ALMOST as if Covid-19 had left no trace on who was already struggling with other health problems. The Annual Report on ‘Cancer Numbers’, in fact, tells us how – despite the fury of Sars-Cov-2 – in Italy today people die of cancer less than the European average. To be precise, -13% in men and -10% in women. In short, in our country, in 2021, deaths from cancers are decreasing and survival is improving. Not just good news, though. However, the pandemic has left a mark: oncologists observe, in fact, a greater number of breast and colon neoplasms operated at an advanced stage. The volume, the result of the collaboration between the Italian Association of Medical Oncology (Aiom), of the Italian Cancer Registers, of the Italian Society of Pathological Anatomy and Diagnostic Cytology (SIAPEC-IAP), of the AIOM Foundation, PASSI (Progress of the Health Authorities for la Salute in Italia), PASSI d’Argento and the National Screening Observatory (ONS), is presented today at a press conference in Rome at the Istituto Superiore di Sanità.
In 2021, 181,330 deaths from cancer are estimated (100,200 men and 81,100 women), 1,870 less than in 2020. More generally, in the last six years there has been an overall decline in cancer mortality of 10% in men and 8%. % in women. From 2015 to date, deaths from stomach cancer have decreased by 18.4% in males, lung cancer by 15.6%, prostate deaths by 14.6% and colorectal cancer by 13.6%. It is not going so well (actually for some years now) for women: in the female population, in fact, deaths from bladder (+ 5.6%) and lung (+ 5%) carcinomas are increasing, closely linked to cigarette smoke, while those in the stomach (-25%), colorectal (-13.2%), ovary (-9%) and breast (-6.8%) decrease. No progress emerges for pancreatic cancer, which continues to show stable mortality rates in males and increasing (+ 3.9%) in females.
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The 5-year survival data is also positive, improving for all cancers reaching 59% in men and 65% in women (compared to 54% and 63% of the previous survey updated to 2015). In seven sites in men and eight in women, survivors are very high, up to 96.2% of thyroid carcinomas in women and 93.2% in the testicle. “Survival in our country – he says Giordano Beretta, President Aiom – is aligned with the highest levels observed in Europe. In Italy, people alive after diagnosis are increasing more and more, in 2020 there were about 3.6 million, 6% of the population, with an increase of 36% compared to 2010. In six cancer sites, survivors are, however, even lower 30%, with pancreatic cancer trailing 11% in both sexes. Research efforts must be directed in particular to these pathologies. In men, the general decrease in mortality mirrors the reduction in cancer deaths due to smoking. But anti-smoking prevention campaigns must be increased to control the epidemic of tobacco-related neoplasms in the female population ”.
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The legacy of the pandemic
Unfortunately, the risk of death has doubled for cancer patients with Sars-CoV-2 infection. The pandemic also weighs on oncological assistance, because neoplasms are observed at an increasingly advanced stage, as emerges from a survey that involved 19 pathological anatomies, representative of the entire national territory. In 2020, 5,758 breast surgeries and 2,952 colorectal surgeries were performed without neoadjuvant therapy. The number of operations is down compared to 2019 (-805 cases, equal to -12% for the breast, and -464 cases, equal to -13% for the colorectal). And the size of the disease at the time of surgery is often greater than that found in the pre-Covid period. The decrease in in situ tumors operated on was 32% for the colorectal and 11% for the breast.
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The investigation of the Italian Society of Pathological Anatomy
A survey conducted by Siapec has estimated, at a national level, the impact of Sars-CoV-2 infection on breast and colorectal cancer surgery. “For breast cancer – underlines Anna Sabino, Siapec-Iap president – the number of cases operated in 2020 was 12% lower (-805 cases) compared to 2019, and this reduction was observed for neoplasms of all sizes, in particular for the smallest ones “. There was a significant increase in pT2 breast tumors (between 2 and 5 cm), compared with a decrease in smaller ones (pT1, between 1 and 5 mm). Also for the colorectal there was a reduction in cases operated in 2020, 13% lower (-464 cases) compared to 2019, with a particularly marked decline for in situ tumors, while there was a significant increase in neoplasms with perforation of the peritoneum. “The results of this survey – continues Sapino – show, in general and for both diseases, a decrease in in situ tumors characterized by high probability of healing (-11% for the breast, -32% for the colorectal) , which may be the consequence of the temporary reduction in cancer screening in 2020 “.
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The delay for screenings
Another survey was conducted by the National Screening Observatory (Ons) which quantified the delay accumulated in 2020 compared to 2019 in terms of invitations, tests and standard months. “The reduction in invitations – he explains Paola Mantellini, director of Ons – was equal to 33% for cervical screening, 31.8% for colorectal screening and 26.6% for mammography. The reduction in examinations was 45.5% for colorectal screening (-1.110.414 tests), 43.4% for cervical screening (-669.742), and 37.6% for mammograms (-751.879). Overall, about 2.5 million fewer screenings were performed ”. Fear of contagion had a decisive impact on participation in prevention programs. The delay months were 5.5 for colorectal screening, 5.2 for cervical screening and 4.5 for mammograms. Missed diagnoses were also estimated: over 3,300 for breast cancer, about 1,300 for colorectal (and 7,474 fewer advanced adenomas) and 2,782 precancerous lesions of the uterine cervix. “It is important to underline that, for all three programs, in autumn 2020 some Regions managed to deliver more tests than in 2019, highlighting a considerable strategic-organizational capacity”, underlines Mantellini.
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The effects of diagnostic delays
What practical consequences will all these delays have? Difficult to make predictions, but oncologists try to prepare for them. “The clinical consequences, in particular a possible advancement of the stage at the time of diagnosis, may be greater for mammography and colorectal screening, as emerged from the survey conducted by Siapec. he claims Diego Serraino, Oncology Reference Center, Irccs, Aviano – Director of the Cancer Registry of Friuli-Venezia Giulia. It has been estimated that 52% of Italian women diagnosed with cancer are cured or destined to recover. Among men, this percentage is lower (39%) due to the higher frequency of malignancies with a more severe prognosis. The healing fraction exceeds 75% for prostate cancer and, in both sexes, for thyroid cancer and melanomas. “For patients – adds Serraino – knowing that they have a life expectancy similar to that of non-sick people is of primary importance. Uncertainty about the future has a negative impact on quality of life and the confirmation that full recovery and recovery are possible has important implications for many practical aspects of life. It opens the doors to patients to the possibility of a complete work and social reintegration “.
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The psychological and social impact
No less important are the psychosocial consequences that especially the first wave of the pandemic had on cancer patients. The Aiom Foundation investigated this precisely by distributing a questionnaire in April and May 2020 to which about 500 patients replied. “60% – he explains Stefania Gori, president of the Aiom Foundation – said he felt very safe in his cancer facility. However, 56.5% expressed concern that their medical staff could get Covid and reported fear of stopping cancer treatment. And, precisely because of the fear, 34% stated that they contacted their doctor more frequently than in the past or that they had canceled visits with the oncologist (13%) ”. Most patients (88%) have perceived changes in their lives since the pre-pandemic period. 93% also reported ‘feeling more vulnerable’ than Covid due to their illness. “About one in five patients – continues Gori – has asked for psychological help, one in six has taken psychotropic drugs for anxiety and more than half has resorted to relaxation practices to moderate stress. Hence the need to guarantee a structured presence of psycho-oncologists in oncologies to provide assistance to patients, family members and caregivers and health personnel “.
How to recover from diagnostic delays
The Minister of Health also spoke about the effects that the pandemic had, Roberto Speranza, in the preface of the volume ‘Cancer numbers 2021′: “The scenario determined by the Sars-CoV-2 epidemic – wrote the Minister – caused a slowdown in the implementation of screening programs, especially during the initial stages of ’emergency. This has had effects on the early diagnosis of many diseases, including cancer. To facilitate the recovery of diagnostic and therapeutic services, the Ministry of Health has promoted an extraordinary funding of about half a billion, making it available to the Regions. In the support-bis decree-law, the duration of this intervention has been extended for the whole of 2021. It is only a first step. Still other resources will be needed ”.
The weapon of lifestyles
In addition to acting at the institutional level to try to recover the damage of the delays accumulated due to the pandemic, every citizen can do his part by adopting lifestyle habits that favor prevention. “Healthy lifestyles are the most important weapon to defeat cancer – he concludes Maria Masocco, scientific director of Silver Steps and Steps, Higher Institute of Health. “Almost 30% of citizens are sedentary. Since 2008, the sedentary lifestyle in the adult population has increased, particularly in the South, where it went from 35% in 2008 to values that reach almost 45% in 2019. More than 4 out of 10 adults are overweight, or 31.5 % overweight and 10.8% obese, with a growing trend for obesity, not only in the South but also in the North. In 2020, the pandemic caused a setback also in the decline in the number of smokers, progressively recorded between 2008 and 2019. This slowdown is particularly sustained by women over 35 years of age, including, for the first time since 2008, there is a reversal of the trend with a modest but not negligible increase in the share of smokers. The share of those who try to quit smoking also drops from 36% in 2019 to 31% during the pandemic, in particular from 39% to 31% among women “.