Impact of the COVID-19 pandemic on reported cancer diagnoses in Bavaria, Germany.

PURPOSE: The aim of our study was to explore the impact of the COVID-19 pandemic on reported cancer cases in Bavaria, Germany, by comparing pre-pandemic (March 2019 to February 2020) and pandemic period (March 2020 to February 2021). METHODS: Data on incident cases were retrieved from the Bavarian Cancer Registry (until 22nd April 2022). We included patients with malignant and in situ neoplasms reported by pathology departments with consistent reporting. We calculated the number of incident cases during the COVID-19 pandemic and the pre-pandemic period with 95% confidence intervals (CI) with Bonferroni correction (α = 0.0018) based on a Poisson approach. We stratified for malignancy (malignant, in situ), tumor site, and month of year. RESULTS: Data was available for 30 out of 58 pathology departments (51.7%) from Bavaria. Incident malignant neoplasms dropped from 42,857 cases in the pre-pandemic period to 39,980 cases in the pandemic period (- 6.7%; 95% CI - 8.7%, - 4.7%). Reductions were higher for colon, rectum, skin/melanoma as well as liver (> 10.0% reduction) and less for breast cancer (4.9% reduction). No case reductions were observed for pancreas, esophagus, ovary, and cervix. Percent changes were largest for April 2020 (- 20.9%; 95% CI - 24.7%, - 16.8%) and January 2021 (- 25.2%; 95% CI - 28.8%, - 21.5%) compared to the previous year. Declines tended to be larger for in situ compared to malignant neoplasms. CONCLUSION: Detection and diagnosis of cancer were substantially reduced during the COVID-19 pandemic. Potential effects, e.g. a stage shift of tumors or an increase of cancer mortality, need to be monitored.

Rare pediatric tumors in Germany - not as rare as expected: a study based on data from the Bavarian Cancer Registry and the German Childhood Cancer Registry.

Very rare pediatric tumors (VRTs) pose a challenge for treating physicians as little is known about the best diagnostic assessment and therapeutic decision-making in these malignancies. A large proportion of these cancers occur in adolescence. Therefore, the established structures of pediatric oncology including cancer registration may partly be circumvented. This may lead to an underregistration in clinical cancer registries of yet unclear extent. The aim of this study is to increase the knowledge on the occurrence of VRTs in pediatric patients in Germany. Pseudonymized data of cases recorded in the Bavarian Cancer Registry (BCR) between 2002 and 2014 were retrieved. VRTs according to the definition of the European Cooperative Study Group for Pediatric Rare Tumors were identified using the ICD and ICD-O classification. The numbers of registered patients were compared to those reported to the German Childhood Cancer Registry (GCCR). 6.3% (n = 290) of all malignancies (n = 4615) in the age below 18 years were classified as VRTs. Median age at diagnosis was 15 years (range 0-17 years). The most common tumor types included malignant melanoma, skin carcinoma, and gonadal tumors. During the same period, 49 pediatric patients from Bavaria with matchable VRTs were reported to the GCCR, accounting for 17% of cases reported to the BCR. CONCLUSIONS: The frequency of VRTs in Germany is underestimated in the national GCCR. With this study, we present population-based data on the incidence of VRTs in Germany for the first time. In order to gain additional knowledge about these malignancies, registration of VRTs must be improved through enhanced data exchange between the GCCR, the public cancer registries, and the clinical Registry for Rare Pediatric Tumors (STEP). WHAT IS KNOWN: • Rare pediatric tumors pose a challenge for treating physicians as limited knowledge is available on these malignancies for diagnostic and therapeutic decision-making. • Little is known about the frequency of these rare tumors in pediatric patients. WHAT IS NEW: • The frequency of rare pediatric tumors in Germany is distinctly underestimated in the German Childhood Cancer Registry. • We present population-based data on the incidence of these rare pediatric cancers for the first time.

[Trends in incidence of lung cancer according to histological subtype among men and women in Germany : Analysis of cancer registry data with the application of multiple imputation techniques]. / Trends der Lungenkrebsinzidenz nach histologischem Subtyp bei Männern und Frauen in Deutschland : Analyse von Krebsregisterdaten unter Einsatz von multipler Imputation.

BACKGROUND: Lung cancer can be described by histological subtype, of which small cell, squamous cell and adenocarcinoma are the most common. International data show that adenocarcinoma is becoming the dominant histological subtype of lung cancer although the relative risk due to smoking has been found to be smaller than that for other histological subtypes. OBJECTIVE: The aim of the analysis was to describe the time trends in incidence of lung cancer among women and men in Germany according to histological subtype. MATERIALS AND METHODS: All lung cancer cases (ICD-10 C33-C34) newly diagnosed between 2003 and 2012 and collected by the epidemiologic cancer registries of the German federal states with average completeness of registration of at least 90% were considered and grouped into histologic subtypes. If data on tumor histology were not microscopically verified or unspecific, multiple imputation techniques were applied to estimate the histologic subtype. RESULTS: Among women age-standardized lung cancer rates increased considerably between 2003 and 2012 (annual percent change APC = 2.7%), mostly driven by a rising adenocarcinoma incidence (APC = 4.7%). Among men overall lung cancer rates decreased during the same time (APC = -1.7%). Still, a slight increase in adenocarcinoma incidence was also observed in men (APC = 1.0%). CONCLUSION: The rising incidence of adenocarcinoma of the lung is alarming. The cancer registry data do not allow risk factor analysis. In the international discussion, the introduction of filter cigarettes as well as the changing composition of cigarettes has been hypothesized as being responsible. Further epidemiologic studies are strongly needed.

Association between month of birth and melanoma risk: fact or fiction?

Background: Evidence on the effect of ultraviolet radiation (UVR) exposure in infancy on melanoma risk in later life is scarce. Three recent studies suggest that people born in spring carry a higher melanoma risk. Our study aimed at verifying whether such a seasonal pattern of melanoma risk actually exists. Methods: Data from the population-based Cancer Registry Bavaria (CRB) on the birth months of 28 374 incident melanoma cases between 2002 and 2012 were analysed and compared with data from the Bavarian State Office for Statistics and Data Processing on the birth month distribution in the Bavarian population. Crude and adjusted analyses using negative binomial regression models were performed in the total study group and supplemented by several subgroup analyses. Results: In the crude analysis, the birth months March-May were over-represented among melanoma cases. Negative binomial regression models adjusted only for sex and birth year revealed a seasonal association between melanoma risk and birth month with 13-21% higher relative incidence rates for March, April and May compared with the reference December. However, after additionally adjusting for the birth month distribution of the Bavarian population, these risk estimates decreased markedly and no association with the birth month was observed any more. Similar results emerged in all subgroup analyses. Conclusions: Our large registry-based study provides no evidence that people born in spring carry a higher risk for developing melanoma in later life and thus lends no support to the hypothesis of higher UVR susceptibility during the first months of life.

The Effect of Exposure to Ultraviolet Radiation in Infancy on Melanoma Risk.

Evidence on the effect of ultraviolet radiation (UVR) exposure in infancy on melanoma risk in later life is scarce. Three recent studies suffering from methodological shortcomings suggested that people born in spring carry a higher melanoma risk. Data from the Bavarian population-based cancer registry on 28374 incident melanoma cases between 2002 and 2012 were analyzed to reexamine this finding. Crude and adjusted analyses - using negative binomial regression models - were performed addressing the relationship. In the crude analysis, the birth months March - May were significantly overrepresented among melanoma cases. However, after additionally adjusting for the birth month distribution of the Bavarian population, the ostensible seasonal effect disappeared. Similar results emerged in all subgroup analyses. Our large registry-based study provides no evidence that people born in spring carry a higher risk for developing melanoma in later life and thus lends no support to the hypothesis of higher UVR-susceptibility during the first months of life.

Replacing surrogate measures by direct quantification of ultraviolet radiation exposure in registry-based analyses of seasonality of melanoma diagnoses.

Seasonal variation in melanoma diagnoses has been observed in numerous studies that used calendar time indicators. Depending on the latitude (and altitude) of the study region, the magnitude of seasonal and year-to-year variation of ultraviolet radiation (UVR) is neglected in these studies. An alternative approach comprises the direct incorporation of UVR measurements into such analyses. The aim of this investigation is a comparative evaluation of these approaches. The population-based Bavarian cancer registry recorded 11 901 incident melanoma cases between 2003 and 2008 that were used for the analysis. UVR intensity data for the same period were available from the solar radiation station at Munich-Neuherberg. Negative binomial regression modelling yielded adjusted relative risks (RR) controlled for year of diagnosis and age in 16 subgroups defined by sex, Breslow thickness and localization. Overall, the analyses showed slightly differing yet consistent results for exposure effects in subgroups. Melanoma evolving on the extremities showed the most pronounced association with increasing level of the UV index among men [e.g. RR=1.086, 95% confidence interval (CI) 1.054-1.119, and RR=1.102, 95% CI 1.046-1.161, for thin and thick melanoma on the upper limbs, respectively] and women (e.g. RR=1.088, 95% CI 1.058-1.119, and RR=1.056, 95% CI 1.010-1.103, for thin and thick melanoma on the lower limbs, respectively). Our analysis provides a benchmark for international comparisons and synthesis of epidemiologic evidence of seasonal variability in melanoma diagnoses. Future studies should use direct UVR measures to enable pooling of risk estimates and resolve remaining inconsistencies potentially resulting from latitudinal differences in exposure between international studies.

Seasonality of cutaneous melanoma diagnoses: a comprehensive comparison of results in Bavaria and Northern Ireland.

Ultraviolet radiation is an established skin carcinogen. By analysing the seasonality of melanoma diagnoses, the effect of this risk factor can be examined indirectly. However, previous studies yielded conflicting results, because of vastly differing analytical methods and diverse study designs. Therefore, to validate the findings by Chaillol and colleagues based on 3868 melanoma diagnoses from Northern Ireland, we used an identical methodology to examine the seasonal effects on monthly incidences of 11,901 cutaneous malignant melanoma cases registered from 2003 until 2008 in Bavaria, Germany. Multivariable regression models for count data were used to estimate the effect of seasons while taking into account sex, age, year of diagnosis, Breslow thickness and anatomical site. Point and interval estimates of the adjusted relative risks associated with seasons were compared with the findings of the Irish study. Both analyses demonstrated a promoting effect of intermittent ultraviolet radiation on cutaneous melanoma of a thickness of 2 mm or less evolving on the extremities, whereas no seasonality for melanomas on the trunk was evident. Differences were identified with regard to thick melanomas. In the present analysis, only melanomas with a Breslow thickness of more than 2 mm were also found to be associated with season, in particular, the melanomas on the limbs. Hence, in contrast to the data of, and to the interpretation by, Chaillol and colleagues, an effect of ultraviolet radiation on melanoma progression from thin to thick cannot be excluded.

Risk of tobacco-related multiple primary cancers in Bavaria, Germany.

BACKGROUND: With the prospect of increasing prevalence of cancer, the issue of multiple primary cancers becomes more relevant. The aim of this study was to estimate the risk of developing a tobacco-related subsequent primary cancer (TRSPC) in persons with a tobacco-related first primary cancer (TRFPC) compared with the general population in Bavaria, Germany. METHODS: Using data from the Population-Based Cancer Registry Bavaria, we analyzed TRFPC and TRSPC diagnosed in Bavaria between 2002 and 2008 to estimate the relative and absolute risk of developing TRSPC using standardized incidence ratios (SIR) and excess absolute risks (EAR). RESULTS: 121,631 TRFPC in men and 75,886 respective cancers in women were registered, which in 2.5% of male and 1.2% of female cancer patients were followed by at least one TRSPC. In both males and females, the highest increased risks compared to the general population were found within the group of cancer in the mouth/pharynx, oesophagus, larynx, and lung/bronchus. CONCLUSIONS: With respect to cancer in the mouth/pharynx, oesophagus, larynx, lung/bronchus, kidney, urinary bladder and urinary tract, smoking was confirmed as a shared risk factor based on our finding of mutually significantly increased risks of TRSPC. The results of this study illustrate the importance of smoking cessation and of continued follow-up care especially of smokers with the aforementioned TRFPC to detect TRSPC at an early stage.

Risk of subsequent primary cancer among prostate cancer patients in Bavaria, Germany.

As the prevalence of prostate cancer in Germany is increasing, the issue of subsequent primary cancer (SPC) becomes more relevant. The aim of this study was to estimate the risk and its changes over time of developing SPC among prostate cancer patients compared with the general male population in Bavaria, southern Germany. Utilizing data from the Population-Based Cancer Registry Bavaria, the risk of SPC was evaluated in 59 259 men with prostate cancer diagnosed between 2002 and 2008 who contributed 159 892 person-years. The relative and absolute risk of developing SPC were calculated using the standardized incidence ratio (SIR) and the excess absolute risk. Changes in the risk were examined by plotting the SIR and its 95% confidence interval against time after the diagnosis of prostate cancer. The overall risk of SPC was significantly increased by 14% compared with the general male population. With regard to specific cancer types, a significantly increased risk of SPC was found for the urinary bladder, kidney, pancreas, melanoma of skin, leukemia, myeloma, brain/nervous system, renal pelvis/ureter, thyroid, and the small intestine. The absolute risk of SPC for most cancer types, however, was below 10 cases per 10 000 person-years. A significantly decreased risk of SPC was found in the lung/bronchus and the liver. Although detection bias cannot be excluded as a contributing factor for our results, we recommend continuing follow-up care of prostate cancer patients particularly with respect to SPC of the urinary system as a precaution.

Geographic differences and time trends of intraoral cancer incidence and mortality in Bavaria, Germany.

OBJECTIVE: To examine possible geographic differences and time trends of intraoral cancer (IOC) incidence and mortality in Bavaria between 2002 and 2008. METHODS: Incidence data for IOC (ICD-10 codes, C01-C06) were obtained from the population-based cancer registry Bavaria. Age-specific and age-standardised IOC incidence and mortality rates in Bavaria and its regions were calculated separately by sex and year of diagnosis. RESULTS: We found an excess incidence of 34% and 25% among men and women in Upper Franconia compared to Bavaria. Incidence and mortality related to IOC in Bavaria are comparable to those found in other European cancer registries. IOC mortality appears to decrease over time in both sexes, whereas IOC incidence appears to decrease only in men. CONCLUSIONS: The observed geographic differences with respect to IOC incidence and mortality in Bavaria may possibly be explained in part by socioeconomic differences.

Population-Based Effects of Mammography Screening in Bavaria on the Distribution of TNM-T Categories with Respect to Different Histological Subgroups.

BACKGROUND: Organized mammography screening was implemented in Bavaria in 2003, with a target population of about 1.5 million women (aged 50-69 years). We evaluated the population-based effects of mammography screening on the distribution of tumor-node-metastasis (TNM)-T categories with regard to different histological subgroups of breast cancer. PATIENTS AND METHODS: Women diagnosed with breast cancer between 2002 and 2008 were included. The annual age-specific incidence rates separated by T category were calculated for different histological subgroups and plotted against time. Time trends were analyzed not only in the screening population but also based on women aged 15-49 and ≥70 years, respectively. Furthermore, correlation coefficients were calculated in order to evaluate the possible association between participation rate and incidence of certain TNM-T categories. RESULTS: With ductal carcinomas, the incidence of early-stage tumors shows a strong increase in the screening population and a significant correlation with the participation rate, whereas with lobular carcinomas there is a stagnation of incidence in women aged 50-69 years irrespective of TNM-T category. CONCLUSIONS: Short-term effects of mammography screening can already be demonstrated. However, depending on breast cancer type, not all women appear to benefit from screening. The expected long-term reduction of breast cancer mortality remains to be seen.

SURVSOFT-Software for nonparametric survival analysis.

Long-term observed and relative survival are important outcome measures of cancer patient care reported routinely by many cancer registries, but no commercial statistical software exists for estimating relative survival or performing period survival analysis. The programs publicly available focus only on certain methods, require specific input data formats and often are macros or functions which require underlying software packages. Here we introduce SURVSOFT, a comprehensive, user-friendly Windows program with graphical user interface. It can handle different input data formats and incorporates a variety of nonparametric statistical methods for survival data analysis. SURVSOFT produces high-resolution graphs, which can be printed, saved or exported to be used with standard graphics editors. The use of SURVSOFT is illustrated by the analysis of survival data from the Bavarian Cancer Registry.

Prognostic impact of blood transfusion in patients undergoing primary surgery and free-flap reconstruction for oral squamous cell carcinoma.

BACKGROUND: The objective of this study was to assess the impact of perioperative transfusion on the prognosis of patients who underwent complete (R0) resection of oral squamous cell carcinoma and reconstruction by microvascular flaps. METHODS: By following an inclusion and exclusion protocol, 223 patients were included in the study who underwent R0 resection of oral squamous cell carcinoma and reconstruction by microvascular flaps at a single center. Clinical and pathologic factors as well as transfusion data were retrieved from a prospective database and analyzed retrospectively. Survival data were assessed using the method of Kaplan and Meier. For multivariate analysis the accelerated failure time model (Weibull distribution) was chosen. RESULTS: The overall survival rate was 71% at 1 year, 67% at 3 years, and 55% at 5 years. In univariate analysis, age (P = .003), tumor size (P = .005), lymph node status (P = .008), tumor differentiation (P = .008), transfusion (P = .006), American Society of Anesthesiologists (ASA) class (P = .001), and mandibular reconstruction (P = .045) were associated significantly with overall survival. Multivariate analysis identified only age, histopathologic differentiation, and ASA class as independent risk factors (P < .001, P = .04, and P = .049, respectively). Age was identified as the strongest independent predictor for overall survival (hazards ratio for each 13-year increase in age, 1.97; 95% confidence interval, 1.36-2.85). CONCLUSIONS: Transfusion of >4 U of blood did not appear to influence overall survival in patients who underwent primary surgery for oral squamous cell carcinoma. Because age and ASA class evolved as the strongest predictors of shortened overall survival, associated comorbidities may require more attention, particularly in elderly or socially deprived patients.

Birth month and risk of glioma in adults: a registry-based study in Bavaria.

The aim of the present study was to evaluate the possible seasonality of birth in adult patients suffering from glioma. For this purpose, data from the database of the population-based cancer registry of Bavaria (Germany) were retrieved. For the period 2002-2005, we identified a total of 2174 patients born between 1931 and 1986 diagnosed with malignant glioma. Statistical analyses failed to document a significant annual periodicity of glioma risk in either men or women with respect to birth month in the observed cohort. Thus, we found no association between month of birth and the risk of glioma. In contrast, an analysis of the official birth rate data of Bavaria revealed marked annual variation in birth rates up until 1965, which decreased markedly in prominence in the years thereafter. Our findings confirm the results of a recent similar study conducted in The Netherlands. Therefore, we support the hypothesis of possible etiological factors of glioma acting in adulthood rather than in the perinatal period.

Registration completeness and tumour-node-metastases category distribution in prostatic and testicular cancer in Bavaria.

Tumour-node-metastases (TNM) category distribution can be used as a short-term surrogate measure for survival probability to evaluate the impact of interventions for improved prevention and early detection of cancer. We aimed to demonstrate whether or not an association between registration completeness and TNM category distribution exists and whether accurate estimates of the TNM category distribution are possible before complete registration. With respect to the diagnosis year 2002, the number of registered cases of prostatic and testicular cancer at the Bavarian cancer registry was determined every 6 months between 2003 and 2006 together with the respective TNM category distributions and the completeness of registration. For the diagnosis year 2002, 6135 and 480 cases of newly developed prostatic and testicular cancer, respectively, were reported to the registry. After 2003, the proportion of prostatic cancer cases labelled 'T1' fluctuated by only 1%. A stable TNM category distribution was seen with a minimum registration completeness of 65-70%. No relevant association between registration completeness and TNM category distribution could be demonstrated for prostatic and testicular cancer. Therefore, in prostatic and testicular cancer, the TNM category distribution can be used for short-term evaluation of quality assurance projects and in health services research.

Patient-centred outcomes comparing transmucosal implant placement with an open approach in the maxilla: a prospective, non-randomized pilot study.

It was the aim of the study to assess differences in patient morbidity between transmucosal implant placement and implant installation after elevation of mucoperiosteal flaps. In five of the patients, implants were placed in the maxilla transmucosally using a CAD/CAM surgical template [test group (TG)]. In the remaining five patients, the implants were installed after the elevation of mucoperiosteal flaps [control group (CG)]. Directly after surgery, at days 1 and 7 after surgery the patients rated pain and discomfort on a visual analogue scale (0=minimal pain and discomfort, 100=maximal pain and discomfort). Optical three-dimensional images were assessed preoperatively and at days 1 and 7 after surgery to determine the visible soft tissue swelling of the upper lip and cheeks. Directly postoperatively, the mean pairwise difference between both groups in view of pain and discomfort ratings (control minus test) was 45.6 (SD, 20.7). At days 1 and 7, the mean differences were 51.6 (SD, 21.8) and 19 (SD, 8), respectively. The overall test of the area under curve (AUC) against the null hypothesis 'AUC of pairwise differences of pain score over study time equals null' yielded a significant difference (P=0.01). The mean pairwise difference between both groups in view of soft tissue volume increase was 6.1 (SD, 2) cm(3) at day 1 after surgery and 4.6 (SD, 1.2) cm(3) at day 7. The overall test of the AUC against the null hypothesis 'AUC of pairwise differences of oedema measurements over study time equals null' yielded a significant difference (P=0.002). Within the limitations of this pilot study, it could be shown that transmucosal implant placement reduces patient morbidity significantly compared with an open approach.