, respectively. For the province of Varese, sex (hazard ratio, 0.39 for women), age group (hazard ratio, 2.2 for 85-99 years), and Charlson Comorbidity Index score (hazard ratio, 2.06 for score greater than 1) were found to be statistically significant. The 2-year mortality rate in hip fractures is associated with sex, age, and comorbidities. Male sex, age older than 85 years, and Charlson Comorbidity Index score greater than 1 are associated with a higher risk. Surgical delay was significant in the Kaplan-Meier survival time analysis but not in the Cox hazard analysis, suggesting that early surgery reduces risk in patients with numerous comorbidities.

Decreasing incidence of late-stage breast cancer after the introduction of organized mammography screening in Italy.

BACKGROUND: After the introduction of a mammography screening program, the incidence of late-stage breast cancer is expected to decrease. The objective of the current study was to evaluate variations in the total incidence of breast cancer and in the incidence of breast cancers with a pathologic tumor (pT) classification of pT2 through pT4 after the introduction of mammography screening in 6 Italian administrative regions. METHODS: The study area included 700 municipalities, with a total population of 692,824 women ages 55 to 74 years, that were targeted by organized mammography screening between 1991 and 2005. The year screening started at the municipal level (year 1) was identified. The years of screening were numbered from 1 to 8. The ratio of the observed 2-year, age-standardized (Europe) incidence rate to the expected rate (the incidence rate ratio [IRR]) was calculated. Expected rates were estimated assuming that the incidence of breast cancer was stable and was equivalent to that in the last 3 years before year 1. RESULTS: The study was based on a total of 14,447 incident breast cancers, including 4036 pT2 through pT4 breast cancers. The total IRR was 1.35 (95% confidence interval, 1.03-1.41) in years 1 and 2, 1.16 (95% confidence interval, 1.10-1.21) in years 3 and 4, 1.14 (95% confidence interval, 1.08-1.20) in years 5 and 6, and 1.14 (95% confidence interval, 1.08-1.21) in years 7 and 8. The IRR for pT2 through pT4 breast cancers was 0.97 (95% confidence interval, 0.90-1.04) in years 1 and 2, 0.81 (95% confidence interval, 0.75-0.88) in years 3 and 4, 0.79 (95% confidence interval, 0.73-0.87) in years 5 and 6, and 0.71 (95% confidence interval, 0.64-0.79) in years 7 and 8. CONCLUSIONS: A significant and stable decrease in the incidence of late-stage breast cancer was observed from the third year of screening onward, when the IRR varied between 0.81 and 0.71.

[Descriptive study of cancer incidence in the area around the Ispra Joint Research Centre (JCR)]. / Studio descrittivo sull'incidenza di tumori maligni nell'area circostante al Centro comune di ricerca (CCR) di Ispra.

OBJECTIVE: to assess the effects of radioactive emissions from the EU Joint Research Centre (JRC) (nuclear) at Ispra, the Local Health Authority (ASL) of Varese carried out an ecological study to measure any excess incidence of cancer in the surrounding population. DESIGN AND SETTING: after estimation of historical exposure levels in the surrounding population, the incidence rates of leukaemia and other exposure-related tumours were calculated from data in the population based Lombardy Cancer Registry (Varese Province). By indirect standardization, the expected cases (based on incidence rate in the Province) were compared with observed cases in the close-by municipality of Ispra, in municipalities within a 5 km radius of the JRC (5kmArea) and in the area covered by the District of Sesto Calende (DistrictArea). RESULTS: in the period 1982-1998, mean populations were 4,687 (Ispra), 32,120 (5kmArea) and 43,707 (DistrictArea); the population of the Province was 793,752. The numbers of cancers registered were 374, 2,920, 4,099 and 72,246 respectively. Significant excesses of leukaemia were not found in Ispra (SIR 0.33, 95% CI 0.07-0.96) or the 5kmArea (SIR 0.83, 95% CI 0.63-1.08). For all cancers combined and for the commonest cancers (breast, colo-rectal) the numbers of incident cases were lower than expected. CONCLUSIONS: consistent with the low levels of exposure detected, and despite the fears of the local people, no incidence excesses of cancers was found in Ispra, the town closest to the JRC, or inforin the surrounding areas. It may be worth searching for excess cancer among exposed workers.

Descriptive epidemiology of selected birth defects, areas of Lombardy, Italy, 1999.

BACKGROUND: Birth defects are a leading cause of neonatal and infant mortality in Italy, however little is known of the etiology of most defects. Improvements in diagnosis have revealed increasing numbers of clinically insignificant defects, while improvements in treatment have increased the survival of those with more serious and complex defects. For etiological studies, prevention, and management, it is important to have population-based monitoring which provides reliable data on the prevalence at birth of such defects. METHODS: We recently initiated population-based birth defect monitoring in the Provinces of Mantova, Sondrio and Varese of the Region of Lombardy, northern Italy, and report data for the first year of operation (1999). The registry uses all-electronic source files (hospital discharge files, death certificates, regional health files, and pathology reports) and a proven case-generation methodology, which is described. The data were checked manually by consulting clinical records in hospitals. Completeness was checked against birth certificates by capture-recapture. Data on cases were coded according to the four-digit malformation codes of the International Classification of Diseases, Ninth Revision (ICD-9). We present data only on selected defects. RESULTS: We found 246 selected birth defects in 12,008 live births in 1999, 148 among boys and 98 among girls. Congenital heart defects (particularly septal defects) were the most common (90.8/10,000), followed by defects of the genitourinary tract (34.1/10, 000) (particularly hypospadias in boys), digestive system (23.3/10,000) and central nervous system (14.9/10,000), orofacial clefts (10.8/10,000) and Down syndrome (8.3/10,000). Completeness was satisfactory: analysis of birth certificates resulted in the addition of two birth defect cases to the registry. CONCLUSION: This is the first population-based analysis on selected major birth defects in the Region. The high birth prevalences for septal heart defect and hypospadias are probably due to the inclusion of minor defects and lack of coding standardization; the latter problem also seems important for other defects. However the data produced are useful for estimating the demands made on the health system by babies with birth defects.

[Use of healthcare services by elderly people in a local health authority in Varese (Italy)]. / I consumi di prestazioni sanitarie negli anziani dell'ASL della provincia di Varese.

Older people use more healthcare than younger people and aging of the population is considered to be one of the main factors leading to consumption of healthcare resources. The aim of this study was to evaluate rates of hospitalization, use of out-patient services and medicine confections among the elderly population (>65 years) in the local health authority of Varese (Italy), in the three-year period from 2003-2005, and to calculate the trend for the years 2006 and 2007. Rates of hospitalization and drug use remained stable while use of out-patient services showed an increasing trend. In spite of the influence of aging on consumption of healthcare resources, the use of medical services is determined mainly by the health state of the population: monitoring of the burden of morbidity in the population should therefore be improved.

[Epidemiologic study Salus domestica: evaluation of health damage in a sample of women living near the Malpensa 2000 airport]. / Studio epidemiologico Salus domestica: valutazione dei danni di salute in un campione di donne residenti nei pressi dell'aeroporto Malpensa 2000.

The opening of the new Malpensa 2000 Airport worried people living in the neighbouring towns about possible effects of acoustic and air pollution on health status. For this reason, Varese Health Unit set up a study involving housewives and General Practitioners. This study has been carried out in 3 Areas: A Area, bordering the airport, B Area, at intermediate distance, and C Area, at long distance. On the whole, 932 housewives (18 to 64 years old) and 92 General Practitioners, were involved. The questionnaire, distributed to housewives between May 1st and November 30th 2000, was filled out in the doctor's surgery who furthermore added clinical data. Chi-square statistics were calculated to test the association between living area and personal data, behavioural and environmental characteristics, and reported disorders. To describe possible interrelationships between living Area and the answers supplied by housewives and General Practitioners the multiple correspondence multivariate analysis technique was applied. The housewives living next to the airport (A area) frequently report insomnia, nocturnal waking, anxiety and difficulty in hearing words. The multivariate analysis has shown a relationship between recently increasing noise noted by the housewives, and the area where they live, as well as a noticeable coherence between the answers given by the housewives and those given by the General Practitioners, who reported higher frequencies of cephalgy, allergies, anxiety neurosis, medical consultation, benzodiazepine's and sleeping disorder's prescriptions in A Area compared to C Area. The airport's presence seems to be associated with the onset of subjective disorders in neighbouring population. Some of these disorders, in particular neuropsychological ones, are clinically confirmed by General Practitioners, and are consistent with different noise exposure levels.

[Public health consumption at the Varese health trust]. / I consumi di prestazioni sanitarie nella Asl della Provincia di Varese.

This study is based on a provincial Atlas assessing territorial differences in hospital admissions and out-patient services. The authors have analysed consumer distribution per District as compared to overall provincial consumption. Results show some geographical inequities that are not always associated to epidemiological reasons. As a matter of fact, some services happen to be more crowded than others, which obviously entails the need for more adequate offers and different diagnostic behaviours as regards treatments. It would therefore be advisable if high consumption levels were assessed to be effectively useful in terms of health production.