Regional comparison of cancer incidence, mortality, and survival on the level of federal states in Germany using funnel plots.

Population-based cancer registries allow the assessment of regional differences in cancer burden. Comparative cancer statistics are usually reported as ranked bar charts and choropleth maps, which can lead to misinterpretations of the presented figures. The aim of the present study is a regional comparison of cancer statistics in Germany on the level of federal states using funnel plots. Population-based cancer registry data on incidence, mortality, and survival on the level of federal states for the year 2011 were used. All cancer sites combined and the most common cancers were considered for the analysis. Funnel plots were used to compare the regional cancer statistics against the national estimates for Germany by sex, cancer site, and federal state. Cancer incidence and mortality showed large regional variation, which differed by sex and cancer site, whereas for cancer survival, essentially, no excess variation was observed. By taking into account statistical variation, funnel plots proved to be a suitable tool for assessing regional variation in cancer incidence, mortality, and survival and therefore can help improve population-based health management and eliminate cancer health disparities.

[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.

Risk of second primary cancers in women diagnosed with endometrial cancer in German and Swedish cancer registries.

Along with the increasing incidence and favorable prognosis, more women diagnosed with endometrial cancer may develop second primary cancers (SPCs). We aimed at investigating risk of SPCs after endometrial cancer in Germany and Sweden to provide insight into prevention strategies for SPCs. Endometrial cancer patients diagnosed at age ≥15 years in Germany during 1997-2011 and in Sweden nationwide during 1997-2012 were selected. Standardized incidence ratios (SIRs), calculated as the ratio of observed to expected numbers of cases, were used to assess the risk of a specific second cancer after endometrial cancer for both German and Swedish datasets. Among 46,929 endometrial cancer survivors in Germany and 18,646 in Sweden, overall 2,897 and 1,706 SPCs were recorded, respectively. Significantly elevated SIRs were observed in Germany for ovarian (SIR = 1.3; 95%CI:1.1-1.5) and kidney cancers [1.6 (1.3-1.8)], while in Sweden the SIRs were 5.4 (4.6-6.3) and1.4 (1.0-1.9), respectively. Elevated risk for second ovarian endometrioid carcinoma was pronounced after early (<55 years) onset endometrial cancer in Germany [9.0 (4.8-15)] and Sweden [7.7 (5.1-11)]. In Germany elevated risks were found for second ovarian endometrioid carcinoma after endometrioid histology of first endometrial cancer [6.3 (4.0-9.4)] and for second kidney cancer after clear cell histology of endometrial cancer [4.9 (1.6-11)]. We found exceptionally elevated risk of second ovarian endometrioid carcinoma after endometrial cancer of the same histology or of early onset. Risk for second kidney cancer was also increased, particularly after endometrial cancer of clear cell histology. Cancer prevention strategies should focus on these cancers after endometrial cancer diagnosis.

Risk of Second Primary Cancers in Multiple Myeloma Survivors in German and Swedish Cancer Registries.

We aimed at investigating the distribution and risk of second primary cancers (SPCs) in multiple myeloma (MM) survivors in Germany and Sweden to provide etiological understanding of SPCs and insight into their incidence rates and recording practices. MM patients diagnosed in 1997-2010 at age ≥15 years were selected from the Swedish (nationwide) and 12 German cancer registries. Standardized incidence ratios (SIRs) were used to assess risk of a specific SPC compared to risk of the same first cancer in the corresponding background population. Among 18,735 survivors of first MM in Germany and 7,560 in Sweden, overall 752 and 349 SPCs were recorded, respectively. Significantly elevated SIRs of specific SPCs were observed for acute myeloid leukemia (AML; SIR = 4.9) in Germany and for kidney cancer (2.3), AML (2.3) and nervous system cancer (1.9) in Sweden. Elevated risk for AML was more pronounced in the earlier diagnosis period compared to the later, i.e., 9.7 (4.2-19) for 1997-2003 period versus 3.5 (1.5-6.9) for 2004-2010 in Germany; 3.8 (1.4-8.3) for 1997-2003 versus 2.2 (0.3-7.8) for 2004-2010 in Sweden. We found elevated risk for AML for overall, early diagnosis periods and longer follow-up times in both populations, suggesting possible side effects of treatment for MM patients.

Distribution and risk of the second discordant primary cancers combined after a specific first primary cancer in German and Swedish cancer registries.

We aimed at investigating the distribution and risk of all second discordant primary cancers (SDPCs) after a specific first primary cancer in Germany and Sweden to provide etiological understanding of SDPCs and insight into their incidence rates and recording practices. Among 1,537,004 survivors of first primary cancers in Germany and 588,103 in Sweden, overall 80,162 and 32,544 SDPCs were recorded, respectively. Standardized incidence ratios (SIRs) of all SDPCs were elevated at levels between 1.1 and 2.1 after 23 (out of overall 29) cancers in Germany and at levels between 1.1 and 1.6 after 24 cancers in Sweden, and among them, elevated SIRs were found after 19 cancers in both populations. Decreased SIRs at levels ranging from 0.5 to 0.9 were found for some cancers with poor prognosis in Germany only. We found elevated risk after 19 out of 29 cancers in both countries, suggesting common etiology of SDPCs after most of first cancers and registration similarity. Decreased risks after some fatal cancers were found only in Germany, which may be attributed to reporting practices or missed death data in Germany.

Survival of cancer patients in urban and rural areas of Germany--a comparison.

BACKGROUND: Cancer care services including cancer prevention activities are predominantly localised in central cities, potentially causing a heterogeneous geographic access to cancer care. The question of an association between residence in either urban or rural areas and cancer survival has been analysed in other parts of the world with inconsistent results. This study aims at a comparison of age-standardised 5-year survival of cancer patients resident in German urban and rural regions using data from 11 population-based cancer registries covering a population of 33 million people. MATERIAL AND METHODS: Patients diagnosed with cancers of the most frequent and of some rare sites in 1997-2006 were included in the analyses. Places of residence were assigned to rural and urban areas according to administrative district types of settlement structure. Period analysis and district type specific population life tables were used to calculate overall age-standardised 5-year relative survival estimates for the period 2002-2006. Poisson regression models for excess mortality (relative survival) were used to test for statistical significance. RESULTS: The 5-year relative survival estimates varied little among district types for most of the common sites with no consistent trend. Significant differences were found for female breast cancer patients and male malignant melanoma patients resident in city core regions with slightly better survival compared to all other district types, particularly for patients aged 65 years and older. CONCLUSION: With regard to residence in urban or rural areas, the results of our study indicate that there are no severe differences concerning quality and accessibility of oncological care in Germany among different district types of settlement.

A Windows application for computing standardized mortality ratios and standardized incidence ratios in cohort studies based on calculation of exact person-years at risk.

Standardized mortality ratios and standardized incidence ratios are widely used in cohort studies to compare mortality or incidence in a study population to that in the general population on a age-time-specific basis, but their computation is not included in standard statistical software packages. Here we present a user-friendly Microsoft Windows program for computing standardized mortality ratios and standardized incidence ratios based on calculation of exact person-years at risk stratified by sex, age and calendar time. The program offers flexible import of different file formats for input data and easy handling of general population reference rate tables, such as mortality or incidence tables exported from cancer registry databases. The application of the program is illustrated with two examples using empirical data from the Bavarian Cancer Registry.

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.

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.