F. La Rosa

Information Technology as Tools for Cancer Registry and Regional Cancer Network Integration

Background. With the publication of large studies from different health systems comparing survival probabilities, cancer registries are increasingly involved in clinical evaluation research. The changing role of registries strictly depends on the integration between the oncology system and proper information technology (IT) tools. IT is fundamental to improving validity and timeliness of data diffusion when both the number of sources linked and the number of variables registered are on the rise. Aims. In this paper, we present a modern web-based management system that allows to integrate different sources, validate and elaborate data thus providing a new evaluation system for the oncology network based on cancer registries. Materials and methods. We developed a Web 2.0 management system for the Umbria Cancer Registry (S.G.RTUP) based on AMPAX technology (Apache, Mysql, PHP, Ajax and XML) and object-oriented programming. ISO/IEC 27001:2005 standard is followed to ensure security access to the information. The S.G.RTUP architecture is modular and extensible and information consistency is guaranteed by entity-relationship principles. Cancer sites, topology, morphology, and behavior are coded according to the International Classification of Diseases. Classical epidemiological indices for a cancer registry are implemented: incidence, mortality, years of potential life lost, and cumulative risk. S.G.RTUP has tools to prepare data for trend analysis and relative survival analysis. Geographical analysis is also implemented. Results. S.G.RTUP is integrated with the Oncology Network and gives timely epidemiological indices for evaluation of oncological activities. The registration system that we developed can effectively manage different data sources. Automatic importing of routinely available data from pathology archives, screening services, and hospital discharge records will reduce the time needed to produce data and will also allow the expansion of registered information. Several services for data visualization and statistical analysis are implemented. A geographic information system based on Google maps API is used for geolocalization of cases and map plotting of incidence and mortality rates. We implemented Besag York and Mollies algorithm for real-time smoothed maps. All services can be dynamically performed over a subset of data that the user can select through an innovative filtering system. Discussion and conclusion. IT contributed to shortening all phases of cancer registration, including linkage with external sources, coding, quality control, data management and analysis and publication of results. Integration in the oncology network and secure Web access allowed us to design with clinicians innovative population-based collaborative studies. Our geographic analysis system enables us to develop sophisticated dynamic geostatistic tools.

Stroke care in the next decades: a projection derived from a community-based study in Umbria, Italy.

Recently published data show that stroke incidence is no longer declining, while case fatality rates has had a less pronunced fall in recent years than in the past. Projections of the increasing number of elderly people, combined with the greater risk of stroke in old age, suggest that in the forthcoming decades we will be faced with an increased request of health resources for patients with stroke. We have therefore used data from a community-based study on stroke incidence and outcome to project the number of first ever strokes, death from stroke and handicap from stroke in Italy, up to the year 2016. Results show that incidence will increase by 22.2%, and death at 6 months from first ever stroke by 29%. However, since patients already handicapped for other reasons are more likely to die from their stroke, the net number of newly handicapped persons will only increased by 5%. These results suggest that in the next decades the major increase in request of health care resources will result from the acute event and the immediate post-ictal phase, and not from the management of chronic handicap after a stroke.

Long term survival of upper aerodigestive tract cancer in male patients in the Umbria region (Italy)

The aim of this work was to make a study of the whole population of a central Italian region, the Umbria region – cancer survival rates for the upper aerodigestive tract, which includes cancers of the head and neck (tongue, oral cavity, pharynx), oesophagus and larynx. In Italy cancer survival rates do not cover entire regions but single municipalities or provinces. Cases of incidence were derived from an ‘ad hoc’ survey carried out during the period 1978–1982. Starting from the nominative data, we studied up to 15 years 245 head and neck, 87 oesophagus and 321 larynx cases of cancer in males. Data for female cases were not considered because of the small number. Cancer cases were followed up mainly by verification at the Registry Office of several municipalities, the Regional Death Registry and the list of persons under the Regional Health Service. Observed survival rates for head and neck cancer were 0.63, 0.29, 0.17 and 0.12 at 1, 5, 10 and 15 years of follow-up respectively; rates for cancers of the oesophagus and larynx were 0.30, 0.08, 0.06, 0.03 and 0.79, 0.54, 0.41, 0.30 respectively. Relative survival rates were 0.65, 0.34, 0.24, 0.23 for cancer of the head and neck, 0.31, 0.10, 0.09, 0.08 for cancer of the oesophagus, and 0.81, 0.63, 0.59, 0.56 for cancer of the larynx, at 1, 5, 10 and 15 years of follow-up. The worst survival rates were observed for oesophagus and hypopharynx. Overall survival values for Umbrian patients were relatively good, being higher than survival data reported for a similar period by Italian Cancer Registries. They were also strikingly similar to survival rates for England and Scotland.

Esophageal cancer mortality: relationship with alcohol intake and cigarette smoking in Italy.

This paper examines changes with time in age-adjusted mortality from esophageal cancer for the years 1950–1981, in relation to changes in smoking habits and alcohol consumption. In both sexes the age-adjusted death rates have shown no marked time variation. Instead in the same period there have been marked temporal variations in consumption of alcohol and tobacco which are considered risk factors associated with esophageal cancer.The male cohort variation seems to indicate some fluctuations in mortality before 1921 and a progressive increase after this year. In females the death rates are very low and the cohort variation is pratically constant.The progressive increase of cohort variation in esophageal cancer mortality for men born after 1921 coincides with a progressive increase in hard alcohol consumption. In the same period there has also been a progressive increase in tobacco consumption but this begun at the turn of this century.

Risk of multiple primary cancers following melanoma and non‐melanoma skin cancer

Background  The relationship between cutaneous malignancies and successive primary cancers has been studied since several years, but it still remains controversial.

Tobacco smoking, coffee, cocoa and tea consumption in relation to mortality from urinary bladder cancer in Italy

This paper examines changes in mortality from urinary bladder cancer in Italy during the years 1950-81 in relation to changes in smoking habits and in coffee, cocoa and tea consumption. The authors found that, in both sexes and for all ages, mortality has been increasing throughout this period, although the rates and relative increase have consistently been much lower and more gradual for women than for men.From the analysis of age-cohort-period variation it seems that bladder cancer mortality can also be influenced by changes in smoking habit patterns and by variation in the quality of diagnoses. The increase in death risk for both sexes in Italy up to cohorts born around 1905-10 can be related to occupational exposures and to high-tar-content tobacco smoking, whereas the tendency for mortality rates to stabilize and decline in cohorts born after 1910 were influenced by changes from high-tar-content and no-filter cigarettes to low-tar-content and filter cigarettes and by prevention measures taken in at-risk working environments.The consumption of coffee, cocoa and tea does not seem to be related to the increase in bladder cancer risk in Italy.

Seasonality of birth for skin melanoma deserves further investigation

Fiessler et al. stated that there is no association between month of birth and risk of melanoma in adult age. The authors analysed a large database from the cancer registry of Bavaria and claimed that their results contradict available studies, including ours from Italy. The arguments presented were: (i) the Bavarian study was larger than the other positive studies; (ii) the study presented methodological improvements over previous available evidence; and (iii) methodological weakness of previous studies was responsible for positive results. We believe that the association between date of birth and adult skin cancer risk should not be dismissed so quickly. The hypothesis of a link between neonatal exposure to UV radiation and adult risk of skin cancer is in line with a wealth of available evidence on UV exposure in the young and with biological/immunological studies on tolerance. Thus, available evidence is sound with respect to biological plausibility and epidemiological data available for older age groups. Methodological criticism by Fiessler et al. of published studies is inappropriate and thus previous evidence is not weakened. In particular, commenting on our finding of an excess skin cancer risk for people born in the spring, they stated that no adjustment was made in our paper for birth month of the reference population. A seasonal effect, similar to our study, is apparent in the Bavarian study. However, seasonality was ascribed to bias on our part since it disappeared with the inclusion of an offset accounting for uneven distribution of births by month. Thus Fiessler et al. indirectly affirmed that our results were biased. However, all our results were ‘adjusted’ using the study population by month or even week of birth (Figure 1). Indeed, seasonality of births was extensively described and we were aware of this phenomenon when writing our paper. The population by date of birth was used as denominator to calculate rates and as an offset in negative binomial regression models presented in our study. People born in the spring were more frequent in our population. Indeed, the inclusion of populations by date of birth in our analyses reduced (but did not cancel) the risk estimates with respect to using a single average population (Figure 2). More precisely, our study dealt with skin cancers and results were significant for other skin cancers and non-significant for melanoma of the skin. Moreover, we used skin cancer cases and regional population by week of birth and spline modelling to provide accurate and flexible estimates of the correlation between date of birth and skin cancer risk. The risk function for melanoma was strikingly similar to other skin cancers, and we speculated that a common risk function for all skin cancers was possible. Of course, it would be entirely inappropriate to include distribution of births as an additional offset variable in our study. Thus, our findings were not biased because of birth distribution and consequently the paper from Bavaria did not represent a methodological improvement on our own study. Instead, it is reasonable to question whether the offset based on the month of birth used in the German paper is equivalent to the use of actual population by date of birth adopted in our paper. Using the distribution of births by period did not reflect population at risk since change due to deaths and migration were not considered. This

Parallelism in the mortality clustering of the most frequent cancer sites in Italy and in the Marche region

Clusters of selected cancer sites mortality, regarding Italy and the Marche region, were compared. Very similar associations were found both in males and in females, in particular between the alcohol-tobacco-related sites. Many clusters agree with the international literature, while others could constitute a starting point for formulating new hypotheses.

Molecular and Chemotaxonomic Studies on Bile Acid Oxidizing Clostridia

Summary Forty-six strains representing species of the genus Clostridium, known to contain nuclear dehydrogenating members, were studied by conventional tests and by gas-liquid chromatographic analysis of the end-products of carbohydrate fermentation. The DNA base composition of the strains was also determined. The conventional data were analyzed by the simple matching coefficient (SsM) and the fermentation endproduct data by the degree of overlap between superimposed traces (SO). Clustering was by the unweighted average pair group method (UPGMA). The resulting phenograms showed remarkable differences between the clustering of the strains depending on whether data based on SsM or SO coefficients were used. The SsM phenogram showed that four of the five clusters contained strains belonging to the same species (C. tertium, C. sphenoides, C. sporogenes, C. bifermentans), and one cluster contained strains from two species (C. paraputrificum and C.butyricum), whereas only one strain (C. indolis) was not included in any cluster. The variability in the range of G+C base composition was less than 4% in four clusters and ranged from 26 to 53 mol% G+C in another cluster. The SO phenogram gave nine clusters. In seven of these, strains from the same named species (C. butyricum, C. sporogenes and C. bifermentans) were sub-divided into more than one cluster and in the two remaining clusters there were strains from two different species: C. tertium with C. paraputrificum in one and C. sphenoides with C. indolis in the other. The range of DNA base composition for strains within the clusters did not exceed 5 mol%.