Colorectal cancer epidemiology in an area with a spontaneous screening program

Abstract

The aim of this study was to analyze and describe the epidemiological characteristics and trends of colorectal cancer in Sassari province (Sardinia, Italy), an area with a spontaneous surveillance program for colorectal malignancies, in the period 1992-2010. Data were obtained from the local tumor registry which makes part of a wider registry web, coordinated, today, by the Italian Association for Tumor Registries. The overall number of colorectal cancer cases registered was 4.284. The male-to-female ratio was 1:0.7 and the mean age 68.3 years for males and 69.4 years for females. The standardized incidence rates were 49.3/100,000 and 31.1/100,000 and the standardized mortality rates 20.4/100,000 and 12.4/100,000 for males and females respectively. An increasing trend in the incidence of colorectal cancer in Sassari province was evidenced. Relative survival at 5 years from diagnosis was 48.6% (52.3% for males and 44.7% for females). A slight increase in mortality rates was observed, as opposed to national figures, probably attributable to the lacking of organized screening strategies in the area.

Full text

COLORECTAL CANCER EPIDEMIOLOGY IN AN AREA WITH A SPONTANEOUS SCREENING
PROGRAM
GIUSEPPE PALMIERI*, PANAGIOTIS PALIOGIANNIS**, FABRIZIO SCOGNAMILLO**, MARIO BUDRONI***, ROSARIA CESARACCIO***,
FABIO PULIGHE**, FRANCESCO TANDA**, MARIO TRIGNANO**, ANTONIO COSSU**
*Institute of Biomolecular Chemistry, Cancer Genetics Unit, C.N.R. Sassari - **Department of Surgical, Microsurgical and Medical
Sciences, University of Sassari, - ***Service of Epidemiology, A.S.L. 1, Italy
[Epidemiologia del cancro colo-rettale in un’area con screening spontaneo]
Introduction
Colorectal cancer is one of the most common
neoplastic diseases in the world with more than
1,200,000 cases in 2008(1). It is the third most inci-
dent neoplastic disease in both sexes, after lung and
prostate cancer in men and breast and cervix cancer
in women(1). It also represents the fourth most fre-
quent neoplastic cause of death after lung, stomach
and liver cancer(1). A consistent and worldwide
increase in colorectal cancer was registered in the
last decades(2,3). This increase may reflect technolog-
ical improvements in modern diagnostic methods
and changes in dietary habits and other risk factors,
as well as continuous improvement of the expectan-
cy of life(3,4,5). Otherwise, the progressive adoption
of screening programs in western countries, useful
to identify individuals with pre-symptomatic neo-
plastic colorectal lesions, should reduce the mortali-
ty for colorectal cancer(4,6,7).
The aim of this population-based study was to
analyze and describe the epidemiological character-
istics and trends of colorectal cancer in the province
of Sassari (Sardinia, Italy), in the period 1992-
2010.
Materials and methods
The epidemiological data presented in this
article were obtained from the “Registry of the
tumors of the Province of Sassari”. This registry
was created in 1992 by the local health agency for
the epidemiological surveillance of tumors. In 1999
it became part of a wider web of tumor registries,
coordinated, today, by the Italian Association for
Tumor Registries (Associazione Italiana Registri
Tumori, AIRTUM). The association coordinates 34
registries in the country, collects and publishes data,
and collaborates with international organizations in
the field.
Every registry collects data on tumoral dis-
eases affecting inhabitants in the territory of juris-
diction through the local hospitals and health care
services, as with other registries (e.g., death regi-
Acta Medica Mediterranea, 2013, 29: 231
ABSTRACT
The aim of this study was to analyze and describe the epidemiological characteristics and trends of colorectal cancer in
Sassari province (Sardinia, Italy), an area with a spontaneous surveillance program for colorectal malignancies, in the period
1992–2010. Data were obtained from the local tumor registry which makes part of a wider registry web, coordinated, today, by the
Italian Association for Tumor Registries. The overall number of colorectal cancer cases registered was 4.284. The male-to-female
ratio was 1:0.7 and the mean age 68.3 years for males and 69.4 years for females. The standardized incidence rates were
49.3/100,000 and 31.1/100,000 and the standardized mortality rates 20.4/100,000 and 12.4/100,000 for males and females respec-
tively. An increasing trend in the incidence of colorectal cancer in Sassari province was evidenced. Relative survival at 5 years from
diagnosis was 48.6% (52.3% for males and 44.7% for females). A slight increase in mortality rates was observed, as opposed to
national figures, probably attributable to the lacking of organized screening strategies in the area.
Key words: Colorectal cancer, adenocarcinoma, screening, surveillance, Sassari.
Received March 11, 2013; Accepted March 26, 2013

232 G. Palmieri, P. Paliogiannis et Al
stries). Demographic, clinical, pathological and
prognostic data are collected for each case of can-
cer and are registered in a digital database. This
database was the data source for the present popula-
tion-based report.
The demographic characteristics of the
patients affected by colorectal cancer were collect-
ed. Crude incidence and mortality rates per 100,000
inhabitants per year were calculated, as were the
standardized rates adjusted for European population
standards. A comparison between incidence and
mortality in the province of Sassari and those in
other Italian provinces was performed.
Additionally, the cumulative risk of developing the
disease and of dying between zero and 74 years of
age was estimated. The age class distribution and
time trends of incidence, mortality, and histology
were also evaluated. Finally, relative 5-year sur-
vival was calculated.
Results
The overall number of cases of colorectal can-
cer registered in the period under investigation was
4,284. Diagnosis was obtained by histological or
cytological reports in 3,945 cases (92.1%) and
using other information sources (clinical reports,
radiological referrals, death certifications, etc) in
326 cases (7.6%). The modality of diagnosis was
not known in 13 cases (0.3%). Among the 4,284
individuals registered, 2,419 were males and 1865
females, with a male-to-female ratio of 1:0.77. The
mean age was 68.3 years for males and 69.4 years
for females. The cumulative risk of developing the
disease was 4.09% for males and 2.44% for
females.
As regards the anatomical distribution of the
tumors 959 (22.4%) were sited in the right colon,
177 (4.1%) in the transverse colon, 427 (10%) in the
left colon, 1,068 (24.9%) in the sigmoid colon and
1,422 (33.2%) in the rectum and anus, while in 231
(5.4%) cases the anatomical site of origin was not
known. Among the 3,945 tumors that had histologi-
cal or cytological diagnosis, 3785 (95.9%) were ade-
nocarcinomas, while only 97 (2.5%) were lesions of
a different histotype. In the remaining 63 (1.6%)
cases the exact histologic type was not specified.
The crude incidence of colorectal malignan-
cies in the period under investigation was
58.9/100,000 for men and 43.9/100,000 for women.
Standardized incidence rates were 49.3/100,000 for
males and 31.1/100,000 for females.
Table 1 shows the distribution of incidence in
relation to age in percentages, while Table 2 shows
the distribution of incidence rates in relation to age.
Peak incidence occurred at 80-84 years for both
males and females. Incidence rates were also calcu-
lated for the following three time periods: 1992-
1998, 1999-2004 and 2005-2010 (Figure 1). There
was a progressive increase in incidence rate in
males, from 41.35/100,000 in the first period, to
50.47/100,000 in the second period and
56.76/100,000 in the last period. The corresponding
figures for females were 27.5/100,000,
30.75/100,000 and 35.44/100,000, respectively. A
steady increase in incidence occurred between 1992
and 2010. Analysis of the trend of mean age at dis-
ease onset for the same periods of time did not
reveal any relevant changes (Figure 2).
Age (years) Males
(Incidence %)
Femmales
(Incidence %)
0-14 0 0
15-29 0.16 0.43
30-44 3.27 3.59
45-59 17.3 17.27
60-74 48.7 40.16
75+ 30.84 38.55
Table 1: Age-class incidence distribution.
Age (years) Incidence
(/100,000)
(Incidence)
(/100,000)
Males Females Males Females
0-14 0 00 0
5-9 0 00 0
10-14 0 00 0
15-19 0 0.4 0.4 0
20-24 0.3 0.7 0 0
25-29 0.9 1.6 00.3
30-34 4.7 3.5 0.3 0.9
35-39 5.1 5.1 2.4 0.9
40-44 14.5 12 3.8 1.9
45-49 25.4 19.1 8.1 5.1
50-54 50.3 43.9 13.7 9.9
55-59 81.4 56.8 30 17.9
60-64 141.8 89.8 39.2 27.1
65-69 213.7 121.5 76.9 44.6
70-74 294.7 140.3 113.5 62.5
75-79 312.4 184.3 165.4 85.1
80-84 378.1 229.4 212.2 125.4
85+ 284.3 215.4 274.4 207.8
Total 58.9 43.9 25.1 19.7
Table 2: Age-class incidence and mortality rates.

Table 3 shows the comparison of the incidence
and mortality in the province of Sassari with those
in other Italian provinces. There were 1868 deaths
in the period under investigation (1032 males and
836 females). Crude overall mortality was
25.1/100,000 for males and 19.7/100,000 for
females. Mean age at death was 71.8 years in males
and 74.5 years in females. Standardized mortality
rates were 20.4/100,000 for males and 12.4/100,000
for females. The cumulative risk of death was rela-
tively low (1.43% for males and 0.85% for
females). Table 2 shows the age-class distribution
of mortality rates. There was a relevant increase in
mortality rates after the sixth decade of life. Figure
1 shows the time trend of mortality between 1992
and 2010: a significant increase in mortality was
registered. Finally, relative survival at 5 years from
diagnosis was 48.6% (52.3% for males and 44.7%
for females).
Discussion
Colorectal cancer is the third most incident
neoplastic disease in the world, after lung and
breast cancer, with more than 1,200,000 cases in
2008(1). World population age-standardized inci-
dence calculated for the same year was
17.2/100,000 (20.3/100,000 for men and
14.6/100,000 for women), while cumulative risk
was 1.96%(1). Colorectal cancer is also the fourth
most frequent cause of neoplastic death, with more
than 600,000 deaths in the world in 2008(1).
Large part of these figures seems to involve
the most developed countries. In the European
Union more than 300,000 cases of colorectal cancer
were estimated in 2008, with a standardized inci-
dence of 31.7/100,000 inhabitants (39.9/100,000 for
men and 25.2/100,000 for women). There were
approximately 150,000 deaths, with standardized
mortality rate of 12.6/100,000 (16.3/100,000 for
males and 9.7/100,000 for females). The highest
figures were observed in countries of the central
Europe (Slovakia, Hungary, Czech Republic)(1,4).
Italy is one of the European countries with relative-
ly high colorectal cancer incidence, while Italian
figures for mortality are within mean European val-
ues. In 2008, more than 50,000 cases were observed
in the country and standardized incidence and mor-
tality rates were 35.5/100,000 and 11.7/100,000
respectively. In the same year more than 19,000
deaths for colorectal cancer were estimated in the
country(1). Data collected by AIRTUM (Table 3)
show slightly higher figures than those reported by
Globocan.
Standardized incidence rates in the province of
Sassari were lower than those estimated for the
entire country (Table 3). Comparisons of the inci-
dence rates with those of other Italian provinces
place our province between those with low inci-
dence rates, such as Napoli and Salerno. Provinces
with higher incidences, like Ferrara, Friuli Venezia
Giulia and Firenze, were generally northern ones.
Colorectal cancer epidemiology in an area with a spontaneous screening program 233
Figure 1: Incidence and mortality rates trends.
Figure 2: Trends of mean age at disease onset and death.
Males Females
Incidence Mortality Incidence Mortality
Alto Adige 65.7 29.3 42.3 16.3
Biella 59.3 26.9 37.4 15.9
Ferrara 75.6 31.8 46.8 18.6
Firenze 70.2 24.7 45.5 17.5
Friuli VG 74 29.7 46.5 15.1
Genova 67 28.1 43.1 14.4
Macerata 60.1 26.4 38.2 15.3
Modena 66.2 26.2 42.3 16.7
Napoli 42.6 19.5 28.7 12.3
Parma 63.6 23 38.5 12.1
Ragusa 48.7 20.5 31 12.9
Reggio E 64.6 22.2 41.1 17.1
Romagna 68.5 25.3 43.5 16
Salerno 42 16.3 27.9 11.4
Sassari 49.3 20.4 31.1 12.4
Torino 63.8 26.4 39.1 12.7
Trento 63.8 29 39.3 17.6
Umbria 69.9 25 45.5 15.7
Varese 62.5 27.8 38.3 13.6
Veneto 63.9 25 40,2 15.9
Mean 64.5 25.3 40.6 15.1
Table 3: Comparison with incidence and mortality rates
of other Italian provinces.

These figures may be probably due to dietetic fac-
tors, such as diffuse consumption of quality ali-
ments, especially vegetables, oil and wine.
Considering the distribution of the disease in
relation to age, less than 10% of the cases occurred
in individuals ≤30 years, while more than 75%
occurred after the sixth decade of life. Incidence
rates increased with aging in both sexes, reaching
peak values in individuals ≥80 years.
The time trends analysis showed a steady
increase in incidence in Sassari province in the peri-
od under investigation. This trend is common to sev-
eral national and international geographical areas,
which have contributed to the global increase in the
number of new colorectal cancer cases reported in
literature. It is not clear whether this is a real increase
in incidence or whether it reflects a general advanc-
ing in the technological means employed for diagno-
sis, an improvement and diffusion of endoscopic cul-
ture, or a progressively wider adoption of surveil-
lance programs in western countries.
Concerning mortality, 1868 (1032 males and
836 females) deaths occurred in the 18 years we
studied. Standardized mortality rates were consider-
ably lower for women and globally lower to those
observed in most provinces in Italy, but higher than
some recent European and world estimates(1).
Considering the age-class mortality trend, a natural
increase in relation to age could be observed in both
sexes, with peaks after the eighth decade of life and
with a slight increase between 1992 and 2010.
Screening strategies, both with faecal occult
blood tests or colonoscopy, can progressively
reduce colorectal cancer mortality, especially if
adequately organized(6,8). Indeed, in the United
States, where organized screening programs have
been started earlier, mortality rates are significantly
lower than in European or Asian countries that
adopted surveillance programs later. In our
province surveillance is performed through a spon-
taneous system adopted in the last decade, with no
charges for a faecal occult blood test and/or a
colonoscopy for individuals ≥50 years; an orga-
nized screening program for colorectal cancer is not
yet available. This may be the explanation of a
slightly increasing mortality trend observed in the
area in the last two decades, as adhesion rates to
spontaneous campaigns can be considerably vari-
able. Conversely, a slight reduction in mortality
rates for colorectal cancer was globally observed in
Italy in the last decades, both for males and
females, parallel to a progressively increasing num-
ber of screening programs in the various provinces
of the country(9,10). Finally, relative survival at 5
years from diagnosis was relatively low (48.6%),
furthermore suggesting the need to enhance prima-
ry prevention.
Conclusions
Our data point out an increasing trend in inci-
dence of colorectal cancer in Sassari province in the
last decades. However, incidence rates were lower
than those of other Italian provinces, especially
those of north Italy. Furthermore, a slightly increas-
ing trend in mortality rates was observed in both
sexes, as opposed to national figures, probably
attributable to the lacking of organized screening
strategies in Sassari province.
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_________
Request reprints from:
Dr. Panagiotis Paliogiannis MD.
Department of Surgical
Microsurgical and Medical Sciences
University of Sassari
Sassari
(Italy)
234 G. Palmieri, P. Paliogiannis et Al