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To evaluate the importance of several risk factors for breast cancer in the Italian female population, a large multicentric case-control study was conducted in 10 breast clinics in Italy. The study included 1,556 women affected by breast cancer, histologically and/or cytologically confirmed. Controls were 1,505 women admitted to a hospital in the same town, matched with cases for residence and with the same age distribution of the Italian female population. The risk factors considered in this study were family history of breast cancer, reproductive history, height and weight, use of oral contraceptives, other hormonal therapies and smoking history. The results of this study confirm the significant role of a positive family history of breast cancer (RR = 2.37); the relative risk was even higher when a first-degree relative was affected or the breast cancer was bilateral. The analysis of the reproductive history showed a significant trend of increasing risk with increasing age at first birth and, although less evident, with increasing number of children. Quetelet's index (kg/m–2) was positively correlated with breast cancer risk, mostly in postmenopausal women. Among other studied factors, only late age at menopause confirmed an increased risk for breast cancer, whereas age at menarche, use of oral contraceptives and smoking histories did not show any significant correlation with breast cancer risk. These results are in substantial agreement with other international studies, but represent an interesting contribution to studies about the Italian female population.

Aims and background Fineneedle aspiration cytology (FNAC) is a routine test in the evaluation of breast lesions. We assessed the diagnostic accuracy of mammography (MG), physical examination (PE), ultrasonography (US) and FNAC in 1064 histologically confirmed breast lesions (638 malignant, 426 benign) observed consecutively at the Cancer Prevention Center of Ravenna (Italy).Methods The performance of each test and the additional contribution of FNAC were determined.Results FNAC was done in 69.6 % of cancers and 39.7 % of benign lesions (P = 0.00000), the frequency of aspiration being significantly associated with severity at MG, PE, and US. For FNAC, the true positive rate was 95.1 % and the true negative rate 67.4 %. Only one breast cancer case was detected by FNAC alone (additional true positive rate 0.2 %). The positive predictive value of FNAC in the absence of other abnormalities was 5 %. The negative predictive value of a benign report at MG, PE, US and FNAC was 100 %.Conclusions All breast lesions should be evaluated by all available techniques, especially FNAC, and open biopsy should be avoided for those reported as benign at all tests.

Aims In 1990, The Bethesda System (TBS) was introduced into spontaneous cervical screening practice in Ravenna, Italy. Negative/benign reports with the recommendation for early repeat smears (RERS) due to some limitation in sample adequacy were considered no longer acceptable. A monitoring program for the rate of unsatisfactory smears (UNS) was implemented. The aim of the present study was to evaluate the effects of such changes in the screening procedure.Methods The frequency of UNS in 1990 was compared with that of UNS+RERS in 1988 (assumed as a baseline year) by the calculation of the standardized rate ratio with the 95% confidence interval (CI). The trend in the standardized rate of UNS from 1990 to 1994 was evaluated by the calculation of the average annual variation with the 95% CI.Results The immediate effect of TBS (1990:1988 comparison) was a significant increase in the rate of UNS attributable to scant cellularity, poor fixation and thick areas (rate ratio, 2.35; 95% CI, 2.18 to 2.53) and to the absence of endocervical component (1.45; 95% CI, 1.30 to 1.60). The rate of UNS attributable to the presence of cytolysis, inflammation, blood and foreign material decreased by about 6 times (0.16; 95% CI, 0.13 to 0.19). The midterm effect of TBS (trend from 1990 to 1994) was a decrease in the total rate of UNS by an average of 2.3% per year. The downward trend was significant for smears showing scant cellularity, poor fixation and thick areas (-1.5% per year) and the absence of endocervical component (-0.7% per year). UNS attributable to the presence of cytolysis, inflammation, blood and foreign material stabilized.Conclusions TBS led to a substantial change in the type of information provided by the cytology report (Immediate effect). The monitoring program according to TBS led to a reduction in UNS attributable to sample taker (midterm effect).

In Italy, where no national screening program for cervical cancer exists, organized programs have developed on a local basis. We performed the first survey of existing organized programs by mailing a standard questionnaire to a large network of possibly involved services. For the present survey, a program was defined as organized if personal invitations were sent. We identified 29 already active organized programs and 4 others in a starting phase. The target population of active programs included 2,074,820 women in the age range 25-64 years, corresponding to 13.5% of the Italian female population of the same age. The situation is rapidly evolving since many regional programs are being implemented. Most programs followed Italian and European recommendations as regards the age limits, interval between screening rounds, presence of a fail-safe system for women referred for colposcopy, presence of protocols for diagnostic workup and treatment, and presence of referral centers for such phases. However, many programs did not meet national guidelines as regards the size of laboratories interpreting smears, which were frequently small. Second-level referral centers also frequently had a very small activity. The average (weighted for size of the invited population) compliance to invitation and coverage (proportion of women with at least one test in the last 3 years) was 32.6% and 66.0%, respectively, therefore needing to be improved. Compliance to colposcopy (weighted for number of referred women) was 81.4%. We found a very high variability in the proportion of women referred for colposcopy that could only be partly explained by different referral protocols and could depend on different criteria of smear interpretation: the average (weighted for number of tested women) was 2.01%. A need for improvement in the process of evaluation and for homogenization of criteria of cytology interpretation was identified: work in this regard is ongoing.

Human papillomavirus cervical infection was investigated in a series of 300 unselected women by comparing morphological diagnoses (cytology and histology) with results of DNA hybridization techniques (filter in situ hybridization of DNA from exfoliated cervical cells and Southern blot analysis of HPV-DNA in cervical biopsy specimens). The prevalence of HPV cervical infection diagnosed by PAP smears was 11.6 %.Despite disadvantages, filter in situ hybridization was confirmed to be particularly useful for screening purposes to detect HPV in cervical scrapings. In 3 cases it was the only applicable method for diagnosing « high-risk » HPV infection. Southern blot hybridization of tissue DNA with HPV 16-DNA revealed the presence of this virus in 8 cases, and HPV 31-DNA and HPV 42-DNA in 1 case each.

Aims and Background In the field of breast cancer control, obtaining population-based data on spontaneous mammography (MG) screening should be a priority. This study focuses on the breast cancer incidence and stage distribution in relation to MG use in Ravenna (Italy), 1987-88.Methods We estimated the MG rates, expected (E) incidence based on mortality data, observed (O) incidence, predicted excess incidence based on MG rates, observed excess incidence, and stage distribution according to the MG history.Results The highest MG rate (37%) was found among residents aged 40-44 but none of these had a T1a-bN0 breast cancer diagnosed nor was the predicted excess incidence demonstrated. Between 45 and 64 years, 80% of self-selected screenees had repeat (“incidence”) MG and the O:E incidence ratio was 1.32 (95% Cl 1.09-1.58). The observed excess incidence was 3.8-fold (95% Cl 2.56-5.16) greater than that predicted. Advanced (T2+ and/or N1+) cases accounted for 42% of patients diagnosed within 3 years of their last MG, for 55% of those diagnosed more than 3 years after their last MG, and for 70% of those with no previous MG. Above age 70, a significant worsening of stage at diagnosis was associated with a clear-cut drop in the proportion of breast cancer patients with previous self-referral for MG.Conclusions The results indicate that self-selection and its implications are major features of spontaneous screening practice.

Aims and Background Screening mammography has been shown to be effective in reducing breast cancer mortality in several randomized clinical trials. One major side effect of screening is the diagnosis of benign breast disease (BBD), which is considered as a nonprogressive lesion, except for a small percentage of lesions considered at high risk. We present data referring to service screening programs active in Italy in 2000 and 2001 and participating in the national survey carried out by the Italian Group for Mammography Screening (GISMa).Methods To all centers participating in the GISMa National Survey, we submitted a questionnaire regarding the service screening protocol and main indicators of performance of the local program in the years 2000 and 2001.Results A total of 657 detected BBD cases, registered by 23 Italian breast cancer screening centers in women 50 to 69 years of age, are included in this study. The BBD detection rate was 2.5 per 1000 at the first screening test and 1.05 per 1000 at repeated tests. The benign/malignant ratio was 0.34 at the first and 0.22 at the repeated test.Conclusions Detection of BBD occurred frequently in breast screening programs, and prognostic implications should be further investigated. Women should be individually informed at screening, and with greater detail at the moment of the recall for assessment, of the implications of BBD detection and receive the necessary, also psychological, counseling to avoid the possible harm related to breast cancer screening.