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The Study describes the epidemiological surveillance of mesothelioma cases carried out by the Italian mesothelioma register (ReNaM). A Regional Operating Centre (COR) is present in nearly all Italian regions (17 out of 20) and it collects malignant mesothelioma cases and investigate the modalities of asbestos exposure by using a structured questionnaire. The register produces malignant mesothelioma incidence measures and analyses of the modalities of the asbestos exposure. The standardized incidence rate of malignant mesothelioma in 2001 was 2.98 (in 100,000 inhabitants) among men and 0.98 among women; a professional (certain, probable, possible) exposure has been detected in 67.4% of defined cases. In addition to the conventional sectors (shipbuilding, railways repair and demolition, asbestos-cement production), also textile, building, transport, chemical and glass industries, petroleum and sugar refineries, electricity production and distribution plants are getting involved. Despite the absence of some regions completing the national coverage and the non homogeneity in collecting and coding data, the epidemiological surveillance of malignant mesothelioma carried out by ReNaM is an important tool for the scientific knowledge and the prevention of asbestos-related diseases.

Objective: lung cancer is the first cause of death in the industrialized country among males and is increasing among females. In 2001 a uniform and standardised list of occupations or jobs known or suspected to be associated with lung cancer has been prepared. The aim of this study is to set up a database of Italian enterprises corresponding to activities related to this list and to assess the number of potentially exposed workers., Design: a detailed and unique list of codes, referred to Ateco91 ISTAT classification with exclusion of the State Railways and the public administration sectors, has been developed. The list is divided into two categories: respectively for occupations or jobs definitely entailing carcinogenic risk and for those which probably/possibly entail a risk. Firms have been selected from the ISPESL database of enterprises and the number of workers has been estimated on the basis of this list., Setting: Italy., Main Outcome Measures: assessment of the number of workers potentially exposed to lung cancer risk and creation of a register of involved firms., Results: the number of potentially exposed workers in the industrial and services sector related to lung cancer risk is 650,886 blue collars and the number of firms censused in Italy is 117,006 units. Corresponding figures in the agriculture sector are 163,340 and 84,839. This type of evaluation, being based on administrative sources rather then on direct measures of exposure, certainly includes an overestimation of exposed workers., Conclusions: the lists based on a standard classification which have been created allow for the creation of databases which can be used to control occupational exposure to carcinogens and to increase comparability between epidemiologic studies based on job-exposure matrix.

Objective: To his study describes the geographical distribution of pleural cancer deaths and asbestosis cases from 1980 to 2000 in Sardinia Region (Italy). For both conditions regionwide registration systems have been available for a relatively long time and allow the identification of statistically significant clusters., Design: For each town we have estimated Standardized Mortality Ratios (SMRs) for pleural cancer and Standardized Incidence Ratios (SIRs) for asbestosis. Expected cases were estimated from age- and gender specific rates in Sardinia. SatScan software was used to identify clusters and to verify their statistical significance., Setting: Sardinia Region (Italy)., Main Outcome Measures: Standardized mortality and incidence rates respectively for pleural cancers and asbestosis cases and territorial clusters., Results: The most important cluster of pleural cancer was identified in the area defined by Carloforte, Calasetta, Portoscuso and Sant'Antioco municipalities (Southwestern Sardinia) with 15 observed cases (p value= 0.003). Other clusters were detected in the municipality of La Maddalena (11 observed cases against 1.91, expected p value= 0.008) and in Southern Sardinia between Cagliari and Sarroch (p value= 0.018). The town of Marrubiu is clearly the most important cluster (p value= 0. 001) with 6 asbestosis cases in the period., Conclusions: These results indicate the urgency of the epidemiological surveillance of asbestos related diseases in Sardinia. The active search for incident cases of malignant mesothelioma in the whole Region and the analysis of modalities of asbestos exposure (according to national guidelines) is an indispensable tool for the primary prevention of occupational, environmental and domestic exposures from unknown asbestos sources of contamination.

Objective: To study the survival for malignant mesothelioma on general population cases over the 1982-2000 period and to evaluate the effectiveness of the new therapeutic protocols (intrapleural immunotherapy and mulitmodality therapy) to improve the prognosis on the group of selected hospital patients treated from 1996 to 2000., Design: Survival analysis of malignant mesothelioma on the general population cases and survival analysis for the 1996-2000 period on the selected group of hospital patients., Setting: The Malignant Mesothelioma Register of the Brescia Province (northern Italy) and Pulmonology Dept. of the General hospital of Brescia., Participants: 353 mesothelioma cases observed in the province of Brescia from 1982 to 2000, 215 of which are residents in the province and 138 from other provinces, 324 are pleural and 29 peritoneal mesothelioma, 141 of all diagnosed between 1982 and 1995 and 212 between 1996 and 2000., Main Outcome Measures: Observed survival (%) at one, three, five-year and median survival by gender, site and residence on the general population cases treated with conventional therapy and on selected hospital patients group treated with intrapleural immunotherapy and mulimodality therapy., Results: Median survival for pleural mesothelioma is of 233 days for the men and 291 days for the women in the group of incident cases; median survival is higher for cases from other provinces (388 and 496 days respectively). From 1996 the number of cases treated with new therapic protocols is steadily increasing, patients without therapy (or only talcaggio) passed from 87% in the period between 1982-1995 to 43% in the period 1996-2000. Nevertheless, multivariate analysis by the Cox model based on incident cases proved that histological subtype and age are the only most important prognostic factors (cases with fibrous morphology and older age are associated with lower survival)., Conclusion: In the incident case group the increase of survival for pleural mesothelioma of cases treated with recent therapeutic protocols doesn't reach statistical significance. These results are similar to those of previous studies conducted to identify prognostic factors for mesothelioma survival; they don't permit confirmation of the efficacy of the recent therapy on the population base cases and only allow one to suppose them in the cases of the non resident population. The efficacy of the recent therapy has to be further investigated with regard to the stage of the disease.

The main objectives of the National Mesothelioma Register (ReNaM), set up by the National Institute for Prevention and Occupational Safety (ISPESL), are: (a) the estimate of malignant mesothelioma incidence in Italy, (b) the definition of exposure to asbestos, (c) the identification of unknown contamination sources, still present on the territory. Cased diagnosed in 1997 in Piedmont, Liguria, Emilia-Romagna, Tuscany and Apulia are reported, regions with more than 17 million inhabitants (30% of national population). ReNaM has facilitated the identification of mesothelioma cases and the description of the previous asbestos exposure in a large geographical area of the country, even though in some regions the definition of exposure to asbestos is not complete. 429 cases are recorded, of which 326 (76%) have been defined as definite malignant mesothelioma. The standardized annual incidence rate just for pleural definite mesothelioma is 1.51 x 100,000 inhabitants (2.26 for males and 0.79 for females). The exposure to asbestos has been defined for 198 mesothelioma cases with histological diagnosis: 125 cases (63%) refer to professional exposure, 10 (5%) to environmental exposure, 5 (2.5%) to domestic exposure. The adoption of a well-constructed national database, the up-date of guidelines and the recent starting up of ReNaM in other italian regions (Lombardy, Veneto, Marche, Campania, Basilicata and Sicily) will shortly lead to obtaining a major representativeness of the Italian situation.

During 1995-1999 among cases compensated by Italian National Institute for Insurance of Occupational Accidents (INAIL), asbestosis was classified as the second occupational disease after hypoacusia with the 7% of total cases. The present study describes the geographical distribution of 1.483 cases in men, notified to INAIL (and subsequently confirmed) during 1984-1992. Age-standardised incidence rates were calculated for the 93 Italian provinces. In addition, standardised incidence ratio (SIR) were computed, comparing the number of observed cases to the number of expected cases on the basis of age specific rates in the large geographical Italian areas (Northeast, Northwest, Centre and South and islands). Empirical Bayes estimates applying the Poisson-Gamma model were also estimated. The geographical distribution of standardised incidence ratios revealed a high excess risk for the province of Gorizia, Livorno, Massa Carrara, La Spezia, Trieste, Alessandria, Caltanissetta and a lower, but still significant, excess risk for the province of Siracusa, Ancona, Napoli, Genova, Reggio Emilia, Brindisi, Bergamo, Arezzo, Taranto, Pavia, Messina, Lecco and Varese. This study suggests the possibility to use the insurance files on asbestosis in order to estimate risks in Italy and to compare geographical clusters. Identification of provinces with significant excess number of compensated cases for asbestosis underscore the need for more detailed surveys aimed to detect conditions correlated with asbestos exposure and identifying persisting environmental pollution. Detailed enquiries are needed in particular in those provinces where excesses cannot be explained by current knowledge on circumstances of the presence of asbestos in the workplace.

Lists of occupations and industries associated with lung cancer are a useful tool to estimate attributable risks for occupational exposures. They were first published in 1982, based on IARC Monographs. List A included industries, processes and occupations definitely entailing carcinogenic risk, list B those probably/possibly carcinogenic. In 1995 the lists had been updated. We carried out a further update, reviewing IARC Monographs Volumes 62-75, focusing on Group 1, 2 A, and 2 B agents, and coded the lists according to widely used classifications: ISIC Rev. 2, ISIC Rev. 3, NACE Rev. 1, and ISTAT ATECO 1991 (for economic activities); ILO-ISCO 1968 and ISTAT-Classificazione delle professioni 1991 (for occupations). In order to evaluate temporal and geographical variations in attributable risk, exposure assessment must be performed consistently across different studies and standard tools to identify exposures, such as the one we propose here, are needed. The lists can also help to develop maps of industrial activities entailing carcinogenic risk at local, regional, and national level, and to identify economic activities that deserve priority action to control occupational exposures to carcinogens. The classifications were originally developed for economic and demographic purposes, and some exposure circumstances cannot be coded with sufficient specificity. This applies to productions or processes (i.e.: PVC production) that could be classified only by codes corresponding to wide groups of economic activities and/or occupations: in these instances we associated no code, so as not to inflate the estimates of exposed workers. As a consequence, however, certain exposures are not represented in the coded version of the lists. Even keeping in mind such limitations, coding makes the lists easier to apply, and increases the comparability of studies on lung cancer and occupation, as well as of surveys on exposure prevalence.

This paper describes methods and results of the Piedmont Malignant Mesothelioma Registry. The Registry is active since 1990 and collects all histologically confirmed incident cases of malignant mesothelioma (m.m.) occurring in the residents of Piedmont. In the period 1990-95, 346 cases of pleural m.m. (211 males and 135 females) and 41 (28 males and 13 females) of peritoneal m.m. have been observed. Amongst the inhabitants of the Local Health Authority of Casale Monferrato, where manufacturing of cement asbestos has determined serious asbestos exposures both in the work place and general environment, there have been 105 pleural m.m. and 17 peritoneal m.m. (incidence rate were 15.6 for men and 13.0 for women and 3.6 for men and 0.6 for women respectively). Leaving out the Local Health Authority (LHA) of Casale Monferrato, the annual incidence rate in Piedmont (for 10(5) person-years, age standardised on the 1981 Italian population), has been 1.0 in men and 0.6 in women for the pleural m.m. (respectively 154 and 87 cases) and 0.09 and 0.06 for peritoneal m.m. (14 and 10 cases). Possible cases of m.m. (cytological and/or x-ray diagnosis) have been searched in the file of hospital admission and discharges (SDO) in 1994-95: 46 additional cases were found, with a 25% increase in incidence rates. The analysis of incidence according to geographical aggregations (defined according to the LHA borders) has identified, besides some already known important sources of exposures, as Casale Monferrato and the LHA of Lanzo (Balangero mine), other areas with excess of incidence as the LHA's of Galliate and Caluso which show an increased incidence of pleural m.m. in men or Vercelli and Chieri with increased incidence of pleural m.m. in women. These observation deserves further analysis.