Open Access

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

  • Prisco Piscitelli1,
  • Maddalena Barba2,
  • Massimo Crespi3,
  • Massimo Di Maio4,
  • Antonio Santoriello5,
  • Massiliamo D’Aiuto6,
  • Alfredo Fucito6, 7,
  • Arturo Losco8,
  • Francesca Pentimalli9,
  • Pasquale Maranta7, 10,
  • Giovanna Chitano11,
  • Alberto Argentiero11,
  • Cosimo Neglia11,
  • Alessandro Distante11,
  • Gian luca Di Tanna12,
  • Maria Luisa Brandi1,
  • Alfredo Mazza7,
  • Ignazio R Marino13 and
  • Antonio Giordano7, 9, 10, 14Email author
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).
https://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

References

  1. Jensen OM, Whelan S: Planning a cancer registry. Danish CancerRegistry. IARC Sci Publ. 1991, 95: 22-28.PubMedGoogle Scholar
  2. Miller M, Swan J: SEER doubles coverage by adding registries for four states. J Natl Cancer Inst. 2001, 93 (7): 500-10.1093/jnci/93.7.500.View ArticlePubMedGoogle Scholar
  3. Ellekjaer H, Holmen J, Krüger O, Terent A: Identification of incident stroke in Norway: hospital discharge data compared with a population-based stroke register. Stroke. 1999, 30 (1): 56-60. 10.1161/01.STR.30.1.56.View ArticlePubMedGoogle Scholar
  4. Mähönen M, Salomaa V, Brommels M, Molarius A, Miettinen H, Pyörälä K, Tuomilehto J, Arstila M, Kaarsalo E, Ketonen M, Kuulasmaa K, Lehto S, Mustaniemi H, Niemelä M, Palomäki P, Torppa J, Vuorenmaa T: The validity of hospital discharge register data on coronary heart disease in Finland. Eur J Epidemiol. 1997, 13 (4): 403-415. 10.1023/A:1007306110822.View ArticlePubMedGoogle Scholar
  5. Brooks JM, Chrischilles E, Scott S, Ritho J, Chen-Hardee S: Information gained from linking SEER Cancer Registry Data to state-level hospital discharge abstracts. Surveillance, Epidemiology, and End Results. Med Care. 2000, 38 (11): 1131-1140. 10.1097/00005650-200011000-00007.View ArticlePubMedGoogle Scholar
  6. Du X, Freeman JL, Warren JL, Nattinger AB, Zhang D, Goodwin JS: Accuracy and completeness of Medicare claims data for surgical treatment of breast cancer. Med Care. 2000, 38 (7): 719-727. 10.1097/00005650-200007000-00004.View ArticlePubMedGoogle Scholar
  7. Cooper GS, Yuan Z, Stange KC, Dennis LK, Amini SB, Rimm AA: Agreement of Medicare claims and tumor registry data for assessment of cancer-related treatment. Med Care. 2000, 38 (4): 411-421. 10.1097/00005650-200004000-00008.View ArticlePubMedGoogle Scholar
  8. Freeman JL, Zhang D, Freeman DH, Goodwin JS: An approach to identifying incident breast cancer cases using Medicare claims data. J Clin Epidemiol. 2000, 53 (6): 605-614. 10.1016/S0895-4356(99)00173-0.View ArticlePubMedGoogle Scholar
  9. Penberthy L, McClish D, Pugh A, Smith W, Manning C, Retchin S: Using hospital discharge files to enhance cancer surveillance. Am J Epidemiol. 2003, 158 (1): 27-34. 10.1093/aje/kwg108.View ArticlePubMedGoogle Scholar
  10. Map of the Italian Cancer Registries.http://www.registri-tumori.it/cms/copertura#,
  11. Piscitelli P, Santoriello A, Buonaguro FM, Di Maio M, Iolascon G, Gimigliano F, Marinelli A, Distante A, Serravezza G, Sordi E, Cagossi K, Artioli F, Santangelo M, Fucito A, Gimigliano R, Brandi ML, Crespi M, Giordano A: Incidence of breast cancer in Italy: mastectomies and quadrantectomies performed between 2000 and 2005. J Exp Clin Cancer Res. 2009, 28: 86-10.1186/1756-9966-28-86.PubMed CentralView ArticlePubMedGoogle Scholar
  12. Health Italian Minister Hospital Discharge Form.http://www.salute.gov.it/ricoveriOspedalieri/paginaInternaRicoveriOspedalieri.jsp?menu=rilevazione&id=1232&lingua=italiano,
  13. Health IMo. Department of Quality Assessment, Management of Medical Care and Ethics.http://www.salute.gov.it/ministero/sezMinistero.jsp?label=ded&id=307,
  14. Center for Diseases Control and Prevention.http://www.cdc.gov/nchs/icd/icd9cm.htm,
  15. Health IMo. ICD9CM codes.http://www.salute.gov.it/ricoveriOspedalieri/paginaInternaMenuRicoveriOspedalieri.jsp?menu=classificazione&id=1278&lingua=italiano,
  16. Giorgi D, Giordano L, Ventura L, Frigerio A, Paci E, Zappa M: Mammography screening in Italy: 2008 survey. Epidemiol Prev. 2010, 34 (5–6 Suppl 4): 9-25.PubMedGoogle Scholar
  17. Millikan R, Dressler L, Geradts J, Graham M: The need for epidemiologic studies of in-situ carcinoma of the breast. Breast Cancer Res Treat. 1995, 35 (1): 65-77. 10.1007/BF00694747.View ArticlePubMedGoogle Scholar
  18. Izquierdo JN, Schoenbach VJ: The potential and limitations of data from population-based state cancer registries. Am J Public Health. 2000, 90 (5): 695-698.PubMed CentralView ArticlePubMedGoogle Scholar
  19. Cardoso F, Senkus-Konefka E, Fallowfield L, Costa A, Castiglione M, ESMO Guidelines Working Group: Locally recurrent or metastatic breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2010, 21 (Suppl 5): v15-v19.View ArticlePubMedGoogle Scholar
  20. Mendlein JM, Franks AL: Hospital discharge data. Using chronic disease data: a handbook for public health practitioners. 1992, Atlanta: Centers for Disease Control and PreventionGoogle Scholar
  21. Keller RB, Soule DN, Wennberg JE, Hanley DF: Dealing with geographic variations in the use of hospitals. The experience of the maine medical assessment foundation orthopaedic study group. J Bone Joint Surg Am. 1990, 72 (9): 1286-1293.PubMedGoogle Scholar
  22. AIRTUM Working Group: Cancer incidence in Italy: 2006 estimates. Epidemiol Prev. 2006, 2: 105-106.Google Scholar
  23. Fisher B, Anderson S, Redmond CK, Wolmark N, Wickerham DL, Cronin WM: Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med. 1995, 333 (22): 1456-1461. 10.1056/NEJM199511303332203.View ArticlePubMedGoogle Scholar
  24. Wapnir IL, Anderson SJ, Mamounas EP, Geyer CE, Jeong JH, Tan-Chiu E, Fisher B, Wolmark N: Prognosis after ipsilateral breast tumor recurrence and locoregional recurrences in five National Surgical Adjuvant Breast and Bowel Project node-positive adjuvant breast cancer trials. J Clin Oncol. 2006, 24 (13): 2028-2037. 10.1200/JCO.2005.04.3273.View ArticlePubMedGoogle Scholar
  25. Pálka I, Kelemen G, Ormándi K, Lázár G, Nyári T, Thurzó L, Kahán Z: Tumor characteristics in screen-detected and symptomatic breast cancers. Pathol Oncol Res. 2008, 14 (2): 161-167. 10.1007/s12253-008-9010-7.View ArticlePubMedGoogle Scholar
  26. Huff L, Bogdan G, Burke K, Hayes E, Perry W, Graham L, Lentzner H: Using hospital discharge data for disease surveillance. Public Health Rep. 1996, 111 (1): 78-81.PubMed CentralPubMedGoogle Scholar
  27. Ferretti S, Guzzinati S, Zambon P, Manneschi G, Crocetti E, Falcini F, Giorgetti S, Cirilli C, Pirani M, Mangone L, Di Felice E, Del Lisi V, Sgargi P, Buzzoni C, Russo A, Paci E: Cancer incidence estimation by hospital discharge flow as compared with cancer registries data. Epidemiol Prev. 2009, 4–5: 14-53.Google Scholar
  28. Parkin DM, Wagner G, Muir CS: The Role of the Registry in Cancer Control. 1985, Lyon, International Agency for Research on CancerGoogle Scholar

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