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Background This study aimed to evaluate the effectiveness of a biennial faecal immunochemical test (FIT) screening programme in reducing annual colorectal cancer (CRC) incidence in its dynamic target population. Methods The target population included over 1,000,000 persons aged 50–69 living in a region of northern Italy. The average annual response rate to invitation was 51.4%. Each observed annual age-standardised (Europe) rate per 100,000 persons between 2005, the year of introduction of the programme, and 2016 was compared with each expected annual rate as estimated with age-period-cohort (men) and age-period (women) models. Results For both sexes, the rates observed in 1997–2004 and those expected in 2005–2016 were stable. Observed rates increased in 2005, peaked in 2006 (the first full year of screening), dropped significantly below the expected level in 2009, and continued to decrease until 2013 (the eighth full year), after which no further significant changes occurred. In the pooled years 2013–2016, the observed incidence rate per 100,000 persons was 102.2 [95% CI: 97.4, 107.1] for men, 75.6 [95% CI: 71.6, 79.7] for women and 88.4 [95% CI: 85.3, 91.5] for both sexes combined, with an observed:expected incidence rate ratio of 0.68 [95% CI: 0.65, 0.71], 0.79 [95% CI: 0.76, 0.82] and 0.72 [95% CI: 0.66, 0.81], respectively. Discussion The study provided multiple consistent proofs of a causal relationship between the introduction of screening and a stable 28% decrease in annual CRC incidence after eight years.

Introduction Mammography is one of the most technically demanding radiographic processes, and mammography quality assurance initiatives are priorities in the implementation of public health screening services. In the optimisation of image quality (IQ), radiographers play a major role. Between 1998 and 2009, the steering committee for mammography of a large population‐based screening service in northern Italy undertook several audit checks of the imaging facilities. In 2009, the target age range of the screening service was extended. The mammogram volume was projected to increase steeply but with no substantial increase in the radiographer workforce. Methods In view of the potential impact on mammographic IQ, the passive audit approach was abandoned in favour of an active radiographer‐oriented IQ review programme. Its technical basis consists of regularly repeated rounds of review of random samples of digital mammograms performed by each first‐level radiographer and by more experienced local reference radiographers, with IQ classification, followed by a training effort and a monitoring work. Results The mammogram volume grew from 140,822 in 2008 to 319,394 in 2014 (+127%) and then stabilised. In 2012, the proportion of mammograms with a poor IQ rose from 0.6% to 19.3%, paralleled by a substantial decrease of mammograms interpreted to have a moderate and perfect IQ. Conversely, a generalised improvement occurred in both rounds of 2016 and in the first round of 2018. Conclusion In the new challenging scenario, the programme proved to be effective. A successful IQ review initiative is one that encourages radiographers to participate with a positive and confident attitude., A regional multicentre image quality review programme for mammography was developed consisting of a process of review of a sample of mammograms with image quality classification, independently performed by all first‐level radiographers and by more experienced local reference radiographers, followed by a training effort and a monitoring work. The programme places emphasis on motivating and training the radiographers and not on testing them. Its results demonstrate that a successful image quality review initiative for radiographers is one that encourages them to participate with a positive and confident attitude.

BackgroundIn Italy, population-based screening programs for breast, cervical and colorectal cancers are mandatory, and Regions are in charge of their delivery. From March to May 2020, a severe lockdown was imposed due to the Covid-19 pandemic by the Italian Ministry of Health, with the suspension of screening programs. This paper describes the impact of the pandemic on Italian screening activities and test coverage in 2020.MethodsThe regional number of subjects invited and of screening tests performed in 2020 were compared with those in 2019. Invitation and examination coverage were also calculated. PASSI surveillance system, through telephone interviews, investigated the population screening test coverage, before and during the pandemic, accordingly to educational attainment, perceived economic difficulties and citizenship.ResultsA reduction of subjects invited and tests performed, with differences among periods and geographic macro areas, was observed in 2020 vs. 2019. The reduction in examination coverage was larger than that in invitation coverage for all screening campaigns. From the second half of 2020, the trend for test coverage showed a decrease in all the macro areas for all the screening campaigns. Compared with the pre-pandemic period, there was a greater difference according to level of education in the odds of having had a test last year vs. never having been screened or not being up to date with screening tests. In addition, foreigners had less access to screening than Italians did.ConclusionsThe lockdown and the ongoing Covid-19 emergency caused an important delay in screening activities. This increased the pre-existing individual and geographical inequalities in access. The opportunistic screening did not mitigate the pandemic impact.FundingThis study was partially supported by Italian Ministry of Health – Ricerca Corrente Annual Program 2023.

(1) Background: This population-based study aimed at identifying the factors associated with the likelihood of detection of stage IA cervical carcinoma—versus the detection of stage IB through IV cervical carcinoma—and the patterns of surgical treatment. (2) Methods: Between 1995–2016, 3750 patients living in the Emilia-Romagna Region (northern Italy) were registered with cervical carcinoma, including 2942 eligible patients (median age, 53). Multivariate analysis was performed using binary logistic regression models. (3) Results: The likelihood of stage IA cervical carcinoma (n = 876, 29.8%) did not change over time, decreased with increasing patient age, and was lower for patients with adenocarcinoma and grade 3–4 disease. Three hundred and fifty (40.0%) patients had a conservative treatment, 317 (36.2%) had hysterectomy, 197 (22.5%) had hysterectomy with lymph node dissection (LND), and 12 (1.4%) had a conservative treatment with LND. The proportion of hysterectomy decreased from 70.6% in 1995–1999 to 46.9% in 2011–2016. The likelihood of hysterectomy increased above the age of 40. Among screening-aged (25–64 years) patients, the likelihood of hysterectomy did not differ between screen-detected and non-screen-detected ones. Hysterectomy was increasingly combined with LND. High tumour grade was the strongest determinant of LND during hysterectomy. (4) Conclusions: This study provided a multifaceted overview of stage IA cervical carcinoma over the last decades.

In Italy, regional governments are in charge of implementing cervical, breast and colorectal cancer screening programmes. The 2020 Coronavirus pandemic led to a national lockdown and the temporary suspension of several non-urgent healthcare activities, including cancer screening. This paper aims to describe the results of a national survey carried out by the National Centre for Screening Monitoring (ONS) on cervical, breast and colorectal cancer screening activities in 2020.A national survey was conducted by ONS in 2020 to assess: the number of screening invitations by Region; the volumes of screening tests and the attitude to attend the screening programme compared to 2019; the number of delayed diagnoses of malignant or pre-malignant lesions caused by the slowing down of screening programmes, based on the average Region-specific screening detection rate for cervical, breast and colorectal cancers.Screening tests for breast, colorectal and cervical cancer decreased by 37.6%, 45.5% and 43.4% in 2020 compared with 2019. In 2020 the estimated numbers of undiagnosed lesions are: 3,324 breast cancers, 1,299 colorectal cancers, 7,474 colorectal advanced adenomas and 2,782 CIN2 or more severe cervical lesions. Participation in cancer screening programmes decreased by 15%, 15% and 20%, for cervical, breast and CRC screening, respectively.An urgent call to action is needed to prevent further delays and to limit the impact of the pandemic on cancer diagnosis and prevention.

Background The European guidelines for quality assurance in colorectal cancer (CRC) screening recommend that interval cancer rate be expressed as a proportion of background incidence rate. Aim To determine the crude and adjusted proportional incidence of interval CRC in an Italian regional two-yearly faecal immunochemical test (FIT) screening programme. Methods The programme (year of implementation, 2005) is targeted at over 1,000,000 people aged 50–69 years. The test is a one-sample OC-Sensor (Eiken Chemical Co., Tokyo, Japan). The study covered one-third of the regional area. Excerpts of 434,295 eligible negative FIT records dated 2005–2012 from 193,193 subjects were retrieved from the regional CRC screening data warehouse. By 31 December 2013, the cohort accumulated 198,302 man-years and 235,370 woman-years. Interval CRCs were identified by record-linkage with the local population-based cancer registry. Their number was divided by the expected number, estimated with age-period-cohort models, to obtain the proportional incidence. Results The proportional incidence of interval CRC for men and women was, respectively, 0.06 (95% confidence interval (CI), 0.04–0.09) and 0.17 (95% CI, 0.13–0.23) in the first interval year, and 0.21 (95% CI, 0.16–0.26) and 0.28 (95% CI, 0.22–0.36) in the second year. Conclusions The results were acceptable and in line with previous studies.

The European Commission Initiative on Breast Cancer recommendation for triennial screening of women aged 70–74 is based on very weak evidence. A cohort of Italian women who had their last biennial screening mammography at age 68–69 was followed up for 5 years, assumed to represent the interval to another hypothetical screening mammography, in order to determine the annual proportional incidence of interval breast cancer. The cohort included 118,370 women. They had their last mammography between 1997 and 2008. Incident breast cancers were identified by record-linking the cohort with the regional breast cancer registry. The expected incidence in the age range 65–74 was estimated with an age-period-cohort model. The number of interval cancers was divided by the expected number to obtain their proportional incidence. Overall, there were 298,658 woman-years at risk with 371 interval cancers versus 988.8 expected. In the first, second, third, fourth, and fifth interval year, the proportional incidence was 0.09 (95% confidence interval, 0.06–0.13), 0.32 (0.25–0.39), 0.60 (0.49–0.73), 0.75 (0.60–0.92), and 0.81 (0.60–1.07), respectively. Between the second and the fifth year, tumour stage and molecular subtype did not change significantly. Though not supported by these findings, the proposal of triennial screening for women aged 70–74 merits further research, because the 95% confidence interval of the third-year proportional incidence of interval cancer included 0.50—the maximum limit considered acceptable for women aged 50–69. • The third-year incidence of breast cancer relative to the expected one was 0.60 (95% confidence interval, 0.49–0.73). • Between the second and the fifth year, tumour stage and molecular subtype did not change significantly (p >0.10). • The proposal of a 3-year screening interval at age 70–74 merits further evaluation.

This cohort study compared colorectal cancer (CRC) incidence and mortality between people who participated in an Italian regional biennial fecal immunochemical test (FIT) screening program and people who did not.The program started in 2005. The target population included over 1,000,000 people aged 50 to 69 years. The FIT was a one-sample OC-Sensor (Eiken Chemical Co, Tokyo, Japan) (cutoff, ≥20 μg hemoglobin/g feces). The average annual response rate to invitation was 51.4%. The records of people invited up to June 2016 were extracted from the screening data warehouse. Attenders were subjects who responded to the first 2 invitations or to the single invitation sent them before they became ineligible. Non-attenders were subjects who did not respond to any of these invitations. The records were linked with the regional CRC registry. People registered up to December 2016 were identified. Self-selection-adjusted incidence rate ratios (IRRs) and incidence-based CRC mortality rate ratios (MRRs) for attenders to non-attenders, with 95% confidence intervals (CIs), were calculated.The cohort generated 2,622,131 man-years and 2,887,845 woman-years at risk with 4490 and 3309 CRC cases, respectively. The cohort of attenders was associated with an IRR of 0.65 (95% CI, 0.61-0.69) for men, 0.75 (95% CI, 0.70-0.80) for women and 0.69 (95% CI, 0.66-0.72) for both sexes combined. The self-selection-adjusted IRR was 0.67 (95% CI, 0.62-0.72) for men and 0.79 (95% CI, 0.72-0.88) for women. The IRR for stage I, II, III, and IV CRC was 1.35 (95% CI, 1.20-1.50), 0.61 (95% CI, 0.53-0.69), 0.60 (95% CI, 0.53-0.68) and 0.28 (95% CI, 0.24-0.32) for men and 1.64 (95% CI, 1.43-1.89), 0.60 (95% CI, 0.52-0.69), 0.73 (95% CI, 0.63-0.85) and 0.35 (95% CI, 0.30-0.42) for women. The overall incidence-based CRC MRR was 0.32 (95% CI, 0.28-0.37) for men, 0.40 (95% CI, 0.34-0.47) for women and 0.35 (95% CI, 0.31-0.39) for both sexes combined. The adjusted MRR was 0.35 (95% CI, 0.29-0.41) for men and 0.46 (95% CI, 0.37-0.58) for women.Attendance to a FIT screening program is associated with a CRC incidence reduction of 33% among men and 21% among women, and a CRC mortality reduction of 65% and 54%, respectively.

Objective To estimate the proportional incidence (PI) of first- and second-year interval breast cancer among women aged 45–49. Methods In the Emilia-Romagna Region (northern Italy), women aged 45–49 are invited to mammography screening annually, and women aged 50–74 biennially. For younger ones, the proportional incidence of interval cancer in the first and unique interval year was calculated using standard methods. For the second, hypothetical year, it was estimated using two different estimates of the ratio between the second- and the first-year proportional incidence observed among women aged 50–54. Overall, 567,151 negative mammography records were used. Results In the first interval year, the observed proportional incidence of interval cancer among women aged 45–49 was 0.27 (95% confidence interval (CI), 0.22–0.33), within the European limit considered desirable for women aged 50–69 (Conclusion The more up-to-date estimate of 0.48, slightly below the maximum limit considered acceptable for women aged 50–69 (

to describe the course of Italian organized cancer screening programmes during the COVID-19 emergency; to provide estimates of the diagnosis of malignant or pre-malignant lesions that will face a diagnostic delay due to the slowing down of screening activities.quantitative survey of aggregated data for each Region and overall for Italy relating to screening tests carried out in the period January-May 2020 compared to those of the same period of 2019; estimate of diagnostic delays starting from the calculation of the average detection rate of the last 3 years available (specific by Region).Italian mass screening programmes. Data on the tests carried out in the target population of the breast (women 50-69 years old), cervix (women 25-64 years old), and colorectal (women and men 50-69 years old) cancer screening.the cumulative delay (in absolute numbers and as a percentage) in the period January-May 2020 compared to the same period of 2019, by Region; the difference of screening tests (in absolute number and in percentage) performed in May 2020 compared to May 2019; the estimate of the fewer lesions diagnosed in 2020 compared with 2019 with relative 95% confidence intervals (95%CI); the 'standard months' of delay (proportion of fewer tests carried out from January to May 2020 for the corresponding number of months).20 Regions out of 21 participated. In the period January-May 2020, the fewer screening tests performed in comparison with the same period of 2019 were: 472,389 (equal to 53.8%) with an average delay of standard months of 2.7 for mammography screening; 585,287 (equal to 54.9%) with an average delay of standard months of 2.7 for colorectal screening; 371,273 (equal to 55.3%) with an average delay of 2.8 standard months for cervical screening. The estimated number of undiagnosed lesions is 2,201 (95%CI 2,173-2,220) breast cancers; 645 (95%CI 632-661) colorectal carcinomas; 3,890 (95%CI 3,855-3,924) advanced colorectal adenomas and 1,497 (95%CI 1,413-1,586) CIN2 or more serious lesions.mass screenings need to be restarted as quickly as possible. In order to make up for the delay that is accumulating, it is necessary to provide for wider delivery times, greater resources, and new organizational approaches. It will also be essential to develop communication strategies suitable for promoting participation during this emergency.

Background & Aims We investigated the magnitude and temporal patterns of the decreasing trend in main performance measures of fecal immunochemical test (FIT) screening for colorectal cancer (CRC) observed in second and subsequent rounds. Methods We followed up 494,187 participants from the first round of a regional biennial FIT screening program in Italy (cut-off value for positivity, 20 μg hemoglobin/g feces) for 5 total rounds (2005–2016). At each round, only compliant participants were eligible. Performance measures from the first, third, fourth, and fifth rounds were compared with those from the second round (the first incidence round) using rate ratios from multivariate Poisson regression models and relative risk ratios from multinomial logistic regression models. Results Between the second and the third rounds, a significant 20% to 30% decrease was found in the proportion of men with a positive FIT result (from 5.2% to 4.3%) and in detection rates of advanced adenoma (from 13.4 to 10.2 per 1000), CRC (from 1.7 to 1.4 per 1000), and advanced neoplasia (from 15.1 to 11.6 per 1000). Positive predictive values (PPVs) decreased by 10% or less between the second and third rounds. Detection rates and PPVs for adenoma stabilized by the fourth and fifth rounds. The PPVs for advanced adenoma, CRC, and advanced neoplasia decreased slightly in men and women by the fourth and fifth rounds. The detection rate of proximal colon cancer stabilized after the second round, whereas the detection rate of distal colon cancer decreased until the fourth round in men (from 0.7 to 0.3 per 1000), and the fifth round in women. Conclusions These findings support the notion that FIT screening prevents progression of a subset of advanced adenomas. Screening intensity could be modulated based on results from previous rounds, with a risk-based strategy.

Objectives To report changes in incidence of cervical tumours by disease stage, following the introduction of an organized cytology-based screening programme. Methods An intention-to-screen study of a cytology-based screening programme targeting 1,219,000 women aged 25–64 in northern Italy was carried out. Based on the previously reported trend in total incidence of cervical cancer, the study period 1995–2014 was divided into 1995–1996 (pre-screening, or reference, years), 1997–1998 (screening implementation phase), 1999–2006 (transition phase, when incidence decreased), and 2007–2014 (steady-state phase, when incidence stabilized again). Tumour stage was categorized as preinvasive (cervical intraepithelial neoplasia grade 3 (CIN3) and adenocarcinoma in situ), early (pT1a), advanced (pT1b or greater, ypT), and unknown (pT1 not otherwise specified, pTx, missing information). Average annual incidence rates observed in each phase were compared with the expected (reference) rates, using the incidence rate ratio, calculated with a Poisson regression model. Results In the steady-state phase, incidence rate ratios were: CIN3, 1.55 (95% confidence interval, 1.41–1.70); early-stage squamous carcinoma, 0.49 (0.36–0.67); advanced-stage squamous carcinoma, 0.44 (0.33–0.57); unknown-stage squamous carcinoma, 0.69 (0.48–0.99); adenocarcinoma in situ, 1.44 (0.72–2.88); early-stage adenocarcinoma, 2.65 (0.82–8.53); advanced-stage adenocarcinoma, 1.03 (0.56–1.91); and unknown-stage adenocarcinoma, 0.46 (0.23–0.92). Conclusions After stabilization, changes in incidence by tumour stage included a 55% increase for CIN3 and a 50–55% decrease both for early- and advanced-stage squamous carcinoma, but no significant changes for glandular tumours. These data will serve to quantify the incremental impact of the implementation of human papillomavirus-based screening, introduced in 2015.

Objective: Cervical cancer prevention shows a variability across Italian Regions unjustified by available evidence, increasing the health, economic and organizational burden. Evidence-based recommendations on topics not covered by international guidelines are needed to tackle existing inequalities. This article describes the rationale, methods, and process for development of the Multisociety Italian Guidelines for cervical cancer prevention. Methods: The Italian legislative framework requires guidelines to be consistent with methodological standards set by the National System for Guidelines (SNLG) of the National Institute of Health. Results: The nine scientific societies involved in cervical cancer prevention participated to the project, including clinicians, policy makers, methodologists, and researchers. Patients were involved as full voting panel members. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was adopted to assess the certainty of evidence collected by systematic reviews. The GRADE Evidenceto- Decision framework (EtD) was used to structure the appraisal of evidence and to formulate final recommendations. The EtD and a conflict-of-interests management policy were adopted to minimize the influence of competing interests. Discussion: Full transparency guided the reporting of each step of the process, to support the implementation of recommendations in each context and the future updating process. Considerations for subgroups, monitoring and evaluation of the implementation of recommendations and research priorities were also provided. A two-step review process by external experts and SNLG reviewers, prior to online publication, ensured the methodological robustness underlying final recommendations. Finally, to increase publication timeliness, guidelines are organised in chapters that group sets of related recommendations to be published independently.

Colorectal cancer screening programmes in Italy invite 50-69-year-old residents for a faecal immunochemical test every two years, regardless of their citizenship.The 2013 National Survey on Italian colorectal cancer screening programmes compared immigrants born in low- or middle-income countries with subjects who were born in Italy, by collecting aggregated data on compliance, faecal immunochemical test results, compliance with colonoscopy, detected lesions and stage at diagnosis separately for Italians and immigrants.Overall, 85 screening programmes invited 3,292,451 subjects, of whom 192,629 had been born abroad (5.9%). Compliance with invitation was lower in immigrants (34.3% vs. 51.3% in Italians), with p0.001. Compliance was higher in females, regardless of the country of birth, in the youngest age group of immigrants but in the oldest of Italians. Immigrants showed a borderline excess of standardised faecal immunochemical test positivity rate at first screening (5.4% vs. 5.1% in Italians, p=0.05) and a significant excess at repeat screenings (4.8% vs. 4.4%, p=0.002). The detection rates for carcinoma and advanced adenomas were lower in immigrants than in Italians at first screening (respectively 1.34‰ vs. 1.62‰ and 8.41‰ vs. 9.25‰) - although the differences were not statistically significant - but not at repeat screening (respectively 1.06‰ vs. 0.98‰ and 6.90‰ vs. 6.79‰).Migrants showed a lower compliance with screening than Italians. The prevalence of neoplasia was lower at first screening and similar to the Italians' at repeat screenings.

To compare the results of 5 years of annual mammography screening at age 45–49 with the results of 5 years of biennial screening at age 50–54 and 55–69. In an Italian screening programme, data from 1,465,335 mammograms were analysed. Recall rates, invasive assessment rates, surgical biopsy (including excisional biopsy and definitive surgical treatment) rates, and cancer detection rates were calculated for the first screen (first) and, cumulatively, for the second and subsequent screens (second+). The rate ratios between younger women and the two groups of older ones were (in parentheses, original figures per 1000 mammograms if not otherwise specified): recall rate: first 1.11 (103.6 vs. 93.5) and 1.11 (vs. 93.2), second+ 2.10 (208.9 vs. 99.7) and 2.77 (vs. 75.5); invasive assessment rate: first 0.94 (23.0 vs. 24.5) and 0.94 (vs. 24.6), second+ 1.63 (35.8 vs. 22.0) and 1.56 (vs. 23.0); surgical biopsy rate: first 0.68 (5.9 vs. 8.6) and 0.45 (vs. 13.2), second+ 1.35 (11.5 vs. 8.5) and 0.88 (vs. 13.0); total detection rate: first 0.63 (4.3 vs. 6.7) and 0.37 (vs. 11.7), second+ 1.30 (8.9 vs. 6.8) and 0.74 (vs. 12.0); total positive predictive value of surgical biopsy: first 0.93 (72.8% vs. 78.0%) and 0.82 (vs. 88.9%), second+ 0.96 (77.2% vs. 80.5%) and 0.83 (vs. 92.7%). Younger women experienced two to threefold higher cumulative recall rates at second+ screens and limited differences in surgical biopsy rate. Albeit encouraging, these results must be completed with further investigation, especially on interval cancer incidence. • At repeated screens, cumulative recall rate was two- to threefold higher for younger women. • Differences in cumulative surgical referral and surgical biopsy rates were moderate. • Differences in positive predictive value of surgical biopsy were particularly small.

Objectives To assess the appropriateness of recommendations for endoscopic surveillance in organised colorectal cancer (CRC) screening programmes based on the faecal immunochemical test (FIT). Design 74 Italian CRC screening programmes provided aggregated data on the recommendations given after FIT-positive colonoscopies in 2011 and 2013. Index colonoscopies were divided into negative/no adenoma and low- risk, intermediate-risk and high-risk adenomas. Postcolonoscopy recommendations included a return to screening (FIT after 2 years or 5 years), an endoscopic surveillance after 6 months or after 1 year, 3 years or 5 years, surgery or other. We assessed the deviation from the postcolonoscopy recommendations of the European Guidelines in 2011 and 2013 and the correlation between overuse of endoscopic surveillance in 2011 and the process indicators associated with the endoscopic workload in 2013. Results 49 704 postcolonoscopy recommendations were analysed. High-risk, intermediate-risk and low-risk adenomas, and no adenomas were reported in 5.9%, 19.3%, 15.3% and 51.5% of the cases, respectively. Endoscopic surveillance was inappropriately recommended in 67.4% and 7%, respectively, of cases with low-risk and no adenoma. Overall, 37% of all endoscopic surveillance recommendations were inappropriate (6696/17 860). Overuse of endoscopic surveillance was positively correlated with the extension of invitations (correlation coefficient (cc) 0.29; p value 0.03) and with compliance with post-FIT+ colonoscopy (cc 0.25; p value 0.05), while it was negatively correlated with total colonoscopy waiting times longer than 60 days (cc −0.26; p value 0.05). Conclusions In organised screening programmes, a high rate of inappropriate recommendations for patients with low risk or no adenomas occurs, affecting the demand for endoscopic surveillance by a third.

Most invasive cervical cancers in industrialized countries are due to the lack of Pap test coverage, very few are due to screening failures. This study aimed at quantifying the proportion of invasive cancers occurring in nonscreened or underscreened women and that in women with a previous negative screening, that is, screening failure, during the first two screening rounds (1996-2002) and in the following rounds (2003-2008) in the Emilia-Romagna region. All cases of invasive cancers registered in the regional cancer registry between 1996 and 2008 were classified according to screening history through a record linkage with the screening programme registry. The incidence significantly decreased from 11.6/100 000 to 8.7/100 000; this decrease is due to a reduction in squamous cell cancers (annual percentage change -6.2; confidence interval: -7.8, -4.6) and advanced cancers (annual percentage change -6.6; confidence interval: -8.8, -4.3), whereas adenocarcinomas and microinvasive cancers were essentially stable. The proportion of cancers among women not yet invited and among nonresponders decreased over the two periods, from 45.5 to 33.3%. In contrast, the proportion of women with a previous negative Pap test less than 5 years and 5 years or more before cancer incidence increased from 5.7 to 13.3% and from 0.3 to 5.5%, respectively. Although nonattendance of the screening programme remains the main barrier to cervical cancer control, the introduction of a more sensitive test, such as the human papillomavirus DNA test, could significantly reduce the burden of disease.

Purpose. To report the accuracy of colposcopically directed biopsy in an internet-based colposcopy quality assurance programme in northern Italy.Methods. A web application was made accessible on the website of the regional Administration. Fifty-nine colposcopists out of the registered 65 logged in, viewed a posted set of 50 digital colpophotographs, classified them for colposcopic impression and need for biopsy, and indicated the most appropriate site for biopsy with a left-button mouse click on the image.Results. Total biopsy failure rate, comprising both nonbiopsy and incorrect selection of biopsy site, was 0.20 in CIN1, 0.11 in CIN2, 0.09 in CIN3, and 0.02 in carcinoma. Errors in the selection of biopsy site were stable between 0.08 and 0.09 in the three grades of CIN while decreasing to 0.01 in carcinoma. In multivariate analysis, the risk of incorrect selection of biopsy site was 1.97 for CIN2, 2.52 for CIN3, and 0.29 for carcinoma versus CIN1.Conclusions. Although total biopsy failure rate decreased regularly with increasing severity of histological diagnosis, the rate of incorrect selection of biopsy site was stable up to CIN3. In multivariate analysis, CIN2 and CIN3 had an independently increased risk of incorrect selection of biopsy site.

Background The objective of this study was to evaluate if mammography screening attendance is associated with a reduction in late-stage breast cancer incidence. Methods The cohort included over 400,000 Italian women who were first invited to participate in regional screening programmes during the 1990s and were followed for breast cancer incidence for 13 years. We obtained individual data on their exposure to screening and correlated this with total and stage-specific breast cancer incidence. Socio-economic status and pre-screening incidence data were used to assess the presence of self-selection bias. Results Overall, screening attendance was associated with a 10% excess risk of in situ and invasive breast cancer (IRR = 1.10; 95% confidence interval (CI): 1.06–1.14), which dropped to 5% for invasive cancers only (IRR = 1.05; 95% CI: 1.01–1.09). There were significant reductions among attenders for specific cancer stages; we observed a 39% reduction for T2 or larger (IRR = 0.61; 95% CI: 0.57–0.66), 19% for node positives (IRR = 0.81; 95% CI: 0.76–0.86) and 28% for stage II and higher (IRR = 0.72; 95% CI: 0.68–0.76). Our data suggest that the presence of self-selection bias is limited and, overall, invited women experienced a 17% reduction of advanced cancers compared with pre-screening rates. Conclusions Comparing attenders' and non-attenders' stage-specific breast cancer incidence, we have estimated that screening attendance is associated with a reduction of nearly 30% for stages II+.

Objective An innovative web-based colposcopy quality assurance programme was implemented in population-based cervical screening services in three north-eastern Italian administrative regions with different colposcopists’ training background. In this study, the levels of intra- and interregional intercolposcopist diagnostic agreement were evaluated. Study design Of the 158 registered colposcopists, 125 accessed the website of the programme, logged-in, viewed a posted set of 50 digital colpophotographs selected by an expert steering committee, and classified them for the colposcopic impression, the visibility of the squamocolumnar junction, and the need for biopsy. Anonymous data were downloaded and analysed using the crude, or observed, proportion of agreement and the kappa coefficient. Results There were 113 eligible colposcopists. Overall, crude agreement on the colposcopic impression, the visibility of the squamocolumnar junction, and the need for biopsy was 0.72, 0.72, and 0.87, with kappa values of 0.60, 0.36, and 0.69, respectively. The homologous kappa values were 0.61, 0.41, and 0.69 in one region, 0.57, 0.36, and 0.69 in another, and 0.66, 0.38, and 0.74 in the third. Total intra- and interregional agreement were nearly identical, with kappa values of 0.59 and 0.60 for the colposcopic impression, 0.38 and 0.35 for the visibility of the squamocolumnar junction, and 0.69 and 0.69 for the need for biopsy. The width of 95% confidence intervals around the above kappa values was ≤0.01. Conclusions The levels of agreement varied between moderate and substantial both within and between regions. Regional differences in training background had minor effects. The interpretation of colposcopy is potentially well-reproducible.

The aim of this study was to determine whether the excess risk of axillary lymph node metastases (N+) differs between interval breast cancers arising shortly after a negative mammography and those presenting later. In a registry-based series of pT1a–pT3 breast carcinoma patients aged 50–74years from the Italian screening programmes, the odds ratio (OR) for interval cancers ( n =791) versus the screen-detected (SD) cancers ( n =1211) having N+ was modelled using forward stepwise logistic regression analysis. The interscreening interval was divided into 1–12, 13–18, and 19–24months. The prevalence of N+ was 28% among SD cancers. With a prevalence of 38%, 42%, and 44%, the adjusted (demographics and N staging technique) OR of N+ for cancers diagnosed between 1–12, 13–18, and 19–24months of interval was 1.41 (95% confidence interval 1.06–1.87), 1.74 (1.31–2.31), and 1.91 (1.43–2.54), respectively. Histologic type, tumour grade, and tumour size were entered in turn into the model. Histologic type had modest effects. With adjustment for tumour grade, the ORs decreased to 1.23 (0.92–1.65), 1.58 (1.18–2.12), and 1.73 (1.29–2.32). Adjusting for tumour size decreased the ORs to 0.95 (0.70–1.29), 1.34 (0.99–1.81), and 1.37 (1.01–1.85). The strength of confounding by tumour size suggested that the excess risk of N+ for first-year interval cancers reflected only their higher chronological age, whereas the increased aggressiveness of second-year interval cancers was partly accounted for by intrinsic biological attributes.

Objectives To evaluate the frequency and correlates of non-adherence to follow-up among patients conservatively treated for CIN2-3. Study design Study population comprised 1560 patients aged 25–64 years from a screening programme in northern Italy. The regional standard protocol was used as a reference. Multinomial logistic regression analysis was used to estimate the odds ratio probability of a patient being lost to follow-up (no check-ups within 27 months of treatment) or incompletely followed-up (1–3 negative check-ups) versus having 4 negative check-ups. Results Three hundred twenty-six patients (21%) were lost to follow-up, 678 (43%) were incompletely followed-up, 352 (23%) presented for 4 negative check-ups and 204 (13%) were diagnosed with persistent disease. The probability of no or incomplete follow-up was greater for patients who lived in the urban district, who were treated in private settings (versus screening centres), who exhibited a visibile squamocolumnar junction on pre-treatment colposcopy, who were treated with cold knife excision and local destructive therapy (versus loop diathermy excision), and whose surgical specimens had positive excision margins. Conclusions Adherence to the reference protocol was poor. Factors involved in follow-up failures require greater clinical attention.

OBJECTIVE To report the results of an Internet-based colposcopy quality assurance program from a population-based cervical screening service in a large region of northern Italy. METHODS In 2010 to 2011, a Web application was made accessible on the Web site of the regional administration. Fifty-nine colposcopists of the registered 65 participated. They logged-in, viewed a posted set of 50 high-quality digital colpophotographs selected by an expert committee, and rated them for colposcopic impression using a 4-tier classification (Negative; abnormal, grade 1 [G1]; abnormal, grade 2 [G2]; suspected invasive cancer [Cancer]) derived from the International Federation for Cervical Pathology and Colposcopy 2002 classification. kappa (κ) coefficients for intercolposcopist agreement and colposcopist-committee agreement were calculated. RESULTS Colposcopist-committee agreement was greater than intercolposcopist agreement (overall κ 0.69 vs 0.60, p

Background Colposcopy, the key step in the management of women with abnormal Pap smear results, is a visual technique prone to observer variation, which implies the need for prolonged apprenticeship, continuous training, and quality assurance (QA) measures. Colposcopy QA programmes vary in level of responsibility of organizing subjects, geographic coverage, scope, model, and type of actions. The programmes addressing the clinical standards of colposcopy (quality of examination and appropriateness of clinical decisions) are more limited in space and less sustainable over time than those focused on the provision of the service (resources, accessibility, etc.). This article reports on the protocol of a QA programme targeting the clinical quality of colposcopy in a population-based cervical screening service in an administrative region of northern Italy. Methods/design After a situation analysis of local colposcopy audit practices and previous QA initiatives, a permanent web-based QA programme was developed. The design places more emphasis on providing education and feedback to participants than on testing them. The technical core is a log-in web application accessible on the website of the regional Administration. The primary objectives are to provide (1) a practical opportunity for retraining of screening colposcopists, and (2) a platform for them to interact with colposcopists from other settings and regions through exchange and discussion of digital colposcopic images. The retraining function is based on repeated QA sessions in which the registered colposcopists log-in, classify a posted set of colpophotographs, and receive on line a set of personal feedback data. Each session ends with a plenary seminar featuring the presentation of overall results and an interactive review of the test set of colpophotographs. This is meant to be a forum for an open exchange of views that may lead to more knowledge and more diagnostic homogeneity. The protocol includes the criteria for selection of colpophotographs and the rationale for colposcopic gold standards. Discussion This programme is an ongoing initiative open to further developments, in particular in the area of basic training. It uses the infrastructure of the internet to give a novel solution to technical problems affecting colposcopy QA in population-based screening services.

We present the main results of the 2010 survey of the Italian screening programmes for colorectal cancer carried out by the National centre for screening monitoring (Osservatorio nazionale screening, ONS) on behalf of the Ministry of health. By the end of 2010, 105 programmes were active, 9 of which had been activated during the year, and 65% of Italians aged 50-69 years were residing in areas covered by organised screening programmes (theoretical extension). Twelve regions had their whole population covered. In the South of Italy and Islands, 5 new programmes were activated in 2010, with a theoretical extension of 29%. The majority of programmes employed the faecal occult blood test (FIT), while some adopted flexible sigmoidoscopy (FS) once in a lifetime and FIT for non-responders to FS. Overall, about 3,404,000 subjects were invited to undergo FIT, 47.2% of those to be invited within the year. The adjusted attendance rate was 48% and approximately 1,568,796 subjects were screened. Large differences in the attendance rate were observed among regions: 10% of programmes reported values lower than 24%. Positivity rate of FIT programmes was 5.5% at first screening (range: 1.6-11.3%) and 4.3% at repeat screening (range: 3.2-6.7%). The average attendance rate to total colonoscopy (TC) was 81.4% and in one region it was lower than 70%. Completion rate for total colonoscopy (TC) was 88.7%. Among the 740,281 subjects attending screening for the first time, the detection rate (DR) per 1,000 screened subjects was 2.4 for invasive cancer and 10.3 for advanced adenomas (AA - adenomas with a diameter ≥1 cm, with villous/tubulo-villous type or with high-grade dysplasia). As expected, the corresponding figures in the 843,204 subjects at repeat screening were lower (1.2‰ and 7.6‰ for invasive cancer and AA, respectively). The DR of cancer and adenomas increased with age and was higher among males. Many programmes reported some difficulties in guaranteeing TC in the appropriate time frame to FIT+ subjects: in 16% of cases the waiting time was longer than two months. Nine programmes employed FS as the screening test: 98% of the target population (about 60,000 subjects) were invited, and 13,629 subjects were screened, with an attendance rate of 24%. Overall, 87% of FS were classified as complete. TC referral rate was 9.5% and the DR per 1,000 screened subjects was 2.8 and 40.6 for invasive cancer and AA, respectively.

Background: In some Italian areas, colonoscopic surveillance of first-degree relatives (FDRs) of colorectal cancer (CRC) patients is provided as a part of local population-based faecal occult blood test (FOBT) screening programmes. The objective of the present study was to assess the feasibility and early results of this surveillance model. Methods: Data from district screening centres were used to evaluate the process of identification and selection of eligible FDRs (residence in the Emilia-Romagna Region, age 40–75 years, no recent colonoscopy) of screen-detected CRC patients and the detected prevalence of disease. The probability for an FDR to undergo colonoscopy and to be diagnosed with CRC and advanced adenoma was estimated using the Kaplan–Meier method. The sex- and age-standardised ratio of detected prevalence to that expected based on results from a colonoscopy screening study of the Italian general population was estimated. Results: Between 2005 and 2011, 9319 FDRs of 2437 screen-detected CRC patients (3.8 per patient) were identified and contacted. Their likelihood of being eligible for, and accepting, colonoscopy was 0.11 (95% confidence interval: 0.11–0.12). Among the 926 subjects undergoing colonoscopy, the prevalence of previous negative screening FOBT was 63%. Eleven CRCs (1.2%) and 100 advanced adenomas (10.8%) were detected. The standardised ratio of detected prevalence to that expected was 0.91 (95% confidence interval: 0.19–2.66) for CRC and 1.48 (1.04–2.05) for advanced adenoma. Conclusions: The procedure of selection of FDRs was extremely ineffective. Due to previous negative screening tests, the prevalence of disease was less than expected. A population-based FOBT screening programme is a highly unsuitable setting for the provision of surveillance to FDRs of CRC patients.

We present the main results of the sixth survey of the Italian screening programmes for colorectal cancer carried out by the National centre for screening monitoring (Osservatorio nazionale screening, ONS) on behalf of the Ministry of health. By the end of 2009, 98 programmes were active, of which 13 had been activated during the year, and 59% of Italians aged 50-69 years were residing in areas covered by organised screening programmes (theoretical extension). Eleven regions had their whole population covered. In the South of Italy and Islands, 4 new programmes were activated in 2009, with a theoretical extension of 22%. The majority of programmes employ the faecal occult blood test (FOBT), while some have adopted flexible sigmoidoscopy (FS) once in a lifetime and FOBT for non-responders to FS. Overall, about 2,935,000 subjects were invited to undergo FOBT, 40% of those to be invited within the year. The adjusted attendance rate was 50% and approximately 1,426,000 subjects were screened. Large differences in the attendance rate were observed among regions, with 10% of programmes reporting values lower than 29%. Positivity rate of FOBT programmes was 5.6% at first screening (range: 2.5-12.4%) and 4.2% at repeat screening (range: 2.5-7.3%). The average attendance rate to total colonoscopy (TC) was 82.5%and in one region it was lower than 70%. Completion rate for total colonoscopy (TC) was 91.2%. Among the 631,460 subjects attending screening for the first time, the detection rate (DR) per 1,000 screened subjects was 2.4 for invasive cancer and 11.6 for advanced adenomas (AA - adenomas with a diameter ≥ 1 cm, with villous/tubulo-villous type or with high-grade dysplasia). As expected, the corresponding figures in the 824,562 subjects at repeat screening were lower (1.3‰ and 7.6‰ for invasive cancer and AA, respectively). The DR of cancer and adenomas increased with age and was higher among males. Many programmes reported some difficulties in guaranteeing TC in the appropriate time frame to FOBT+ subjects: in 16% of cases the waiting time was longer than two months. Nine programmes employed FS as the screening test: 65% of the target population (about 60,000 subjects) were invited and 9 511 subjects were screened, with an attendance rate of 24.3%. Overall, 81% of FS were classified as complete. Overall TC referral rate was 11% and the DR per 1,000 screened subjects was 2.6 and 43.7 for invasive cancer and AA, respectively.

Background Although poorly described in the literature, the practice of early (short-interval) rescreen after a negative screening mammogram is controversial due to its financial and psychological burden and because it is of no proven benefit. Methods The present study targeted an Italian 2-yearly screening programme (Emilia-Romagna Region, 1997-2002). An electronic dataset of 647,876 eligible negative mammography records from 376,257 women aged 50-69 years was record-linked with the regional breast cancer registry. The statistical analysis addressed the following research questions: (1) the prevalence of recommendation for early ( Results RES was used in eight out of 13 screening centres, where it was found in 4171 out of 313,320 negative reports (average rate 1.33%; range 0.05%-4.33%). Reports with RES were more likely for women aged 50-59 years versus older women (odds ratio (OR) 1.33; 95% CI 1.25-1.42), for the first versus subsequent screening rounds (OR 1.91; 95% CI 1.79-2.04) and with a centre-specific recall rate below the average of 6.2% (OR 1.41; 95% CI 1.32-1.50). RES predicted a 3.51-fold (95% CI 0.94-9.29) greater proportional incidence of first-year interval cancers, a 1.90-fold (95% CI 1.62-2.22) greater recall rate at the next screen, a 1.72-fold (95% CI 1.01-2.74) greater detection rate of cancer at the next screen and a non-significantly decreased risk of late disease stage (OR 0.59; 95% CI 0.23-1.53). Conclusion The prevalence of RES was in line with the maximum standard level established by the Italian national guidelines. RES identified a subset of women with greater incidence of interval cancers and greater prevalence of cancers detected at the next screen.

We present the main results from the fourth survey of the Italian screening programmes for colorectal cancer carried out by the National Centre for Screening Monitoring (Osservatorio Nazionale Screeninng, ONS) on behalf of the Ministry of Health. During 2007, fi ve new programmes were activated, but three other programmes were stopped, including the regional programme of Basilicata, and by the end of the year 46.6% of Italians aged 50-69 years were residing in areas covered by organised screening programmes (theoretical extension). Seven regions had their whole population covered. In the South of Italy and Islands only one new programme was activated in 2007, while two others were stopped, with a decline of theoretical extension from 10% to 7%. The majority of programmes employ the faecal occult blood test (FOBT), while some have adopted flexible sigmoidoscopy (FS) once in a lifetime, or a combination of both. Overall, about 2,600,000 subjects were invited to undergo FOBT, 79.1% of those to be invited within the year. The adjusted attendance rate was 46.3% and approximately 1,131,900 subjects were screened. Large differences in the attendance rate were observed among Regions, with 10% of programmes reporting values lower than 33%. Positivity rate of FOBT programmes was 5.6% at first and 4% at repeat screening. The average attendance rate for total colonoscopy (TC) was 78.7% and in two Regions it was lower than 60%. Completion rate of TC was 91.6%. Among the 914,029 subjects attending screening for the first time, the detection rate (DR) per 1,000 screened subjects was 2.7 for invasive cancer and 12.2 for advanced adenomas (AA, adenomas with a diameter/=1 cm, with villous/tubulovillous type or with high-grade dysplasia). As expected, the corresponding figures at repeat screening were lower. The DR of cancer and adenomas increased with age and was higher among males; 25% of screen-detected cancers were in TNM stage III+. Many programmes reported some difficulties in guaranteeing TC in the appropriate time frame to SOF+ subjects: in 23.9% of cases the waiting time was longer than two months. Seven programmes employed FS as the screening test: 66.5% of the target population (about 50,000 subjects) were invited and 8,678 subjects were screened, with an attendance rate of 27.7%. Overall, 88% of FS were classified as complete. Overall TC referral rate was 11.1% and the DR per 1,000 screened subjects was 4.4 and 58.4 for invasive cancer and AA, respectively.

We present the main results of the third survey of the Italian screening programmes for colorectal cancer carried out by the ONS (Osservatorio Nazionale Screening, National Centre for Screening Monitoring) on behalf of the Ministry of Health. During 2006, many new programmes were activated and by the end of the year, 44% of Italians aged 50-69 years were residing in areas covered by organised screening programmes (theoretical extension). Five regions had their entire population covered. In the South of Italy and Islands only one new programme was activated in 2006, with a 10% theoretical extension. The majority of programmes employ the faecal occult blood test (FOBT), while some have adopted the flexible sigmoidoscopy (PS) once in a lifetime, or a combination of both. Overall, about 2,107,000 subjects were invited to undergo FOBT, 70.3% of those to be invited within the year. The adjusted attendance rate was 44.6% and approximately 907,000 subjects were screened. Major differences in the attendance rate were observed among regions, with 10% of programmes reporting values lower than 26%. Positivity rate of FOBT programmes was 5.3% at first and 3.9% at repeat screening: it increased with age and was higher among males than females in all age groups. The average attendance rate to total colonoscopy (TC) was 81% (10th-9Oth percentiles: 64%, 93%). Completion rate of TC was 89%, with higher rates among males. At first screening, the detection rate (DR) per 1,000 screened subjects was 3.1 and 14.6 for invasive cancer and advanced adenomas (AA--adenomas with a diameteror =1 cm, with villous/tubulo-villous type or with high-grade dysplasia), respectively; the corresponding figures at repeat screening were 1.3 per thousand for cancer and 7.7 per thousand for AA. The DR of cancer and adenomas increased with age and was higher among males; 25% of screen-detected cancers were in TNM stage III+. The positive predictive value (PPV) was 6.8% for cancer and 32.1% for AA at first screening, and 4.0% for cancer and 23.4% for AA at repeat screening. Given the high PPVof a positive FOBT, obtaining a high attendance at TC is therefore crucial. Seven programmes employed PS as the screening test: 51.4% of the target population (about 50,000 subjects) were invited and 7,589 subjects were screened, with an attendance rate of 29.2%. Overall, 88% of FS were classified as complete. TC referral rates ranged between 6.1 and 17.8%, due to different referral criteria. Among subjects referred to colonoscopy, the prevalence of proximal AA and cancer ranged from 6 to 18.2%. The overall DR (subjects with at least one advanced lesion) ranged from 4.9 to 7.5%. In conclusion, during 2006, organised colorectal cancer screening programmes in Italy grew considerably, covering almost half of the eligible population at a national level. Many programmes were activated in the second part of the year, thus their results should be evaluated with caution. However, reported experiences showed good results in terms of attendance and DR, although some critical aspects need to be carefully addressed when planning and implementing screening activity.

GISMa analyses the interval cancer (IS) topic providing guidelines and reference standards in addition to CE recommendations. IC identification is based on Cancer Registries (CR), if existing, or on hospital discharge records, in alternative. The optimal measure of IC frequency (inversely correlated with sensitivity) is the IC proportional incidence (observed IC/carcinomas expected in absence of screening). Other formulas (IC/IC + screen detected cancers; IC rate per 1000 negative screens) look less reliable. IC stage at diagnosis (if available through CR) must be compared with screen detected cancer and cancer detected in non-attenders. Review of mammograms preceding the IC (coded as screening error, minimal signs, or occult) should be done mainly with a blind procedure (IC mixed with negative controls), as this procedure is more representative of the original scenario and more respectful of radiologist's rights.

Colorectal cancer screening programmes, which are supported by national and international recommendations, are gradually developing andspreading throughout Italy. The programmes strive to guarantee maximum equality, improve quality of life, and inform the target population about benefits and possible risks. These goals can only be achieved with adequate planning and training for the staff involved. Moreover, it is essential to regularly verify the quality of each step of the process, with a system that can constantly monitor the parameters used for the evaluation of quality and efficacy. The present document, created by the Italian Group for Colorectal Screening (GISCoR), proposes a unified method for collecting and reporting screening data using commonly agreed terminology, definitions and classifications, thus making it possible to compare data with standards and data from other programmes, and to plan suitable interventions. The indicators considered refer to the entire screening process, including organisational, logistic and performance indicators. The indicators are provided in the form of concise and easy-to-use data sheets. Every data sheet contains briefsections: definition of the indicator, goal, the data necessary to build it, the formula required to build it, possible problems of interpretation, acceptable and desirable standards.

12,987 invasive breast cancer cases were diagnosed in women aged 50-69 upto the year 2001 in nine Italian areas where a screening programme was active. Cases were followed up in 2005 for a total of 1921 breast cancer failures. The 10-year survival rates were 85.3% for the invited group against 75.6% for the non-invited. A time dependent analysis was performed using 5-year intervals. Crude hazard ratios for the invited group in comparison to the not invited group were 0.52 and 0.64 respectively in the (0-5) year and [5-10] year time windows. Hazard ratio adjusted for tumour characteristics was 0.96 in the [5-10] year time window, suggesting minimal or any length bias. Consistent with the results of randomised trials, these analyses of service screening data document a mortality reduction of 36% at 5-10 years after diagnosis.

We present the main results from the second survey of the Italian screening programmes for colorectal cancer carried out by the National Centre for Screening Monitoring on behalf of the Ministry of Health. During 2005, 52 programmes, adopting faecal occult blood testing (FOBT), sigmoidoscopy (FS), or a combination of both, were active in Italy. Overall, 827,473 subjects were invited to FOBT and 376,240 were screened; the adjusted attendance rate (47.1%) equals the best performances reported in the literature. Positivity rate of FOBT programmes was 5.8% at first and 4.1% at repeat screening: it increased with age and was higher among males than females in all age groups. The average attendance rate to colonoscopy (TC) was 82% (range: 56%-100%). Completion rate of TC was 91%, with higher rates among males. At first screening, the detection rate (DR) per 1000 screened subjects was 3.7 and 16.8 for invasive cancer and advanced adenomas (AA) (adenomas with a diameteror =1 cm, with villous/tubulo-villous type or with high-grade dysplasia) respectively; the corresponding figures at repeat screening were 1.1 for cancer and 4.9 for AA. The DR of cancer and adenomas increased with age and it was higher among males, 55% of screen-detected cancers were at TNM stage I. The positive predictive value (PPV) was 7.4% for cancer and 32.9% for AA at first screening, and 4.5% for cancer and 20.5% for AA at repeat screening. Given this high PPV of positive FOBT, to obtain a high attendance at TC is crucial. The six FS programmes invited almost half of their target population (about 40,000 subjects) and 5,821 subjects were screened, with an attendance rate of 29.1%. Overall 89.0% of FS were classified as complete. TC referral rates ranged between 7.7 and 13.8%, due to different referral criteria. Among subjects referred to colonoscopy the prevalence of proximal AA and cancer ranged from 5.4 to 11.1%. The overall DR (subjects with at least one advanced lesion) ranged from 3.5 to 7.0%. In conclusion, during 2005 the organised programmes for colorectal cancer screening in Italy increased considerably, covering about one third of the eligible population at a national level. Many programmes were activated in the second part of the year, thus their results have to be evaluated with caution. However, the reported experiences showed good results in terms of attendance and DR, although some critical aspects need to be carefully addressed when planning and implementing screening activity.

BACKGROUND The degree of applicability of the Bethesda System 2001 (TBS 2001) for cervicovaginal cytology to a public health setting is unknown, and extrapolations from available data are unwarranted. METHODS A “before/after” study design was used to evaluate the impact of TBS 2001 on an organized, population-based screening program in northern Italy. Between 2003–2004, 6 cytology laboratories converted from TBS 1991 to TBS 2001. A set of screening indicators based on TBS 2001 (85,012 patients) were compared with those based on TBS 1991 (199,833 patients) by means of their laboratory- and patient age-standardized ratio with a 95% confidence interval (CI). RESULTS The prevalence of cervical intraepithelial neoplasm (CIN)2-3/carcinoma was stable between the 2 populations. TBS 2001 had no effect on the unsatisfactory rate (1.99% vs. 2.03% for TBS 1991) nor on follow-up compliance rate (93.2% vs. 92.3%). The reporting rate of atypical squamous cells (ASC) decreased from 17.1 to 14.7 per 1000 (ratio, 0.86; 95% CI, 0.81–0.91), the total positivity rate from 31.1 to 29.0 per 1000 (ratio, 0.93; 95% CI, 0.90–0.97), and the ASC:SIL (squamous intraepithelial lesion) ratio from 1.38 to 1.16. Compared with the ASCUS (ASC of undetermined significance) reports of TBS 1991, the predictive value for CIN2-3/carcinoma decreased from 5.2 to 3.5% (ratio, 0.68; 95% CI, 0.48–0.93) among ASCUS reports, but increased from 5.1 to 17.2% (ratio, 3.41; 95% CI, 1.64–6.28) among ASC-cannot exclude high grade lesion (ASC-H) reports. ASC-H had a 5.01-fold (95% CI, 2.23–10.2) greater predictive value than ASCUS. CONCLUSIONS TBS 2001 is applicable to cervical screening in a public health setting. Cancer (Cancer Cytopathol) 2006;. © 2006 American Cancer Society.

In order to obtain the maximum benefit from breast cancer screening it is essential for every programme to reach high levels of sensitivity and specificity. This can only be achieved if skill and a comprehensive quality assurance system is applied to the entire process, involving each individual part of the programme. Monitoring of outcomes and continuous evaluation of the entire screening process are key operational objectives for a successful population screening programme. The aim of this document, born in the framework of the Italian Group for Mammography Screening (GISMa), is to propose a unique methodology for collecting and reporting screening data using commonly agreed terminology, definitions and classifications. The indicators considered are those referred to the entire screening process and its sequelae, such as organizational, logistic and performance indicators. The indicators are provided under form of a synthetic and easy to use card. Every card is structured in short sections: definition, aim of the indicator, the data necessary to build it, the summarizing formula, possible problems of interpretation, the acceptable and desirable standards (derived both from the experience of national and European breast cancer screening programmes).

Diagnostic reproducibility and accuracy in cytology and histology are major issues in Oncologic Screenings (cervix, breast and colorectal cancer). Slides standard set represents the most used method to compare diagnostic proficiency. Emilia-Romagna Region (Italy) realized a software to manage cytological and histological whole-slides digital images building a picture archive and communication system (PACS) among regional pathologists and realizing an e-learning platform (Docebo) for applicants: slides were “teaching objects” for a seminar educational software. Collected and cataloged cases in an on-line digital archive of slides, enact as database for a casistic atlas online.

Diagnostic reproducibility and accuracy in cytology and histology are major issues in oncologic screening programs (cervix, breast and colorectal cancer). Slides standard set represents the most used method to compare diagnostic proficiency. Emilia-Romagna Region (Italy) realized a software to manage cytological and histological whole-slides digital images building, a picture case storage and communication system (PACS) among pathologists in Emilia-Romagna Region and realizing an e-learning platform (Docebo) for applicants: slides were “a teaching system” for a retraining program. Collected and catalogued cases in an on-line digital archive of slides, enact as database for a casistic atlas online.