Introduction: Approximately a third of cancer-related deaths are attributable to modifiable factors. Methods: As a pilot experience, a cross-sectional survey was conducted in 8,000 citizens residing in four different municipalities of the Salerno province (Sarno, Pagani, San Valentino Torio, and San Marzano sul Sarno) to investigate key lifestyle and dietary habits. Results: A total of 703 of participants (8.7%) reported a history of malignancy. Alarmingly, 30.5% declared to be a current smoker, while 78.8% did not report any kind of physical activity. Encouragingly, 64.5% declared to be abstemious, and 83.0% declared to consume fruit and vegetables every day, while 4.7% and 31.9% declared not to consume meat and fried food, respectively, at any time. Never-consumers of fruit and vegetables had higher odds of having a history of colorectal cancer (OR = 5.01; 95% CI = 1.46–17.15; p = 0.01). Conclusions: The PREVES study has served to prove the validity of an operational model allowing to integrate hospital and territorial healthcare services, which we expect to be applied at a larger scale. Key information regarding dietary and lifestyle habits of the investigated population was obtained. Larger studies conducted using more accurate approaches to investigate diet, such as 24-h recalls and food frequency questionnaires, are warranted.

Cancer represents one of the greatest challenge of humanity, being responsible of approximately one in six deaths worldwide, with almost 10 million cancer-related deaths estimated to have occurred in 2020 [1]. Importantly, 30–40% of cancer-related deaths are attributable to modifiable dietary and lifestyle factors [2‒4], such as cigarette smoking, passive smoking, obesity and physical inactivity, consumption of alcohol and processed and red meat, inadequate intake of fruits and vegetables, exposure to ultraviolet radiation [5]. Most of these factors also affect the risk of other pathologic conditions that carry a considerable sanitary burden, such as diabetes [6] and cardiovascular diseases [7], which emphasizes the importance of acquiring population-level data regarding dietary and lifestyle factors in order to develop specific community-based interventions.

The Local Health Authority (ASL) of Salerno is a public healthcare provider that promotes health at an individual, group, and community level, with an annual budget of almost 2 billion euros and a jurisdiction over around one million people residing in the 158 municipalities of the Salerno province. ASL of Salerno, in line with its general objectives, supported the PREVES study, a cross-sectional survey led by the Oncology Unit of the “Andrea Tortora” Hospital. This survey involved collaboration among family physicians, local authorities, and hospital staff. The main aim of the PREVES study was to gather population-level data on crucial lifestyle and dietary habits. Additionally, the study aimed to acquire valuable insights for the creation of innovative organizational and operational models for proximity networks that integrate hospital and territorial healthcare services. This article presents the final results of the PREVES study.

Study Design

A cross-sectional survey was conducted in four different municipalities of the Salerno province (Sarno, Pagani, San Valentino Torio, and San Marzano sul Sarno) using a structured questionnaire to collect information about age, sex, current residency, history of malignancy, dietary habits, history of hypertension, history of diabetes, smoker/nonsmoker status, sedentary status. The main objective of the study was to gather population-level information regarding main dietary choices and lifestyle habits. As an exploratory objective, the relationship between dietary and lifestyle variables and main dietary choices were investigated by assessing consumption of meat, fruit and vegetables, fried foods, alcoholic beverages, bottled water. Citizens of both sexes aged 40–75 years could be enrolled in the PREVES study on the conditions that they were deemed capable to answer the questionnaire, they resided in one of the four abovementioned municipalities at the time of enrollment, and they gave their written informed consent. A convenience sampling method was used in this study. Citizens were invited to participate to the survey by their family physicians, who were also responsible to obtain written informed consent. The interview was then arranged to be administered either face to face or by telephone by the study staff. The questionnaire was collected on paper and then reported on an Excel data sheet at the Clinical Trial Office of the Oncology Unit at the “Andrea Tortora” Hospital (Pagani, Italy). This study was endorsed by the City Councils of the four participating municipalities, which contributed to increased study awareness among the population.

Statistical Methods

The target to recruit at least 10% of the male and female resident population aged 40–75 years was chosen on an empirical basis. Collected variables were presented by descriptive statistics. Interval-scale variables were summarized by mean, standard deviation, median, and interquartile range. Nominal-scale variables were summarized by relative frequencies and 95% confidence interval. Logistic regression was used to evaluate the odds of having a positive history of malignancy with respect to available dietary and lifestyle variables.

A total of 9,090 citizens residing in the four selected municipalities were invited to participate to the survey since September 2020 to July 2022, and 8,000 citizens were finally recruited. The target to enroll >10% of male and female individuals aged 40–75 years was accomplished in all four municipalities, as shown in Table 1, with 10–30% of recruitable citizens participating to the survey. The majority of recruited subjects were females (53.78%); they came from the municipality of Sarno (42.8%) and were 40–64 years old (69.8%). Importantly, hypertension was reported by 28% of subjects, while approximately 1 in 10 citizens reported to be diabetic. Of note, 703 of participants reported a history of malignancy, of whom approximately 7.5% reported to have experienced cancer recurrence (Table 2). The five most frequently reported malignancies included colorectal cancer (15.5%), breast cancer (10.5%), prostate cancer (9.6%), bladder cancer (8.9%), and thyroid cancer (8.1%). Assessment of lifestyle and dietary habits showed that one in three declared to be a smoker, while one in five did not report any kind of physical activity, and approximately two-thirds declared to be abstemious. Of note, less than 5% did not report any kind of meat consumption, while a third of subjects did not report any kind of consumption of fried food. Approximately 20% of subjects did not report to consume bottled water, while the majority of participants (88%) reported to consume fruit and vegetables every day (Table 3). Univariate analysis testing the association of individual lifestyle and dietary habits as independent variables with a prior history of a particular malignancy as dependent variables showed statistically significant positive associations between no consumption of fruit and vegetables and colorectal cancer, any kind of alcohol consumption and brain cancer, and being sedentary and lymphoma (Table 4).

Table 1.

Proportion of included subjects with respect to the eligible population

Enrolled male subjects (40–75 years old), nTotal male population (40–75 years old), n%Enrolled female subjects (40–75 years old), nTotal female population (40–75 years old), n%
Pagani 1,048 7,907 13.25 1,252 8,412 14.88 
Sarno 1,593 7,189 22.15 1,834 7,487 24.5 
San Marzano  sul Sarno 667 2,313 28.83 779 2,369 32.88 
San Valentino  Torio 389 2,467 15.76 438 2,424 18.06 
Enrolled male subjects (40–75 years old), nTotal male population (40–75 years old), n%Enrolled female subjects (40–75 years old), nTotal female population (40–75 years old), n%
Pagani 1,048 7,907 13.25 1,252 8,412 14.88 
Sarno 1,593 7,189 22.15 1,834 7,487 24.5 
San Marzano  sul Sarno 667 2,313 28.83 779 2,369 32.88 
San Valentino  Torio 389 2,467 15.76 438 2,424 18.06 
Table 2.

Demographic data of the study population

Categorical variables and categoriesIndividuals falling into categories (absolute number)Total evaluable individuals (absolute number)%
Gender 8,000 
 Males 3,697 46.21 
 Females 4,303 53.78 
Residency 8,000 
 Pagani 2,300 28.7 
 San Marzano sul Sarno 1,446 18.1 
 San Valentino Torio 827 10.3 
 Sarno 3,427 42.8 
Age classes 8,000 
 40–64 years 5,584 69.8 
 65–74 years 1,961 24.5 
 >75 years 455 5.7 
Hypertension 8,000 
 Yes 2,240 28 
 No 5,760 72 
Diabetes 8,000 
 Yes 943 11.8 
 No 7,057 88.2 
History of malignancy 8,000 
 Yes 703 8.78 
 No 7,297  
Recurrent cancer 700 
 Yes 53 7.5 
 No 647 92.5 
Categorical variables and categoriesIndividuals falling into categories (absolute number)Total evaluable individuals (absolute number)%
Gender 8,000 
 Males 3,697 46.21 
 Females 4,303 53.78 
Residency 8,000 
 Pagani 2,300 28.7 
 San Marzano sul Sarno 1,446 18.1 
 San Valentino Torio 827 10.3 
 Sarno 3,427 42.8 
Age classes 8,000 
 40–64 years 5,584 69.8 
 65–74 years 1,961 24.5 
 >75 years 455 5.7 
Hypertension 8,000 
 Yes 2,240 28 
 No 5,760 72 
Diabetes 8,000 
 Yes 943 11.8 
 No 7,057 88.2 
History of malignancy 8,000 
 Yes 703 8.78 
 No 7,297  
Recurrent cancer 700 
 Yes 53 7.5 
 No 647 92.5 
Table 3.

Information regarding lifestyle and dietary habits

Lifestyle habitsIndividuals falling into categoriesTotal evaluable individuals%
Current smoker 8,000 
 Yes 2,476 31 
 No 5,524 69 
Sedentary 8,000 
 Yes 6,308 78.8 
 No 1,692 21.2 
Abstemious 8,000 
 Yes 5,164 64.50 
 No 2,836 35.40 
Dietary habits 
Any kind of meat consumption 
 Yes 7,624 8,000 95.30 
 No 376 4.70 
Frequency 
 Never 376 8,000 4.7 
 Once a week 2,091 26.13 
 Twice a week 4,774 59.7 
 Every day 759 9.5 
Bottled water consumption 
 Yes 6,517 8,000 81.46 
 No 1,483 18.50 
Dairy products consumption 
 Yes 7,040 8,000 88 
 No 960 12 
Frequency 
 Never 960 8,000 12 
 Once a week 2,863 35.7 
 Twice a week 2,700 33.7 
 Every day 1,478 18.5 
Fried food consumption 
 Yes 5,446 8,000 68.07 
 No 2,554 31.92 
Frequency 
 Never 2,554 8,000 31.92 
 Once a week 3,327 41.58 
 Twice a week 1,935 24.18 
 Every day 184 2.3 
Fruit and vegetables consumption 
 Yes 7,912 8,000 98.9 
 No 88 1.1 
Frequency 
 Never 88 7,989 1.10 
 Once a week 155 1.94 
 Twice a week 1,144 14.31 
 Every day 6,601 83.01 
Lifestyle habitsIndividuals falling into categoriesTotal evaluable individuals%
Current smoker 8,000 
 Yes 2,476 31 
 No 5,524 69 
Sedentary 8,000 
 Yes 6,308 78.8 
 No 1,692 21.2 
Abstemious 8,000 
 Yes 5,164 64.50 
 No 2,836 35.40 
Dietary habits 
Any kind of meat consumption 
 Yes 7,624 8,000 95.30 
 No 376 4.70 
Frequency 
 Never 376 8,000 4.7 
 Once a week 2,091 26.13 
 Twice a week 4,774 59.7 
 Every day 759 9.5 
Bottled water consumption 
 Yes 6,517 8,000 81.46 
 No 1,483 18.50 
Dairy products consumption 
 Yes 7,040 8,000 88 
 No 960 12 
Frequency 
 Never 960 8,000 12 
 Once a week 2,863 35.7 
 Twice a week 2,700 33.7 
 Every day 1,478 18.5 
Fried food consumption 
 Yes 5,446 8,000 68.07 
 No 2,554 31.92 
Frequency 
 Never 2,554 8,000 31.92 
 Once a week 3,327 41.58 
 Twice a week 1,935 24.18 
 Every day 184 2.3 
Fruit and vegetables consumption 
 Yes 7,912 8,000 98.9 
 No 88 1.1 
Frequency 
 Never 88 7,989 1.10 
 Once a week 155 1.94 
 Twice a week 1,144 14.31 
 Every day 6,601 83.01 
Table 4.

Significant (p < 0.05) findings of logistic regression analysis (assessable factors associated with the history of a specific cancer)

Prior history of cancerNumber of cases (% prevalence)VariableOdds ratio95% CIp value
Colorectal cancer 85 cases/8,000; 1.06 Fruit and vegetables (no vs. yes) 5.01 1.46–17.15 0.010 
Brain cancer 11 cases/8,000; 0.14 Abstemious (no vs. yes) 5.93 1.44–24.32 0.013 
Lymphoma 31 cases/8,000; 0.39 Sedentary (yes vs. no) 8.33 1.11–100 0.039 
Prior history of cancerNumber of cases (% prevalence)VariableOdds ratio95% CIp value
Colorectal cancer 85 cases/8,000; 1.06 Fruit and vegetables (no vs. yes) 5.01 1.46–17.15 0.010 
Brain cancer 11 cases/8,000; 0.14 Abstemious (no vs. yes) 5.93 1.44–24.32 0.013 
Lymphoma 31 cases/8,000; 0.39 Sedentary (yes vs. no) 8.33 1.11–100 0.039 

Population surveys represent a valuable source of information regarding public health issues of critical importance and are capable to guide community-based interventions, especially in the field of preventive medicine, such as education campaigns aimed at improving the population attitude toward modifiable risk factors associated with dietary and lifestyle habits [8]. The PREVES study was an ambitious project, which was carried out in less than 2 years with only minor economic resources. Study activities mainly relied on the voluntary contribution of dozens of family physicians, who were coordinated by the Oncology Unity of the Tortora Hospital in Pagani. This successful experience can contribute to build a model of proximity networks that can efficiently integrate hospital and territorial healthcare services. In spite of the limited available resources, encouraging results were obtained. First, 88% of the citizens who were contacted via their family physician and invited to participate to the study responded positively and completed the survey. Approximately 20% of potentially eligible subjects residing in one of the four selected municipalities were finally enrolled in the study. We believe that this result can strengthen the confidence that the population has toward the ASL of Salerno. Confidence is a key factor influencing population behaviors with important sanitary, economic, and social implications, including participation to organized screening campaigns and the inclination of citizens to migrate from the region (generally a region in the South) where they reside to a different region (generally a region in the North) as they expect to receive better healthcare. In this regard, it must be noted that the Campania Region presents a low coverage for organized breast cancer screening (only ∼18%), organized colorectal cancer screening ((only ∼13%), and organized cervical cancer screening (only ∼14%), which are considerably worse compared with the ∼60% coverage rates of other Northern Italian regions like Veneto [9].

The results of the PREVES study regarding lifestyle and dietary habits are in line with the regional findings of PASSI, which gathers data on a monthly basis on health-related attitudes, opinions, behaviors, and practices from the majority of the Italian Local Health Units [10]. PASSI showed that the citizens of the Campania Region show worse levels of physical activity, a higher prevalence of obesity, a lower consumption of fruit and vegetables, a higher meat consumption, as well as a higher proportion of smokers, compared to the national average [9]. Consistently with these results, we found that almost 80% of participants defined themselves as sedentary and approximately a third defined themselves as current smokers. Importantly, our results seem to show a positive attitude of the population toward proper diet, with >80% of interviewed individuals consuming fruit and vegetables every day, <10% consuming meat every day, and <5% consuming fried food every day. When we explored potential associations between history of individual tumors and lifestyle and dietary variables, we reported a significant association between prior colorectal cancer diagnosis and no consumption of fruit and vegetables, with an approximately 5-fold increased odds ratio of a positive colorectal cancer history for nonconsumers of fruit and vegetables. This result is consistent with the findings of a meta-analysis including ∼20,000 colorectal cancer cases showing an inverse association vegetables (summary risk ratio per 100 g/day: 0.97, 95% CI 0.96–0.98; n = 15) and fruit (summary risk ratios per 100 g/day: 0.97, 95% CI 0.95–0.99; n = 16) [11].

We also found evidence of a potentially protective effect of being abstemious against brain cancer, although this finding is not consistent with the existing literature [12]. Finally, we found that being sedentary was associated with increased odds of having a history of lymphoma, which is consistent with the findings of a meta-analysis of 18 studies reporting a protective effect for physical activity against lymphoma (p = 0.034), with a 1% risk reduction per 3 MET hours/week (relative risk: 0.99, 95% CI 0.98–1.00) [13].

Our study suffers from two major limitations. First, a convenient sampling method was employed, which may generate distortions of the sample, although approximately 20% of the potentially eligible population was included in our survey. Second, dietary and lifestyle factors were assessed using simple questions compared to other more refined methods, such as 24-h recall or validated dietary questionnaires (such as the one used in the EPIC study [14]), which limits the generalizability of our findings. Nevertheless, we believe that the large sample size and the importance of the information recorded, along with the success of the recruitment process carried out within an effective cooperation between different healthcare operators of ASL of Salerno, is capable to add considerable value to the PREVES experience.

In conclusion, PREVES allowed to reach approximately 20% of the population of four municipalities in the proximity of the Pagani Hospital, with limited resources and in a relatively short period of time. We believe that PREVES contributed to strengthen confidence of the population toward ASL, a key determinant of important processes, and also provided key information regarding dietary and lifestyle habits of the investigated population, which suggests the importance of education initiatives to tackle smoking and sedentary behavior.

The authors wish to acknowledge the valuable contribution to enrollment provided by AFT (territorial functional aggregation of general practitioners), Mayors (Michele Strianese, Carmela Zuottolo, Giuseppe Canfora, Raffaele Maria De Prisco), and City Councils of the Municipalities of San Marzano sul Sarno, San Valentino Torio, Sarno, Pagani and to the Province of Salerno. A special thanks to Dr. Antonella Sciscio for her valuable suggestions in writing the manuscript and to the current President of the Province of Salerno, Franco Alfieri, for his contributions in disseminating the results of the PREVES study.

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Campania Sud (protocol number 138639 approved on September 16, 2020). Written informed consent was obtained from all subjects involved in the study.

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

This research was partially funded by AstraZeneca S.P.A., Grant No. 197897, which provided financial support to ASL Salerno.

Conceptualization and methodology, resources, supervision, project administration, and funding acquisition: Giuseppe Di Lorenzo; software and formal analysis: Carlo Buonerba; investigation: Giuseppe Di Lorenzo, Concetta Ingenito, Mario Iervolino, Gennaro Sosto, Primo Sergianni, Ferdinando Primiano, Arianna Piscosquito, Michela Iuliucci, Roberta Rubino, Simona Gatani, Francesco Maria Ugliano, Luca Scafuri, Ferdinando Costabile, Bruno D’Ambrosio, Alessandra D’Antonio, Antonio Crescenzo, and Francesca Cappuccio Carlo Buonerba; data curation: Concetta Ingenito and Carlo Buonerba; writing – original draft preparation: Carlo Buonerba; writing – review and editing: all the authors. Giuseppe Di Lorenzo, Concetta Ingenito, Mario Iervolino, Gennaro Sosto, Primo Sergianni, Ferdinando Primiano, Arianna Piscosquito, Michela Iuliucci, Roberta Rubino, Simona Gatani, Francesco Maria Ugliano, Luca Scafuri, Ferdinando Costabile, Bruno D’Ambrosio, Alessandra D’Antonio, Antonio Crescenzo, and Francesca Cappuccio Carlo Buonerba have read and agreed to the published version of the manuscript.

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy constraints.

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