PROGRESS IN CANCER INCIDENCE, MORTALITY, AND SURVIVAL

Cancer mortality has declined over the last three decades in most high-income countries reflecting improvements in cancer prevention, diagnosis, treatments, and management. However, there are persisting and substantial differences in mortality, incidence, and survival worldwide. Using the World Health Organization (WHO) database I worked on the trends and projections analysis of mortality from various cancer sites. I computed age-specific rates for each 5-year age group, calendar year, and sex globally. I then computed age-standardized mortality rates per 100,000 person-years using the direct method based on the world standard population. I performed joinpoint models to identify the years when significant changes in trends occurred and I calculated the corresponding annual percent changes. For the mortality projections, I predicted the number deaths and rates for a specific calendar year, using a logarithmic Poisson count data joinpoint regression model. My first study on this topic aimed to provide an up-to-date overview of trends in cancer mortality, incidence, and survival among adults, retrieving data from high-quality population-based cancer registries in seven high-income countries and the European Union. Mortality from all cancers and most common cancer sites has declined over the last three decades, except for pancreas and lung (in women). The patterns for incidence were less consistent between countries, except for a steady decrease in stomach cancer in both sexes and lung cancer in men. Survival for all cancers and the selected cancer sites increased in all countries, although there is still substantial variability. Although overall cancer death rates continue to decline, incidence rates have been levelling off among males and have been moderately increasing among females. These trends reflect population changes in cancer risk factors, screening test use, diagnostic practices, and treatment advances. Many cancers can be prevented or treated effectively if they are diagnosed early. Population-based cancer incidence and mortality data can be used to inform efforts to decrease the cancer burden and regularly monitor progress toward goals. I had the opportunity to collaborate with the University of Miami Miller School of Medicine, which provided data on cancer mortality among Italy-born Americans in California, Florida, Massachusetts, and New York Departments of Vital Statistics. The comparison of cancer mortality rates and risk factors among foreign-born populations in a host country with those in the country of origin provides insights into differences in access to care, timely diagnosis, and disease management between the two countries. Moreover, cancer studies on specific European-born populations in the USA are scarce. Using official Italian death certificate data and resident population estimates based on the official census from the WHO, I was able to conduct a study to compare cancer mortality rates between Italians and Italy-born Americans. Generational differences in smoking prevalence patterns between the USA and Italy may explain the advantages for Italy-born Americans for lung and other tobacco-related cancers compared to their Italian male counterparts. The lower prevalence of Helicobacter pylori, alcohol consumption, and hepatitis B and C virus in the USA may justify the lower mortality for stomach and liver cancer, among Italy-born Americans. Earlier and more widespread adoption of cancer screening and effective treatments in the USA is likely to be influential in breast, colorectal, and prostate cancer mortality. I then focused my studies on urologic cancer mortality over time and predictions. I carried out a time-trend analysis for selected European countries for prostate, testis, bladder, and kidney cancers over the last four decades. Prostate cancer mortality in the EU decreased over recent years and the projections are favorable. Less favourable trends were observed in eastern Europe, though starting from relatively low rates. Testicular cancer mortality declined over time in most countries, however levelling off in northern and western countries, after reaching very low rates. Bladder cancer mortality trends were less favourable in central and eastern countries compared to northern and western ones. Kidney cancer mortality reported a slight increase in men and stable rates in women over the last decade in the EU. To sum up, over the last four decades, mortality from prostate, testis, and bladder cancers but not from kidney cancer, declined in most European countries. Prostate cancer mortality rates remain lower in Mediterranean countries than in northern and central Europe. Rates for all urologic cancers remain higher in central and eastern Europe. I wrote a book chapter on the epidemiology of prostate cancer, including all the aspects I studied for my PhD. In addition, I published as a co-author other papers on mortality over time and prediction analysis focusing on different aspects and various cancer mortality causes: mortality from soft tissue sarcomas, childhood cancer mortality, colorectal cancer mortality in young adults, and mortality from gastric and esophageal cancer, and differences between eastern and western EU cancer mortality. I submitted an abstract for the Africa Mortality Symposium on mortality cancer trends in the Republic of South Africa, the Republic of Mauritius, and Réunion and I am currently working on European prediction of cancer mortality rates for 2023. The research group I work has been publishing cancer mortality predictions annually since 2011. Moreover, during these three years, I was involved in the CEFIC project (PI Prof. Negri from University of Bologna) titled “Incidence trends of selected endocrine-related diseases and conditions in Europe and North America, and the contribution of changes in human reproduction”. Among the endocrine-related diseases and conditions, there were four cancer sites considered: endometrium, breast, testis, and prostate. I gave my contribution to this project by evaluating the cancer incidence trends in high-income countries worldwide and reviewing the association between selected reproductive factors and the selected cancers. Thus, we investigated changes in relevant reproductive factors and estimated their influence on cancer occurrence. During my PhD, I have been collaborating with the department of Oncology at the Mario Negri Institute. Under the supervision of Dr Bosetti I have worked on various projects. In particular, I was involved in updating of a meta-analysis concerning aspirin use and the risk of twelve solid tumors with a dose-response analysis finalizing three publications. Moreover, the Mario Negri Institute manages the Italian Register of Multiple Sclerosis, collecting data from more than 100 Italian centers including more than 70.000 patients. Based on this real-world dataset, I have dealt with several aspects related to multiple sclerosis, being involved in the drafting of two papers one concerning two methods for measuring the disability accumulated over time and another one studying patients’ and referral centers’ characteristics in relation to multiple sclerosis phenotypes. In my last PhD year, I worked at the Department of Quantitative Methods and Economics of the University of Las Palmas supervised by Prof. Serra-Majem for nine months. This training period aimed to gain new experience in conducting cost-effectiveness studies. I conducted a study aimed to quantify the over cost due to obesity among patients hospitalized for Covid-19. In collaboration with the Department of Public Health, I conducted an effectiveness analysis of a primary prevention intervention with a Mediterranean diet supplemented with extra-virgin olive oil or nuts using the data from PREDIMED Trial. Lastly, I took part in the WOMEDS Study, a project aimed to analyse gender inequality among medical doctors in Spain. During these months abroad, I co-wrote three papers, currently under revision.