The burden of breast cancer in Italy: mastectomies and quadrantectomies performed between 2001 and 2008 based on nationwide hospital discharge records

  • Prisco Piscitelli1,

    Affiliated with

    • Maddalena Barba2,

      Affiliated with

      • Massimo Crespi3,

        Affiliated with

        • Massimo Di Maio4,

          Affiliated with

          • Antonio Santoriello5,

            Affiliated with

            • Massiliamo D’Aiuto6,

              Affiliated with

              • Alfredo Fucito6, 7,

                Affiliated with

                • Arturo Losco8,

                  Affiliated with

                  • Francesca Pentimalli9,

                    Affiliated with

                    • Pasquale Maranta7, 10,

                      Affiliated with

                      • Giovanna Chitano11,

                        Affiliated with

                        • Alberto Argentiero11,

                          Affiliated with

                          • Cosimo Neglia11,

                            Affiliated with

                            • Alessandro Distante11,

                              Affiliated with

                              • Gian luca Di Tanna12,

                                Affiliated with

                                • Maria Luisa Brandi1,

                                  Affiliated with

                                  • Alfredo Mazza7,

                                    Affiliated with

                                    • Ignazio R Marino13 and

                                      Affiliated with

                                      • Antonio Giordano7, 9, 10, 14Email author

                                        Affiliated with

                                        Journal of Experimental & Clinical Cancer Research201231:96

                                        DOI: 10.1186/1756-9966-31-96

                                        Received: 18 May 2012

                                        Accepted: 18 June 2012

                                        Published: 20 November 2012

                                        Abstract

                                        Background

                                        Where population coverage is limited, the exclusive use of Cancer Registries might limit ascertainment of incident cancer cases. We explored the potentials of Nationwide hospital discharge records (NHDRs) to capture incident breast cancer cases in Italy.

                                        Methods

                                        We analyzed NHDRs for mastectomies and quadrantectomies performed between 2001 and 2008. The average annual percentage change (AAPC) and related 95% Confidence Interval (CI) in the actual number of mastectomies and quadrantectomies performed during the study period were computed for the full sample and for subgroups defined by age, surgical procedure, macro-area and singular Region. Re-admissions of the same patients were separately presented.

                                        Results

                                        The overall number of mastectomies decreased, with an AAPC of −2.1% (−2.3 -1.8). This result was largely driven by the values observed for women in the 45 to 64 and 65 to 74 age subgroups (−3.0%, -3.4 -3.6 and −3.3%, -3.8 -2.8, respectively). We observed no significant reduction in mastectomies for women in the remaining age groups. Quadrantectomies showed an overall +4.7 AAPC (95%CI:4.5–4.9), with no substantial differences by age. Analyses by geographical area showed a remarkable decrease in mastectomies, with inter-regional discrepancies possibly depending upon variability in mammography screening coverage and adherence. Quadrantectomies significantly increased, with Southern Regions presenting the highest average rates. Data on repeat admissions within a year revealed a total number of 46,610 major breast surgeries between 2001 and 2008, with an overall +3.2% AAPC (95%CI:2.8-3.6).

                                        Conclusions

                                        In Italy, NHDRs might represent a valuable supplemental data source to integrate Cancer Registries in cancer surveillance.

                                        Keywords

                                        Hospital discharge records Breast cancer Mastectomies Quadrantectomies Cancer surveillance

                                        Background

                                        Cancer incidence data are a cornerstone of epidemiology research, health monitoring and resource allocation for interventions aimed at cancer prevention and control. Cancer Registries (CRs) contribute to cancer surveillance at local level, throughout the process of systematic collection of data about the occurrence and characteristics of reportable neoplasms[1]. In United States, the National cancer statistics are built on data from a network of CRs called the Surveillance, Epidemiology and End Results Program (SEER). The SEER has now expanded its coverage to 26% of the total population of the United States, accounting for 65.4 million people. Registries included in the SEER share requirements in data reporting and verification procedures throughout a quality improvement process restructured in year 2000. However, the exclusive use of CRs poses limits to the nationwide ascertainment of incident cancer cases, with major concerns arising from the percentage of US population still uncovered[2].

                                        Various secondary databases have been proposed as potential tools to enhance the detection of incident cases and related treatments for a number of diseases, including cancer[36]. The accuracy of secondary data sources in capturing cases has been explored with results varying upon the source selected and gold standard used[69]. In the study from Penberthy et al., the Virginia Cancer Registry (CR) and a statewide hospital discharge file (HDF) were both tested for accuracy in correctly identifying a cancer and its site of origin. Data from inpatient medical records were used as the gold standard. Based on the conclusions stated, nor the CR neither the HDF was sufficient independently to allow the complete capture of incident cancer cases. However, HDF accuracy in capturing incident cancer cases was high, with the overall positive predictive value being 94% and site specific values ranging from 86% (cervix) to 98% (breast)[9]. In Italy, the government supports cancer surveillance throughout a network of population-based local CRs included in the Italian Association of Cancer Registries (AIRTUM). Currently, the AIRTUM covers 33.8% of the Italian population, namely 19 million people out of 61 million inhabitants. A notable disproportion in CRs coverage exists among Northern, Central and Southern areas of Italy (i.e., 50.2%, 25.5% and 17.9%, respectively)[10].

                                        We have previously underlined the need to integrate data from the Italian CRs with additional sources and identified the National Hospital Discharge Records (NHDRs) as a potential tool[11].

                                        In this study we aimed to evaluate the burden of breast cancer in Italian women by analyzing data from the NHDRs through a non-model-based methodology with a specific focus on major surgical procedures. Compared to our previous work, data have been updated to reflect a larger time window (2001–2008 vs. 2000–2005) and methods refined to overcome some of the limitations from our previous study.

                                        Materials and methods

                                        Data source

                                        We used the NHDR database which includes records from all the Italian public and private hospitals. Data were made available by the Italian Ministry of Health relatively to the time frame between 2001 and 2008. These data were subject to a systematic quality assessment performed at a Regional and central level. The matching with the National Institute for Statistics (ISTAT) by social security code showed a percentage of correct linkage increasing from 95.6% in 2001 (50,921 records matched out of 53,226) to 99.8% in 2008 (58,367 records matched out of 58,492)[12, 13]. The years 1999 and 2000 were excluded due to incomplete data.

                                        Breast cancer cases were identified on the basis of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)[14, 15]. We considered patients diagnosed with invasive breast cancer (i.e., malignant neoplasm of breast, ICD-9CM codes: 174.0-174.9 and 175.0-175.9). Data related to patients with in situ breast carcinoma (ICD-9-CM major diagnosis 233) were also included.

                                        Population

                                        Eligible women were patients diagnosed with incident, histologically-confirmed breast cancer who underwent major breast surgical procedures between 2001 and 2008, as identified based on the following codes from the ICD-9-CM: 85.41-48 (mastectomies), 85.22 (quadrantectomies), 85.23 (subtotal mastectomies)[14, 15]. In data analysis, mastectomies and subtotal mastectomies (ICD-9-CM codes: 85.41-48 and 85.23, respectively) were ascribed to the same category of major breast surgery (i.e., mastectomies). Excision biopsies and tumorectomies (ICD9-CM code 85.21) were not included. Thus, patients with benign lesions were not considered in our analysis. In order to minimize the overlap between prevalent and incident cases, repeated admissions in any calendar year and across different years for the entire time window considered were discounted and reported separately. We included records pertinent to ordinary hospitalization as well as day hospital regimens.

                                        Statistical analyses

                                        Data were analyzed using STATA/SE version 11 for Windows (StataCorp LP, College Station, TX, USA) and Microsoft Office Excel 2007 (Microsoft Corp, Seattle, WA, USA). The average annual percentage change (AAPC) and related 95% Confidence Interval (CI) in the actual number of mastectomies and quadrantectomies performed during the study period were computed using a Poisson regression model. To describe time trends, we carried out joinpoint regression analysis.

                                        Analyses were performed for the full sample as well as for subgroups defined by type of surgical procedure (mastectomies and quadrantectomies), age (25–39, 40–44, 45–64, 65–74 and ≥75 years old), and geographical area [i.e., Region and macro-areas (Northern, Central and Southern Italy)]. Results by geographical area were presented in a frame including the indicators of extension and adherence to the national breast cancer screening programs[16].

                                        Results

                                        Mastectomies and quadrantectomies performed in Italy between 2001 and 2008 are reported in Table1 and Table2, respectively. The overall number of mastectomies decreased from 15,754 (year 2001) to 14,197 (year 2008), with an AAPC of −2.1% (−2.3 -1.8). This result is largely driven by the values observed for women in the 45 to 64 and 65 to 74 age subgroups (−3.0%, -3.4 -3.6 and −3.3%, -3.8 -2.8, respectively) and, at a lesser extent, in women aged 75 years and older (−1.2%, -1.7 -0.7). We observed no significant reduction in mastectomies for women aged 25–39 years (+0.3%; -0.8–1.3) and 40-44 years (+1.5%; 0.5–2.5).
                                        Table 1

                                        Mastectomies 1 performed in Italy between 2001 and 2008

                                        Age-group

                                        2001

                                        2002

                                        2003

                                        2004

                                        2005

                                        2006

                                        2007

                                        2008

                                        Subtotals

                                        AAPC (95%CI)2

                                        25 - 39

                                        854

                                        819

                                        849

                                        851

                                        800

                                        786

                                        812

                                        921

                                        6,692

                                         
                                                  

                                        +0.3 (−0.8; 1.3)

                                        40 - 44

                                        907

                                        875

                                        962

                                        957

                                        927

                                        1008

                                        955

                                        999

                                        7,590

                                         
                                                  

                                        + 1.5 (0.5; 2.5)

                                        45 - 64

                                        5849

                                        5805

                                        5353

                                        5251

                                        4950

                                        4811

                                        4783

                                        4974

                                        41,776

                                         
                                                  

                                        −3.0 (−3.4; -3.6)

                                        65 - 74

                                        3870

                                        3802

                                        3646

                                        3596

                                        3310

                                        3193

                                        3129

                                        3178

                                        27,724

                                         
                                                  

                                        −3.3 (−3.8; -2.8)

                                        75 - 100

                                        4274

                                        4464

                                        4516

                                        4265

                                        4126

                                        4157

                                        4053

                                        4125

                                        33,980

                                         
                                                  

                                        −1.2 (−1.7; -0.7)

                                        Subtotals

                                        15,754

                                        15,765

                                        15,326

                                        14,920

                                        14,113

                                        13,955

                                        13,732

                                        14,197

                                        117,762

                                         
                                                  

                                        −2.1 (−2.3; -1.8)

                                        Data are reported by age.

                                        1Reported data are absolute numbers unless otherwise specified.

                                        2 AAPC (95%CI): Average Annual Percentage Change and 95% Confidence Interval.

                                        Table 2

                                        Quadrantectomies 1 performed in Italy between 2001 and 2008

                                        Age group

                                        2001

                                        2002

                                        2003

                                        2004

                                        2005

                                        2006

                                        2007

                                        2008

                                        Subtotals

                                        AAPC (95%CI)2

                                        25 - 39

                                        1337

                                        1375

                                        1474

                                        1691

                                        1722

                                        1730

                                        1706

                                        1650

                                        12,685

                                         
                                                  

                                        +3.6 (2.8; 4.3)

                                        40 - 44

                                        1664

                                        1839

                                        1886

                                        2216

                                        2296

                                        2473

                                        2510

                                        2610

                                        17,494

                                         
                                                  

                                        +6.7 (6.0; 7.4)

                                        45 - 64

                                        11573

                                        12032

                                        12334

                                        12952

                                        13294

                                        13614

                                        13908

                                        14820

                                        104,527

                                         
                                                  

                                        +3.4 (3.1; 3.6)

                                        65 - 74

                                        5021

                                        5331

                                        5510

                                        5913

                                        6048

                                        6550

                                        6732

                                        7154

                                        48,259

                                         
                                                  

                                        +5.1 (4.7; 5.5)

                                        75 - 100

                                        2545

                                        2912

                                        3139

                                        3336

                                        3624

                                        3936

                                        4103

                                        4566

                                        28,161

                                         
                                                  

                                        + 8.1 (7.5; 8.6)

                                        Subtotals

                                        22,140

                                        23,489

                                        24,343

                                        26,108

                                        26,984

                                        28,303

                                        28,959

                                        30,800

                                        211,126

                                         
                                                  

                                        +4.7 (4.5; 4.9)

                                        1 Reported data are absolute numbers unless otherwise specified.

                                        2 AAPC: Average Annual Percentage Change and 95% Confidence Interval.

                                        Data are reported by age groups.

                                        As shown in Table2, there was a +4.7% increase in quadrantectomies (95%CI 4.5-4.9) with the actual numbers rising from 22,140 (year 2001) to 30,800 (year 2008). Temporal trends of mastectomies and quadrantectomies between 2001 and 2008 are shown in Figure1. Mastectomies were always performed during ordinary hospitalizations, while quadrantectomies performed in a day hospital regimen progressively increased over the 8-year period (+74.2%), accounting for more than 17.5% of the overall breast surgery procedures in 2008 (data available upon request).
                                        http://static-content.springer.com/image/art%3A10.1186%2F1756-9966-31-96/MediaObjects/13046_2012_Article_631_Fig1_HTML.jpg
                                        Figure 1

                                        Temporal Trends in Mastectomies and Quadrantectomies performed in Italy between 2001 and 2008. Joinpoint analysis for mastectomies and quadrantectomies (absolute numbers) performed in Italy between 2001–8.

                                        In Table3, we present data by singular Italian Region and macro-areas (i.e., Northern, Central and Southern Italy). Remarkable decreases in the number of mastectomies performed in Italy between 2001 and 2008 were observed in Northern and Central Italy (−2.7%, -3.0 -2.4 and −2.9%, -3.4 -2.4, respectively) but not in Southern Italy (0.3%, -0.3–0.8), where statistically significant reductions were reported for Campania, Calabria and Sicily only.
                                        Table 3

                                        Mastectomies 1 (Ms) and Quadrantectomies 1 (Qs) performed in Italy between 2001 and 2008

                                        Region

                                        Mammographic screening coverage (%)*

                                        Adherence to mammographic screening (%)§

                                        2001

                                        2002

                                        2003

                                        2004

                                        2005

                                        2006

                                        2007

                                        2008

                                        AAPC (95%CI)2

                                        Piemonte Ms

                                        68.6%

                                        65.6%

                                        1222

                                        1177

                                        1138

                                        1146

                                        1112

                                        1140

                                        1053

                                        1032

                                        −2.1 (−2.9; -1.2)

                                        Qs

                                          

                                        1686

                                        1636

                                        1714

                                        1856

                                        1881

                                        2024

                                        2160

                                        2268

                                        +4.9 (4.2; 5.6)

                                        Valle d'Aosta Ms

                                        92,3%

                                        79,0%

                                        35

                                        26

                                        26

                                        28

                                        16

                                        30

                                        24

                                        23

                                        −4.2 (−9.8; +1.6)

                                        Qs

                                          

                                        50

                                        62

                                        64

                                        73

                                        76

                                        77

                                        64

                                        72

                                        +3.7 (0.0; 7.6)

                                        Lombardia Ms

                                        92,8%

                                        64,5%

                                        3690

                                        3511

                                        3295

                                        3199

                                        2985

                                        2844

                                        2845

                                        3063

                                        −3.4 (−3.9; -2.9)

                                        Qs

                                          

                                        6257

                                        6542

                                        6428

                                        6667

                                        6915

                                        7048

                                        7245

                                        7322

                                        +2.3 (1.9; 2.7)

                                        P. A. di Bolzano Ms

                                        n.a.

                                        52,5%

                                        122

                                        113

                                        107

                                        110

                                        93

                                        94

                                        95

                                        89

                                        −4.3 (−7.1; -1.4)

                                        Qs

                                          

                                        97

                                        69

                                        70

                                        87

                                        78

                                        142

                                        144

                                        175

                                        +13.5 (10.2; 17.0)

                                        P. A. di Trento Ms

                                        80,9%

                                        79,2%

                                        115

                                        127

                                        129

                                        128

                                        146

                                        135

                                        119

                                        134

                                        +1.2 (−1.5; +3.9)

                                        Qs

                                          

                                        136

                                        175

                                        166

                                        216

                                        208

                                        236

                                        209

                                        251

                                        +9.4 (7.5; 11.4)

                                        Veneto Ms

                                        76,8%

                                        77,1%

                                        1512

                                        1475

                                        1457

                                        1267

                                        1200

                                        1312

                                        1305

                                        1406

                                        −1.8 (−2.6; -1.0)

                                        Qs

                                          

                                        1510

                                        1612

                                        1588

                                        1674

                                        1595

                                        1893

                                        2075

                                        2296

                                        +14.7 (13.8; 15.6)

                                        Friuli Venezia Giulia Ms

                                        98,7%

                                        62,6%

                                        539

                                        550

                                        571

                                        529

                                        529

                                        534

                                        545

                                        527

                                        −0.5 (−1.8; 0.8)

                                        Qs

                                          

                                        533

                                        526

                                        563

                                        606

                                        710

                                        930

                                        809

                                        798

                                        +8.2 (6.9; 9.4)

                                        Liguria Ms

                                        34,4%

                                        66,9%

                                        405

                                        393

                                        402

                                        376

                                        420

                                        350

                                        301

                                        334

                                        −3.4 (−4.9; -1.8)

                                        Qs

                                          

                                        809

                                        847

                                        893

                                        1.010

                                        993

                                        1.063

                                        1049

                                        1077

                                        +6.2 (5.1; 7.3)

                                        Emilia Romagna Ms

                                        96,0%

                                        72,4%

                                        1530

                                        1542

                                        1382

                                        1372

                                        1200

                                        1253

                                        1274

                                        1262

                                        −3.3 (−4.1; -2.5)

                                        Qs

                                          

                                        2061

                                        2169

                                        2148

                                        2.378

                                        2644

                                        2690

                                        2666

                                        2927

                                        +5.2 (4.6; 5.8)

                                        Total Northern Italy Ms

                                        82,0%

                                        67,9%

                                        9,170

                                        8,914

                                        8,507

                                        8,155

                                        7,701

                                        7,692

                                        7,561

                                        7,870

                                        −2.7 (−3.0; -2.4)

                                        Qs

                                          

                                        13,139

                                        13,638

                                        13,634

                                        14,567

                                        15,100

                                        16,103

                                        16,421

                                        17,186

                                        +3.3 (3.0; 3.5)

                                        Toscana Ms

                                        86,4%

                                        69,5%

                                        968

                                        994

                                        841

                                        853

                                        796

                                        814

                                        845

                                        782

                                        −3.0 (−4.0; 2.0)

                                        Qs

                                          

                                        1661

                                        1859

                                        1871

                                        2055

                                        1960

                                        2037

                                        2010

                                        2022

                                        +2.3 (1.6; 3.0)

                                        Umbria Ms

                                        89,0%

                                        73,3%

                                        249

                                        197

                                        195

                                        216

                                        190

                                        179

                                        161

                                        209

                                        −3.1 (−5.1; -1.0)

                                        Qs

                                          

                                        443

                                        429

                                        453

                                        436

                                        471

                                        501

                                        482

                                        550

                                        +3.1 (1.6; 4.5)

                                        Marche Ms

                                        74,2%

                                        54,2%

                                        485

                                        515

                                        483

                                        486

                                        472

                                        413

                                        371

                                        378

                                        −4.4 (−5.7; -3.0)

                                        Qs

                                          

                                        482

                                        537

                                        536

                                        587

                                        653

                                        678

                                        731

                                        753

                                        +6.7 (5.4; 8.0)

                                        Lazio Ms

                                        63,6%

                                        47,6%

                                        1516

                                        1652

                                        1456

                                        1489

                                        1405

                                        1382

                                        1325

                                        1368

                                        −2.4 (−3.2; -1.6)

                                        Qs

                                          

                                        2.222

                                        2376

                                        2581

                                        2771

                                        2950

                                        2759

                                        2849

                                        3330

                                        +4.9 (4.2; 5.5)

                                        Abruzzo Ms

                                        56,6%

                                        50,5%

                                        267

                                        270

                                        206

                                        225

                                        219

                                        187

                                        217

                                        236

                                        −2.8 (−4.7; -0.8)

                                           

                                        381

                                        375

                                        310

                                        376

                                        332

                                        386

                                        424

                                        421

                                        +2.3 (0.7; 3.9)

                                        Total Central Italy Ms

                                        78,5%

                                        59,7%

                                        3,485

                                        3,628

                                        3,181

                                        3,269

                                        3,082

                                        2,975

                                        2,919

                                        2,973

                                        −2.9 (−3.4; -2.4)

                                        Qs

                                          

                                        5,189

                                        5,576

                                        5,751

                                        6,225

                                        6,366

                                        6,361

                                        6,496

                                        7,076

                                        +3.9 (3.5; 4.3)

                                        Molise Ms

                                        48,5%

                                        43,4%

                                        62

                                        55

                                        83

                                        74

                                        69

                                        63

                                        76

                                        47

                                        −1.2 (−4.8; +2.6)

                                        Qs

                                          

                                        46

                                        70

                                        83

                                        117

                                        103

                                        115

                                        95

                                        121

                                        +9.8 (6.4; 13.4)

                                        Campania Ms

                                        50,0%

                                        29,6%

                                        897

                                        909

                                        950

                                        968

                                        878

                                        786

                                        813

                                        797

                                        −2.4 (−3.4; -1.4)

                                        Qs

                                          

                                        1.194

                                        1271

                                        1323

                                        1429

                                        1495

                                        1568

                                        1687

                                        1885

                                        +6.4 (5.6; 7.3)

                                        Puglia Ms

                                        25,3%

                                        33,4%

                                        987

                                        928

                                        903

                                        933

                                        901

                                        963

                                        959

                                        1051

                                        +0.9 (0.0; 1.9)

                                        Qs

                                          

                                        1.010

                                        1174

                                        1182

                                        1315

                                        1324

                                        1361

                                        1410

                                        1520

                                        +12.8 (11.7; 13.8)

                                        Basilicata Ms

                                        100,0%

                                        49,2%

                                        88

                                        98

                                        78

                                        75

                                        89

                                        110

                                        107

                                        114

                                        +4.3 (1.1; 7.6)

                                        Qs

                                          

                                        81

                                        59

                                        92

                                        97

                                        99

                                        110

                                        112

                                        135

                                        +8.9 (5.6; 12.3)

                                        Calabria Ms

                                        51,8%

                                        26,2%

                                        295

                                        322

                                        320

                                        287

                                        237

                                        239

                                        245

                                        221

                                        −5.1 (−6.9; -3.4)

                                        Qs

                                          

                                        195

                                        225

                                        233

                                        302

                                        355

                                        380

                                        362

                                        434

                                        +11.7 (9.8; 13.7)

                                        Sicilia Ms

                                        49,2%

                                        41,7%

                                        770

                                        911

                                        856

                                        743

                                        724

                                        719

                                        654

                                        696

                                        −3.4 (−4.5; -2.4)

                                        Qs

                                          

                                        1.286

                                        1476

                                        1616

                                        1542

                                        1691

                                        1819

                                        1765

                                        1846

                                        +4.6 (3.8; 5.4)

                                        Sardegna Ms

                                        57,2%

                                        54,1%

                                        -

                                        -

                                        448

                                        416

                                        432

                                        408

                                        398

                                        428

                                        −1.1 (−3.4; +1.1)

                                        Qs

                                          

                                        -

                                        -

                                        429

                                        514

                                        451

                                        486

                                        611

                                        597

                                        +6.7 (4.5; 8.9)

                                        Total Southern Italy Ms

                                        46,5%

                                        36,3%

                                        3,099

                                        3,223

                                        3,638

                                        3,496

                                        3,330

                                        3,288

                                        3,252

                                        3,354

                                        +0.3 (−0.3; +0.8)

                                        Qs

                                          

                                        3,812

                                        4,275

                                        4,958

                                        5,316

                                        5,518

                                        5,839

                                        6,042

                                        6,538

                                        +7.2 (6.8; 7.7)

                                        Subtotal ITALY Ms

                                        72,7%

                                        60,0%

                                        15,754

                                        15,765

                                        15,326

                                        14,920

                                        14,113

                                        13,955

                                        13,732

                                        14,197

                                        −2.1 (−2.3; -1.8)

                                        Qs

                                          

                                        22,140

                                        23,489

                                        24,343

                                        26,108

                                        26,984

                                        28,303

                                        28,959

                                        30,800

                                        +12.9 (12.7; 13.2)

                                        Total ITALY Ms + Qs

                                          

                                        37,894

                                        39,254

                                        39,669

                                        41,028

                                        41,097

                                        42,258

                                        42,691

                                        44,997

                                        +2.2 (2.0; 2.3)

                                        Data are reported by region and macro-area (Northern, Central, and Southern Italy).

                                        1 Reported data are absolute numbers unless otherwise specified.

                                        2 AAPC: Average Annual Percentage Change and 95% Confidence Interval.

                                        * Percentage of women aged 50–69 years old (on total screening target population) invited to perform mammographic screening in 2007–2008 (2-year cumulative data).18§ Adherence rate to mammography screening in year 2008 (adjusted by excluding women performing mammography outside official programs).16

                                        Percentages of coverage and adherence to mammographic screening in 2007–08 are also reported.16

                                        Quadrantectomies significantly increased across all the Regions but Valle D’Aosta and Abruzzo. When macro-areas were considered, the most remarkable increase was reported for Southern Regions (+ 3.3%, 3.0–3.5;+ 3.9%, 3.5–4.3 and + 7.2%, 6.8–7.7 for Northern, Central and Southern regions, respectively).

                                        In Table4, we report mastectomies and quadrantectomies performed on repeated admissions in the same year between 2001 and 2008. Overall, a total number of 46,610 repeated breast surgeries was performed in Italy between 2001 and 2008. Our data showed a significant increase in any of the subcategories considered but the first one (i.e., subcategory including women who underwent repeated breast surgery once within the same year).
                                        Table 4

                                        1 Mastectomies and 1 Quadrantectomies performed on repeated admissions between 2001 and 2008

                                        Re-interventions (n) in the same patient

                                        2001

                                        2002

                                        2003

                                        2004

                                        2005

                                        2006

                                        2007

                                        2008

                                        AAPC (95%CI)2

                                        1 re-intervention in the same year

                                        3268

                                        3243

                                        3241

                                        3039

                                        2950

                                        2667

                                        2347

                                        1796

                                        −6.8 (−7.3; -6.3)

                                        2 re-interventions in the same year

                                        1387

                                        1981

                                        2419

                                        2834

                                        3092

                                        3484

                                        3560

                                        3794

                                        +12.9 (12.2; 13.5)

                                        3 re-interventions in the same year

                                        27

                                        56

                                        132

                                        166

                                        220

                                        240

                                        290

                                        295

                                        +27.5 (24.4; 30.7)

                                        >3 re-interventions in the same year

                                        0

                                        0

                                        7

                                        3

                                        17

                                        16

                                        15

                                        24

                                        +45.9 (29.9; 63.9)

                                        Total Re-interventions

                                        4682

                                        5280

                                        5799

                                        6042

                                        6279

                                        6407

                                        6212

                                        5909

                                        +3.2 (2.8; 3.6)

                                        Data is presented by categories defined upon the number of repeat major breast surgeries within a year.

                                        1 Reported data are absolute numbers unless otherwise specified.

                                        2AAPC: Average Annual Percentage Change (with 95% Confidence Interval, CI).

                                        Discussion

                                        In the present study, data from the NHDRs proved a valuable tool in the ascertainment of the real figures of incident breast cancer cases. Indeed, the current indications for quadrantectomies or mastectomies in operable breast cancer, along with the use of well defined codes assigned to breast surgeries at the time of patient discharge, render breast cancer particularly prone to traceability through NHDRs. Based on our results, mastectomies decreased in all the age groups but two (i.e., women aged 25–39 and 40–44 years). Conversely, quadrantectomies showed a significant increase across all the age groups. There was a significant decrease in the number of mastectomies in Northern and Central Italy but not in Southern Italy, where the inter-regional differences were remarkable. Quadrantectomies significantly increased across all the different Regions (but Valle D’Aosta and Abruzzo) and macro areas considered.

                                        This study has several strengths. Data were made available by the Italian Ministry of Health. Given that the hospital discharge records provide the basis for hospital care reimbursement within a diagnosis-related groups (DRGs) system, these data are subject to a systematic quality assessment performed at a Regional and central level. Dedicated programs and multidisciplinary workgroups are in place at the Department of Quality Assessment, Management of Medical Care and Ethics of the Italian Ministry of Health to enhance data accuracy and completeness. Constant efforts have led to substantial improvements in data quality. Demographic data accuracy was high. However, inter-regional differences in the completeness of reporting exist and must be taken into account when considering these data[12].

                                        We specifically focused on breast cancer patients having undergone mastectomy or quadrantectomy, whose basic requirement is a histologically-confirmed diagnosis of primary breast cancer. At the same time, we excluded women having undergone excision biopsies and tumorectomies. This approach significantly minimized the inclusion of false positive cases.

                                        Repeated admissions were identified and discounted over the entire 8-year period. This increases our confidence in the ability of the NHDRs to differentiate patients with incident breast cancer cases, included in the present study, from patients with prevalent cancers. Data on repeat admissions were approached in a separate set of analyses (Table4). Future work will be oriented towards the identification of factors associated with surgery-related hospital readmissions in breast cancer patients, with a specific focus on tumor size and histology, lymph node involvement, type of surgical treatment and patient demographics.

                                        In our analysis, we included data on in situ breast carcinoma. The latter accounted for a small average number of major breast surgeries performed on a yearly basis [i.e., 234 mastectomies (range: 227–301), and 1004 quadrantectomies (range: 725–1300) per year]. In situ breast cancer holds the potentials for malignant transformation. The systematic collection, analysis and reporting of data on carcinoma in situ might help identify risk factors and clarify underlying mechanisms of malignant transformation, thus contributing to breast cancer control research and more targeted treatments[17, 18].

                                        Our study has also some limitations. Based on pre-defined selection criteria, our study population includes women eligible for quadrantectomies or mastectomies. The latter category encompasses patients diagnosed with early and locally advanced breast cancer, while generally excluding patients with metastatic breast cancer (MBC) at the time of diagnosis. On this basis, our analysis is expected to underestimate the actual number of breast cancer incident cancer cases. Currently, the percentage of breast cancer patients who are metastatic at diagnosis approximates 6%, with a 5-year survival rate of 21%[19].

                                        We analyzed data related to the time frame spanning from 2001 to 2008. Variations in admitting practices and treatment protocols for the disease of interest might have occurred over time and by area. In few cases, this could have caused discrepancies between the hospital discharges and the actual occurrence of the disease considered[20, 21].

                                        Notwithstanding the exclusion of incident cases of metastatic breast cancer (by inclusion criteria), the rates obtained from the analysis of the hospital discharge records were higher than those reported by the Italian Ministry of Health in 2006. According to the CRs 2006 report, the number of estimated breast cancer cases for the year 2006 was 37,542[22]. In the same year, we observed 42,258 cases (i.e., +11%). Several factors might contribute to such a discrepancy. First, in our study the linking process allowed the discharge of repeat hospital admission between 2001 and 2008, but discharge data related to patients who had been admitted for breast cancer in years prior to 2001 might still be present. Indeed, 10–15 percent of patients undergoing breast conservative therapy for operable breast cancer (i.e., breast-conserving surgery and postoperative breast irradiation) will develop a loco-regional recurrence within 10 years[23]. This risk is slightly higher than that of a loco-regional recurrence following mastectomy (5 to 10 percent)[23, 24]. However, these rates include both metastases occurring in the ipsilateral preserved breast (i.e., local recurrence) and regional lymph nodes, (i.e., regional recurrence), with only the first representing a potential target for breast surgery. Second, our analysis included data on carcinoma in situ of the breast, which are not routinely collected and analyzed by CRs[17]. Third, the official estimates were based on the use of the Mortality and Incidence Analysis Model method (MIAMOD), a back-calculation approach which obtains cancer-specific morbidity measures by using official mortality data and model-based relative survival from local cancer registry data. As such, the MIAMOD method reflects the limitations stemming from the incomplete coverage and disproportion among macro-areas which characterize the Italian network of CRs[10]. On this basis, underreporting of cases and, consequently, underestimation of the cancer burden cannot be excluded when using the MIAMOD approach.

                                        Significant increases in quadrantectomies were reported in women aged 25 to 39 and 40 to 44 years. Women in these age groups are still formally uncovered by the breast cancer screening programs activated by the Italian Ministry of Health, despite they represent 13.6% of women undergoing total major breast procedures[16].

                                        In general, our figures showed inverse trends for mastectomies and quadrantectomies performed in Italy between 2001 and 2008. The increase observed for quadrantectomies and the decrease concerning mastectomies might be interpreted in light of the progressive expansion of the screening programs, and the better adherence to updated treatment protocols[16]. Indeed, mammographic screen-detected cancers show more favorable prognostic features at diagnosis and need less extensive treatment compared to symptomatic cancers[25]. The heterogeneous distribution of such interventions (i.e., screening programs), particularly in Southern Italy, might account for the differences in trends across macro areas and singular regions.

                                        Several studies have investigated the use of hospital discharge records to enhance cancer surveillance. In 1996, Huff and co-authors estimated disease occurrence rates from hospital discharge data for breast, cervical and lung cancer at a state- and county level for the state of Maine, US. Consistently with our results, rates from hospital discharge data were higher than rates from cancer registry data. It is noteworthy that the breast cancer rates from NHDRs and Cancer Registry data were the ones with the higher correlation among those considered (correlation coefficients were 0.87, 0.79 and 0.55 for breast, lung and cervical cancer, respectively)[26]. We have previously proposed the use of the NHDRs to evaluate the breast cancer burden in Italy[11]. Results across our two studies are fairly consistent. However, results from our previous study were limited by the inclusion of repeat hospital admissions. Moreover, a different and more restricted time window was considered (i.e., 2000–2005). Ferretti et al. used an algorithm based on Regional hospital discharge records to estimate breast cancer incidence in three Italian regions covered by the Italian net of CRs (e.g., Emilia Romagna, Toscana and Veneto). Incidence rates of the two methods showed no statistical differences. However, the authors ascribed the agreement between hospital discharge records and CRs incidence rates to a cross effect of both sensitivity and specificity limitations of the discharge records algorithm[27].

                                        Conclusions

                                        A National system of population-based CRs is essential to monitor cancer patterns and trends at a National and local level and to orient health monitoring and resource allocation decisions[28]. However, the exclusive use of CRs may pose limits to the estimate of cancer burden, mainly due to incomplete and heterogeneous coverage. We suggest the use of the NHDRs to supplement the net of CRs. The latter source (NHDRs) may be a valuable and relatively efficient tool for enhancing cancer surveillance.

                                        Abbreviations

                                        et al: 

                                        And co-authors

                                        AAPC: 

                                        Average annual percentage change

                                        CR: 

                                        Cancer registry

                                        CRs: 

                                        Cancer registries

                                        CI: 

                                        Confidence interval

                                        e.g: 

                                        Exampli gratia

                                        HDF: 

                                        Hospital discharge file

                                        i.e: 

                                        Id est

                                        ICD-9-CM: 

                                        International classification of diseases, ninth revision, clinical modification

                                        AIRTUM: 

                                        Italian association of cancer registries

                                        Ms: 

                                        Mastectomies

                                        MIAMOD: 

                                        Mortality and incidence analysis model

                                        NHDRs: 

                                        National hospital discharge Records

                                        ISTAT: 

                                        National Institute for Statistics

                                        Qs: 

                                        Quadrantectomies

                                        SEER: 

                                        Surveillance, epidemiology and end results program

                                        US: 

                                        United states.

                                        Declarations

                                        Acknowledgements

                                        This work was supported by the Human Health Foundation, Spoleto (PG), Italy (http://​www.​hhfonlus.​org), the Sbarro Health Research Organization, Philadelphia, PA (http://​www.​shro.​org), the DoD, Army Research and Development, and the DoH Commonwealth of Pennsylvania. Authors are also grateful to the Euro Mediterranean Scientific Institute (ISBEM, Brindisi), for data management and analysis.

                                        Authors’ Affiliations

                                        (1)
                                        Department of Internal Medicine, University of Florence
                                        (2)
                                        Scientific Direction, Regina Elena National Cancer Institute
                                        (3)
                                        Epidemiology, Regina Elena National Cancer Institute
                                        (4)
                                        Local Health Authority of Naples (ASL NA1), Centro piazza Nazionale 95
                                        (5)
                                        Department of General Surgery, Second University of Naples
                                        (6)
                                        Department of Senology, National Cancer Institute G. Pascale Foundation
                                        (7)
                                        Sbarro Institute for Cancer Research and Molecular Medicine and Center of Biotechnology, College of Science and Technology Temple University, BioLife Science
                                        (8)
                                        Radiotherapy, Local Health Authority Salerno
                                        (9)
                                        INT-CROM, National Cancer Institute G. Pascale Foundation - Cancer Research Center
                                        (10)
                                        Human Health Foundation
                                        (11)
                                        Euro Mediterranean Biomedical Institute (ISBEM) Research Centre
                                        (12)
                                        Department of Public Health and Infectious Diseases, La Sapienza University of Rome
                                        (13)
                                        Department of Surgery, Jefferson Medical College, Thomas Jefferson University
                                        (14)
                                        Department of Human Pathology & Oncology, University of Siena, Strada delle Scotte
                                        (15)
                                        the Human Health Foundation Study Group,in memory of Prof. Giovan Giacomo Giordano

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                                        © Piscitelli et al.; licensee BioMed Central Ltd. 2012

                                        This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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