Systematic strategy of prophylactic coronary angiography improves long-term outcome after major vascular surgery in medium- to high-risk patients: a prospective randomized study

OBJECTIVES: This study was undertaken to determine the impact of a strategy of systematic coronary angiography on immediate- and long-term outcome of patients at medium-high risk who were undergoing surgical treatment of peripheral arterial disease. BACKGROUND: Despite pre-operative risk stratification according to the current guidelines, vascular surgery patients still represent a high-risk population, as 30-day cardiovascular complications and mortality rates still remain as high as 15% to 20% and 3% to 5%, respectively. METHODS: In all, 208 consecutive patients scheduled for elective surgical treatment of major vascular disease and with a revised cardiac risk index > or =2 were randomly allocated to either a "selective strategy" group (group A, n = 103), in whom coronary angiography was performed based on the results of noninvasive tests, or to a "systematic strategy" group (group B, n = 105), consisting of patients who systematically underwent pre-operative coronary angiography. RESULTS: The 2 groups were similar with respect to baseline clinical characteristics, revised cardiac risk index, and type of vascular surgery performed. The myocardial revascularization rate in group B was higher than in group A (58.1% vs. 40.1%; p = 0.01). In-hospital major adverse cardiovascular event rate was not significantly lower in group B (p = 0.07). At 58 +/- 17 months of follow-up, group B showed significantly better survival (p = 0.01) and freedom from death/cardiovascular events (p = 0.003). CONCLUSIONS: In this study, a strategy of routine coronary angiography positively impacted long-term outcome of peripheral arterial disease surgical patients at medium-high risk. This is the first such demonstration in a randomized, prospective trial. Multicenter trials to confirm this finding in a larger population are warranted

Systematic strategy of prophylactic coronary angiography improves long-term outcome after major vascular surgery in medium- to high-risk patients: a prospective randomized study

OBJECTIVES: This study was undertaken to determine the impact of a strategy of systematic coronary angiography on immediate- and long-term outcome of patients at medium-high risk who were undergoing surgical treatment of peripheral arterial disease. BACKGROUND: Despite pre-operative risk stratification according to the current guidelines, vascular surgery patients still represent a high-risk population, as 30-day cardiovascular complications and mortality rates still remain as high as 15% to 20% and 3% to 5%, respectively. METHODS: In all, 208 consecutive patients scheduled for elective surgical treatment of major vascular disease and with a revised cardiac risk index > or =2 were randomly allocated to either a "selective strategy" group (group A, n = 103), in whom coronary angiography was performed based on the results of noninvasive tests, or to a "systematic strategy" group (group B, n = 105), consisting of patients who systematically underwent pre-operative coronary angiography. RESULTS: The 2 groups were similar with respect to baseline clinical characteristics, revised cardiac risk index, and type of vascular surgery performed. The myocardial revascularization rate in group B was higher than in group A (58.1% vs. 40.1%; p = 0.01). In-hospital major adverse cardiovascular event rate was not significantly lower in group B (p = 0.07). At 58 +/- 17 months of follow-up, group B showed significantly better survival (p = 0.01) and freedom from death/cardiovascular events (p = 0.003). CONCLUSIONS: In this study, a strategy of routine coronary angiography positively impacted long-term outcome of peripheral arterial disease surgical patients at medium-high risk. This is the first such demonstration in a randomized, prospective trial. Multicenter trials to confirm this finding in a larger population are warranted

Bollettino storico di Salerno e Principato Citra. A.8, n.1 (1990) 

A.8, n.1 (1990): M.A. Iannelli, Note di vita materiale e politica nel territorio capaccese tra X e XII secolo, P. 3 ; G. Granito, Gli Abenavoli di Aversa sullo sfondo dell’epopea normanna, P. 9 ; A. Carucci, IX centenario di una leggenda affrescata nel Duomo di Salerno, P. 25 ; M. Bignardi, La città di Masuccio, P. 35 ; V. Cimmelli, I beni stabili e le rendite del monastero certosino di S. Giacomo di Capri nella valle del Sarno in età moderna, P. 45 ; D. Cosimato, Sull’allevamento della bufala e l’evoluzione del «territorio» durante il sec. XVII in provincia di Principato Citra, P. 59 ; F. Sofia, «Andavano a mano a mano con la faccia a riso... voglia Iddio che questi non avessero da fare qualche ’mbruoglia»: prime note sui matrimoni clandestini nella diocesi di Salerno in età moderna, P. 71 ; G. Cirillo, Economia e società nel Principato Citra: la distribuzione del reddito a metà 1700, P. 81 ; C. Pellecchia, La fiera del «Crocifisso», P. 109 ; M. Pasca, Recenti «itinerari» della Scuola Medica Salernitana, P. 113. M.A. Iannelli, Vietri: rilettura di un problema; R. D’Andria, L’archeologia della fabbrica; A. La Stella, Terra cotta e architettura; M. Bignardi, Dei «vizi» pubblici e delle «virtù» private; R. Carafa, Ad Ariano Irpino un Museo delle Ceramiche; A.P. Fiorillo, Ceramica d’arte in Parlamento; M.A. IannellI, La Fabbrica Finto; R. D’Andria, Rifa; Andrea D’Arien- zo; Giancappetti; Guido Gambone; Salvatore Procida; Giovannino Carraro; Intervista al Sindaco di Vietri Donato Cufari; Intervista a Ciro Rota, Vicepresidente dell’ERSVA, Direttore del Centro Studi della CNA; Intervista al prof. Antonio Ragona (Conservatore del Museo della Ceramica di Caltagirone), P. 117

Burden and centralised treatment in Europe of rare tumours: results of RARECAREnet - a population-based study

Background Rare cancers pose challenges for diagnosis, treatments, and clinical decision making. Information about rare cancers is scant. The RARECARE project defined rare cancers as those with an annual incidence of less than six per 100 000 people in European Union (EU). We updated the estimates of the burden of rare cancers in Europe, their time trends in incidence and survival, and provide information about centralisation of treatments in seven European countries. Methods We analysed data from 94 cancer registries for more than 2 million rare cancer diagnoses, to estimate European incidence and survival in 2000–07 and the corresponding time trends during 1995–2007. Incidence was calculated as the number of new cases divided by the corresponding total person-years in the population. 5-year relative survival was calculated by the Ederer-2 method. Seven registries (Belgium, Bulgaria, Finland, Ireland, the Netherlands, Slovenia, and the Navarra region in Spain) provided additional data for hospitals treating about 220 000 cases diagnosed in 2000–07. We also calculated hospital volume admission as the number of treatments provided by each hospital rare cancer group sharing the same referral pattern. Findings Rare cancers accounted for 24% of all cancers diagnosed in the EU during 2000–07. The overall incidence rose annually by 0.5% (99·8% CI 0·3–0·8). 5-year relative survival for all rare cancers was 48·5% (95% CI 48·4 to 48·6), compared with 63·4% (95% CI 63·3 to 63·4) for all common cancers. 5-year relative survival increased (overall 2·9%, 95% CI 2·7 to 3·2), from 1999–2001 to 2007–09, and for most rare cancers, with the largest increases for haematological tumours and sarcomas. The amount of centralisation of rare cancer treatment varied widely between cancers and between countries. The Netherlands and Slovenia had the highest treatment volumes. Interpretation Our study benefits from the largest pool of population-based registries to estimate incidence and survival of about 200 rare cancers. Incidence trends can be explained by changes in known risk factors, improved diagnosis, and registration problems. Survival could be improved by early diagnosis, new treatments, and improved case management. The centralisation of treatment could be improved in the seven European countries we studied. Funding The European Commission (Chafea)

The impact of overdiagnosis on thyroid cancer epidemic in Italy,1998–2012

Aims: In Italy, incidence rates of thyroid cancer (TC) are among the highest worldwide with substantial intracountry heterogeneity. The aim of the study was to examine time trends of TC incidence in Italy and to estimate the proportion of TC cases potentially attributable to overdiagnosis. Methods: Data on TC cases reported to Italian cancer registries during 1998–2012 aged <85 years were included. Age-standardised incidence rates (ASR) were computed by sex, period, and histology. TC overdiagnosis was estimated by sex, period, age, and Italian region. Results: In Italy between 1998–2002 and 2008–2012, TC ASR increased of 74% in women (from 16.2 to 28.2/100,000) and of 90% in men (from 5.3 to 10.1/100,000). ASR increases were nearly exclusively due to papillary TC (+91% in women, +120% in men). In both sexes, more than three-fold differences emerged between regions with highest and lowest ASR. Among TC cases diagnosed in 1998–2012 in Italy, we estimated that overdiagnosis accounted for 75% of cases in women and 63% in men and increased over the study period leading to overdiagnosis of 79% in women and 67% in men in 2008–2012. Notably, overdiagnosis was over 80% among women aged <55 years, and substantial variations were documented across Italian regions, in both genders. Conclusion(s): Incidence rates of TC are steadily increasing in Italy and largely due to overdiagnosis. These findings call for an update of thyroid gland examination practices in the asymptomatic general population, at national and regional levels

Epidemiology of rare cancers and inequalities in oncologic outcomes

Rare cancers epidemiology is better known compared to the other rare diseases. Thanks to the long history of the European population-based cancer registries and to the EUROCARE huge database, the burden of rare cancers has been estimated the European (EU28) population. A considerable fraction of all cancers is represented by rare cancers (24%). They are a heterogeneous group of diseases, but they share similar problems: uncertainty of diagnosis, lack of therapies, poor research opportunities, difficulties in clinical trials, lack of expertise and of centres of reference. This paper analyses the major epidemiological indicators of frequency (incidence and prevalence) and outcome (5-year survival) of all rare cancers combined and of selected rare cancers that will be in depth treated in this monographic issue. Source of the results is the RARECAREnet search tool, a database publicly available. Disparities both in incidence and survival, and consequently in prevalence of rare cancers were reported across European countries. Major differences were shown in outcome: 5-year relative survival for all rare cancers together, adjusted by age and case-mix, varied from 55% or more (Italy, Germany, Belgium and Iceland) and less than 40% (Bulgaria, Lithuania and Slovakia). Similarly, for all the analyzed rare cancers, a large survival gap was observed between the Eastern and the Nordic and Central European regions. Dramatic geographical variations were assessed for curable cancers like testicular and non epithelial ovarian cancers. Geographical difference in the annual age-adjusted incidence rates for all rare cancers together varied between &gt;140 per 100,000 (Italy, Scotland, France, Germany, and Switzerland) and &lt;100 (Finland, Portugal, Malta, and Poland). Prevalence, the major indicator of public health resources needs, was about 7–8 times larger than incidence. Most of rare cancers require complex surgical treatment, thus a multidisciplinary approach is essential and treatment should be provided in centres of expertise and/or in networks including expert centres. Networking is the most appropriate answer to the issues pertaining to rare cancers. Actually, in Europe, an opportunity to improve outcome and reduce disparities is provided by the creation of the European Reference Networks for rare diseases (ERNs). The Joint Action of rare cancers (JARC) is a major European initiative aimed to support the mission of the ERNs. The role of population based cancer registries still remains crucial to describe rare cancers management and outcome in the real word and to evaluate progresses made at the country and at the European level

Mesothelioma and thymic tumors: Treatment challenges in (outside) a network setting

The management of patients with mesothelioma and thymic malignancy requires continuous multidisciplinary expertise at any step of the disease. A dramatic improvement in our knowledge has occurred in the last few years, through the development of databases, translational research programs, and clinical trials. Access to innovative strategies represents a major challenge, as there is a lack of funding for clinical research in rare cancers and their rarity precludes the design of robust clinical trials that could lead to specific approval of drugs. In this context, patient-centered initiatives, such as the establishment of dedicated networks, are warranted. International societies, such as IMIG (International Mesothelioma Interest Group) and ITMIG (International Thymic Malignancy Interest Group) provide infrastructure for global collaboration, and there are many advantages to having strong regional groups working on the same issues. There may be regional differences in risk factors, susceptibility, management and outcomes. The ability to address questions both regionally as well as globally is ideal to develop a full understanding of mesothelioma and thymic malignancies. In Europe, through the integration of national networks with EURACAN, the collaboration with academic societies and international groups, the development of networks in thoracic oncology provides multiplex integration of clinical care and research, ultimately ensuring equal access to high quality care to all patients, with the opportunity of conducting high level clinical and translational research projects

Treatment challenges in and outside a network setting: Soft tissue sarcomas

Patients with soft tissue sarcoma (STS) experienced better outcomes when treated according to existing clinical practice guidelines either at reference institution or dedicated treatment networks. Despite increasing evidence supporting referral to sarcoma specialised units, up to half of patients are not managed according to guidelines, particularly those in the early stage of their disease requiring surgery. Also, criteria to certify expertise of institutions, such as the treatment volume, are debated and health authorities have only recently started identification of these centres and creation of treatment networks in Europe as well as in several countries. This process have important implications for both patient outcomes and innovation of existing treatment strategies through clinical research, making improvement of clinical pathways a priority for health care authorities. This article will discuss issues with management of patients with STS, such as pathological diagnosis and adherence to guidelines, and the definition of referral centres and networks will be illustrated along with existing experiences and population-based data

Rare ovarian tumours: Epidemiology, treatment challenges in and outside a network setting

Purpose of the review: More than 50% of all gynaecological cancers can be classified as rare tumours (defined as an annual incidence of <6 per 100,000) and such tumours represent an important challenge for clinicians. Recent findings: Rare cancers account for more than one fifth of all new cancer diagnoses, more than any of the single common cancers alone. Reviewing the RARECAREnet database, some of the tumours occur infrequently, whilst others because of their natural history have a high prevalence, and therefore appear to be more common, although their incidence is also rare. Harmonization of medical practice, guidelines and novel trials are needed to identify rare tumours and facilitate the development of new treatments. Ovarian tumours are the focus of this review, but we comment on other rare gynaecological tumours, as the diagnosis and treatment challenges faced are similar. Future: This requires European collaboration, international partnerships, harmonization of treatment and collaboration to overcome the regulatory barriers to conduct international trials. Whilst randomized trials can be done in many tumour types, there are some for which conducting even single arm studies may be challenging. For these tumours alternative study designs, robust collection of data through national registries and audits could lead to improvements in the treatment of rare tumours. In addition, concentring the care of patients with rare tumours into a limited number of centres will help to build expertise, facilitate trials and improve outcomes