Diabetes mellitus in long-term survivors with colorectal, breast, or prostate cancer: Prevalence and prognosis. A population-based study.

BACKGROUND: Patients with cancer are at increased risk of diabetes mellitus (DM). Previous studies on the prevalence and prognostic impact of DM in cancer survivors were limited by small sample sizes or short follow-up times. We aimed to compare the patient-reported prevalence of DM in long-term cancer survivors (LTCS), who survived 5 years or more after cancer diagnosis, with that in cancer-free controls, and to estimate the mortality risk among LTCS according to DM status. METHODS: Our population-based cohort comprised 6952 LTCS diagnosed with breast, colorectal, or prostate cancer between 1994 and 2004, recruited in 2008-2011 (baseline), and followed until 2019. A total of 1828 cancer-free individuals served as controls. Multivariable logistic regression was used to compare the prevalence of DM in LTCS and controls, and according to covariates at baseline. Mortality among LTCS according to DM was assessed by Cox proportional hazards regression. RESULTS: A total of 962 (13.8%) LTCS at baseline reported DM. Prevalence of DM in LTCS was not higher than in cancer-free controls, both at baseline (odds ratio, 0.80; 95% CI, 0.66-0.97) and at follow-up (odds ratio, 0.83; 95% CI, 0.67-1.04). Prevalence of DM in LTCS was associated with cancer site, older age, lower education, higher socioeconomic deprivation, higher body mass index, physical inactivity, other comorbidities, and poorer prognosis (adjusted hazard ratio [all-cause mortality] = 1.29; 95% CI, 1.15-1.44). CONCLUSION: DM in LTCS is prevalent, but not higher than in cancer-free population controls. Cancer survivors with concurrent DM are at a potentially higher risk of death. PLAIN LANGUAGE SUMMARY: Cancer and diabetes mellitus (DM) are two serious threats to global health. In our study, prevalence of DM in long-term cancer survivors who survived 5 years or more after cancer diagnosis was not higher than in cancer-free controls. This should not be interpreted as an indication of a lower risk of DM in cancer survivors. Rather, it highlights the potentially poor prognosis in diabetic cancer survivors. Therefore, keeping a continuous satisfactory DM and hyperglycemia management is essential during long-term cancer survivorship.

German, Austrian, and Swiss guidelines for systemic treatment of gastric cancer.

The updated edition of the German, Austrian and Swiss Guidelines for Systemic Treatment of Gastric Cancer was completed in August 2023, incorporating new evidence that emerged after publication of the previous edition. It consists of a text-based "Diagnosis" part and a "Therapy" part including recommendations and treatment algorithms. The treatment part includes a comprehensive description regarding perioperative and palliative systemic therapy for gastric cancer and summarizes recommended standard of care for surgery and endoscopic resection. The guidelines are based on a literature search and evaluation by a multidisciplinary panel of experts nominated by the hematology and oncology scientific societies of the three involved countries.

Trends in cancer incidence by socioeconomic deprivation in Germany in 2007 to 2018: An ecological registry-based study.

Age-standardized cancer incidence has decreased over the last years for many cancer sites in developed countries. Whether these trends led to narrowing or widening socioeconomic inequalities in cancer incidence is unknown. Using cancer registry data covering 48 million inhabitants in Germany, the ecological association between age-standardized total and site specific (colorectal, lung, prostate and breast) cancer incidence in 2007 to 2018 and a deprivation index on district level (aggregated to quintiles) was investigated. Incidence in the most and least deprived districts were compared using Poisson models. Average annual percentage changes (AAPCs) and differences in AAPCs between deprivation quintiles were assessed using Joinpoint regression analyses. Age-standardized incidence decreased strongly between 2007 and 2018 for total cancer and all cancer sites (except female lung cancer), irrespective of the level of deprivation. However, differences in the magnitude of trends across deprivation quintiles resulted in increasing inequalities over time for total cancer, colorectal and lung cancer. For total cancer, the incidence rate ratio between the most and least deprived quintile increased from 1.07 (95% confidence interval: 1.01-1.12) to 1.23 (1.12-1.32) in men and from 1.07 (1.01-1.13) to 1.20 (1.14-1.26) in women. Largest inequalities were observed for lung cancer with 82% (men) and 88% (women) higher incidence in the most vs the least deprived regions in 2018. The observed increase in inequalities in cancer incidence is in alignment with trends in inequalities in risk factor prevalence and partly utilization of screening. Intervention programs targeted at socioeconomically deprived and urban regions are highly needed.

Benefit finding, posttraumatic growth and health-related quality of life in long-term cancer survivors: a prospective population-based study.

BACKGROUND: We explored the relationship between benefit finding (BF)/posttraumatic growth (PTG) at baseline and health-related quality of life (HRQOL) at baseline and follow-up in long-term cancer survivors (LTCS; ≥5-year post-diagnosis). MATERIALS AND METHODS: HRQOL was assessed in LTCS in 2009-2011 (5- to 16-year post-diagnosis, baseline) and re-assessed in 2018/2019 (14- to 24-year post-diagnosis, follow-up). BF and PTG were measured at baseline; mean scores were dichotomized into 'none-to-low' (<3) and 'moderate-to-high' (> =3). Linear regression models and linear mixed regression models were employed to assess the association of BF/PTG with HRQOL. RESULTS: Of the 6057 baseline participants, 4373 were alive in 2019, of whom 2704 completed the follow-up questionnaire. Cross-sectionally, LTCS with none-to-low BF reported better HRQOL at baseline and at follow-up than LTCS with higher BF. Longitudinally, no difference was found between none-to-low and moderate-to-high BF on the HRQOL change from baseline to follow-up. HRQOL differences between the PTG groups were not statistically significant cross-sectionally and longitudinally, except those participants with moderate-to-high PTG reported higher role functioning and global health status/QOL. CONCLUSIONS: Cross-sectionally, BF was significantly negatively related to subscales of HRQOL, while PTG was positively correlated to role functioning and global health status/QOL. The results add further evidence that BF and PTG are two different positive psychological concepts.

Small-area analysis on socioeconomic inequalities in cancer survival for 25 cancer sites in Germany.

Socioeconomic inequalities in cancer survival have been reported in various countries but it is uncertain to what extent they persist in countries with relatively comprehensive health insurance coverage such as Germany. We investigated the association between area-based socioeconomic deprivation on municipality level and cancer survival for 25 cancer sites in Germany. We used data from seven population-based cancer registries (covering 32 million inhabitants). Patients diagnosed in 1998 to 2014 with one of 25 most common cancer sites were included. Area-based socioeconomic deprivation was assessed using the categorized German Index of Multiple Deprivation (GIMD) on municipality level. We estimated 3-month, 1-year, 5-year and 5-year conditional on 1-year age-standardized relative survival using period approach for 2012 to 2014. Trend analyses were conducted for periods between 2003-2005 and 2012-2014. Model-based period analysis was used to calculate relative excess risks (RER) adjusted for age and stage. In total, 2 333 547 cases were included. For all cancers combined, 5-year survival rates by GIMD quintile were 61.6% in Q1 (least deprived), 61.2% in Q2, 60.4% in Q3, 59.9% in Q4 and 59.0% in Q5 (most deprived). For most cancer sites, the most deprived quintile had lower 5-year survival compared to the least deprived quintile even after adjusting for stage (all cancer sites combined, RER 1.16, 95% confidence interval 1.14-1.19). For some cancer sites, this association was stronger during short-term follow-up. Trend analyses showed improved survival from earlier to recent periods but persisting deprivation differences. The underlying reasons for these persisting survival inequalities and strategies to overcome them should be further investigated.

Distress mediates the relationship between cognitive appraisal of medical care and benefit finding/posttraumatic growth in long-term cancer survivors.

BACKGROUND: The objective of this study was to ascertain long-term cancer survivors' (LTCS') appraisal of medical care and how these perceptions may influence their health and well-being, including benefit finding (BF) and posttraumatic growth (PTG). METHODS: In total, 6952 LTCS from a multiregional population-based study in Germany completed the Benefit Finding Scale, the Posttraumatic Growth Inventory, the Questionnaire on Stress in Cancer, and self-designed questions on cognitive appraisal of medical care. The authors explored the mediating role of distress between medical care appraisal and BF and PTG and the possible moderation of time since diagnosis in this relationship. RESULTS: LTCS' medical care appraisals ("no unresolved/untreated symptoms," "satisfaction with cancer care," and "satisfaction with care for other diseases") were positively associated with BF. PTG was positively associated with "no unresolved/untreated symptoms" and negatively associated with "satisfaction with care for other diseases." Cancer distress partially mediated the associations between appraisals of medical care and BF, between "no unresolved/untreated symptoms" and PTG and between "satisfaction with care for other diseases" and PTG; whereas it totally mediated the association between "satisfaction with cancer care" and PTG. Time was a significant moderator in the model; the negative indirect effect of cognitive appraisal on BF and PTG through cancer distress weakened with longer time since diagnosis. CONCLUSIONS: Cancer survivors' medical care appraisal is associated with their perceptions of BF and PTG through distress. Therefore, distress screening could be part of the regular workup to identify distressed cancer survivors who are not satisfied with medical care; these survivors may benefit from interventions to reduce distress and increase BF and PTG.

Prevalence of benefit finding and posttraumatic growth in long-term cancer survivors: results from a multi-regional population-based survey in Germany.

BACKGROUND: Cancer studies reported mixed results on benefit finding (BF) and posttraumatic growth (PTG) prevalence and few were focused on long-term survivors. METHODS: BF and PTG were assessed in a multi-regional population-based study in Germany with 6952 breast, colorectal and prostate cancer survivors, using the Benefit Finding Scale and Posttraumatic Growth Inventory. We calculated the age-adjusted prevalence, stratified by demographical and clinical characteristics. RESULTS: Overall, 66.0% of cancer survivors indicated moderate-to-high BF, and 20.5% moderate-to-high PTG. Age-adjusted prevalence of BF and PTG differed according to cancer type (breast > colorectal > prostate) and sex (female > male). BF and PTG prevalence were higher in younger than in older respondents; the age-adjusted prevalence was higher in respondents who survived more years after diagnosis. The strength and direction of associations of age-adjusted prevalence with cancer stage, disease recurrence, and time since diagnosis varied according to cancer type and sex. CONCLUSIONS: A substantial proportion of long-term cancer survivors reported moderate-to-high BF and PTG. However, the prevalence was lower in older and male cancer survivors, and during the earlier years after cancer diagnosis. Further longitudinal studies on PTG and BF in cancer survivors are warranted to address heterogeneity in survivors' experience after cancer diagnosis.

Water and Soil Pollution: Ecological Environmental Study Methodologies Useful for Public Health Projects. A Literature Review.

Health risks at population level may be investigated with different types of environmental studies depending on access to data and funds. Options include ecological studies, case-control studies with individual interviews and human sample analysis, risk assessment or cohort studies. Most public health projects use data and methodologies already available due to the cost of ad-hoc data collection. The aim of the article is to perform a literature review of environmental exposure and health outcomes with main focus on methodologies for assessing an association between water and/or soil pollutants and cancer. A systematic literature search was performed in May 2019 using PubMed. Articles were assessed by four independent reviewers. Forty articles were identified and divided into four groups, according to the data and methods they used, i.e.: (1) regression models with data by geographical area; (2) regression models with data at individual level; (3) exposure intensity threshold values for evaluating health outcome trends; (4) analyses of distance between source of pollutant and health outcome clusters. The issue of exposure assessment has been investigated for over 40 years and the most important innovations regard technologies developed to measure pollutants, statistical methodologies to assess exposure, and software development. Thanks to these changes, it has been possible to develop and apply geo-coding and statistical methods to reduce the ecological bias when considering the relationship between humans, geographic areas, pollutants, and health outcomes. The results of the present review may contribute to optimize the use of public health resources.

[Oral and pharyngeal cancer: incidence, mortality, and survival in Germany]. / Mundhöhlen- und Pharynxkarzinome: Inzidenz, Mortalität und Überleben in Deutschland.

BACKGROUND: Lip, oral cavity, and pharynx cancers (ICD-10: C00-C14) describe a heterogeneous group of tumors with strong variations in incidence, mortality, and survival by entity. OBJECTIVES: This work provides a detailed overview of epidemiologic measures for these tumor entities, taking into account heterogeneity in age, sex, location, and stage. MATERIAL AND METHODS: Incidence and mortality data for Germany for the years 1999-2016 were extracted from the interactive database of the Center for Cancer Registry Data (ZfKD). Age and stage distributions and five-year relative survival were calculated on the pooled ZfKD data set (diagnosis years 1999-2017). RESULTS: In 2016, overall incidence and mortality for all entities were 17.6 and 7.0 per 100,000 men and 6.5 and 1.8 per 100,000 women, respectively. The five-year relative survival in 2015-2017 was 53 and 63%, respectively. There were marked differences in survival as well as age and stage distributions between entities. Trend analyses showed an increase in age at diagnosis, particularly in male patients, and no change in stage distributions. However, five-year relative survival increased from 45% (men) and 59% (women) in 1999-2002 to 52% and 63% in 2013-2017. CONCLUSION: The marked heterogeneity of the studied tumors highlights the need to differentiate the analysis by sex and entity for meaningful interpretation of epidemiologic metrics. With the expansion of clinical cancer registration in Germany, additional analyses including other important clinical factors will be possible in the future.

Disclosing progress in cancer survival with less delay.

Cancer registration plays a key role in monitoring the burden of cancer. However, cancer registry (CR) data are usually made available with substantial delay to ensure best possible completeness of case ascertainment. Here, we investigate empirically with routinely available data whether such a delay is mandatory for survival analyses or whether data can be used earlier to provide more up-to-date survival estimates. We compared distributions of prognostic factors and period relative survival estimates for three population-based CRs in Germany (Schleswig-Holstein (SH), Rhineland-Palatinate (RP), Saarland (SA)) computed on datasets extracted one (DY+1) to 5 years after the year of diagnosis (DY+5; reference). Analyses were conducted for seven cancer sites and various survival analyses scenarios. The proportion of patients registered in the datasets at a given time varied strongly across registries with 57% (SH), 2% (RP) and 26% (SA) registered in DY+1 and >93% in all registries in DY+3. Five-year survival estimates for the most recent three-year period were comparable to estimates from the reference dataset already in DY+1 (mean absolute deviations = 0.2-0.6% units). Deviations >1% units were only observed for pancreatic and lung cancer in RP and leukemia in SA (all ≤1.5% units). For estimates of 1-year survival based on the most recent 1-year period only, slightly longer delays were required, but reasonable estimates were still obtained after 1-2 years, depending on the CR and cancer site. Thus, progress in cancer survival could be disclosed in a more timely manner than commonly practiced despite delays in completeness of registration.

Age-specific health-related quality of life in disease-free long-term prostate cancer survivors versus male population controls-results from a population-based study.

BACKGROUND: Prostate cancer (PC) and its treatment may affect PC survivors differently with respect to age. However, little is known regarding age-specific health-related quality of life (HRQoL) in PC survivors 5 years or even ≥ 10 years post-diagnosis. METHODS: The sample included 1975 disease-free PC survivors (5-16 years post-diagnosis) and 661 cancer-free population controls, recruited from two German population-based studies (CAESAR+, LinDe). HRQoL in both populations was assessed using the EORTC QLQ-C30 questionnaire. Additionally, PC survivors completed the PC-specific EORTC QLQ-PR25 questionnaire. Differences in HRQoL between survivors and controls, as well as differences according to age and time since diagnosis were analyzed with multiple regression after adjustment for age, education, stage, and time since diagnosis, where appropriate. RESULTS: In general, PC survivors reported HRQoL and symptom-burden levels comparable to the general population, except for significantly poorer social functioning and higher burden for diarrhea and constipation. In age-specific analyses, PC survivors up to 69 years indicated poorer global health and social functioning than population controls. Stratification by time since diagnosis revealed little difference between the subgroups. On PC-specific symptoms, burden was highest for urinary bother and symptoms, and lowest for bowel symptoms. Younger age was associated with less urinary symptoms but higher urinary bother. CONCLUSION: Long-term disease-free PC survivors reported overall good HRQoL, but experienced persistent specific detriments. Our data suggest that these detriments do not improve substantially with increasing time since diagnosis. Targeted interventions are recommended to prevent PC-related and treatment-related symptoms becoming chronic and to enhance social functioning.

Health-related quality of life in long-term disease-free breast cancer survivors versus female population controls in Germany.

PURPOSE: Little is known about breast cancer (BC) survivors' health-related quality of life (HRQoL) > 5 or even > 10 years past diagnosis. It is of interest whether, in the long run, survivors' HRQoL aligns with that of the general population. Study objectives were to (1) compare disease-free BC survivors' HRQoL to that of non-cancer controls, and (2) compare long-term survivors (LTS, 5-9 years post-diagnosis), very long-term survivors (VLTS, ≥ 10 years post-diagnosis), and controls with respect to their HRQoL. METHODS: The samples of 2647 disease-free BC survivors (5-16 years post-diagnosis) and 1005 population controls were recruited in German multi-regional population-based studies. HRQoL was assessed by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). Differences in HRQoL were assessed with multiple regression, controlling for age and education. RESULTS: Disease-free BC survivors < 80 years (at survey) reported overall global health status/quality of life comparable to controls, but statistically significant lower physical, role, emotional, social, and cognitive functioning. They also indicated more fatigue, insomnia, dyspnoea, and financial difficulties. However, differences were only of trivial or small clinical relevance. At age 80-89, no differences between BC survivors and controls were observed. Deficits in emotional and cognitive functioning and some symptoms (e.g. insomnia and fatigue) persist, as both LTS and VLTS reported more detriments than controls. CONCLUSIONS: In view of the persistent, small but significant detriments in disease-free BC survivors' cognitive and emotional functioning and higher symptom burden, possibilities to prevent detriments from becoming chronic should be explored.

Return to work after cancer. A multi-regional population-based study from Germany.

Background: With improving prognosis, the ability to return to work after cancer has become a realistic goal but only little is known regarding details such as sustainability, financial consequences, and potential determinants of return to work in long-term survivors in Germany. Methods: We studied return to work in a population-based sample of 1558 long-term cancer survivors, diagnosed in 1994-2004 with breast, colorectal or prostate cancer before age 60 (mean 50.1). Information regarding employment status and financial difficulties was obtained via mailed questionnaires from patients who were identified by six population-based cancer registries in Germany. Cumulative incidence of return to work was determined by time-to-event analysis with consideration of competing events. Chi2 tests and multiple logistic regression modeling were employed to identify potential sociodemographic and clinical determinants of return to work. Results: Within a mean period since diagnosis of 8.3 years, 63% of all working-age cancer survivors initially returned to their old job and another 7% took up a new job. Seventeen percent were granted a disability pension, 6% were early retired (not cancer-related), 4% became unemployed, and 1% left the job market for other reasons. Resumption of work occurred within the first 2 years after diagnosis in 90% of all returnees. Cancer-related reduction of working hours was reported by 17% among all returnees and 6% quit their job due to cancer within 5 years past return to work. The probability of return to work was strongly related with age at diagnosis, tumor stage, education, and occupational class but did not differ with respect to the tumor site, gender nor marital status. Conclusions: Most long-term survivors after breast, colorectal, or prostate cancer of working-age are able to return to work. However, financial problems might arise due to a reduction in working hours. An additional provision of targeted interventions for high-risk groups should be discussed.

Colorectal cancer screening by colonoscopy and trends in disease-specific mortality: a population-based ecological study of 358 German districts.

PURPOSE: Screening for colorectal cancer (CRC) by colonoscopy was implemented in Germany in 2002. Although the procedure has proven to be effective in reducing disease-specific mortality in numerous clinical studies, its effect at the population level is unclear. We performed an ecological study at the level of 358 German districts, testing the hypothesis that a higher participation rate in screening colonoscopy is associated with a stronger decline in CRC mortality from 2001 to 2012. METHODS: Information on the use of colonoscopy in each district was extracted from settlement data, used for the remuneration of physicians of the ambulant sector from 2008 to 2011. Yearly mortality rates for each district from 2001 to 2012 were derived from the official mortality statistics. A spatial model was fitted, considering other factors which might influence early detection of CRC (fecal occult blood test (FOBT), diagnostic colonoscopy, material and social area deprivation, and rural-urban disparities). RESULTS: The population-weighted mean annual participation rate during 2008-2011 in screening colonoscopy was 2.0% (range 0.6 to 3.9%). The weighted mean annual percentage change (APC) of CRC mortality was - 2.9% (range - 7.8 to 1.2%). According to the fully adjusted model, a 1% higher annual participation rate in colonoscopy screening was associated with an additional annual change in CRC mortality rate of - 0.34% (p = 0.015). Given an annual 2.0% participation rate, colonoscopy screening attributed 23% to the observed decline. CONCLUSIONS: Our real-world data from Germany provide first evidence that colonoscopy screening for CRC is effective in reducing disease-specific mortality at the population level.

Health-related quality of life in long-term survivors with localised prostate cancer by therapy-Results from a population-based study.

OBJECTIVE: Several therapies for localised prostate cancer (PC) are available; all yield similar survival rates. However, each therapy has significant side effects that can influence patients' health-related quality of life (HRQoL) in the long run. METHODS: The study sample included 911 survivors with localised PC, 5-15 years post-diagnosis who were identified from the population-based CAESAR + study in Germany. HRQoL was assessed using the EORTC QLQ-C30 and EORTC QLQ-PR25 questionnaires. The association between type of therapy and HRQoL was assessed with multivariable linear regression and global F-test adjusting for age, time since diagnosis and comorbidities. RESULTS: Overall, survivors treated with radical prostatectomy (RP) or radiotherapy (RT) alone reported the best HRQoL and the lowest symptom burden. Conversely, survivors treated with androgen deprivation therapy (ADT) (& RP/RT) or RP & RT (in combination) reported the worst HRQoL and the highest symptom burden. Significant differences among treatment groups in HRQoL were found for global health status (p = 0.041), social functioning (p = 0.007), urinary symptoms (p = 0.035), bowel symptoms (p = 0.017) and hormonal treatment-related symptoms (p < 0.001) among other symptoms. CONCLUSIONS: Long-term localised PC survivors formerly treated with a combination of RP and RT or with ADT report poorer HRQoL and more symptoms than patients treated with either RP or RT alone.

The acceptance and applicability of a patient-reported experience measurement tool in oncological care: a descriptive feasibility study in northern Germany.

BACKGROUND: Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are tools for assessing outcomes of and experiences with health care from the patient's perspective. In Germany, PROMs are widely used in research for evaluating patient outcomes and quality of care. However, the application of PREMs is rather scant, especially in oncology. The study aimed to assess the feasibility of patient-centred quality evaluation in oncological care in Germany using the German adaptation of the Danish National Cancer Patient Questionnaire. This questionnaire is a PREM/PROM-tool addressing patients of all cancer sites and covering the entire cancer patient pathway. METHODS: The Danish National Cancer Patient Questionnaire was translated into German via forward-backward translation. Face-validity was tested among three cancer patients in a conventional pre-test. The German adaptation contains 99 questions. A pilot test was carried out among 245 newly diagnosed breast and colorectal cancer patients in the German federal state Schleswig-Holstein. Patients were recruited via clinics participating in the Oncological Care Registry (12 specialised units in seven hospitals) and contacted six to nine months after diagnosis. Response behaviour and response patterns were compared to the Danish study population (n = 1964). RESULTS: The willingness among clinicians to support patient recruitment as well as the response rate of patients to the questionnaire was high (65%). Moreover, response behaviour and response patterns of German and Danish patients were consistent. Despite the generally good response behaviour of patients to the single items, the authors observed that questions assessing the diagnostic process did not fully capture German pathways. Only 19.3% of the German patients stated that their diagnostic process was initiated by a visit to a general practitioner (GP) in contrast to 52% in Denmark. The assessment of patient experiences in the diagnostic phase heavily focuses on experiences in general practice, which does not seem appropriate in the German health care setting. CONCLUSION: The translation was successful, and the feasibility of a future large-scale study within existing structures is given. However, some modifications of questions heavily related to the Danish health care system, especially referring to the diagnostic phase, are necessary.

[The cartographic depiction of regional variation in morbidity : Data analysis options using the example of the small-scale cancer atlas for Schleswig-Holstein]. / Die kartografische Darstellung regionaler Unterschiede in der Morbidität : Möglichkeiten der Datenanalyse am Beispiel des kleinräumigen Krebsatlasses Schleswig-Holstein.

The cancer registry in Germany collects area-wide small-area data that can be presented in themes (disease mapping). Because of the occurrence of random extreme values of rates, mapping without prior spatial-statistical data analysis is problematic from a methodological and risk-communicative viewpoint - the extreme values easily mislead the card reader and obscure actual spatial patterns.The problem of data instability can generally be met by aggregation or by smoothing. The cancer atlas for Schleswig-Holstein is based on data from 1142 municipalities (median population: 721) for the diagnostic years 2001-2010. Maps for incidence (as a standardized incidence ratio), mortality (as a standardized mortality ratio), and relative survival (as a relative excess risk) were smoothed by using a Bayesian method (BYM model). The maps show that spatial differences can be made visible by smoothing.Data aggregation is the methodically simpler way, but means a loss of information. The atlas shows that small-scale mapping is possible while preserving the entire spatial information. The method of smoothing is complex, but useful for generating hypotheses. The spatial patterns found are complex, difficult to interpret, and require the collaboration of specialists from different professions, because of the diverse influencing factors (data collection, lifestyle factors, early detection, risk factors, etc.). The effort required to explain the methodology in a language easy to understand should not be underestimated.

Socioeconomic deprivation and cancer survival in Germany: an ecological analysis in 200 districts in Germany.

Although socioeconomic inequalities in cancer survival have been demonstrated both within and between countries, evidence on the variation of the inequalities over time past diagnosis is sparse. Furthermore, no comprehensive analysis of socioeconomic differences in cancer survival in Germany has been conducted. Therefore, we analyzed variations in cancer survival for patients diagnosed with one of the 25 most common cancer sites in 1997-2006 in ten population-based cancer registries in Germany (covering 32 million inhabitants). Patients were assigned a socioeconomic status according to the district of residence at diagnosis. Period analysis was used to derive 3-month, 5-year and conditional 1-year and 5-year age-standardized relative survival for 2002-2006 for each deprivation quintile in Germany. Relative survival of patients living in the most deprived district was compared to survival of patients living in all other districts by model-based period analysis. For 21 of 25 cancer sites, 5-year relative survival was lower in the most deprived districts than in all other districts combined. The median relative excess risk of death over the 25 cancer sites decreased from 1.24 in the first 3 months to 1.16 in the following 9 months to 1.08 in the following 4 years. Inequalities persisted after adjustment for stage. These major regional socioeconomic inequalities indicate a potential for improving cancer care and survival in Germany. Studies on individual-level patient data with access to treatment information should be conducted to examine the reasons for these socioeconomic inequalities in cancer survival in more detail.

Colorectal Cancer Survival in German-Danish Border Regions-A Registry-Based Cohort Study.

The aim of this study was (i) to update the reporting of colorectal cancer survival differences over time in the German-Danish border region (Schleswig-Holstein, Southern Denmark, and Zealand) and (ii) to assess the extent to which it can be explained by stage and primary treatment. Incident invasive colorectal cancer cases diagnosed from 2004 to 2016 with a follow-up of vital status through 31 December 2017 were extracted from cancer registries. Analyses were conducted by anatomical subsite and for four consecutive periods. Kaplan-Meier curves and log-rank tests were computed. Cox regression models using data from Schleswig-Holstein from 2004 to 2007 as the reference category were run while controlling for age, sex, stage, and treatment. The cox regression models showed decreasing hazard ratios of death for all three regions over time for both anatomical subsites. The improvement was stronger in the Danish regions, and adjustment for age, sex, stage, and treatment attenuated the results only slightly. In 2014-2016, colon cancer survival was similar across regions, while rectal cancer survival was significantly superior in the Danish regions. Regional survival differences can only partially be explained by differing stage distribution and treatment and may be linked additionally to healthcare system reforms and screening efforts.

Population-Based Clinical Cancer Registration in Germany.

INTRODUCTION: In 2013, a new federal law obligated all German federal states to collect additional clinical data in population-based cancer registries as an active tool for monitoring and improving the quality of cancer care, increasing transparency and promoting health research. Now, 10 years later, the current status of the expanded cancer registration is presented, including current figures on cancer in Germany. METHODS: Reporting of cancer is mandatory for physicians, and about 5 to 10 reports from different healthcare providers are expected for each case. A uniform national dataset of about 130 items is used, and reports are usually sent electronically to the registry. We used the most recent data available from cancer registries up to the year of diagnosis in 2019. We calculated incidence rates and 5-year relative survival (5YRS) for common cancers. Data on clinical outcomes and benchmarking based on quality indicators (QIs) from guidelines were provided by the Cancer Registry Schleswig-Holstein (CR SH). RESULTS: All federal state cancer registries met most of the previously defined national eligibility criteria. Approximately 505,000 cancer cases were registered in 2019, with breast, prostate, colorectal and lung cancer being the most common cancers. The age-standardised cancer incidence has slightly decreased during the last decade. and spatial heterogeneity can be observed within Germany. 5YRS for all cancers was 67% and 63% for women and men, respectively. Therapy data for rectal cancer in 2019-2021 from the CR SH are shown as an example: 69% of the registered patients underwent surgery, mostly with curative intent (84%) and tumour-free resection (91%). Radiotherapy was given to 33% of the patients, and chemotherapy was given to 40%. Three selected QIs showed differences between involved healthcare providers. DISCUSSION: The implementation of population-based clinical cancer registration can be considered a success. Comprehensive recording of diagnosis, treatment and disease progression and the use of registry data for quality assurance, benchmarking and feedback have been implemented.