Cesare Cislaghi

Descriptive epidemiology of gastric cancer in Italy

National trends in death certification rates from cancer of the stomach in Italy over the period 1955 to 1979 were analyzed using a standard cross‐sectional approach and a log‐linear Poisson model to isolate the effects of birth cohort, calendar period, and age. Overall, age‐standardized death certification rates decreased from 47.04 to 30.74/100,000 males (average annual rate of change, assuming that the decrease has been constant, ‐1.8%) and from 34.55 to 19.27/100,000 females (average annual rate of change ‐2.4%). The decreases were even larger in middle age for both sexes. Both cohort and period of death curves were markedly downwards. However, cohort values did not decrease for generations born around the second world war (1935–1945), thus indirectly confirming the importance of (dietary) habits in childhood on subsequent gastric cancer risk. Further, the geographic distribution of certified mortality from gastric cancer in the 95 Italian provinces over the period 1975 to 1977 was analyzed. Death certification rates were about 10% lower for both sexes in the 14 provinces including the largest urban concentrations (over 250,000 inhabitants) than in the remaining areas. This finding might be related to earlier availability of modern food processing and storage in urban areas. It is, however, more difficult to explain the lower mortality rates (about 50% in both sexes) in the southern compared with the central and northern areas, since southern Italy is the less developed part of the country. Likewise, there appears to be at present little satisfactory explanation for the several clusters of exceedingly high mortality areas scattered in northern and central Italy, since some of these areas are several hundred kilometers apart, and there is no obvious common denominator in diet or other environmental factors that may explain their highergastric cancer mortality rates.

Birth cohort, time, and age effects in Italian cancer mortality.

Italian death certification data from 1955 to 1979 for total cancer mortality and 30 cancer sites in the population aged 25 to 74, were analyzed using a log‐linear Poisson model to isolate the effects of birth cohort, calendar period of death, and age. The most frequent cohort pattern was characterized by increases up to the generations born between 1920 and 1930, followed by stabilization or a slight decrease. This pattern was evident for total cancer mortality in men, and for several common sites, including larynx, lung, esophagus, bladder, female breast, and ovary. Only four sites (pancreas, pleura, intestines in both sexes, and kidney in men) showed cohort values still rising in more recent generations. Stable cohort and period of death curves were observed for cancers of the prostate and testis, whereas trends were steadily going down for neoplasms of the stomach, and (cervix) uteri. Finally, there were a few discontinuous trends (e.g., in the case of brain neoplasms, leukemias, and lymphomas), which probably reflect different effects of improvements in diagnosis and/or treatment. Period of death values increased for lung and other tobacco related sites (chiefly in males) and, up to the early 1970s, for a few other common sites, including intestines, and the female breast. Downward trends over the calendar period were evident for cancers of the stomach and of the (cervix) uteri. Therefore, total cancer mortality trends over the calendar period of death were moderately increasing for men, and slightly decreasing for women. Cancer 59:1221‐1232, 1987.

Descriptive epidemiology of intestinal cancer in Italy

Trends in the death rates from cancers of the intestine (including colon and rectum) in Italy from 1956 to 1981 were analyzed with a standard cross‐sectional approach and a log‐linear age/period/cohort model. In both sexes there were steady increases in mortality rates between the middle 1950s and the middle 1970s, chiefly explainable in terms of cohort effects. This was followed by a leveling off and stabilization, starting from the younger age groups and more evident in women. The analyses of the geographic distribution of intestinal cancer mortality in the 95 Italian provinces during 1975 to 1977 showed higher rates in the north of the country and in large urban concentrations, and a bimodal distribution of mortality rates, whose minimum corresponded to a distinct north/south separation. Trend surface models fitted to intestinal cancer standardized mortality ratios showed a high determination coefficient even for the simplest models. Residuals, corresponding to outliers, were scattered in a few northern and central areas. In addition, mortality rates for cancers of the intestine in middle age people were considered according to geographic area of birth and of residence at death. In both sexes rates of migrant populations were influenced both by area of birth and residence, and, in particular, there was a widespread unfavorable effect of residence on migrants from the South to the North (the major migrant flux in Italy). The temporal and geograhpic variations in intestinal cancer rates observed in this study indicate that Italy may well be a particularly interesting situation for etioiogic investigations of colorectal cancers.

Cancer mortality in young adults : Italy 1955-1985

SummaryAlthough cancer mortality in young adults accounts for only a small proportion of all cancer deaths, it is important since it provides useful indications of the most likely future trends, and relevant information on the role of exposure to specific, or newer, carcinogens. We, therefore, analysed trends in cancer mortality between 1955 and 1985 among Italian men and women aged 20–44 years. In those three decades, overall cancer mortality declined steadily, by 27% in young women (from 33.8 to 24.7/100000, world standard) but only by 3% (from 27.3 to 26.4/100000) among men. The decline for men, however, was 16% from the peak rate of 31.5 reached in 1970–1974. The major underlying component causing the different trends in the two sexes was lung and other tobacco-related neoplasms, which had been considerably on the increase in young men up to the early 1970s, and levelled-off thereafter, while showing no appreciable change in women. The falls were about 50% for stomach cancer in both sexes, and over 80% for cervical cancer. A clear impact of improved treatment was reflected in the substantial declines in Hodgkins disease, of testicular cancer in the last decade and, possibly, in the favourable trends in cancers of the breast, bone, brain and leukemias over the most recent calendar periods. Only two sites showed appreciable and persisting upward trends: oral cavity in men and skin melanoma in both sexes. They therefore constitute priorities for intervention in the near future.

[A mass murder or mere statistical data? The 2015 surplus of deaths].

Epidemiol Prev 2016; 40 (1):9-11. doi: 10.19191/EP16.1.P009.005 Quando l’11 dicembre 2015 il quotidiano Avvenire ha pubblicato l’articolo del demografo Blangiardo dal titolo «Attenti ai morti», molti di noi, usi all’analisi dei dati di mortalità, sono rimasti basiti. Abbiamo subito pensato che ci si trovasse davanti a un errore di registrazione: 45.000 morti in più in soli otto mesi non si erano mai osservati e qualcuno li ha addirittura paragonati ai morti della Prima guerra mondiale, evocando così un evento che forse – come si vedrà in seguito – ne è la spiegazione, ma meno evidente di quanto si possa pensare. La prima notazione su quanto successo è relativa al pressoché totale silenzio dei sistemi di monitoraggio sanitario. A posteriori, alcuni hanno fatto notare che loro «l’avevano detto», ma di sicuro quanti sono preposti alla vigilanza sanitaria, dal Ministero a tutte le altre istituzioni regionali e locali, non avevano sufficientemente preso in seria considerazione l’accaduto. Se i sistemi di monitoraggio non si attivano immediatamente per un aumento di tale entità, a che servono? Ora gli epidemiologi stanno studiando, analizzando, interpretando quanto successo, ma l’epidemiologia può essere solo un’epidemiologia ex post, anzi, tardivamente ex post ? A livello internazionale qualcuno se ne era accorto subito e aveva pubblicato una nota già a marzo 2015, ma nel pool degli autori non compariva nessun italiano e l’articolo era rimasto muto sulle riviste.1 La seconda notazione concerne quanto successo dopo, appena la notizia è rimbalzata: le facili interpretazioni si sono moltiplicate, alcune colpevoli di leggerezza, altre della voglia di usare la notizia per accusare qualcuno; ci sono state voci, per la verità, che hanno invitato alla prudenza nell’interpretazione dell’accaduto ponendo solo ipotesi relative alle possibili cause, ma anche avvertendo di quali potevano essere i pericoli di fraintendimento. L’Istat, per esempio, ha fatto un comunicato, peraltro forse un po’ scarno, in cui criticava quanti proiettavano i 45.000 decessi dei primi otto mesi sull’intero anno 2015 ipotizzando che potessero diventare 60.000 per un incremento lineare, ma rimandava ogni altra analisi chiarificatrice a quando fossero disponibili dati completi. I dati ufficiali dell’Istat oggi sono abbastanza aggiornati per quanto riguarda il numero complessivo di decessi – che viene pubblicato con circa solo tre mesi di distanza dall’accaduto – ma la distribuzione per età dei deceduti è molto più tardiva e, purtroppo, la disponibilità delle informazioni sulle cause di morte ha un ritardo medio che supera i due anni. Molte Regioni, però, hanno anagrafi degli assistiti e sistemi di rilevazione della mortalità (i ReNCaM, Registri nazionali delle cause di morte) che perlopiù producono informazioni molto più tempestive, il che fa riflettere sulla questione se i sistemi informativi debbano o meno essere solo unificati al centro oppure siano più efficienti se anche attivi a livello regionale e locale. I dati mensili Istat riportano un notevole eccesso di decessi rispetto al 2014 nei mesi di gennaio-marzo e poi nel mese di luglio; quest’ultimo è un evento di più facile lettura e peraltro già segnalato da chi si occupa di monitorare gli effetti delle ondate di calore. Il luglio 2015 è stato un mese eccezionale sul versante meteorologico e qualcuno ha suggerito che i sistemi di attenzione e prevenzione potrebbero non aver funzionato al meglio anche a causa delle ristrettezze economiche dei servizi sanitari dovute alla crisi economica, ma l’ipotesi non ha ancora una conferma. L’eccesso comunque più importante in senso numerico è stato sicuramente quello dei mesi invernali. E’ stato facile, allora, dare immediatamente la colpa di tutto l’incremento all’influenza, sia indicando una maggiore probabile virulenza dell’agente patogeno nel 2015, sia sospettando una minore efficacia del vaccino distribuito sul ceppo virale in questione, sia, infine, riferendosi a una preoccupante diminuzione della copertura vaccinale più volte denunciata e innescata da una coincidenza tra inoculazione vaccinale e decesso in alcuni soggetti, coincidenza assolutamente spiegabile in termini probabilistici.

Italian Atlas of Cancer Mortality

Analyses of the geographical variation of cancer death certification between the 95 Italian provinces based on published data for the early 1970s showed substantial variations in mortality, higher rates being generally registered in northern areas, and marked gradients for most common neoplasms (Cislaghi et al. 1978). Originally, it was suspected that this pattern might have been influenced by under-certification of cancer deaths in southern regions. However, subsequent checks both of internal (e. g., between various age groups) and external (e. g., between death certification and cancer registration data) data reliability (Zanetti et al. 1982) showed a satisfactory degree of reliability of Italian cancer death certification, with the exception of a few selected problem areas of diagnosis and certification (i. e., cancers of liver, prostate, and brain, and the distinctions between colon and rectum or corpus and cervix uteri), which are probably also found in data from most other developed countries.

Indicators for Assessment in Health Services

The transition from a set of healthcare statistics to a Health Information System took place in Italy following the reform of National Statistical Institute (ISTAT) and the establishment of the National Health Service. The introduction of epidemiological monitoring was the characterising element of the new information cycle, with different needs of aetiological type (research on disease determinants) and of evaluation type (efficacy and efficiency). The definition of an indicator set for government of the healthcare system was the object of several laws dealing with public health indicators, cost and expenditure indicators, realisation and appropriateness indicators, performance and outcome indicators. The final section was dedicated to the definition, compilation and use of such indicators.

L’equità nella salute e nella sanità in Italia dopo trent’anni di Servizio sanitario nazionale

Nel trentesimo anniversario della riforma sanitaria che ha introdotto in Italia il Servizio sanitario nazionale (Ssn) l’articolo si chiede se sia possibile valutarne i risultati in termini di equita nella distribuzione della salute, nelle risorse, nell’organizzazione e nella qualita dell’assistenza. La storia di questi trent’anni di Ssn non sembra aver modificato sostanzialmente l’intensita delle disuguaglianze geografiche e sociali di salute a sfavore del Mezzogiorno e delle classi sociali piu svantaggiate, disuguaglianze che traggono origine prevalentemente da cause non sanitarie. Sul versante dell’assistenza sanitaria, mentre l’utilizzo dei Lea e la distribuzione delle risorse finanziarie sembra procedere verso una maggiore coerenza con la distribuzione del bisogno, l’accesso, l’appropriatezza e gli esiti dell’assistenza nei singoli percorsi a maggiore impatto sulla salute mostrano ancora significative disuguaglianze sociali e geografiche. L’articolo discute le responsabilita e le implicazioni per le politiche di queste disuguaglianze. Parole chiave. Disuguaglianze geografiche, disuguaglianze sociali, livelli di assistenza, politiche, salute.