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.

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.

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.

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.

Health and life insurance-related problems in very long-term cancer survivors in Germany: a population-based study

Purpose

Limited research suggests that cancer survivors have problems with insurance. Our study aimed to gain insight into the proportion of very long-term (14–24 years post-diagnosis) survivors of breast, colorectal, and prostate cancers who had problems with health (HI) and life (LI) insurance.

Methods

We used data from CAESAR (CAncEr Survivorship—A multi-Regional population-based study). Participants completed questions on change in insurance providers since cancer diagnosis, problems with requesting (additional) HI or LI, and how potential problems were resolved. We conducted logistic regression to determine factors associated with change in statutory HI.

Results

Of the 2714 respondents, 174 (6%) reported having changed HI providers. Most switched between different statutory HI providers (86%), 9% from statutory to private, and 5% from private to statutory. Respondents who changed statutory HI providers were more likely to be prostate cancer survivors (OR 2.79, 95% CI 1.01–7.68) while being ≥ 65 years at time of diagnosis (OR 0.58, 95% CI 0.35–0.96) and having ≥ 2 comorbid conditions (OR 0.61, 95% CI 0.40–0.92) were associated with reduced odds for change. Problems in changing HI were minimal and were resolved with additional contribution. Of the 310 respondents who tried to get LI, 25 respondents reported having difficulties, of whom the majority had their request rejected.

Conclusion

Most cancer survivors did not change their HI nor tried to buy LI after cancer diagnosis. Problems with changing statutory HI were generally resolved with additional contribution while the main problem encountered when buying LI was rejection of request.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00432-021-03825-x.

Socioeconomic deprivation and cancer survival in a metropolitan area: An analysis of cancer registry data from Hamburg, Germany

Background

Few studies have investigated socioeconomic inequalities within cities. Yet, such analyses are particularly important given the increasing international trend to urbanization. Here we investigated area-based socioeconomic inequalities in cancer survival in Hamburg, a port city in the North of Germany (population: 1.84 million people).

Methods

Patients with a diagnosis of colorectal, lung, female breast, and prostate cancer in 2004–2018 (follow-up until 31.12.2018) and registered in the Hamburg cancer registry were included. Area-based socioeconomic deprivation on urban district level was assigned to the patients and grouped in five quintiles. Relative survival in 2014–2018 was calculated using the period approach. Trend analyses between 2004 and 2018 were conducted. Relative excess risks adjusted for age and stage were computed with model-based period analyses.

Findings

For the 73,106 included patients, age-standardized 5-year relative survival in 2014–2018 decreased with increasing deprivation with significant differences between the most and least deprived group of 14·7 (prostate), 10·8 (colorectal), 8·0 (breast), and 2·5 (lung) percent units. Standardization by cancer stage decreased the difference for prostate cancer to 8·5 percent units and for breast cancer to 3·6 percent units but had only a minor effect for colorectal and lung cancer. Similar socioeconomic inequalities were already present in 2004–08.

Interpretation

Strong socioeconomic inequalities in cancer survival were observed in Hamburg, which could be partly explained by differences in the stage distribution. Further research including information on screening participation as well as information on cancer care are important to further understand and finally overcome these inequalities.

Funding

10.13039/501100005972German Cancer Aid.

Survival of breast cancer patients in German-Danish border regions - A registry-based cohort study

BACKGROUND AND AIM

Denmark reports slightly lower breast cancer survival before 2010 than its neighbouring country Germany. Previous research is limited by lacking stage and treatment information. This study aims to investigate differences in breast cancer survival between the bordering regions Schleswig-Holstein (Germany), Southern Denmark and Zealand (Denmark) using registry data including stage and treatment information.

METHOD

Invasive female breast cancer cases diagnosed during 2004-2013 with follow up through 31st December 2014 were extracted from cancer registries. Cases notified by death certificates only and those aged 90+ years were excluded. Kaplan-Meier curves and log-rank tests were computed. Cox regression analysis was conducted with adjustment for year of diagnosis, age, stage, and treatment.

RESULTS

The analytical sample included 42,966 cases. Kaplan-Meier curves and log-rank tests show significant survival differences between the regions. The Cox regression model adjusted for year of diagnosis and age shows significantly worse overall survival of breast cancer patients in both Danish regions compared to Schleswig-Holstein with hazard ratios (HR) of 1.09 (95 % CI: 1.04; 1.15) for patients from Southern Denmark (SD) and 1.25 (95 % CI: 1.18; 1.32) for residents of Zealand (ZL). This effect diminished after adjustment for stage and treatment (HR: 1.05 (SD), 1.09 (ZL) 95 % CI: 0.99; 1.10 (SD), 1.03; 1.15 (ZL)).

CONCLUSION

Survival differences can be explained by differing stage distribution and treatment administration, which formerly were more favourable in Schleswig-Holstein. The survival gap will probably close due to Denmark's national screening program and increased use of adjuvant cancer therapy.

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.

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.

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.

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.

Age-specific prevalence and determinants of depression in long-term breast cancer survivors compared to female population controls

Background

Depression is more prevalent in breast cancer (BC) survivors than in the general population. However, little is known about depression in long‐term survivors. Study objectives were: (1) to compare the age‐specific prevalence of depressive symptoms (a) in BC survivors vs female population controls, (b) in disease‐free BC survivors vs BC survivors with self‐reported recurrence vs controls, and (2) to explore determinants of depression in BC survivors.

Methods

About 3010 BC survivors (stage I‐III, 5‐16 years post‐diagnosis), and 1005 population controls were recruited in German multi‐regional population‐based studies. Depression was assessed by the Geriatric Depression Scale‐15. Prevalence of mild/severe and severe depression only were estimated via logistic regression, controlling for age and education. Multinomial logistic regression was used to explore determinants of mild and severe depression.

Results

Compared with population controls, BC survivors were more likely to report mild/severe depression (30.4% vs 23.8%, p = .0003), adjusted for age and education. At all age groups <80 years, prevalence of both mild/severe and severe depression only was significantly higher in BC survivors, while BC survivors ≥80 years reported severe depression less frequently than controls. BC survivors with recurrence reported significantly higher prevalence of mild/severe depression than disease‐free survivors and controls, but prevalence in disease‐free survivors and controls was comparable. Age, income, living independently, recurrence, and BMI were significant determinants of mild depression in BC survivors. Age, education, employment, income, recurrence, and BMI were significant determinants of severe depression.

Conclusions

Long‐term BC survivors <80 years report significantly higher prevalence of depressive symptoms than controls, which might be explained by recurrence and individual factors. The findings suggest that depression in BC survivors is common, and even more after BC recurrence. Clinicians should routinize screening and normalize referral to psychological care.

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.

Area-Based Socioeconomic Inequalities in Colorectal Cancer Survival in Germany: Investigation Based on Population-Based Clinical Cancer Registration

Background: Socioeconomic inequalities in colorectal cancer survival have been observed in many countries. To overcome these inequalities, the underlying reasons must be disclosed.

Methods: Using data from three population-based clinical cancer registries in Germany, we investigated whether associations between area-based socioeconomic deprivation and survival after colorectal cancer depended on patient-, tumor- or treatment-related factors. Patients with a diagnosis of colorectal cancer in 2000–2015 were assigned to one of five deprivation groups according to the municipality of the place of residence using the German Index of Multiple Deprivation. Cox proportional hazards regression models with various levels of adjustment and stratifications were applied.

Results: Among 38,130 patients, overall 5-year survival was 4.8% units lower in the most compared to the least deprived areas. Survival disparities were strongest in younger patients, in rectal cancer patients, in stage I cancer, in the latest period, and with longer follow-up. Disparities persisted after adjustment for stage, utilization of surgery and screening colonoscopy uptake rates. They were mostly still present when restricting to patients receiving treatment according to guidelines.

Conclusion: We observed socioeconomic inequalities in colorectal cancer survival in Germany. Further studies accounting for potential differences in non-cancer mortality and exploring treatment patterns in detail are needed.

Socioeconomic differences and lung cancer survival in Germany: Investigation based on population-based clinical cancer registration

OBJECTIVES

Studies from several countries reported socioeconomic inequalities in lung cancer survival. Hypothesized reasons are differences in cancer care or tumor characteristics. We investigated associations of small-area deprivation and lung cancer survival in Germany and the possible impact of differences in patient, tumor or treatment factors.

MATERIALS AND METHODS

Patients registered with a primary tumor of the lung between 2000-2015 in three German population-based clinical cancer registries were included. Area-based socioeconomic deprivation on municipality level was measured with the categorized German Index of Multiple Deprivation. Association of deprivation with overall survival was investigated with Cox regression models.

RESULTS

Overall, 22,905 patients were included. Five-year overall survival from the least to the most deprived quintile were 17.2%, 15.9%, 16.7%, 15.7%, and 14.4%. After adjustment for patient and tumor factors, the most deprived group had a lower survival compared to the least deprived group (Hazard Ratio (HR) 1.06, 95% confidence interval (CI) 1.01-1.11). Subgroup analyses revealed lower survival in the most deprived compared to the least deprived quintile in patients with stage I-III [HR: 1.14, 95% CI: 1.06-1.22]. The association persisted when restricting to patients receiving surgery but was attenuated for subgroups receiving either chemotherapy or radiotherapy.

CONCLUSION

Our results indicate differences in lung cancer survival according to area deprivation in Germany, which were more pronounced in patients with I-III stage cancer. Future research should address in more detail the underlying reasons for the observed inequalities and possible approaches to overcome them.

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.

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 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.

"Still a Cancer Patient"-Associations of Cancer Identity With Patient-Reported Outcomes and Health Care Use Among Cancer Survivors

Background

The concept of cancer identity is gaining attention as more individuals are living with cancer as a chronic illness. Research is limited, and results suggest that a self-identity as “cancer patient” rather than a “cancer survivor” is associated with depression and lower health-related quality of life (HRQL). We aimed to identify factors associated with patient identity and investigate the associations between patient identity and treatment, health care use, psychosocial distress, and HRQL.

Methods

We used data from the population-based CAncEr Survivorship: A multi-Regional (CAESAR) study. Breast, colorectal, and prostate cancer survivors diagnosed during 1994–2004 completed a postal survey on patient identity, HRQL, psychological distress, and health care use in 2009–2011. We calculated odds ratios and the 95% confidence interval of having a patient identity. Analyses were adjusted for age, sex, education, and cancer stage, where appropriate.

Results

Of the 6057 respondents, colorectal cancer survivors (25%) were least likely to consider themselves patients, and prostate cancer survivors (36%) the most likely. Being male, younger age, comorbidity, higher cancer stage, and disease recurrence were associated with patient identity. Treatment was associated with patient identity, except among female colorectal cancer survivors. Having a patient identity was associated with higher health care use within the past 12 months. Survivors who still consider themselves patients were more likely to be depressed and reported significantly lower HRQL.

Conclusions

A significant proportion of cancer survivors still consider themselves patients five to 15 years postdiagnosis. Sensitivity to individuals’ self-identity should be considered when exploring their cancer experience.

Baseline data of oral and pharyngeal cancer before introducing an oral cancer prevention campaign in Germany

OBJECTIVES

Oral and pharyngeal cancer is still a serious health problem with an annual incidence of about 13,000 in Germany. This study aimed at describing trends of incidence and mortality in Germany by age, sex, and sub-site as a baseline for an oral cancer prevention campaign.

METHODS

Using data from the National Association of Population-based Cancer Registries, incidence rates for oral and pharyngeal cancer (ICD-10, C00-C14) from 2003 to 2011 and mortality rates from 1990 to 2012 were analysed by age, sex, and sub-site (C00-C06, C07-C08, C09-C14). Trends were described by annual percentage changes.

RESULTS

Men are 2.5-times more likely than women to be diagnosed and 3-times more likely to die from this tumour. Incidence and mortality in women increased slightly during the last decade, while incidence and mortality in men remained stable at a high level. While a decline was observed for younger age groups, an increase was seen in the elderly. For some sub-sites a deviation from this overall pattern was observed.

CONCLUSIONS

The decrease in this tumour in younger age groups is pleasing and may be attributed to public efforts in non-smoker protection in recent years. Further efforts are needed to counteract the increasing burden of disease in older age groups and in men.

Less pitfalls and variation in population based cancer survival comparisons within the European Union: Lessons from colorectal cancer patients in neighbouring regions in Denmark and Germany - The Fehmarn Belt project

BACKGROUND

International comparisons of cancer registry based survival are often used as a marker of the performance of health care services on cancer. These are debated for comparability, validity and lack of detail with respect to prognostic factors. With a view to cross border collaborative cancer research and care in the European Union (EU), we used the established routine registration systems for cancer in the neighbouring regions Zealand, Denmark, and Schleswig-Holstein, Germany, to study if available routine registration suffices for the study of diagnosis, treatment and follow-up for colorectal cancer patients. The aim was to assess to which extent differences in survival between the regions could be explained.

METHODS

Colorectal cancer patients recorded 2004-2010 in Schleswig-Holstein (colon: 10,631; rectum 5683) and region Zealand (colon: 3205; rectum 1747) were studied. Excluding cases aged 90+ or only known from death certificates, one- and four-year relative survival by stage for the periods 2004-2006 and 2007-2009 (one-year) were calculated.

FINDINGS

A high proportion of patients in Schleswig-Holstein were known only from death certificates (colon 11%; rectum 6.9%) compared to <0.3% in region Zealand. Colon cancer incidence (asr-e) (men 36; women 28) and mortality (men 12; women 8.7) in Schleswig-Holstein were 10 per 100,000 lower than in Zealand; minor differences were seen for rectum cancer. One and four-year overall survival increased in both regions but was superior in Schleswig-Holstein. For patients with reported stage I-III, negligible differences in survival were seen; with further restriction to patients with treatment reported, even so in stage IV patients 2007-2009.

INTERPRETATION

Improved data quality and comparability than presently used in the large international survival studies is needed. If stage and treatment is taken into account, more valid international comparisons of cancer survival are possible. Reporting and follow-up must be improved and cases only known from death certificates (DCO) minimised. A high proportion DCO (excluded from analyses) may produce higher survival, whereas a low the opposite. Co-morbidity and socio-economic status should be included alongside other prognostic variables in survival studies. Barriers towards proper follow-up and monitoring of outcome e.g. privacy legislation must be considered with a view to future patient mobility.

[Are speed cameras able to reduce traffic noise disturbances? An intervention study in Luebeck]

BACKGROUND

Disturbance by traffic noise can result in health problems in the long run. However, the subjective perception of noise plays an important role in their development.

OBJECTIVES

The aim of this study was to determine if speed cameras are able to reduce subjective traffic noise disturbance of residents of high-traffic roads in Luebeck?

METHODS

In August 2012 a speed camera has been installed in 2 high-traffic roads in Luebeck (IG). Residents living 1.5 km in front of the installed speed cameras and behind them received a postal questionnaire to evaluate their subjective noise perception before (t0), 8 weeks (t1) and 12 months (t2) after the installation of the speed camera. As controls (CG) we asked residents of another high-traffic road in Luebeck without speed cameras and residents of 2 roads with several consecutive speed cameras installed a few years ago. Furthermore, objective measures of the traffic noise level were conducted.

RESULTS

Response rates declined from 35.9% (t0) to 27.2% (t2). The proportion of women in the CG (61.4-63.7%) was significantly higher than in the IG (53.7-58.1%, p<0.05), and responders were significantly younger (46.5±20.5-50±22.0 vs. 59.1±17.0-60.5±16.9 years, p<0.05). A reduction of the perceived noise disturbance of 0.2 point, measured on a scale from 0 (no disturbance) to 10 (heavy disturbance), could be observed in both IG and CG. Directly asked, 15.2% of the IG and 19.3% of the CG reported a traffic noise reduction at t2. The objective measure shows a mean reduction of 0.6 dB at t1.

CONCLUSION

The change of noise level of 0.6 dB, which could only be experienced by direct comparison, is in line with the subjective noise perception. As sole method to reduce traffic noise (and for health promotion) a speed camera is insufficient.

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.

[Temporal changes in quality of life after prostate carcinoma]

INTRODUCTION

Each year more than 60,000 German men are diagnosed with prostate cancer. The incidence nearly doubled in the last 10 years due to intensified use of PSA testing for early detection. To date, either radical prostatectomy or radiotherapy is recommended for treatment of localized prostate cancer. Both strategies have similar survival chances (83-94%), but show different side effects. In view of the good prognosis implications for health-related quality of life (QoL) may play an important role in the therapy decision-making process and should be discussed with patients.

MATERIALS AND METHODS

Prostate cancer patients were asked twice about oncological health care and QoL (EORTC QLQ-C30, Version 2) as part of the OVIS study conducted in Schleswig-Holstein. The first questioning took place 16 months after the initial diagnosis and the second one at month 42. QoL was compared with German reference data. Logistic regression identified predictors for (a) low QoL at baseline (as indicated by global health status/QoL below the group median) and (b) clinically relevant detriments, defined as a difference of ≥10 points, in the chronological sequence.

RESULTS

Prostate cancer patients (n=1,345; median age at diagnosis 66 years) report a mean global QoL score that is higher than that of a healthy German reference sample (difference 6.3). In the temporal course, 56% of patients did not experience a clinically relevant change in QoL (<10 points difference). However, 20% reported a clinically relevant decrease and 24% a clinically relevant increase (≥ 10 points difference) regarding global health status/QoL. Higher age, lower social class, chemotherapy, undesired side effects and long-term complications as well as rehabilitative care predict low QoL at baseline, while progression of the disease and living in an urban surrounding as well as young age at diagnosis predict a decrease of QoL in the chronological sequence.

CONCLUSIONS

Self-reported QoL of prostate cancer patients depends on various personal and medical factors. Physicians should be aware of these factors and include them in the discussion about the appropriate therapy method with their patients. In general, therapists and family members have problems describing the QoL of their patients and relatives. Assessing the QoL and QoL-influencing factors with a short questionnaire seems to be feasible and may be helpful in the therapy decision-making process.

Indicators of data quality: revision of a guideline for networked medical research

Data quality significantly impacts the reliability and validity of empirical medical research. Specific measures can be used to check the quality of data during operation of a research project like a register. Furthermore these indicators allow an assessment of data quality independently from the institution responsible for data recording. A previously developed set of 24 data quality indicators was compared with measures of three research projects, each representing a specific view on the topic. The structure of the set was confirmed, being able to capture most of the projects' measures under the headings plausibility, organization, and correctness. Solely two indicators about metadata could not be appropriately mapped. However, several measures not considered so far were added to reach a number of 51 quality indicators in a first draft of a revised set. Most of the new indicators refine existing ones; e. g. the indicator "allowed values for missings" refines the existing indicator "allowed values for qualitative data elements". Seven projects' measures contribute supplementary aspects of data quality. The draft of the revised set of quality indicators will now be reviewed within and beyond the group.

Different aspects of self-reported quality of life in 450 german melanoma survivors

The present study was aimed at assessing quality of life (QoL) in a total of 450 melanoma patients who filled out the EORTC QLQ-C30 (Q1; 15 months post diagnosis) as part of the OVIS Study. Follow-up questionnaires (Q2) were administered two years after Q1. The analyses presented herein were based on the following assumptions: QoL of melanoma patients is worse than that of a German reference population. Further, both tumor location and tumor stage have an influence on self-reported QoL, with patients with tumors located on face, head, neck, and advanced tumor stage (T3/T4) reporting the worst QoL levels. Finally, patients' QoL improves over time based on the theory of disease adaptation. In contrast to the above assumptions, with the exception of global health/QoL scores, differences between OVIS and the reference population were below the minimal clinical important difference of ten points. Furthermore, no clinically meaningful differences were found between patients after stratifying our data by tumor location and tumor stage. Finally, no clinically relevant changes were seen between Q1 and Q2 across all scales of the EORTC QLQ-C30. However, when data were stratified by patients with stable disease versus those with progression, clinically relevant differences were found between Q1 and Q2 predominantly in women in the latter group regarding emotional function, insomnia, dyspnoea, and fatigue. The lack of clinically meaningful differences across strata (tumor location; tumor stage), time, and patients compared to a reference population is surprising. However, it is possible that the instrument used, a generic QoL instrument, is generally not sensitive enough to detect differences in melanoma patients. Our findings may further be explained by the fact that all patients included in our sample had been diagnosed well before Q1, i.e., main illness adaptation processes may have occurred before study entry.

[Demographic change and cancer]

BACKGROUND

The demographic changes in Germany lead to a modified age structure of the population towards a growing proportion of elderly people. As many diseases like cancer usually appear in higher age groups, increasing numbers of cases are expected. The quantification of this development is an important indicator of the future burden of the health system.

MATERIAL AND METHODS

Currently available age- and sex-specific incidence rates of the most frequent cancer sites, based on population-based cancer registries, were assigned 'ceteris paribus' to the expected populations of the years 2030, 2050 and 2060 (12th coordinated population prediction, predicted by the Federal Statistical Office).

RESULTS

The number of incident cancer cases will increase from 494,000 in 2010 to 642,000 in 2050 (+26%). There are considerable differences among the different cancer sites (–29% to +47%).

CONCLUSIONS

Caused by demographic changes, sizably higher numbers of incident cancer cases have to be expected in the future in Germany. The declining population will cause an even more strongly increasing cancer burden in the population.

[Disease numbers in pneumology - a projection to 2060]

BACKGROUND

The demographic change leads to a change in the age-composition of the population. We have calculated a status quo projection of the absolute numbers for five diagnoses of the lung (COPD, CAP, lung cancer, bronchial asthma and tuberculosis) for Germany up to 2060.

MATERIAL AND METHODS

Based on the 12 (th) coordinated population prediction of the Federal Statistics Office, we transferred age- and sex-specific incidence and prevalence rates, respectively, to the expected population. All described developments are based solely on demographic changes.

RESULTS

The absolute numbers of bronchial asthma and tuberculosis will experience a minor decrease. We expect at first increasing and later decreasing case numbers for COPD and lung cancer. A major increase of the case numbers for CAP will be probable. By reason of a decreasing population, the rates (burden of disease for the population) will increase considerably.

DISCUSSION

The demographic change is mainly caused by increasing life expectancy, constantly low birth rates, and the entry of the baby-boom generation into the age of higher disease risks. A discussion about prioritisation of health care is needed because of the rising burdens for the health system, including diseases of the lung.

Projection of Morbidity 2030 and 2050: Impact for the National Health System and Blood Supply

BACKGROUND: The German population will decrease by 16% until 2050, and the ratio of young to old people is shifting towards the elderly. Because risk of disease rises with age, an aging society will be confronted with a higher burden of diseases. METHODS: A projection of status quo case numbers and crude rates of selected diseases was done for the years 2030 and 2050. Actual sex- and age-specific rates were transferred to the predicted population figures (11th coordinated population prediction). RESULTS: Cancer incidence will rise from 461,000 (2007) to 588,000 cases (2050) (+27%). Crude incidence rate will increase by 52%. Number of femoral neck fractures will rise by 88% (rate +122%). For other diseases incidence and prevalence will increase up to 144%. CONCLUSION: Blood (products) will be necessary for the therapy of many of the presented diseases. Therefore, it can be assumed that future demand of blood will rise in a similar manner as the rising number of diseases. The projected developments describe an extraordinary challenge for the German health care system and in particular for transfusion medicine. It is necessary to develop new concepts to meet this future demands and to ensure a high-performance health care system.

Recent Trends in Breast Cancer Incidence and Mortality in Germany

SUMMARY: BACKGROUND: Breast cancer is the most common cancer among women in Germany with high public health impact. In the last decade rapid changes in risk factor patterns, early breast cancer detection, and therapy have taken place. Their effects on breast cancer epidemiology in Germany are described. MATERIALS AND METHODS: A register-based survey using recent incidence data from German cancer registries was performed. Mortality data were provided by the Central Federal Statistical Office. We calculated age-standardized rates and 5- and 10-year trends. RESULTS: Breast cancer incidence increased until the year 2002, thereafter a discreet decline occurred until 2005 (-6.8%). In the age group 50-59 years this reduction was most pronounced (-12%). Mortality declined from 1996/7 to 2004/5 by 19%, with the strongest effect in women younger than 55 years (approximately 30%). Regional patterns of breast cancer incidence and mortality revealed differences within Germany of greater than 30%. CONCLUSION: Declining hormone replacement therapy prescription is the most likely factor to explain the drop in breast cancer incidence. The reduction in mortality might be caused by better therapy and enhanced early detection during the last decade. Differences in breast cancer incidence and mortality between Eastern and Western Germany give reason for further research and discussion.

The population-based oncological health care study OVIS - recruitment of the patients and analysis of the non-participants

Background

The ageing of the population is expected to bring an enormous growth in demand for oncological health care. In order to anticipate and respond to future trends, cancer care needs to be critically evaluated. The present study explores the possibility of conducting representative and population-based research on cancer care on the basis of data drawn from the Cancer Registry.

Methods

A population-based state-wide cohort study (OVIS) has been carried out in Schleswig-Holstein, Germany. All patients with malignant melanoma, breast, or prostate cancer were identified in the Cancer Registry. Epidemiological data were obtained for all the patients and screened for study eligibility. A postal questionnaire requesting information on diagnosis, therapy, QoL and aftercare was sent to eligible patients.

Results

A total of 11,489 persons diagnosed with the cancer types of interest in the period from January 2002 to July 2004 were registered in the Cancer Registry. Of the 5,354 (47%) patients who gave consent for research, 4,285 (80% of consenters) completed the questionnaire. In terms of relevant epidemiological variables, participants with melanoma were not found to be different from non-participants with the same diagnosis. However, participants with breast or prostate cancer were slightly younger and had smaller tumours than patients who did not participate in our study.

Conclusion

Population-based cancer registry data proved to be an invaluable resource for both patient recruitment and non-participant analysis. It can help improve our understanding of the strength and nature of differences between participants and non-respondents. Despite minor differences observed in breast and prostate cancer, the OVIS-sample seems to represent the source population adequately.

The OVIS study: health related quality of life measured by the EORTC QLQ-C30 and -BR23 in German female patients with breast cancer from Schleswig-Holstein

The OVIS study is a population-based study that aims at evaluating medical care in Schleswig-Holstein (Germany). In this paper, the health related quality of life (QoL, EORTC QLQ-C30 and -BR23) of 1,927 women with breast cancer is reported. The global health status/QoL score was comparable to reference data of the age-adjusted German general population, but clinical meaningful differences (> or = 10 points) were found for all functioning scales (with the exception of physical functioning) and for three of the symptom scales/items (fatigue, dyspnoe, insomnia) with OVIS patients showing more deficits. Furthermore, OVIS patients scored higher on the item financial difficulties. Logistic regression analyses revealed that coming from an urban surrounding, having a higher social status and attendance to a regular aftercare predicted a good overall QoL, while factors that were related to perceived complications in the course of the therapy raised the risk for a low QoL rating. It is of interest, that attendance to a rehabilitation and interest in self-help groups independently predicted an increased risk for a low quality of life. Overall, we assume the global QoL is rating slightly too optimistic since major deficits were reported on the specific physical and functional scales/items.