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Characteristics of people living in Italy after a cancer diagnosis in 2010 and projections to 2020

Characteristics of people living in Italy after a cancer diagnosis in 2010 and projections to 2020 Background: Estimates of cancer prevalence are widely based on limited duration, often including patients living after a cancer diagnosis made in the previous 5 years and less frequently on complete prevalence (i.e., including all patients regardless of the time elapsed since diagnosis). This study aims to provide estimates of complete cancer prevalence in Italy by sex, age, and time since diagnosis for all cancers combined, and for selected cancer types. Projections were made up to 2020, overall and by time since diagnosis. Methods: Data were from 27 Italian population-based cancer registries, covering 32% of the Italian population, able to provide at least 7 years of registration as of December 2009 and follow-up of vital status as of December 2013. The data were used to compute the limited-duration prevalence, in order to estimate the complete prevalence by means of the COMPREV software. Results: In 2010, 2,637,975 persons were estimated to live in Italy after a cancer diagnosis, 1.2 million men and 1.4 million women, or 4.6% of the Italian population. A quarter of male prevalent cases had prostate cancer (n = 305,044), while 42% of prevalent women had breast cancer (n = 604,841). More than 1.5 million people (2.7% of Italians) were alive since 5 or more years after diagnosis and 20% since ≥15 years. It is projected that, in 2020 in Italy, there will be 3.6 million prevalent cancer cases (+ 37% vs 2010). The largest 10-year increases are foreseen for prostate (+ 85%) and for thyroid cancers (+ 79%), and for long-term survivors diagnosed since 20 or more years (+ 45%). Among the population aged ≥75 years, 22% will have had a previous cancer diagnosis. (Continued on next page) * Correspondence: stefano.guzzinati@regione.veneto.it; registro.tumori@regione.veneto.it; dalmaso@cro.it; epidemiology@cro.it Deceased Veneto Tumor Registry, Veneto Region, Padova, Passaggio Gaudenzio 1, 35131 Padova, Italy Cancer Epidemiology Unit, CRO Aviano National Cancer Institute IRCCS, Via Franco Gallini 2, 33081 Aviano, PN, Italy Full list of author information is available at the end of the article © The Author(s). 2018, corrected publication 20O21pen Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Guzzinati et al. BMC Cancer (2018) 18:169 Page 2 of 13 (Continued from previous page) Conclusions: The number of persons living after a cancer diagnosis is estimated to rise of approximately 3% per year in Italy. The availability of detailed estimates and projections of the complete prevalence are intended to help the implementation of guidelines aimed to enhance the long-term follow-up of cancer survivors and to contribute their rehabilitation needs. Keywords: Cancer prevalence, Projections, Survivors, Italy Background agreed to participate in the study and were able to Estimates of cancer prevalence are widely based on lim- provide at least 7 years of cancer registration as of ited duration prevalence, including only patients living December 31, 2009 (Appendix 1)andfollow-upof after a cancer diagnosis made in the previous 5 years vital status as of December 31, 2013. The Italian le- [1, 2]. Prevalence, regardless of the time since diagnosis gislation identifies Cancer Registries as collectors of (i.e., complete prevalence), is less frequently estimated personal data for surveillance purposes without ex- than limited duration prevalence [3–9]. Overall age- plicit individual consent. The approval of a research standardized cancer incidence and mortality rates have ethic committee is not required, since this descrip- declined over the past 10 years in the majority of high tive study was conducted without any direct or in- income countries, whereas the complete prevalence has direct intervention on patients. been consistently increasing in the early 2000s [3, 4, 6, Prevalence for all malignant tumours (ICD-10: C00- 8, 10, 11]. Complete prevalence is generally measured C43, C45-C96) and 34 cancer types or their combina- in absolute numbers and proportions, i.e., not age- tions were estimated and presented in this study for all standardized. Thus, improved survival [12, 13]and age groups. Urinary bladder cancers with benign or un- population ageing (increasing absolute number of new certain behaviour, and in situ tumours were also in- cancer diagnoses) imply a progressive increase in cluded. Only non melanoma skin cancers (ICD-10 C44) tumour prevalence. were excluded. ICD-O-3 morphology codes were used to Cancer prevalence includes patients currently treated define specific subtypes. for cancer; those who have become cancer free, but still have a measurable excess risk of recurrence or death; Statistical methods and, finally, patients having death rates similar to those The clinical and demographic characteristics of the of the general population who can be considered “cured persons registered with a diagnosis of cancers in the patients” [14]. Many of these individuals are possibly af- Italian CRs were used to estimate: 1) how many of fected by physical, cognitive, and/or psychosocial limita- them were still alive at January 1, 2010 regardless tions [15]. of time since diagnosis -i.e., complete prevalence The aim of this study was to provide a description of count- by cancer type, sex, and age group; 2) the the number of people living in Italy at January 1, 2010 prevalence proportion in Italy at 2010 for each can- after a cancer diagnosis, for all cancers combined and cer type, by sex, and age; 3) the complete prevalence for a selection of cancer types by sex, age, and time since (count and proportion) at 1st January 2015 and diagnosis. In addition, projections of cancer prevalence 2020, overall and by time since diagnosis; and 4) de- in Italy are presented up to the year 2020. Estimates and scribe the changing over time of these estimates. projections of complete tumour prevalence and charac- For each cancer registry we computed the limited teristics of prevalent patients are necessary to help clini- duration prevalence, i.e. the number of patients diag- cians and health care planners in improving long-term nosed in the period of the registration activity (be- care of patients and in allocating appropriately health tween 7 and 34 years) at January 1, 2010, using the care resources. Moreover, they may provide helpful counting method implemented in SEER*Stat software information to a growing number of cancer patients or [16]. This maximum limited duration prevalence was former patients. corrected, using the COMPREV software [17], by means of completeness index [18, 19], to estimate Methods the total number of cancer patients alive, regardless Study design and data sources of when they were diagnosed. Completeness indices This is a descriptive analysis of individual data col- were estimated by cancer type, sex, age, and time lected during the period 1976-2009 from 27 since diagnosis. Prevalence was computed as an ab- population-based Italian cancer registries (i.e., 32% solute number, as well as a proportion per 100,000 of the entire Italian population in 2010), which residents people by cancer type, sex, age group, area Guzzinati et al. BMC Cancer (2018) 18:169 Page 3 of 13 of residence, and years since diagnosis. Patients with age: 3.1% at age 45-54 years, 6.6% at 55-64 years, more than one primary cancer were included in the 12.1% at 65-74 years, and nearly 17% after age 75 years computation of prevalence for each cancer type or (Appendix 2)with differencesby sex(Tables 1 and 2). combination. In the analyses for all types combined, Men living in Italy after a cancer diagnosis in 2010 only the first cancer was considered. Completeness were 1,194,033, corresponding to 4.3% (4250/ indices were obtained by statistical regression models 100,000) of all Italian male population (Table 1). of incidence and survival using data from 8 long-term This proportion increased from less than 1% below registries (Appendix 1) with an available observation the age of 45 years, to > 20% for men aged ≥75 years. period of at least 18 years before 2010 [20, 21]. Rela- The most frequent tumours in terms of prevalence tive survival and incidence functions were estimated were prostate (305,044 of prevalent cases at January, by means of parametric models within the period 1st 2010) representing 25.5% of all cases or 1.1% of 1985-2011 for survival and 1985-2009 for incidence. all Italian men, followed by bladder (192,611 men, The survival model was a parametric cure model as- 16.1%) and colorectal (185,532 men, 15.5%) tumours. suming that a proportion of individuals with cancer Italian women living after a cancer diagnosis were were bound to die (fatal cases) with a survival follow- 1,443,942 (Table 2), corresponding to 4.8% of all Ital- ing a Weibull distribution, while the remaining pro- ian women. Breast cancer represented 41.9% of all portion (cured fraction) had the same mortality rate cancers (604,841), followed by colorectal cancers as that of the general population with the same age (171,847, 11.9% of all female prevalent cases, 0.6% of and gender stratification [14, 20]. The parameters of all Italian women) and by endometrial cancers the survival model were estimated by cancer type, (103,321, 7.2% and 0.3%, respectively). Notably, the sex, and age class (0-14, 15-44, 45-54, 55-64, 65-74, fourth most frequent cancer type diagnosed in Italian 75+ years) through the SAS procedure NLIN. A prevalent women is thyroid (93,341 women, 6.5% of period effect was included on the hazard of dying of all female prevalent cases). Prevalent women were cancer. Incidence data were categorised according to younger than men. Women aged 15-44 years living cancer type, sex, five-year age group, and birth cohort after a diagnosis represented 1% of the whole Italian (< 1899, 1900-1904,…, 2005-2009). A sixth degree population, they were 4% at ages 45-54 years, 7% at polynomial age-cohort model of crude incidence rates ages 55-64 years, 11% at ages 65-74 years, and 14% was fitted through the SAS LOGISTIC procedure for for women aged ≥75 years (Table 2). each cancer type and sex [21]. More than 1.5 million people (i.e., 2.7% of all Italian Complete prevalence proportions were projected to residents) were alive after ≥5 years since diagnosis. They 2020 by cancer type, sex, age, and registry, assuming were 60% of all prevalent cases, 64% of women and 55% that complete prevalence will follow a linear func- of men. The distribution of prevalent cases by time since tion, based on the trend of the last three calendar diagnosis depends on cancer type (Fig. 1). The percent- years (i.e., 2007-2009). This simplified assumption age of prevalent cases diagnosed since less than 2 years (linear and constant trend) may not be valid for varied from 39% for lung cancer patients to 15% for long-term projections, but it is reasonable for short female breast and 7% for cervical cancer patients. Con- or medium-term (e.g., 10-year) ones. Other assump- versely, the percentage of prevalent cases diagnosed tions (e.g., log-linear models) were explored [4, 6], ≥15 years before was 59% for cervical cancer, 35% for showing consistent results for common cancer types, stomach cancer and 31% for endometrial cancer, but but unstable projections for the rarest. only 4% for prostate and 13% for lung cancer patients. The absolute number of prevalent cases in Italy Notably, patients diagnosed ≥15 years before were was obtained using proportions of prevalence esti- 21% of all prevalent cases (16% among men and 25% mates (age-, sex-, and cancer type-specific) from CRs among women). included in this study, multiplied by the Italian na- tional population by sex and age observed at January Prevalence projections for 2020 1, 2010. Proportions projected to 2020 were thus In 2020, there will be 3.6 million prevalent cancer cases in multiplied to Italian population forecasted at January Italy (Table 3), 1.9 million women and 1.7 million men, 1, 2020 [22]. with a 10-year increase of 37% (41 and 33% in men and women, respectively). In 2020, 2.6% of all Italian women Results (0.8 millions) will be alive after a breast cancer diagnosis Prevalence estimates at 2010 and more than half a million patients (2.1% of all men) will In Italy in 2010, 2,637,975 persons were alive after a cancer be alive after a prostate cancer diagnosis (Table 3). The lar- diagnosis, corresponding to 4.6% of all the Italian popula- gest 10-year increases are foreseen for prostate (+ 85%) and tion (Appendix 2). Prevalence proportions increase with for thyroid cancers (+ 79%, 212,863 cases), which will Guzzinati et al. BMC Cancer (2018) 18:169 Page 4 of 13 Table 1 Complete cancer prevalence by cancer type and age in Italian men at January 1, 2010 Cancer type Prevalent cases Prevalence proportion per 100,000 men All ages % 00-14 15-44 45-54 55-64 65-74 75-84 85+ All ages 00-14 15-44 45-54 55-64 65-74 75-84 85+ All types but skin non-melanoma 1,194,033 4844 84,172 87,091 198,505 363,932 357,051 98,439 4250 111 732 2079 5715 13,029 20,534 21,955 Upper aero-digestive tract 26,745 2.2% 19 1654 3320 6536 8063 5786 1367 100 0 15 84 199 311 337 313 Esophagus 3067 0.3% 0 54 252 722 1105 781 153 12 0 1 7 23 45 51 40 Stomach 45,970 3.8% 2 764 2583 6661 13,618 16,538 5802 158 0 6 58 180 470 926 1268 Small intestine 3384 0.3% 0 221 350 760 987 850 216 13 0 2 8 23 38 52 46 Colon, rectum, anus 185,532 15.5% 3 2718 8722 29,332 59,931 63,698 21,130 654 0 23 210 840 2108 3618 4682 Liver 17,454 1.5% 57 317 1539 3831 6347 4752 610 63 2 3 37 110 228 280 142 Biliary tract 4251 0.4% 0 70 238 713 1365 1443 421 15 0 0 6 20 47 80 103 Pancreas 5856 0.5% 3 198 598 1383 1876 1462 336 21 0 2 14 39 69 84 75 Larynx 44,810 3.8% 0 236 2105 8399 15,082 14,819 4169 160 0 2 51 240 540 854 965 Lung 63,048 5.3% 16 804 2771 11,014 22,765 21,682 3996 219 0 7 64 306 787 1229 890 Thymus, heart, mediastinum 2290 0.2% 42 384 435 548 516 331 33 7 1 3 9 14 18 18 9 Bone 4808 0.4% 152 1910 924 771 596 418 37 16 3 16 20 21 19 22 10 Skin melanoma 44,977 3.8% 21 6730 7411 9817 11,117 7867 2014 165 0 61 181 291 408 470 488 Mesothelioma 2090 0.2% 0 72 127 457 913 466 54 8 0 1 3 13 34 27 12 Kaposi sarcoma 5611 0.5% 3 567 658 864 1255 1498 766 21 0 5 17 26 46 90 174 Connective tissue 11,757 1.0% 226 2685 1696 2043 2459 2002 647 41 6 23 41 59 87 111 144 Penis 4285 0.4% 0 91 413 795 1309 1255 422 14 0 1 9 22 45 68 84 Prostate 305,044 25.5% 3 438 3387 34,764 112,958 122,376 31,118 1112 0 5 88 1048 4138 7143 6878 Testis 37,937 3.2% 86 17,116 8495 5349 3317 2389 1187 133 2 149 197 152 128 133 243 Kidney 62,815 5.3% 314 2842 5609 12,652 19,613 17,524 4262 226 7 25 134 364 703 1030 984 Bladder 192,611 16.1% 25 2802 8582 28,948 59,204 70,749 22,302 686 0 26 204 821 2104 4074 5053 Choroidal melanoma 1801 0.2% 0 115 209 365 484 519 109 7 0 1 6 11 18 30 25 Brain and central nervous system 16,110 1.3% 568 5391 2881 2930 2525 1423 391 54 13 46 65 81 82 78 66 Thyroid 25,512 2.1% 31 6428 5811 5876 4665 2351 349 89 1 56 137 165 166 136 80 Hodgkin lymphoma 27,821 2.3% 165 9685 5488 5229 4133 2684 437 95 4 83 129 139 141 148 99 Non-Hodgkin lymphoma 56,808 4.8% 629 8344 8754 11,691 13,802 11,185 2403 203 14 72 206 339 501 655 574 Leukemias 36,105 3.0% 1939 7620 4086 5656 8050 6703 2051 124 43 65 94 158 276 373 444 Multiple myeloma (plasma cell) 12,787 1.1% 0 326 1158 2636 4050 3680 938 45 0 3 27 75 143 215 207 Guzzinati et al. BMC Cancer (2018) 18:169 Page 5 of 13 Table 2 Complete cancer prevalence by cancer type and age in Italian women at January 1, 2010 Cancer type Prevalent cases Prevalence proportion per 100,000 women All ages % 00-14 15-44 45-54 55-64 65-74 75-84 85+ All ages 00-14 15-44 45-54 55-64 65-74 75-84 85+ All types but skin non-melanoma 1,443,942 3903 112,527 176,656 277,374 363,646 357,146 152,690 4836 93 988 4095 7496 11,243 13,994 14,500 Upper aero-digestive tract 15,433 1.1% 19 1562 1687 3156 3696 3624 1688 54 0 14 41 87 123 148 158 Esophagus 1125 0.1% 0 17 102 199 348 358 101 4 0 03613 16 11 Stomach 35,537 2.5% 0 651 1896 3992 8619 12,953 7426 117 0 5 41 104 254 497 698 Small intestine 2597 0.2% 0 136 277 495 688 752 250 9 0 1 6 14 21 29 28 Colon, rectum, anus 171,847 11.9% 12 2754 8640 24,517 45,322 59,479 31,123 571 0 24 204 658 1377 2287 2901 Liver 7331 0.5% 61 258 371 943 2182 2926 589 25 1 2 9 25 68 114 58 Biliary tract 5565 0.4% 3 60 286 836 1517 1932 931 18 0 0 6 22 44 72 84 Pancreas 6271 0.4% 0 326 495 1239 1699 1733 780 21 0 3 11 33 55 68 69 Larynx 4407 0.3% 2 68 364 898 1211 1358 508 16 0 1 8 26 41 55 52 Lung 23,721 1.6% 5 611 2373 4933 7158 6662 1980 80 0 6 53 133 224 268 186 Thymus, heart, mediastinum 2212 0.2% 61 514 406 410 443 306 72 7 2 49912 11 7 Bone 9124 0.6% 100 2259 2163 1950 1306 973 374 28 3 19 43 47 38 38 32 Skin melanoma 57,515 4.0% 30 10,718 9929 10,950 11,657 9953 4278 198 1 98 237 302 372 404 432 Mesothelioma 674 0.0% 0 18 68 148 224 174 42 2 0 0248 8 5 Kaposi sarcoma 1990 0.1% 0 105 60 197 349 750 528 7 0 12612 30 49 Connective tissue 9917 0.7% 203 1893 1399 1812 1890 1791 929 34 5 17 32 49 62 71 91 Breast 604,841 41.9% 0 26,663 82,068 128,514 165,456 142,658 59,483 2046 0 236 1906 3516 5164 5643 5751 Vagina and vulva 9689 0.7% 17 256 557 982 2377 3570 1931 32 0 2 13 27 71 137 183 Cervix uteri 58,879 4.1% 4 4321 8073 10,569 13,177 15,641 7093 193 0 38 184 280 397 591 675 Corpus uteri (endometrium) 103,321 7.2% 0 1490 5745 21,047 31,548 31,158 12,333 342 0 13 135 553 964 1198 1147 Ovary 45,620 3.2% 65 4058 6617 10,544 11,399 9729 3209 149 1 34 154 276 352 372 291 Kidney 35,250 2.4% 411 2369 2841 5290 9461 10,650 4229 122 9 21 68 149 293 436 418 Bladder 47,822 3.3% 6 1362 2562 6101 11,410 16,786 9594 164 0 12 62 172 359 676 897 Choroidal melanoma 1713 0.1% 0 149 210 294 445 414 202 6 0 14914 18 21 Brain and central nervous system 23,145 1.6% 501 6210 3661 3565 3875 3978 1355 72 12 52 82 96 114 133 105 Thyroid 93,341 6.5% 68 22,813 21,805 21,597 16,956 8578 1524 307 2 199 498 571 521 356 153 Hodgkin lymphoma 20,433 1.4% 102 9116 3990 3104 2222 1401 498 67 2 79 93 84 67 58 43 Non-Hodgkin lymphoma 53,907 3.7% 262 5635 6626 10,917 13,615 12,731 4120 181 6 49 153 290 422 505 407 Leukemias 31,196 2.2% 1450 7445 3465 4400 5626 6067 2742 101 34 64 78 115 166 235 256 Multiple myeloma (plasma cell) 12,278 0.9% 0 217 887 2367 3611 3814 1382 41 0 2 22 64 112 150 124 Guzzinati et al. BMC Cancer (2018) 18:169 Page 6 of 13 Fig. 1 Complete prevalence by time since diagnosis for selected cancer types* in Italy at January 1, 2010. *Cancer types diagnosed in > 50,000 persons, sorted by number of cases Table 3 Projected complete prevalence (cases) at January 1, 2020 by sex and 10-year variations in Italy Prevalent cases Variation (%) 2020 10-year period Cancer Type Men Women Total Men Women Total All types but skin non-melanoma 1687,049 1,922,086 3,609,135 41.3% 33.1% 36.8% Upper aero-digestive tract 36,081 21,831 57,911 34.9% 41.5% 37.3% Stomach 50,327 32,033 82,360 9.5% −9.9% 1.0% Colon, Rectum, Anus 280,277 233,245 513,522 51.1% 35.7% 43.7% Liver 25,234 8531 33,765 44.6% 16.4% 36.2% Larynx 47,015 6006 53,020 4.9% 36.3% 7.7% Lung 77,159 40,657 117,816 22.4% 71.4% 35.8% Skin Melanoma 80,069 89,831 169,900 78.0% 56.2% 65.8% Connective Tissue 17,040 11,815 28,855 44.9% 19.1% 33.1% Female Breast 834,154 834,154 37.9% 37.9% Cervix Uteri 51,136 51,136 −13.2% −13.2% Corpus Uteri (endometrium) 122,553 122,553 18.6% 18.6% Ovary 49,807 49,807 9.2% 9.2% Prostate 563,960 563,960 84.9% 84.9% Testis 63,395 63,395 67.1% 67.1% Kidney 97,249 47,151 144,400 54.8% 33.8% 47.2% Bladder 255,015 58,608 313,624 32.4% 22.6% 30.4% Brain and central nervous system 23,505 29,314 52,819 45.9% 26.7% 34.6% Thyroid 45,949 166,914 212,863 80.1% 78.8% 79.1% Hodgkin Lymphoma 37,692 29,314 67,006 35.5% 43.5% 38.9% Non- Hodgkin Lymphoma 82,780 73,584 156,364 45.7% 36.5% 41.2% Leukaemias 45,880 39,100 84,980 27.1% 25.3% 26.3% Multiple Myeloma 19,472 17,159 36,631 52.3% 39.8% 46.1% Cancer types with more than 20,000 prevalent cases at 2010 Guzzinati et al. BMC Cancer (2018) 18:169 Page 7 of 13 Table 4 Projected complete prevalence at January 1, 2020 by sex and age groups in Italy SEX, Cancer type Prevalent cases Prevalence proportion per 100,000 All ages % 00-44 45-74 75+ All ages 00-44 45-74 75+ MEN and WOMEN All types but skin non-melanoma 3,609,135 100.0% 228,145 1,897,543 1,483,448 5731 726 16,383 21,657 Colon, rectum, anus 513,522 14.2% 4954 231,800 276,767 808 15 2080 3952 Skin melanoma 169,900 4.7% 24,038 101,180 44,682 271 76 857 673 Female breast 834,154 23.1% 29,758 498,614 305,781 2622 201 8215 7297 Corpus uteri (endometrium) 122,553 3.4% 1707 65,765 55,081 379 10 1104 1269 Prostate 563,960 15.6% 1174 255,514 307,272 2056 12 5634 12,343 Bladder 313,624 8.7% 4130 128,332 181,162 563 15 1323 2836 Thyroid 212,863 5.9% 41,112 145,562 26,189 309 127 1084 379 Non-Hodgkin lymphoma 156,364 4.3% 14,948 87,255 54,161 247 47 739 789 MEN All types but skin non-melanoma 1687,049 100% 95,056 834,967 757,026 5444 615 15,678 28,728 Colon, rectum, anus 280,277 16.6% 2250 135,206 142,821 902 13 2573 5267 Skin melanoma 80,069 4.7% 8760 50,437 20,872 256 57 898 815 Prostate 563,960 33.4% 1174 255,514 307,272 2056 12 5634 12,343 Bladder 255,015 15.1% 2636 106,086 146,294 958 20 2323 5932 Thyroid 45,949 2.7% 9141 31,444 5364 142 59 490 209 Non-Hodgkin lymphoma 82,780 4.9% 8959 49,513 24,309 271 58 871 946 WOMEN All types but skin non-melanoma 1,922,086 100% 133,089 1,062,575 726,422 5992 888 17,374 17,007 Colon, rectum, anus 233,245 12.1% 2704 96,594 133,947 720 17 1633 3105 Skin melanoma 89,831 4.7% 15,278 50,742 23,811 284 102 822 581 Breast 834,154 43.4% 29,758 498,614 305,781 2622 201 8215 7297 Corpus uteri (endometrium) 122,553 6.4% 1707 65,765 55,081 379 10 1104 1269 Bladder 58,608 3.0% 1494 22,246 34,868 195 10 405 859 Thyroid 166,914 8.7% 31,971 114,119 20,825 508 218 1761 516 Non-Hodgkin lymphoma 73,584 3.8% 5989 37,743 29,852 225 37 618 688 Most frequent cancer types are shown: Cancer types or combinations with > 100,000 prevalent cases become the third most frequent prevalent cancer types to 2020 (+ 3% in the examined period), while a 19% among Italian women. A more than 50% increases are also increase was observed for cases diagnosed between 2 expected in 2020 for prevalence after diagnosis of testicular and 5 years before, 30-34% for cases diagnosed be- cancer (63,395 patients) or skin melanoma (169,900). A tween 5 and 20 years earlier, and 45% increased for limited change in prevalence (variations < 10%) is expected long-term survivors diagnosed ≥20 years before for ovary, larynx, and stomach, with cervical cancer being (Fig. 2). the only cancer type showing a decline in prevalence (− 13%) (Table 3). Discussion Nearly 22% (21,657/100,000) of population aged In 2010, 2.6 million people were living in Italy after ≥75 years in 2020 will have had a previous cancer a cancer diagnosis and this number will reach 3.6 diagnosis (Table 4). Below 45 years of age, prevalent million in 2020, increasing from 4.6% to 5.7% (i.e., cases will be 228,145 (i.e., 0.8% of all cases, 726/ one out of 17 Italians) of the overall population. The 100,000) and, in both sexes, the most frequent cancer estimated overall trend in the present decade in Italy type will be thyroid cancer, experienced by 31,971 (+ 3.2% per year) is comparable to that estimated in women and 9141 men. the same period in the USA (+ 2.8% per year) [5], Prevalent cases diagnosed within 2 years were the UK (+ 3.3%) [4], and Switzerland (+ 2.5%) [6]. only group showing a negligible increase from 2010 Guzzinati et al. BMC Cancer (2018) 18:169 Page 8 of 13 75 years or older (38% in men, 35% in women). In this age group, they will reach 41% in 2020, with more than 20% of men and 14% of women will have experienced a previous cancer diagnosis. These pro- portions were similar to those reported by other studies, showing also that elderly cancer patients had more severe comorbidity conditions than non cancer patients [26]. At the opposite end of the age spectrum, 8% of Italian prevalent cases were younger than 44 years of age and 10% were aged 45–54 years. It has been re- cently estimated that 44,135 persons living in Italy in 2010 had had a cancer diagnosis during childhood Fig. 2 Complete cancer prevalence (proportions) in Italy from [27]; they represented 0.07% of the Italian population 2006 to 2020 by years since diagnosis. *Data for 2006 obtained from ref. 21. Filled symbols (e.g., � ) represent estimated values, and 1.7% of prevalent cases diagnosed at any age. In empty symbols (e.g., ο) represent projected values similar studies conducted in the USA [28], a sub- stantial proportion of morbidities emerged in child- The expected 37% increase in the present decade hood cancer patients several years after diagnosis, in Italy will be more marked (i.e., nearly + 50%) and there is growing awareness on potentially long- among long-term survivors diagnosed ≥20 years be- term risks affecting the survivors’ future physical, fore;theywillbemorethanhalfamillioninItaly cognitive, and/or psychosocial health [29]. The im- (519,356), 14% of all prevalent cases (11% in men pact of a cancer diagnosis is rather different between and 18% in women). Most of them can be considered younger and older survivors, the first facing more as cured since they had already reached a similar life pronounced socio-economic consequences [30, 31], expectancy (i.e., death rates) of the corresponding as well as psychosocial impairments in fertility and general population [14]. sexuality [32, 33]. A higher proportion of women (55%) than that of We acknowledge the several limitations of our ana- men emerged among prevalent cancer cases at 2010 lyses. First, data from Italian cancer registries (AIR- in the present Italian study, in agreement with find- TUM) included one third of the Italian population in ings from most studies conducted in other countries 2010 and the representativeness for the national [4–6, 9] but France (where 53% were men, 6.4% of prevalence estimates may be questionable [34]. To the French population) [8]. In Italy, female breast overcome this issue, we adjusted estimated propor- cancer cases represented 23% of all prevalent cases, tions in cancer registry areas for the age distribution and affected the distribution of cancer prevalence by of the whole Italian population. Moreover, since can- age. The thyroid cancer epidemic in Italy also con- cer registries have been active in Italy from a rela- tributed to an excess in females, below age 45 years tively recent time period, the complete prevalence has thyroid cancer was the most frequent prevalent type been estimated through statistical models. Notably, in 2010 (29,340 men and women), and this number the validation of complete prevalence estimation by will substantially increase to more than 41,000 in means of COMPREV method in Italy and elsewhere 2020. It should be noted, however, that a large pro- [19] is reasonably reassuring. In particular, the valid- portion of thyroid cancer incidence and prevalence ation of COMPREV method shows negligible (i.e., < may be affected by overdiagnosis; i.e., the detection 5%) differences, when comparing observed prevalence of cancer cases that would not otherwise result in for cancer registries with ≥30 years of observation causing symptoms or deaths [23, 24]. and estimated prevalence using complete indexes ap- An important role on variation of cancer preva- plied to the same registries and truncated data [21, lence is played by screening programmes, inducing a page 34]. reduction of cervical and colorectal prevalent cancers On the other hand, the strengths of this cases, while early detection of breast and prostate population-based study are represented by the size of cancers may inflate number of prevalent cases [25]. the study population, which included nearly 1.7 mil- In particular, screening can prevent cervical cancer, lion incident cancer cases, and its long-term follow- with a consequent major effect on prevalence reduc- up, more than a half of these cases were followed-up tion, i.e., − 13% in 10 years in the present study. for > 20 years post diagnosis. In addition, data and Distribution of cancer prevalence by age is also period used were updated in the present study (see noteworthy. In 2010, 37% of prevalent patients were Appendix 1), including an additional number of years Guzzinati et al. BMC Cancer (2018) 18:169 Page 9 of 13 of observation and follow-up, in comparison with pre- Appendix 1 vious studies on the same topic [21]. The accuracy of future projections of prevalence is Population and incident cases in Italian cancer registries necessarily uncertain and lies on statistical models with ≥7 years of registration in period 1976-2009 based on assumptions reflecting unknown evolution CANCER Period of Population Incident of incidence, survival, and demographic changes. REGISTRY activity at January cases up This may also affect comparisons with trends re- 1st 2010 to 2009 ported in other countries, obtained using different Period Years (per 1000) of registration included assumptions and statistical models [4, 6, 26]. In our to 2009 medium-term projections, the hypothesis that Alto 1995–2010 15 494 37,119 complete prevalence at 2020 can be predicted by a Adige - Sudtirol linear function of calendar year as regressor variable Biella 1995–2010 15 185 20,362 is supported by empirical evidence, at least for all Catania- 2003–2011 7 1727 58,753 cancer types combined and for most frequent cancer Messina types, consistently showing an approximate linear Catanzaro 2003–2009 7 230 7755 trend in recent years [5, 21]. Notably, the use of a Como 2003–2011 7 577 24,963 longer period (5 calendar years) to estimate linear slope did not materially modify the estimates. Ferrara 1991–2011 19 354 50,925 Detailed estimates and projections of numbers of Friuli 1995–2010 15 1219 128,738 persons living after different cancer diagnoses are Venezia Giulia particularly relevant for policy makers to better plan Genova 1986–2009 24 592 112,812 health care resource allocation and meet cancer pa- tients needs, including not only initial treatment, but Latina 1996–2011 14 531 32,330 also rehabilitation and long-term surveillance. How- Mantova 1999–2010 11 404 27,541 ever, to date, guidelines pertaining to survivorship Milano 1999–2010 11 1215 103,283 care have been largely based on consensus rather Modena 1988–2011 22 676 84,155 than on empirical evidence [35–37]. Napoli 1996–2011 14 561 28,250 In the USA, the main driver of cancer costs growth is Nuoro 2003–2011 7 219 7889 population ageing, with an overall increase of 27% by the year 2020 from 2010 levels [38]. The largest increase Palermo 2003–2011 7 1239 40,926 in expenditures is attributable to the continuing phase of Parma 1978–2011 32 420 80,744 care (i.e., > 1-year post-diagnosis and > 1 year from Ragusa 1981–2011 29 303 31,283 death) for prostate and female breast cancer, with 42 Reggio 1996–2011 14 508 41,379 and 32% increase respectively [38]. Although health care Emilia costs in the continuing phase of care is lower than in Romagna 1993–2011 17 1058 119,458 the first course of treatment (first year since diagnosis) Salerno 1996–2009 14 1089 63,293 and in the last year of life, the large number of survi- Sassari 1992–2011 18 467 37,988 vors in the continuing phase of care is driving most of healthcare resources. Similar findings, on the Siracusa 1999–2011 11 400 18,927 distribution of cancer burden by phase of care, are Sondrio 1998–2011 12 181 13,003 expected in Italy [39]. Trapani 2002–2009 8 429 15,591 Umbria 1994–2011 16 875 85,138 Varese 1976-2011 34 860 137,184 Conclusions Veneto 1990–2009 20 2097 245,898 The availability of reliable and accurate estimates of complete prevalence and predictions of the rising All CRs 18,909 1,655,687 tide of people living after cancer diagnosis may be Italy 59,190 helpful not only to epidemiologists and health-care All types but skin non-melanoma planners, but also to clinicians in developing CRs included to estimate model-based incidence and survival (47% of all cancer cases) guidelines to enhance and standardize the long-term follow-up of cancer survivors. Furthermore, these estimates are intended for patients to help recovering social activities and supporting rehabilita- tion demands. Guzzinati et al. BMC Cancer (2018) 18:169 Page 10 of 13 Appendix 2 Complete cancer prevalence (cases and proportion) by cancer type and age at prevalence in Italian men and women at January 1, 2010 Cancer type Prevalent cases Prevalence proportion × 100,000 All ages % 00-14 15-44 45-54 55-64 65-74 75-84 85+ All ages 00-14 15-44 45-54 55-64 65-74 75-84 85+ All types but skin non-melanoma 2,637,975 8747 196,699 263,746 475,879 727,578 714,197 251,129 4552 102 859 3103 6635 12,068 16,620 16,700 Upper aero-digestive tract 42,178 1.6% 38 3216 5007 9692 11,759 9410 3055 76 0 14 62 142 209 224 204 Esophagus 4192 0.2% – 71 354 921 1453 1139 254 8 – 0 5 15 28 30 20 Stomach 81,507 3.1% 2 1415 4479 10,654 22,237 29,491 13,229 137 0 6 49 141 354 669 866 Small intestine 5981 0.2% – 356 627 1255 1675 1602 466 11 – 2 7 18 29 38 33 Colon, rectum, anus 357,379 13.5% 15 5472 17,362 53,849 105,252 123,177 52,253 611 0 23 207 746 1715 2821 3426 Liver 24,785 0.9% 119 575 1910 4774 8529 7678 1199 43 1 3 23 66 142 180 83 Biliary tract 9816 0.4% 3 131 524 1549 2882 3375 1352 16 0 0 6 21 45 75 90 Pancreas 12,128 0.5% 3 524 1093 2622 3575 3194 1116 21 0 2 12 36 61 75 71 Larynx 49,217 1.9% 2 304 2469 9297 16,293 16,177 4676 86 0 1 29 129 271 376 321 Lung 86,769 3.3% 21 1415 5144 15,947 29,923 28,343 5976 147 0 6 58 216 484 654 394 Thymus, heart, 4501 0.2% 103 898 842 958 959 636 105 7 1 3 9 11 15 14 8 mediastinum Bone 13,932 0.5% 251 4168 3087 2721 1902 1391 411 22 3 17 32 34 29 32 26 Skin melanoma 102,492 3.9% 52 17,448 17,339 20,767 22,774 17,820 6292 182 1 80 210 296 388 430 448 Mesothelioma 2763 0.1% – 90 195 605 1137 640 96 5 – 02 8 20 15 7 Kaposi sarcoma 7601 0.3% 3 672 718 1061 1605 2248 1294 14 0 3 9 16 27 54 86 Connective tissue 21,674 0.8% 429 4578 3095 3855 4349 3793 1576 37 6 20 37 54 74 87 107 Female breast 604,841 22.9% – 26,663 82,068 128,514 165,456 142,658 59,483 2046 – 236 1906 3516 5164 5643 5751 Vagina and vulva 9689 0.4% 17 256 557 982 2377 3570 1931 32 0 2 13 27 71 137 183 Cervix uteri 58,879 2.2% 4 4321 8073 10,569 13,177 15,641 7093 193 0 38 184 280 397 591 675 Corpus uteri 103,321 3.9% – 1490 5745 21,047 31,548 31,158 12,333 342 – 13 135 553 964 1198 1147 (endometrium) Ovary 45,620 1.7% 65 4058 6617 10,544 11,399 9729 3209 149 1 34 154 276 352 372 291 Penis 4285 0.2% – 91 413 795 1309 1255 422 14 – 1 9 22 45 68 84 Prostate 305,044 11.6% 3 438 3387 34,764 112,958 122,376 31,118 1112 0 5 88 1048 4138 7143 6878 Testis 37,937 1.4% 86 17,116 8495 5349 3317 2389 1187 133 2 149 197 152 128 133 243 Kidney 98,065 3.7% 725 5211 8450 17,941 29,073 28,174 8491 172 8 23 101 253 483 674 585 Bladder 240,433 9.1% 31 4164 11,144 35,049 70,614 87,535 31,896 416 0 19 132 485 1165 2041 2123 Choroidal melanoma 3514 0.1% – 264 419 658 929 933 311 6 – 1 5 10 16 23 22 Brain and central 39,255 1.5% 1069 11,602 6542 6495 6400 5401 1746 63 13 49 74 89 99 111 94 nervous system Thyroid 118,853 4.5% 99 29,241 27,617 27,474 21,622 10,929 1872 202 1 127 321 375 357 268 131 Guzzinati et al. BMC Cancer (2018) 18:169 Page 11 of 13 Complete cancer prevalence (cases and proportion) by cancer type and age at prevalence in Italian men and women at January 1, 2010 (Continued) Cancer type Prevalent cases Prevalence proportion × 100,000 All ages % 00-14 15-44 45-54 55-64 65-74 75-84 85+ All ages 00-14 15-44 45-54 55-64 65-74 75-84 85+ Hodgkin lymphoma 48,254 1.8% 266 18,801 9478 8333 6355 4085 935 81 3 81 111 110 101 94 59 Non-Hodgkin lymphoma 110,715 4.2% 891 13,979 15,380 22,608 27,417 23,916 6523 191 10 61 179 314 458 565 456 Leukemias 67,301 2.6% 3389 15,065 7551 10,057 13,676 12,770 4793 112 39 64 86 136 217 291 312 Multiple myeloma (plasma cell) 25,066 1.0% – 542 2044 5003 7662 7494 2320 43 – 2 24 69 126 176 149 For sex-specific types proportions were also sex-specific Guzzinati et al. BMC Cancer (2018) 18:169 Page 12 of 13 Acknowledgements USL Ferrara, Ferrara, Italy. Reggio Emilia Cancer Registry, Epidemiology unit, The authors thank Mrs. Luigina Mei for editorial assistance. AUSL ASMN-IRCCS, Azienda USL di Reggio Emilia, Reggio Emilia, Italy. Palermo and Province Cancer Registry, Clinical Epidemiology Unit, Azienda Funding Ospedaliera Universitaria Policlinico “Paolo Giaccone”, Palermo, Italy. North The study was funded by the Italian Association for Cancer Research (AIRC) Sardinia Cancer Registry, Azienda Regionale per la Tutela della Salute, Sassari, 21 22 (grant no. 16921). Role of funding source: The funding sources had no role Italy. Sudtyrol Cancer Registry, Bolzano, Italy. Cancer Registry of Latina in study design, collection, analysis or interpretation of data, the writing of Province, AUSL Latina, Latina, Italy. Cancer Registry ASP Ragusa, Ragusa, 24 25 the report, or the decision to submit the article for publication. Italy. Cancer Registry of ASL Napoli 3 Sud, Napoli, Italy. Mantova Cancer Registry, Epidemilogy Unit, Agenzia di Tutela della Salute (ATS) della Val Availability of data and materials Padana, Mantova, Italy. Como Cancer Registry, ATS Insubria, Varese, Italy. 27 28 Dataset supporting our findings is available, according to AIRTUM guidelines, Registro Tumori Piemonte, Provincia di Biella CPO, Biella, Italy. Cancer at the following website: www.registri-tumori.it. Registry of of the Province of Siracusa, Local Health Unit of Siracusa, Siracusa, Italy. Trapani Cancer Registry, Dipartimento di Prevenzione della Salute, Authors’ contributions Trapani, Italy. Sondrio Cancer Registry, Health Protection Agency, Sondrio, SG and LDM drafted the study protocol, designed the study, and drafted the Italy. Nuoro Cancer Registry, RT Nuoro, ASSL Nuoro/ATS Sardegna, Nuoro, manuscript with the support of RDA. All authors (SG, SV, RDA, CP, CB, RC, SiF, Italy. Catanzaro Cancer Registry, Azienda Sanitaria 7, Catanzaro, Italy. 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Characteristics of people living in Italy after a cancer diagnosis in 2010 and projections to 2020

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Springer Journals
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Copyright © The Author(s). 2018. corrected publication 2021
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1471-2407
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10.1186/s12885-018-4053-y
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Abstract

Background: Estimates of cancer prevalence are widely based on limited duration, often including patients living after a cancer diagnosis made in the previous 5 years and less frequently on complete prevalence (i.e., including all patients regardless of the time elapsed since diagnosis). This study aims to provide estimates of complete cancer prevalence in Italy by sex, age, and time since diagnosis for all cancers combined, and for selected cancer types. Projections were made up to 2020, overall and by time since diagnosis. Methods: Data were from 27 Italian population-based cancer registries, covering 32% of the Italian population, able to provide at least 7 years of registration as of December 2009 and follow-up of vital status as of December 2013. The data were used to compute the limited-duration prevalence, in order to estimate the complete prevalence by means of the COMPREV software. Results: In 2010, 2,637,975 persons were estimated to live in Italy after a cancer diagnosis, 1.2 million men and 1.4 million women, or 4.6% of the Italian population. A quarter of male prevalent cases had prostate cancer (n = 305,044), while 42% of prevalent women had breast cancer (n = 604,841). More than 1.5 million people (2.7% of Italians) were alive since 5 or more years after diagnosis and 20% since ≥15 years. It is projected that, in 2020 in Italy, there will be 3.6 million prevalent cancer cases (+ 37% vs 2010). The largest 10-year increases are foreseen for prostate (+ 85%) and for thyroid cancers (+ 79%), and for long-term survivors diagnosed since 20 or more years (+ 45%). Among the population aged ≥75 years, 22% will have had a previous cancer diagnosis. (Continued on next page) * Correspondence: stefano.guzzinati@regione.veneto.it; registro.tumori@regione.veneto.it; dalmaso@cro.it; epidemiology@cro.it Deceased Veneto Tumor Registry, Veneto Region, Padova, Passaggio Gaudenzio 1, 35131 Padova, Italy Cancer Epidemiology Unit, CRO Aviano National Cancer Institute IRCCS, Via Franco Gallini 2, 33081 Aviano, PN, Italy Full list of author information is available at the end of the article © The Author(s). 2018, corrected publication 20O21pen Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Guzzinati et al. BMC Cancer (2018) 18:169 Page 2 of 13 (Continued from previous page) Conclusions: The number of persons living after a cancer diagnosis is estimated to rise of approximately 3% per year in Italy. The availability of detailed estimates and projections of the complete prevalence are intended to help the implementation of guidelines aimed to enhance the long-term follow-up of cancer survivors and to contribute their rehabilitation needs. Keywords: Cancer prevalence, Projections, Survivors, Italy Background agreed to participate in the study and were able to Estimates of cancer prevalence are widely based on lim- provide at least 7 years of cancer registration as of ited duration prevalence, including only patients living December 31, 2009 (Appendix 1)andfollow-upof after a cancer diagnosis made in the previous 5 years vital status as of December 31, 2013. The Italian le- [1, 2]. Prevalence, regardless of the time since diagnosis gislation identifies Cancer Registries as collectors of (i.e., complete prevalence), is less frequently estimated personal data for surveillance purposes without ex- than limited duration prevalence [3–9]. Overall age- plicit individual consent. The approval of a research standardized cancer incidence and mortality rates have ethic committee is not required, since this descrip- declined over the past 10 years in the majority of high tive study was conducted without any direct or in- income countries, whereas the complete prevalence has direct intervention on patients. been consistently increasing in the early 2000s [3, 4, 6, Prevalence for all malignant tumours (ICD-10: C00- 8, 10, 11]. Complete prevalence is generally measured C43, C45-C96) and 34 cancer types or their combina- in absolute numbers and proportions, i.e., not age- tions were estimated and presented in this study for all standardized. Thus, improved survival [12, 13]and age groups. Urinary bladder cancers with benign or un- population ageing (increasing absolute number of new certain behaviour, and in situ tumours were also in- cancer diagnoses) imply a progressive increase in cluded. Only non melanoma skin cancers (ICD-10 C44) tumour prevalence. were excluded. ICD-O-3 morphology codes were used to Cancer prevalence includes patients currently treated define specific subtypes. for cancer; those who have become cancer free, but still have a measurable excess risk of recurrence or death; Statistical methods and, finally, patients having death rates similar to those The clinical and demographic characteristics of the of the general population who can be considered “cured persons registered with a diagnosis of cancers in the patients” [14]. Many of these individuals are possibly af- Italian CRs were used to estimate: 1) how many of fected by physical, cognitive, and/or psychosocial limita- them were still alive at January 1, 2010 regardless tions [15]. of time since diagnosis -i.e., complete prevalence The aim of this study was to provide a description of count- by cancer type, sex, and age group; 2) the the number of people living in Italy at January 1, 2010 prevalence proportion in Italy at 2010 for each can- after a cancer diagnosis, for all cancers combined and cer type, by sex, and age; 3) the complete prevalence for a selection of cancer types by sex, age, and time since (count and proportion) at 1st January 2015 and diagnosis. In addition, projections of cancer prevalence 2020, overall and by time since diagnosis; and 4) de- in Italy are presented up to the year 2020. Estimates and scribe the changing over time of these estimates. projections of complete tumour prevalence and charac- For each cancer registry we computed the limited teristics of prevalent patients are necessary to help clini- duration prevalence, i.e. the number of patients diag- cians and health care planners in improving long-term nosed in the period of the registration activity (be- care of patients and in allocating appropriately health tween 7 and 34 years) at January 1, 2010, using the care resources. Moreover, they may provide helpful counting method implemented in SEER*Stat software information to a growing number of cancer patients or [16]. This maximum limited duration prevalence was former patients. corrected, using the COMPREV software [17], by means of completeness index [18, 19], to estimate Methods the total number of cancer patients alive, regardless Study design and data sources of when they were diagnosed. Completeness indices This is a descriptive analysis of individual data col- were estimated by cancer type, sex, age, and time lected during the period 1976-2009 from 27 since diagnosis. Prevalence was computed as an ab- population-based Italian cancer registries (i.e., 32% solute number, as well as a proportion per 100,000 of the entire Italian population in 2010), which residents people by cancer type, sex, age group, area Guzzinati et al. BMC Cancer (2018) 18:169 Page 3 of 13 of residence, and years since diagnosis. Patients with age: 3.1% at age 45-54 years, 6.6% at 55-64 years, more than one primary cancer were included in the 12.1% at 65-74 years, and nearly 17% after age 75 years computation of prevalence for each cancer type or (Appendix 2)with differencesby sex(Tables 1 and 2). combination. In the analyses for all types combined, Men living in Italy after a cancer diagnosis in 2010 only the first cancer was considered. Completeness were 1,194,033, corresponding to 4.3% (4250/ indices were obtained by statistical regression models 100,000) of all Italian male population (Table 1). of incidence and survival using data from 8 long-term This proportion increased from less than 1% below registries (Appendix 1) with an available observation the age of 45 years, to > 20% for men aged ≥75 years. period of at least 18 years before 2010 [20, 21]. Rela- The most frequent tumours in terms of prevalence tive survival and incidence functions were estimated were prostate (305,044 of prevalent cases at January, by means of parametric models within the period 1st 2010) representing 25.5% of all cases or 1.1% of 1985-2011 for survival and 1985-2009 for incidence. all Italian men, followed by bladder (192,611 men, The survival model was a parametric cure model as- 16.1%) and colorectal (185,532 men, 15.5%) tumours. suming that a proportion of individuals with cancer Italian women living after a cancer diagnosis were were bound to die (fatal cases) with a survival follow- 1,443,942 (Table 2), corresponding to 4.8% of all Ital- ing a Weibull distribution, while the remaining pro- ian women. Breast cancer represented 41.9% of all portion (cured fraction) had the same mortality rate cancers (604,841), followed by colorectal cancers as that of the general population with the same age (171,847, 11.9% of all female prevalent cases, 0.6% of and gender stratification [14, 20]. The parameters of all Italian women) and by endometrial cancers the survival model were estimated by cancer type, (103,321, 7.2% and 0.3%, respectively). Notably, the sex, and age class (0-14, 15-44, 45-54, 55-64, 65-74, fourth most frequent cancer type diagnosed in Italian 75+ years) through the SAS procedure NLIN. A prevalent women is thyroid (93,341 women, 6.5% of period effect was included on the hazard of dying of all female prevalent cases). Prevalent women were cancer. Incidence data were categorised according to younger than men. Women aged 15-44 years living cancer type, sex, five-year age group, and birth cohort after a diagnosis represented 1% of the whole Italian (< 1899, 1900-1904,…, 2005-2009). A sixth degree population, they were 4% at ages 45-54 years, 7% at polynomial age-cohort model of crude incidence rates ages 55-64 years, 11% at ages 65-74 years, and 14% was fitted through the SAS LOGISTIC procedure for for women aged ≥75 years (Table 2). each cancer type and sex [21]. More than 1.5 million people (i.e., 2.7% of all Italian Complete prevalence proportions were projected to residents) were alive after ≥5 years since diagnosis. They 2020 by cancer type, sex, age, and registry, assuming were 60% of all prevalent cases, 64% of women and 55% that complete prevalence will follow a linear func- of men. The distribution of prevalent cases by time since tion, based on the trend of the last three calendar diagnosis depends on cancer type (Fig. 1). The percent- years (i.e., 2007-2009). This simplified assumption age of prevalent cases diagnosed since less than 2 years (linear and constant trend) may not be valid for varied from 39% for lung cancer patients to 15% for long-term projections, but it is reasonable for short female breast and 7% for cervical cancer patients. Con- or medium-term (e.g., 10-year) ones. Other assump- versely, the percentage of prevalent cases diagnosed tions (e.g., log-linear models) were explored [4, 6], ≥15 years before was 59% for cervical cancer, 35% for showing consistent results for common cancer types, stomach cancer and 31% for endometrial cancer, but but unstable projections for the rarest. only 4% for prostate and 13% for lung cancer patients. The absolute number of prevalent cases in Italy Notably, patients diagnosed ≥15 years before were was obtained using proportions of prevalence esti- 21% of all prevalent cases (16% among men and 25% mates (age-, sex-, and cancer type-specific) from CRs among women). included in this study, multiplied by the Italian na- tional population by sex and age observed at January Prevalence projections for 2020 1, 2010. Proportions projected to 2020 were thus In 2020, there will be 3.6 million prevalent cancer cases in multiplied to Italian population forecasted at January Italy (Table 3), 1.9 million women and 1.7 million men, 1, 2020 [22]. with a 10-year increase of 37% (41 and 33% in men and women, respectively). In 2020, 2.6% of all Italian women Results (0.8 millions) will be alive after a breast cancer diagnosis Prevalence estimates at 2010 and more than half a million patients (2.1% of all men) will In Italy in 2010, 2,637,975 persons were alive after a cancer be alive after a prostate cancer diagnosis (Table 3). The lar- diagnosis, corresponding to 4.6% of all the Italian popula- gest 10-year increases are foreseen for prostate (+ 85%) and tion (Appendix 2). Prevalence proportions increase with for thyroid cancers (+ 79%, 212,863 cases), which will Guzzinati et al. BMC Cancer (2018) 18:169 Page 4 of 13 Table 1 Complete cancer prevalence by cancer type and age in Italian men at January 1, 2010 Cancer type Prevalent cases Prevalence proportion per 100,000 men All ages % 00-14 15-44 45-54 55-64 65-74 75-84 85+ All ages 00-14 15-44 45-54 55-64 65-74 75-84 85+ All types but skin non-melanoma 1,194,033 4844 84,172 87,091 198,505 363,932 357,051 98,439 4250 111 732 2079 5715 13,029 20,534 21,955 Upper aero-digestive tract 26,745 2.2% 19 1654 3320 6536 8063 5786 1367 100 0 15 84 199 311 337 313 Esophagus 3067 0.3% 0 54 252 722 1105 781 153 12 0 1 7 23 45 51 40 Stomach 45,970 3.8% 2 764 2583 6661 13,618 16,538 5802 158 0 6 58 180 470 926 1268 Small intestine 3384 0.3% 0 221 350 760 987 850 216 13 0 2 8 23 38 52 46 Colon, rectum, anus 185,532 15.5% 3 2718 8722 29,332 59,931 63,698 21,130 654 0 23 210 840 2108 3618 4682 Liver 17,454 1.5% 57 317 1539 3831 6347 4752 610 63 2 3 37 110 228 280 142 Biliary tract 4251 0.4% 0 70 238 713 1365 1443 421 15 0 0 6 20 47 80 103 Pancreas 5856 0.5% 3 198 598 1383 1876 1462 336 21 0 2 14 39 69 84 75 Larynx 44,810 3.8% 0 236 2105 8399 15,082 14,819 4169 160 0 2 51 240 540 854 965 Lung 63,048 5.3% 16 804 2771 11,014 22,765 21,682 3996 219 0 7 64 306 787 1229 890 Thymus, heart, mediastinum 2290 0.2% 42 384 435 548 516 331 33 7 1 3 9 14 18 18 9 Bone 4808 0.4% 152 1910 924 771 596 418 37 16 3 16 20 21 19 22 10 Skin melanoma 44,977 3.8% 21 6730 7411 9817 11,117 7867 2014 165 0 61 181 291 408 470 488 Mesothelioma 2090 0.2% 0 72 127 457 913 466 54 8 0 1 3 13 34 27 12 Kaposi sarcoma 5611 0.5% 3 567 658 864 1255 1498 766 21 0 5 17 26 46 90 174 Connective tissue 11,757 1.0% 226 2685 1696 2043 2459 2002 647 41 6 23 41 59 87 111 144 Penis 4285 0.4% 0 91 413 795 1309 1255 422 14 0 1 9 22 45 68 84 Prostate 305,044 25.5% 3 438 3387 34,764 112,958 122,376 31,118 1112 0 5 88 1048 4138 7143 6878 Testis 37,937 3.2% 86 17,116 8495 5349 3317 2389 1187 133 2 149 197 152 128 133 243 Kidney 62,815 5.3% 314 2842 5609 12,652 19,613 17,524 4262 226 7 25 134 364 703 1030 984 Bladder 192,611 16.1% 25 2802 8582 28,948 59,204 70,749 22,302 686 0 26 204 821 2104 4074 5053 Choroidal melanoma 1801 0.2% 0 115 209 365 484 519 109 7 0 1 6 11 18 30 25 Brain and central nervous system 16,110 1.3% 568 5391 2881 2930 2525 1423 391 54 13 46 65 81 82 78 66 Thyroid 25,512 2.1% 31 6428 5811 5876 4665 2351 349 89 1 56 137 165 166 136 80 Hodgkin lymphoma 27,821 2.3% 165 9685 5488 5229 4133 2684 437 95 4 83 129 139 141 148 99 Non-Hodgkin lymphoma 56,808 4.8% 629 8344 8754 11,691 13,802 11,185 2403 203 14 72 206 339 501 655 574 Leukemias 36,105 3.0% 1939 7620 4086 5656 8050 6703 2051 124 43 65 94 158 276 373 444 Multiple myeloma (plasma cell) 12,787 1.1% 0 326 1158 2636 4050 3680 938 45 0 3 27 75 143 215 207 Guzzinati et al. BMC Cancer (2018) 18:169 Page 5 of 13 Table 2 Complete cancer prevalence by cancer type and age in Italian women at January 1, 2010 Cancer type Prevalent cases Prevalence proportion per 100,000 women All ages % 00-14 15-44 45-54 55-64 65-74 75-84 85+ All ages 00-14 15-44 45-54 55-64 65-74 75-84 85+ All types but skin non-melanoma 1,443,942 3903 112,527 176,656 277,374 363,646 357,146 152,690 4836 93 988 4095 7496 11,243 13,994 14,500 Upper aero-digestive tract 15,433 1.1% 19 1562 1687 3156 3696 3624 1688 54 0 14 41 87 123 148 158 Esophagus 1125 0.1% 0 17 102 199 348 358 101 4 0 03613 16 11 Stomach 35,537 2.5% 0 651 1896 3992 8619 12,953 7426 117 0 5 41 104 254 497 698 Small intestine 2597 0.2% 0 136 277 495 688 752 250 9 0 1 6 14 21 29 28 Colon, rectum, anus 171,847 11.9% 12 2754 8640 24,517 45,322 59,479 31,123 571 0 24 204 658 1377 2287 2901 Liver 7331 0.5% 61 258 371 943 2182 2926 589 25 1 2 9 25 68 114 58 Biliary tract 5565 0.4% 3 60 286 836 1517 1932 931 18 0 0 6 22 44 72 84 Pancreas 6271 0.4% 0 326 495 1239 1699 1733 780 21 0 3 11 33 55 68 69 Larynx 4407 0.3% 2 68 364 898 1211 1358 508 16 0 1 8 26 41 55 52 Lung 23,721 1.6% 5 611 2373 4933 7158 6662 1980 80 0 6 53 133 224 268 186 Thymus, heart, mediastinum 2212 0.2% 61 514 406 410 443 306 72 7 2 49912 11 7 Bone 9124 0.6% 100 2259 2163 1950 1306 973 374 28 3 19 43 47 38 38 32 Skin melanoma 57,515 4.0% 30 10,718 9929 10,950 11,657 9953 4278 198 1 98 237 302 372 404 432 Mesothelioma 674 0.0% 0 18 68 148 224 174 42 2 0 0248 8 5 Kaposi sarcoma 1990 0.1% 0 105 60 197 349 750 528 7 0 12612 30 49 Connective tissue 9917 0.7% 203 1893 1399 1812 1890 1791 929 34 5 17 32 49 62 71 91 Breast 604,841 41.9% 0 26,663 82,068 128,514 165,456 142,658 59,483 2046 0 236 1906 3516 5164 5643 5751 Vagina and vulva 9689 0.7% 17 256 557 982 2377 3570 1931 32 0 2 13 27 71 137 183 Cervix uteri 58,879 4.1% 4 4321 8073 10,569 13,177 15,641 7093 193 0 38 184 280 397 591 675 Corpus uteri (endometrium) 103,321 7.2% 0 1490 5745 21,047 31,548 31,158 12,333 342 0 13 135 553 964 1198 1147 Ovary 45,620 3.2% 65 4058 6617 10,544 11,399 9729 3209 149 1 34 154 276 352 372 291 Kidney 35,250 2.4% 411 2369 2841 5290 9461 10,650 4229 122 9 21 68 149 293 436 418 Bladder 47,822 3.3% 6 1362 2562 6101 11,410 16,786 9594 164 0 12 62 172 359 676 897 Choroidal melanoma 1713 0.1% 0 149 210 294 445 414 202 6 0 14914 18 21 Brain and central nervous system 23,145 1.6% 501 6210 3661 3565 3875 3978 1355 72 12 52 82 96 114 133 105 Thyroid 93,341 6.5% 68 22,813 21,805 21,597 16,956 8578 1524 307 2 199 498 571 521 356 153 Hodgkin lymphoma 20,433 1.4% 102 9116 3990 3104 2222 1401 498 67 2 79 93 84 67 58 43 Non-Hodgkin lymphoma 53,907 3.7% 262 5635 6626 10,917 13,615 12,731 4120 181 6 49 153 290 422 505 407 Leukemias 31,196 2.2% 1450 7445 3465 4400 5626 6067 2742 101 34 64 78 115 166 235 256 Multiple myeloma (plasma cell) 12,278 0.9% 0 217 887 2367 3611 3814 1382 41 0 2 22 64 112 150 124 Guzzinati et al. BMC Cancer (2018) 18:169 Page 6 of 13 Fig. 1 Complete prevalence by time since diagnosis for selected cancer types* in Italy at January 1, 2010. *Cancer types diagnosed in > 50,000 persons, sorted by number of cases Table 3 Projected complete prevalence (cases) at January 1, 2020 by sex and 10-year variations in Italy Prevalent cases Variation (%) 2020 10-year period Cancer Type Men Women Total Men Women Total All types but skin non-melanoma 1687,049 1,922,086 3,609,135 41.3% 33.1% 36.8% Upper aero-digestive tract 36,081 21,831 57,911 34.9% 41.5% 37.3% Stomach 50,327 32,033 82,360 9.5% −9.9% 1.0% Colon, Rectum, Anus 280,277 233,245 513,522 51.1% 35.7% 43.7% Liver 25,234 8531 33,765 44.6% 16.4% 36.2% Larynx 47,015 6006 53,020 4.9% 36.3% 7.7% Lung 77,159 40,657 117,816 22.4% 71.4% 35.8% Skin Melanoma 80,069 89,831 169,900 78.0% 56.2% 65.8% Connective Tissue 17,040 11,815 28,855 44.9% 19.1% 33.1% Female Breast 834,154 834,154 37.9% 37.9% Cervix Uteri 51,136 51,136 −13.2% −13.2% Corpus Uteri (endometrium) 122,553 122,553 18.6% 18.6% Ovary 49,807 49,807 9.2% 9.2% Prostate 563,960 563,960 84.9% 84.9% Testis 63,395 63,395 67.1% 67.1% Kidney 97,249 47,151 144,400 54.8% 33.8% 47.2% Bladder 255,015 58,608 313,624 32.4% 22.6% 30.4% Brain and central nervous system 23,505 29,314 52,819 45.9% 26.7% 34.6% Thyroid 45,949 166,914 212,863 80.1% 78.8% 79.1% Hodgkin Lymphoma 37,692 29,314 67,006 35.5% 43.5% 38.9% Non- Hodgkin Lymphoma 82,780 73,584 156,364 45.7% 36.5% 41.2% Leukaemias 45,880 39,100 84,980 27.1% 25.3% 26.3% Multiple Myeloma 19,472 17,159 36,631 52.3% 39.8% 46.1% Cancer types with more than 20,000 prevalent cases at 2010 Guzzinati et al. BMC Cancer (2018) 18:169 Page 7 of 13 Table 4 Projected complete prevalence at January 1, 2020 by sex and age groups in Italy SEX, Cancer type Prevalent cases Prevalence proportion per 100,000 All ages % 00-44 45-74 75+ All ages 00-44 45-74 75+ MEN and WOMEN All types but skin non-melanoma 3,609,135 100.0% 228,145 1,897,543 1,483,448 5731 726 16,383 21,657 Colon, rectum, anus 513,522 14.2% 4954 231,800 276,767 808 15 2080 3952 Skin melanoma 169,900 4.7% 24,038 101,180 44,682 271 76 857 673 Female breast 834,154 23.1% 29,758 498,614 305,781 2622 201 8215 7297 Corpus uteri (endometrium) 122,553 3.4% 1707 65,765 55,081 379 10 1104 1269 Prostate 563,960 15.6% 1174 255,514 307,272 2056 12 5634 12,343 Bladder 313,624 8.7% 4130 128,332 181,162 563 15 1323 2836 Thyroid 212,863 5.9% 41,112 145,562 26,189 309 127 1084 379 Non-Hodgkin lymphoma 156,364 4.3% 14,948 87,255 54,161 247 47 739 789 MEN All types but skin non-melanoma 1687,049 100% 95,056 834,967 757,026 5444 615 15,678 28,728 Colon, rectum, anus 280,277 16.6% 2250 135,206 142,821 902 13 2573 5267 Skin melanoma 80,069 4.7% 8760 50,437 20,872 256 57 898 815 Prostate 563,960 33.4% 1174 255,514 307,272 2056 12 5634 12,343 Bladder 255,015 15.1% 2636 106,086 146,294 958 20 2323 5932 Thyroid 45,949 2.7% 9141 31,444 5364 142 59 490 209 Non-Hodgkin lymphoma 82,780 4.9% 8959 49,513 24,309 271 58 871 946 WOMEN All types but skin non-melanoma 1,922,086 100% 133,089 1,062,575 726,422 5992 888 17,374 17,007 Colon, rectum, anus 233,245 12.1% 2704 96,594 133,947 720 17 1633 3105 Skin melanoma 89,831 4.7% 15,278 50,742 23,811 284 102 822 581 Breast 834,154 43.4% 29,758 498,614 305,781 2622 201 8215 7297 Corpus uteri (endometrium) 122,553 6.4% 1707 65,765 55,081 379 10 1104 1269 Bladder 58,608 3.0% 1494 22,246 34,868 195 10 405 859 Thyroid 166,914 8.7% 31,971 114,119 20,825 508 218 1761 516 Non-Hodgkin lymphoma 73,584 3.8% 5989 37,743 29,852 225 37 618 688 Most frequent cancer types are shown: Cancer types or combinations with > 100,000 prevalent cases become the third most frequent prevalent cancer types to 2020 (+ 3% in the examined period), while a 19% among Italian women. A more than 50% increases are also increase was observed for cases diagnosed between 2 expected in 2020 for prevalence after diagnosis of testicular and 5 years before, 30-34% for cases diagnosed be- cancer (63,395 patients) or skin melanoma (169,900). A tween 5 and 20 years earlier, and 45% increased for limited change in prevalence (variations < 10%) is expected long-term survivors diagnosed ≥20 years before for ovary, larynx, and stomach, with cervical cancer being (Fig. 2). the only cancer type showing a decline in prevalence (− 13%) (Table 3). Discussion Nearly 22% (21,657/100,000) of population aged In 2010, 2.6 million people were living in Italy after ≥75 years in 2020 will have had a previous cancer a cancer diagnosis and this number will reach 3.6 diagnosis (Table 4). Below 45 years of age, prevalent million in 2020, increasing from 4.6% to 5.7% (i.e., cases will be 228,145 (i.e., 0.8% of all cases, 726/ one out of 17 Italians) of the overall population. The 100,000) and, in both sexes, the most frequent cancer estimated overall trend in the present decade in Italy type will be thyroid cancer, experienced by 31,971 (+ 3.2% per year) is comparable to that estimated in women and 9141 men. the same period in the USA (+ 2.8% per year) [5], Prevalent cases diagnosed within 2 years were the UK (+ 3.3%) [4], and Switzerland (+ 2.5%) [6]. only group showing a negligible increase from 2010 Guzzinati et al. BMC Cancer (2018) 18:169 Page 8 of 13 75 years or older (38% in men, 35% in women). In this age group, they will reach 41% in 2020, with more than 20% of men and 14% of women will have experienced a previous cancer diagnosis. These pro- portions were similar to those reported by other studies, showing also that elderly cancer patients had more severe comorbidity conditions than non cancer patients [26]. At the opposite end of the age spectrum, 8% of Italian prevalent cases were younger than 44 years of age and 10% were aged 45–54 years. It has been re- cently estimated that 44,135 persons living in Italy in 2010 had had a cancer diagnosis during childhood Fig. 2 Complete cancer prevalence (proportions) in Italy from [27]; they represented 0.07% of the Italian population 2006 to 2020 by years since diagnosis. *Data for 2006 obtained from ref. 21. Filled symbols (e.g., � ) represent estimated values, and 1.7% of prevalent cases diagnosed at any age. In empty symbols (e.g., ο) represent projected values similar studies conducted in the USA [28], a sub- stantial proportion of morbidities emerged in child- The expected 37% increase in the present decade hood cancer patients several years after diagnosis, in Italy will be more marked (i.e., nearly + 50%) and there is growing awareness on potentially long- among long-term survivors diagnosed ≥20 years be- term risks affecting the survivors’ future physical, fore;theywillbemorethanhalfamillioninItaly cognitive, and/or psychosocial health [29]. The im- (519,356), 14% of all prevalent cases (11% in men pact of a cancer diagnosis is rather different between and 18% in women). Most of them can be considered younger and older survivors, the first facing more as cured since they had already reached a similar life pronounced socio-economic consequences [30, 31], expectancy (i.e., death rates) of the corresponding as well as psychosocial impairments in fertility and general population [14]. sexuality [32, 33]. A higher proportion of women (55%) than that of We acknowledge the several limitations of our ana- men emerged among prevalent cancer cases at 2010 lyses. First, data from Italian cancer registries (AIR- in the present Italian study, in agreement with find- TUM) included one third of the Italian population in ings from most studies conducted in other countries 2010 and the representativeness for the national [4–6, 9] but France (where 53% were men, 6.4% of prevalence estimates may be questionable [34]. To the French population) [8]. In Italy, female breast overcome this issue, we adjusted estimated propor- cancer cases represented 23% of all prevalent cases, tions in cancer registry areas for the age distribution and affected the distribution of cancer prevalence by of the whole Italian population. Moreover, since can- age. The thyroid cancer epidemic in Italy also con- cer registries have been active in Italy from a rela- tributed to an excess in females, below age 45 years tively recent time period, the complete prevalence has thyroid cancer was the most frequent prevalent type been estimated through statistical models. Notably, in 2010 (29,340 men and women), and this number the validation of complete prevalence estimation by will substantially increase to more than 41,000 in means of COMPREV method in Italy and elsewhere 2020. It should be noted, however, that a large pro- [19] is reasonably reassuring. In particular, the valid- portion of thyroid cancer incidence and prevalence ation of COMPREV method shows negligible (i.e., < may be affected by overdiagnosis; i.e., the detection 5%) differences, when comparing observed prevalence of cancer cases that would not otherwise result in for cancer registries with ≥30 years of observation causing symptoms or deaths [23, 24]. and estimated prevalence using complete indexes ap- An important role on variation of cancer preva- plied to the same registries and truncated data [21, lence is played by screening programmes, inducing a page 34]. reduction of cervical and colorectal prevalent cancers On the other hand, the strengths of this cases, while early detection of breast and prostate population-based study are represented by the size of cancers may inflate number of prevalent cases [25]. the study population, which included nearly 1.7 mil- In particular, screening can prevent cervical cancer, lion incident cancer cases, and its long-term follow- with a consequent major effect on prevalence reduc- up, more than a half of these cases were followed-up tion, i.e., − 13% in 10 years in the present study. for > 20 years post diagnosis. In addition, data and Distribution of cancer prevalence by age is also period used were updated in the present study (see noteworthy. In 2010, 37% of prevalent patients were Appendix 1), including an additional number of years Guzzinati et al. BMC Cancer (2018) 18:169 Page 9 of 13 of observation and follow-up, in comparison with pre- Appendix 1 vious studies on the same topic [21]. The accuracy of future projections of prevalence is Population and incident cases in Italian cancer registries necessarily uncertain and lies on statistical models with ≥7 years of registration in period 1976-2009 based on assumptions reflecting unknown evolution CANCER Period of Population Incident of incidence, survival, and demographic changes. REGISTRY activity at January cases up This may also affect comparisons with trends re- 1st 2010 to 2009 ported in other countries, obtained using different Period Years (per 1000) of registration included assumptions and statistical models [4, 6, 26]. In our to 2009 medium-term projections, the hypothesis that Alto 1995–2010 15 494 37,119 complete prevalence at 2020 can be predicted by a Adige - Sudtirol linear function of calendar year as regressor variable Biella 1995–2010 15 185 20,362 is supported by empirical evidence, at least for all Catania- 2003–2011 7 1727 58,753 cancer types combined and for most frequent cancer Messina types, consistently showing an approximate linear Catanzaro 2003–2009 7 230 7755 trend in recent years [5, 21]. Notably, the use of a Como 2003–2011 7 577 24,963 longer period (5 calendar years) to estimate linear slope did not materially modify the estimates. Ferrara 1991–2011 19 354 50,925 Detailed estimates and projections of numbers of Friuli 1995–2010 15 1219 128,738 persons living after different cancer diagnoses are Venezia Giulia particularly relevant for policy makers to better plan Genova 1986–2009 24 592 112,812 health care resource allocation and meet cancer pa- tients needs, including not only initial treatment, but Latina 1996–2011 14 531 32,330 also rehabilitation and long-term surveillance. How- Mantova 1999–2010 11 404 27,541 ever, to date, guidelines pertaining to survivorship Milano 1999–2010 11 1215 103,283 care have been largely based on consensus rather Modena 1988–2011 22 676 84,155 than on empirical evidence [35–37]. Napoli 1996–2011 14 561 28,250 In the USA, the main driver of cancer costs growth is Nuoro 2003–2011 7 219 7889 population ageing, with an overall increase of 27% by the year 2020 from 2010 levels [38]. The largest increase Palermo 2003–2011 7 1239 40,926 in expenditures is attributable to the continuing phase of Parma 1978–2011 32 420 80,744 care (i.e., > 1-year post-diagnosis and > 1 year from Ragusa 1981–2011 29 303 31,283 death) for prostate and female breast cancer, with 42 Reggio 1996–2011 14 508 41,379 and 32% increase respectively [38]. Although health care Emilia costs in the continuing phase of care is lower than in Romagna 1993–2011 17 1058 119,458 the first course of treatment (first year since diagnosis) Salerno 1996–2009 14 1089 63,293 and in the last year of life, the large number of survi- Sassari 1992–2011 18 467 37,988 vors in the continuing phase of care is driving most of healthcare resources. Similar findings, on the Siracusa 1999–2011 11 400 18,927 distribution of cancer burden by phase of care, are Sondrio 1998–2011 12 181 13,003 expected in Italy [39]. Trapani 2002–2009 8 429 15,591 Umbria 1994–2011 16 875 85,138 Varese 1976-2011 34 860 137,184 Conclusions Veneto 1990–2009 20 2097 245,898 The availability of reliable and accurate estimates of complete prevalence and predictions of the rising All CRs 18,909 1,655,687 tide of people living after cancer diagnosis may be Italy 59,190 helpful not only to epidemiologists and health-care All types but skin non-melanoma planners, but also to clinicians in developing CRs included to estimate model-based incidence and survival (47% of all cancer cases) guidelines to enhance and standardize the long-term follow-up of cancer survivors. Furthermore, these estimates are intended for patients to help recovering social activities and supporting rehabilita- tion demands. Guzzinati et al. BMC Cancer (2018) 18:169 Page 10 of 13 Appendix 2 Complete cancer prevalence (cases and proportion) by cancer type and age at prevalence in Italian men and women at January 1, 2010 Cancer type Prevalent cases Prevalence proportion × 100,000 All ages % 00-14 15-44 45-54 55-64 65-74 75-84 85+ All ages 00-14 15-44 45-54 55-64 65-74 75-84 85+ All types but skin non-melanoma 2,637,975 8747 196,699 263,746 475,879 727,578 714,197 251,129 4552 102 859 3103 6635 12,068 16,620 16,700 Upper aero-digestive tract 42,178 1.6% 38 3216 5007 9692 11,759 9410 3055 76 0 14 62 142 209 224 204 Esophagus 4192 0.2% – 71 354 921 1453 1139 254 8 – 0 5 15 28 30 20 Stomach 81,507 3.1% 2 1415 4479 10,654 22,237 29,491 13,229 137 0 6 49 141 354 669 866 Small intestine 5981 0.2% – 356 627 1255 1675 1602 466 11 – 2 7 18 29 38 33 Colon, rectum, anus 357,379 13.5% 15 5472 17,362 53,849 105,252 123,177 52,253 611 0 23 207 746 1715 2821 3426 Liver 24,785 0.9% 119 575 1910 4774 8529 7678 1199 43 1 3 23 66 142 180 83 Biliary tract 9816 0.4% 3 131 524 1549 2882 3375 1352 16 0 0 6 21 45 75 90 Pancreas 12,128 0.5% 3 524 1093 2622 3575 3194 1116 21 0 2 12 36 61 75 71 Larynx 49,217 1.9% 2 304 2469 9297 16,293 16,177 4676 86 0 1 29 129 271 376 321 Lung 86,769 3.3% 21 1415 5144 15,947 29,923 28,343 5976 147 0 6 58 216 484 654 394 Thymus, heart, 4501 0.2% 103 898 842 958 959 636 105 7 1 3 9 11 15 14 8 mediastinum Bone 13,932 0.5% 251 4168 3087 2721 1902 1391 411 22 3 17 32 34 29 32 26 Skin melanoma 102,492 3.9% 52 17,448 17,339 20,767 22,774 17,820 6292 182 1 80 210 296 388 430 448 Mesothelioma 2763 0.1% – 90 195 605 1137 640 96 5 – 02 8 20 15 7 Kaposi sarcoma 7601 0.3% 3 672 718 1061 1605 2248 1294 14 0 3 9 16 27 54 86 Connective tissue 21,674 0.8% 429 4578 3095 3855 4349 3793 1576 37 6 20 37 54 74 87 107 Female breast 604,841 22.9% – 26,663 82,068 128,514 165,456 142,658 59,483 2046 – 236 1906 3516 5164 5643 5751 Vagina and vulva 9689 0.4% 17 256 557 982 2377 3570 1931 32 0 2 13 27 71 137 183 Cervix uteri 58,879 2.2% 4 4321 8073 10,569 13,177 15,641 7093 193 0 38 184 280 397 591 675 Corpus uteri 103,321 3.9% – 1490 5745 21,047 31,548 31,158 12,333 342 – 13 135 553 964 1198 1147 (endometrium) Ovary 45,620 1.7% 65 4058 6617 10,544 11,399 9729 3209 149 1 34 154 276 352 372 291 Penis 4285 0.2% – 91 413 795 1309 1255 422 14 – 1 9 22 45 68 84 Prostate 305,044 11.6% 3 438 3387 34,764 112,958 122,376 31,118 1112 0 5 88 1048 4138 7143 6878 Testis 37,937 1.4% 86 17,116 8495 5349 3317 2389 1187 133 2 149 197 152 128 133 243 Kidney 98,065 3.7% 725 5211 8450 17,941 29,073 28,174 8491 172 8 23 101 253 483 674 585 Bladder 240,433 9.1% 31 4164 11,144 35,049 70,614 87,535 31,896 416 0 19 132 485 1165 2041 2123 Choroidal melanoma 3514 0.1% – 264 419 658 929 933 311 6 – 1 5 10 16 23 22 Brain and central 39,255 1.5% 1069 11,602 6542 6495 6400 5401 1746 63 13 49 74 89 99 111 94 nervous system Thyroid 118,853 4.5% 99 29,241 27,617 27,474 21,622 10,929 1872 202 1 127 321 375 357 268 131 Guzzinati et al. BMC Cancer (2018) 18:169 Page 11 of 13 Complete cancer prevalence (cases and proportion) by cancer type and age at prevalence in Italian men and women at January 1, 2010 (Continued) Cancer type Prevalent cases Prevalence proportion × 100,000 All ages % 00-14 15-44 45-54 55-64 65-74 75-84 85+ All ages 00-14 15-44 45-54 55-64 65-74 75-84 85+ Hodgkin lymphoma 48,254 1.8% 266 18,801 9478 8333 6355 4085 935 81 3 81 111 110 101 94 59 Non-Hodgkin lymphoma 110,715 4.2% 891 13,979 15,380 22,608 27,417 23,916 6523 191 10 61 179 314 458 565 456 Leukemias 67,301 2.6% 3389 15,065 7551 10,057 13,676 12,770 4793 112 39 64 86 136 217 291 312 Multiple myeloma (plasma cell) 25,066 1.0% – 542 2044 5003 7662 7494 2320 43 – 2 24 69 126 176 149 For sex-specific types proportions were also sex-specific Guzzinati et al. BMC Cancer (2018) 18:169 Page 12 of 13 Acknowledgements USL Ferrara, Ferrara, Italy. Reggio Emilia Cancer Registry, Epidemiology unit, The authors thank Mrs. Luigina Mei for editorial assistance. AUSL ASMN-IRCCS, Azienda USL di Reggio Emilia, Reggio Emilia, Italy. Palermo and Province Cancer Registry, Clinical Epidemiology Unit, Azienda Funding Ospedaliera Universitaria Policlinico “Paolo Giaccone”, Palermo, Italy. North The study was funded by the Italian Association for Cancer Research (AIRC) Sardinia Cancer Registry, Azienda Regionale per la Tutela della Salute, Sassari, 21 22 (grant no. 16921). Role of funding source: The funding sources had no role Italy. Sudtyrol Cancer Registry, Bolzano, Italy. Cancer Registry of Latina in study design, collection, analysis or interpretation of data, the writing of Province, AUSL Latina, Latina, Italy. Cancer Registry ASP Ragusa, Ragusa, 24 25 the report, or the decision to submit the article for publication. Italy. Cancer Registry of ASL Napoli 3 Sud, Napoli, Italy. Mantova Cancer Registry, Epidemilogy Unit, Agenzia di Tutela della Salute (ATS) della Val Availability of data and materials Padana, Mantova, Italy. Como Cancer Registry, ATS Insubria, Varese, Italy. 27 28 Dataset supporting our findings is available, according to AIRTUM guidelines, Registro Tumori Piemonte, Provincia di Biella CPO, Biella, Italy. Cancer at the following website: www.registri-tumori.it. Registry of of the Province of Siracusa, Local Health Unit of Siracusa, Siracusa, Italy. Trapani Cancer Registry, Dipartimento di Prevenzione della Salute, Authors’ contributions Trapani, Italy. Sondrio Cancer Registry, Health Protection Agency, Sondrio, SG and LDM drafted the study protocol, designed the study, and drafted the Italy. Nuoro Cancer Registry, RT Nuoro, ASSL Nuoro/ATS Sardegna, Nuoro, manuscript with the support of RDA. All authors (SG, SV, RDA, CP, CB, RC, SiF, Italy. Catanzaro Cancer Registry, Azienda Sanitaria 7, Catanzaro, Italy. 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BMC Cancer – Springer Journals

Published: Feb 9, 2018

Keywords: Cancer prevalence; Projections; Survivors; Italy

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