[The future incidence of colorectal and lung cancers: results of the calculation of different scenarios for the year 2020]

BACKGROUND

Cancer is a common disease that places a large burden on health-care systems. Although the rise of incident cancer cases over recent decades in Germany can largely be explained by demographic ageing, other factors also affect these numbers. The aim of this work was to calculate the incidence of colorectal and lung cancers, two of the most common cancer sites, for the year 2020 under different scenarios.

MATERIALS AND METHODS

The calculations were based on national incidence estimates by the Centre for Cancer Registry Data at the Robert Koch Institute. Two scenarios were calculated for each of the two cancer sites and by gender. The "status quo" scenario accounts only for demographic ageing, assuming constant age-specific incidence rates. The second scenario additionally assumes that trends in incidence rates observed from 2000 to 2009 continue up to the year 2020.

RESULTS

The "status quo" scenarios showed an increase in incident cancer cases of between 12 and 24%, depending on gender and cancer site. The "continuing trends" scenarios resulted in smaller increases for colorectal cancer (+3 to + 17%), while the results for lung cancer differed widely between women (+ 64%) and men (+ 2%). In general, large increases are expected for the highest age groups and the age groups of the baby boomer generation.

DISCUSSION

Changes in the age structure of the German population will lead to an increase in incident cancer cases and a higher portion of geriatric patients. Additionally, further increasing incidence rates would result in a dramatic growth in the number of female lung cancer patients.

Changes in cancer incidence attributable to tobacco smoking in Germany, 1999-2008

Tobacco smoking, a major cancer risk factor, is very common in Germany as in many other high-income countries. Few studies have assessed the burden of tobacco-associated cancer incidence in the German population. We calculated the proportion of cancers attributable to tobacco smoking to estimate the burden of tobacco-associated cancer in 1999 and 2008. Smoking prevalence was determined from national surveys of a representative sample of the German population in 1998 and 2008-2011, and data on relative risks were obtained from meta-analyses. Cancer incidence for the years 1999 and 2008 was estimated by the German Centre for Cancer Registry Data at the Robert Koch Institute. We estimate that 72,208 incident cancer cases were attributable to tobacco smoking in Germany in 2008, an increase of >6,200 cases over 1999 levels. Among the cases in 2008 were 55,057 cases among men (22.8% (95% CI, 21.3-24.1) of all new cases) and 17,151 cases among women (7.9% (95% CI, 7.21-8.68) of all new cases). The highest proportions attributable to smoking were estimated for cancer of the lung, larynx, pharynx and the lower urinary tract. Tobacco smoking is currently responsible for more than one in five cancer cases among men and nearly 1 in 12 among women. Considering the increasing trends in cancer incidence and, until very recently, rising prevalence of smoking among women, it can be expected that the number of tobacco-attributable cancer cases will rise further.

[The (German) Center for Cancer Registry Data (ZfKD) at the Robert Koch Institute (RKI) in Berlin]

Cancer represents the second most common cause of death in Germany. The country's federal states operate regional population-based cancer registries that collect and analyze data on cancer patients. This provides an essential basis for describing the cancer burden in the German population. In order to obtain valid and reliable information on cancer incidence at the national level, the Robert Koch Institute (RKI) set up the Federal Cancer Surveillance Unit in 1983 as a central institution for evaluating this cancer registry data. In August 2009, when the Federal Cancer Registry Data Act (BKRG) came into force, the Center for Cancer Registry Data (ZfKD) at the RKI took over the work of the Cancer Surveillance Unit with a broader remit. In the future, it will also regularly publish findings on survival, prevalence, and tumor stage distribution. A newly established record linkage process will help identify multiple submissions from the federal states. Further innovations and new tasks of the ZfKD include expanding an interactive Internet platform and encouraging a more intensive use of cancer registry data for epidemiological research by providing datasets to external scientists. The range of information available to the interested public is also to be expanded.

[Linkage of data of the medical service of the health insurances with data of a cancer registry]

BACKGROUND

The aim of this study was to examine whether a linkage of data sets of the Epidemiological Cancer Registry North Rhine-Westphalia (EKR-NRW) and the Medical Service of the Health Insurances (MDK WL) is feasible, which problems may occur during execution and what could be a solution strategy.

METHODS

Data of the EKR-NRW were used to identify all cancer cases in the district of Munster, for which an expert opinion regarding nursing needs from the period 2004-2008 was available at the MDK WL. For this purpose factually anonymised data of the EKR-NRW and the MDK WL were linked by means of a semi-automatic probabilistic record linkage.

RESULTS

Data linkage yielded 18 877 cancer cases but required great technical and temporal input. The processing of management data and the use of "routine channels" (ISDN connection), which provide the necessary safety for data transfer, but are designed for a considerably smaller amount of data, accounted for this. The interface problem (converting data from text format to a hierarchical XML format) can be solved with Excel or SAS.

CONCLUSION

A record linkage with factually anonymised data from the MDK WL and the EKR-NRW is feasible. This allows, among other things, quantifying the needs for nursing care in persons with a cancer diagnosis.

Symptomatic intracranial atherosclerotic stenoses: prevalence and prognosis in patients with acute cerebral ischemia

BACKGROUND

In Caucasian patients with acute stroke or transient ischemic attack (TIA) due to symptomatic intracranial atherosclerotic stenoses (ICAS), only limited data on the recurrent stroke rate and its associated risk factors have been reported. In view of the increasing options for endovascular interventions, we sought to investigate the prevalence, risk for recurrent stroke and mortality in these patients.

METHODS

A total of 304 consecutive patients with acute ischemic stroke or TIA due to 50-99% ICAS were prospectively documented in 19 German stroke centers. In 201 patients (68.1% of the survivors), a central biannual telephone follow-up could assess recurrent stroke and mortality up to a median of 2 years after the index event.

RESULTS

An ischemic cerebrovascular event attributable to symptomatic ICAS was found in 2.24% of the consecutively admitted patients. The overall cumulative recurrent stroke rate after admission was 17.9% (95% CI = 13.4-23.5) for the first year and 23.3% (95% CI = 17.8-29.8) over 3 years. After correction for age and sex, only previous stroke (HR = 2.11, 95% CI = 1.14-3.91) and diabetes (HR = 2.41, 95% CI = 1.33-4.37) were significantly associated with recurrent stroke.

CONCLUSION

Although the prevalence of this etiology seems very low in patients admitted to German stroke centers, we found a high risk of recurrent stroke in patients with symptomatic ICAS. Whether endovascular interventions can reduce this high risk needs to be determined in a randomized trial.

[Cancer survival analysis in Germany--heading towards representative and comparable findings]

Cancer is an important issue within the German health care system with an estimated annual number of 435 000 incident cases and almost 210 000 deaths. Data of population-based cancer registries enable us to identify improvements of survival in oncological patients due to progress in therapeutic care and secondary prevention, as well as to investigate regional and international differences of this outcome. Comparing cancer survival rates, however, requires considering the impact of both methodical approaches and data quality. Potential factors of influence like algorithms, reference population, completeness of case ascertainment and quality of follow-up are discussed. For the first time harmonized proceedings are recommended in order to achieve comparability of population-based cancer survival rates in Germany.

Long-term outcome of Guillain-Barré syndrome

OBJECTIVES

To investigate long-term neurological residua after Guillain-Barré syndrome (GBS) and to evaluate the predictive value of respiratory insufficiency during the acute stage of the disease.

METHODS

Thirty-four patients with GBS including 5 patients with Miller-Fisher syndrome admitted to a university hospital between 1994 and 2002 underwent a neurological and electrophysiological follow-up examination 7 - 86 months after onset of GBS.

RESULTS

Of the 34 patients, 5 patients had completely recovered, 11 patients demonstrated mild residual symptoms and/or signs, and 18 patients presented with functionally relevant neurological deficits predominantly in the lower extremity, although all patients could walk without assistance and none showed respiratory failure. Nerve conduction studies revealed abnormal findings in 30 patients. Autonomic function testing of the cardiovascular system showed a pathological blood pressure response to standing in 27 of 33 patients. No association was found between the course of the disease and sleep-disordered breathing at follow-up. Age at onset, need for mechanical ventilation, and duration of the plateau phase correlated with severity of neurological residua at follow-up.

CONCLUSIONS

There was a high persistence of residual sensorimotor signs and symptoms after GBS in our cohort. In addition, abnormal blood pressure declines not associated with clinically overt orthostatic dysregulation were detected in the majority of our patients at follow-up. This is in contrast to previous reports describing a gradual improvement of autonomic dysfunction after 2 - 18 months. A combined prognostic score based on patient age, duration of the plateau phase, and ventilatory failure in the acute stage of GBS might predict the long-term outcome.

Intravenous thrombolysis in German stroke units before and after regulatory approval of recombinant tissue plasminogen activator

BACKGROUND

Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) within 3 h after onset of focal cerebral ischemia was approved in Germany in August 2000.

METHODS

11 neurology departments with acute stroke units participated in the German Stroke Study Collaboration before (n = 2,925) and after (n = 3,204) approval of rt-PA in Germany and consecutively registered all patients admitted within 24 h following acute ischemic stroke.

RESULTS

Frequency of intravenous thrombolysis in patients admitted within 24 h after symptom onset increased from 4.8% before approval to 7.9% after approval of rt-PA. Among patients treated with rtPA, age increased significantly and the delay between symptom onset and imaging was significantly shorter in the second study period.

CONCLUSIONS

The observed improvement in management and quantity of intravenous thrombolysis may be explained by greater experience and greater legal security following regulatory approval of rtPA.

Offenes Foramen ovale, Vorhofseptumaneurysma und Hirninfarkt

The role of a patent foramen ovale (PFO) in stroke is still regarded as controversial, as is the optimal strategy of secondary prevention for such patients. The best available evidence is derived from case-control studies, which in all show a statistically significant relationship but cannot be judged as conclusive for methodologic reasons. Besides paradoxic embolism, different pathomechanisms of stroke due to abnormalities of the atrial septum are possible that can rarely be verified in clinical routine. While the risk of stroke recurrence seems to be low at least for younger patients, to date no definite recommendations for secondary prevention can be given. Several ongoing randomized clinical trials might increase the store of evidence in this topic over the next years. However, primary and secondary risk seem to be substantially increased for the combined defect of PFO and atrial septum aneurysm. To allow further risk stratification, other potentially important factors such as shunt size and coagulation disorders should be targeted in future studies.

Age and National Institutes of Health Stroke Scale Score within 6 hours after onset are accurate predictors of outcome after cerebral ischemia: development and external validation of prognostic models

BACKGROUND AND PURPOSE

To date, no validated, comprehensive, and practicable model exists to predict functional recovery within the first hours of cerebral ischemic symptoms. The purpose of this study was to externally validate 2 prognostic models predicting functional outcome and survival at 100 days within the first 6 hours after onset of acute cerebral ischemia.

METHODS

On admission to a participating hospital, patients were registered prospectively and included according to defined criteria. Follow-up was performed 100 days after the event. With the use of prospectively collected data, 2 prognostic models were developed and internally calibrated in 1079 patients and externally validated in 1307 patients. By means of age and National Institutes of Health Stroke Scale (NIHSS) score as independent variables, model I predicts incomplete functional recovery (Barthel Index <95) versus complete functional recovery, and model II predicts mortality versus survival.

RESULTS

In the validation data set, model I correctly predicted 62.9% of the patients who were incompletely restituted or had died and 83.2% of the completely restituted patients, and model II correctly predicted 57.9% of the patients who had died and 91.5% of the surviving patients. Both models performed better than the treating physicians' predictions made within 6 hours after admission.

CONCLUSIONS

The resulting prognostic models are useful to correctly stratify treatment groups in clinical trials and should guide inclusion criteria in clinical trials, which in turn increases the power to detect clinically relevant differences.

[Diagnosis related groups in stroke treatment. An analysis from the stroke data bank of the German Stroke Foundation]

BACKGROUND

The upcoming introduction of diagnosis related groups (DRG) as an exclusive base for future calculation of hospital proceeds in Germany requires a thorough analysis of cost data for various diseases.

OBJECTIVE

To compare the resulting combined cost weights of the Australian Refined DRG system (AR-DRG) with the proceeds based on actual per-day rates in stroke treatment.

PATIENTS AND METHODS

Between 1998 and 1999, data from 6520 patients (median age 68 years, 43% women) with acute stroke or transient ischemic attack (TIA) were prospectively documented in 15 departments of Neurology with an acute stroke unit, 9 departments of general Neurology and 6 departments of Internal Medicine. Prior to grouping cases into DRGs, all available data were transferred into ICD-10-SGB-V 2.0 or the Australian procedure system (MBS-Extended). Hospital proceeds for the respective cases were calculated based on per-day rates of the documenting hospitals.

RESULTS

The resulting cost weights demonstrate a good homogeneity compared to the length of stay. When introducing the AR-DRG with a uniform base rate in Germany, a relative decrease of hospital proceeds can be expected in Neurology Departments and for treatment of TIAs.

CONCLUSION

Preservation of the existing structure of acute stroke care in Germany requires a supplement to a uniform base rate in Neurology departments.

[Clinical presentation and prognosis of brain stem infarcts. An evaluation of the Stroke Databank of the German Stroke Foundation]

Due to the great variety of clinical classification systems and syndromes, a representative overview of the etiology and prognosis of brain stem infarctions is missing. From the German Stroke Data Bank we therefore investigated 455 patients with visible brainstem infarction on cerebral imaging in comparison to patients with other infarct localizations. Follow-up after 3 and 12 months assessed functional outcome and recurrence of cerebral ischemia. Of 455 patients with acute brainstem infarction, 115 had additional infarctions in other vascular territories. In the remaining 340 patients with isolated brainstem infarction, the classification was: small vessel disease in 36.2%, macroangiopathy in 22.6%, and cardioembolism in 11.2%. After 3 months, 10% of the patients with isolated brainstem infarction had died and 55.6% were functionally independent. Mortality was 43.5% in patients with combined brainstem infarction. Our study highlights the frequency of small vessel disease as well as the relatively favorable prognosis in isolated brainstem infarction and preserved consciousness.