Diego Baiocchi

Dying of cancer in Italy: impact on family and caregiver. The Italian Survey of Dying of Cancer

Objective: To describe the effect of terminal cancer on the patient’s family, finances and daily life. Methods: A cluster sample of 2000 adults (⩾18 years old) who had died from cancer, and who were representative of Italy, was studied. 1900 caregivers were identified and 68% responded to a post-bereavement survey. Caregivers included the patient’s child (46%), his/her spouse (31%), other relatives or friends (20%) or a health professional (3%). The median age of a caregiver was 54 years and 69% were females. During the last 3 months of the patient’s life, 44% of caregivers reported difficulties in their regular employment. Results: Of the 68% of families who had to pay for some of the care, 37% had to pay for drugs, 36% for nursing and assistance and 22% for physicians. Paying for care was more frequent in the south of Italy (OR 2.5; 95% CI 1.0 to 6.3) and when the patient was a housewife (OR for unit increase 2.7; 95% CI 1.6 to 6.1). To cover the costs of patient care, 26% of families used all or most of their savings. Economic difficulties were greater in the south of Italy (OR 3; 95% CI 1.8 to 5.1), for female caregivers (OR 1.4; 95% CI 1.0 to 1.9) and for disadvantaged patients. The duration of time the patient was completely dependent strongly determined the effect caregiving had on their regular employment and on the family’s financial situation. Conclusions: Although in Italy families are responsible for a small percentage of the overall costs of patient care, the effect of cancer on savings and daily life can be substantial. Strong geographical and gender differences emerged from this study.

Direct mailing of faecal occult blood tests for colorectal cancer screening: a randomized population study from Central Italy

Background Sending faecal occult blood tests (FOBT) by mail has been proposed both as a method to increase participation and a way to reduce staff costs in colorectal cancer screening. Methods Two multicentre randomized controlled trials (ISRCTN10351276) were performed: one randomly assigned 3196 individuals who had previously participated in colorectal screening to receive a FOBT kit at home or a standard invitation; in the second, 4219 people aged 50–69 years who did not respond to a screening invitation were either sent a FOBT or a standard recall letter. The cost per returned kit was calculated in each arm. Results Participation was higher with direct FOBT mailing in both trials: relative risk 1.11 (95% CI 1.06–1.17) and 1.36 (95% CI 1.16–1.60) for previous responders and non-responders, respectively. The cost per returned kit for previous responders ranged from 4.24€ to 16.10€, and from 3.29€ to 7.36€ with FOBT mailing and standard invitation, respectively, not including staff costs; for non-responders it ranged from 17.13€ to 46.80€, and from 7.36€ to 18.30€ with FOBT mailing and standard recall, respectively. Conclusions The FOBT mailing strategy modestly increased participation. This method can be used on a population of previous responders to reduce personnel costs and workload. When used as a reminder to non-responders, this method increases costs.

Risk of CIN2 in Women With a Pap Test Without Endocervical Cells vs. Those With a Negative Pap Test With Endocervical Cells

OBJECTIVE To measure the risk of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) in the 4.5 years following a negative Pap smear with adequate endocervical cells (ECC) (+) or absent/scarce ECC (-). STUDY DESIGN A prospective, nonconcurrent study of the archives of 11 Italian population-based screening programs was conducted. Only 25-50-year-old women with a first negative Pap test were included. RESULTS Women were classified as ECC+ or ECC- and followed for 4.5 years. The endpoint was the occurrence of a CIN2+ histologic diagnosis. Eligible subjects with negative Pap tests ECC+ and ECC- numbered 469,694 and 20,596, respectively. At least 1 subsequent test was available during follow-up for 335,763 and 11,972 subjects, and 691 and 13 CIN2+ lesions were observed, respectively. The risk of CIN2+ was 2.06 and 1.09 per 1,000 women over 4.5 years, and age-adjusted relative risk associated with ECC--was 0.55 (95% CI 0.28-1.06). CONCLUSION Women with a negative Pap ECC--have a lower risk of CIN2+ than women with a negative Pap ECC+ and should repeat screening with frequency (3-5 years in Europe), independent of age.

A comparison of different strategies used to invite subjects with a positive faecal occult blood test to a colonoscopy assessment. A randomised controlled trial in population-based screening programmes.

OBJECTIVE The purpose of this parallel randomised controlled trial was to compare compliance with different modalities used to invite patients with a positive immunochemical faecal occult blood test (FIT+) for a total colonoscopy (TC). METHOD FIT+ patients from nine Italian colorectal cancer screening programmes were randomised to be invited for a TC initially by mail or by phone and, for non-compliers, to be recalled by mail, for counselling with a general practitioner, or to meet with a specialist screening practitioner (nurse or healthcare assistant). RESULTS In all, 3777 patients were randomised to different invitation strategies. Compliance with an initial invitation by mail and by phone was similar (86.0% vs. 84.0%, relative risk - RR: 1.02; 95%CI 0.97-1.08). Among non-responders to the initial invitation, compliance with a recall by appointment with a specialist practitioner was 50.4%, significantly higher than with a mail recall (38.1%; RR:1.33; 95%CI 1.01-1.76) or with a face-to-face counselling with the GP (30.8%; RR:1.45;95%CI 1.14-1.87). CONCLUSION Compliance with an initial invitation for a TC by mail and by phone was similar. A personal meeting with a specialist screening practitioner was associated with the highest compliance among non-compliers with initial invitations, while the involvement of GPs in this particular activity seemed less effective.

Efficacy of disease management profiles. The mammographic screening program of Lazio.

BACKGROUND Screening programs are considered disease management profiles. The aim of the present study was to evaluate the efficacy of screening programs compared to regularly offered health care services, using early outcomes and process indicators. METHOD In the study period (1/7/99-30/6/01), six breast cancer screening programs were active in 12 health districts in the Lazio region of Italy. Screening histories of all the incident cases of women surgically treated for a breast neoplasm were reconstructed (not contacted, contacted, non-participants, participants). The subpopulations were then compared for the appropriateness of treatments received. RESULTS We identified 3251 women who were treated for malignant neoplasms of the breast and 1562 treated for benign neoplasms. The incidence of malignant neoplasms was higher in the women contacted for screening (incidence rate ratio, 1.45; 95% CI, 1.32-1.60), and the incidence of treatment for non-malignancies was similar in the two populations (incidence rate ratio, 1.00: 95% CI, 0.86-1.16). The percentage of surgery for non-malignancies detected by screening was 16.7%, whereas among the cases diagnosed outside a screening program it was 33.8%. Of malignancies detected outside of screening, 16.6% had a surgical treatment that was too invasive, among the screen-detected malignancies the percentage fell to 11% (prevalence rate ratio, 0.66; 95% CI, 0.48-0.91). Women contacted for screening showed a higher incidence of localized and in situ tumors, whereas the incidence of non-localized and metastatic tumors was basically the same in the two groups. CONCLUSIONS The first round of screening programs led to more surgical interventions, a similar incidence of mastectomy and of interventions for benign neoplasm, but a lower incidence of unnecessary treatment.

Validating regional Hospital Information System data through comparison with a local cancer register to identify interval cancers of a breast screening program

The objective of this study was to evaluate the accuracy of the Hospital Information System (HIS) in monitoring the breast cancer incidence and interval cancers compared with the cancer registry (CR). The HIS data linked with CR and Mammographic Screening Information System data for breast cancer cases diagnosed in the period 1999–2003. The sensitivity and positive predictive value of the HIS data were calculated using the CR as a gold standard. One thousand two hundred and thirty-six breast cancers were registered by the CR and 1028 were reported in the HIS. The sensitivity rate was 83.2% and the positive predictive value was 83.0%; similar results were obtained in the screening target population (50–69 years old). Fifteen invasive breast cancers occurred among screened women identified by HIS (four interval cancers and 11 screen-detected), two were registered as in situ in the CR. The HIS seems to have the potential to identify interval breast cancers, but the low accuracy of information does not permit an exact measure of the incidence.