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Treatment modifications and contact restrictions were common during the COVID-19 pandemic and can be stressors for mental health. There is a lack of studies assessing pandemic-related risk factors for anxiety and depression of cancer patients and survivors systematically in multifactorial models. A total of 2391 participants, mean age 65.5 years, ≤5 years post-diagnosis of either lung, prostate, breast, colorectal cancer, or leukemia/lymphoma, were recruited in 2021 via the Baden-Württemberg Cancer Registry, Germany. Sociodemographic information, pandemic-related treatment modifications, contact restrictions, and anxiety/depression (Hospital Anxiety and Depression Scale, HADS) were assessed via self-administered questionnaire. Clinical information (diagnosis, stage, and treatment information) was obtained from the cancer registry. Overall, 22% of participants reported oncological care modifications due to COVID-19, mostly in follow-up care and rehabilitation. Modifications of active cancer treatment were reported by 5.8%. Among those, 50.5% had subclinical anxiety and 55.4% subclinical depression (vs. 37.4% and 45.4%, respectively, for unchanged active treatment). Age <60 years, female sex, lung cancer, low income, and contact restrictions to peer support groups or physicians were identified as independent risk factors for anxiety. Risk factors for depression were lung cancer (both sexes), leukemia/lymphoma (females), recurrence or palliative treatment, living alone, low income, and contact restrictions to relatives, physicians, or caregivers. The study demonstrates that changes in active cancer treatment and contact restrictions are associated with impaired mental well-being. The psychological consequences of treatment changes and the importance for cancer patients to maintain regular contact with their physicians should be considered in future responses to threats to public health., (© 2024 The Author(s). International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

Purpose: The COVID-19 pandemic was associated with severe disruptions in healthcare worldwide. Cancer patients are at particular risk of adverse consequences from delays in diagnosis and treatment. To evaluate the available data on the impact of the pandemic on cancer diagnoses, oncological care and patient well-being in Germany, the German Society for Epidemiology (DGEpi) in collaboration with the Epidemiological Cancer Registry of Lower Saxony invited to a workshop on "COVID & Cancer" (held on 26-27 October 2023 in Hanover, Germany). This report provides a summary of the scientific presentations, highlights methodological challenges, and recognises essential evidence gaps., Methods: Twelve studies addressing various aspects in relation to cancer diagnoses, oncological care and patient well-being during the COVID-19 pandemic in Germany and two talks sharing experiences from the UK and the Netherlands were presented at the workshop., Results and Conclusions: Results from German cancer registries consistently showed lower number of incident cancer diagnoses among adults during the first months of the pandemic compared to the respective months of the years before the pandemic. Data from the cancer registries of Baden-Württemberg and Lower Saxony found especially for breast cancer a notable drop (by approximately one third) in the numbers of diagnoses during the first restriction period (April-May 2020), during which the nationwide mammography screening programme in Germany was temporarily suspended. Overall, the extent and ways, in which the pandemic had adversely affected cancer diagnoses, oncological care and created service backlogs, is still not adequately understood. The long-term consequences are yet to be determined., (© 2024. The Author(s).)

The COVID-19 pandemic affected the diagnostics and treatment of breast cancer. Numerous studies reported an early decline in breast cancer (BC) incidence during the COVID-19 pandemic. Less evidence is available on changes in medical care. Reports from individual patients have provided anecdotal evidence for a shift from breast-conserving surgery to mastectomy to reduce the number of visits to radiation units during the pandemic. This study aimed to explore changes in BC incidence and surgical treatment in the south of Germany. Using data from the Baden-Württemberg Cancer Registry, the age-standardized incidence of BC (ICD-10 C50 and D05) (women) in 2018-2021 was investigated overall and by age and stage using standardized incidence ratios. Among pre-operative stage I/IIA BC patients, differences in the time to surgery and type of surgery were investigated using negative binomial and logistic regression models. The incidence of invasive BC decreased significantly from 170.9 per 100,000 women in 2018/2019 to 159.7 in 2020 and increased to 169.2 in 2021. This decrease resulted from a lower incidence around April 2020 and was also observed for non-invasive BC. In 2021, incidence of invasive BC was still decreased by 8% in women aged 80 + years. Surgical treatment was analyzed in 22,708 BC patients with a pre-operative stage ≤ IIA. The median time to surgery was 33 days in 2018/2019, 32 days in 2020 and 36 days in 2021. The proportion of mastectomies increased from 16.1% in 2018/2019 to 17.1% in 2020 and 17.3% in 2021 (adjusted odds ratio and 95% confidence interval (2021 vs. 2018/2019): 1.13 (1.03-1.24)). The adjusted increase was strongest for patients aged 50-59 years (1.34 (1.09-1.64)) and those with high-grade tumors (1.27 (1.07-1.51)). While the early return to pre-pandemic age-standardized BC incidence rates is promising, missed cases have not been caught up until 2021. Furthermore, the decreased incidence in elderly women in 2021 warrants further attention. In early-stage BC, a slightly greater rate of mastectomies was observed, although such a change was not recommended. This result underlines the importance of good communication of adapted treatment guidelines in such exceptional circumstances., (© 2024. The Author(s).)

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., (© 2023 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

How can we improve the interoperability of medical guidelines and the implementation and measurement of outcomes in medical health care for cancer patients as well as for care providers? This is the aim of the working group "Quality and Cross-linking". The following publication gives an overview of the targets reached in the development of guidelines together with quality indicators and documentation in cancer registries., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

In response to the ongoing coronavirus disease 2019 (COVID-19) pandemic, governments imposed various measures to decrease the rate of disease spread, and health care policy makers prioritized resource allocation to accommodate COVID-19 patients. We conducted a cross-sectional online survey in Germany (July 2020-June 2021) to assess the frequency of changes to cancer care among cancer patients and to explore the psychological impact of the pandemic writ large. Cancer patients who contacted the Cancer Information Service (Krebsinformationsdienst, KID) of the German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ) via email were invited to complete an online questionnaire, capturing demographics, cancer specifics (e.g., type, disease phase, primary place of treatment, etc.), and any changes to their medical, follow-up, psycho-oncological or nursing care. General level of psychological distress was measured using the Hospital Anxiety and Depression Scale (HADS) along with face-validated items regarding worries and social isolation specific to the pandemic. In total, 13% of 621 patients reported a change to their treatment or care plan. Of those patients with changes, the majority of changes were made to follow-up care after treatment (56%), to monitoring during treatment (29%) and to psychological counseling (20%). Of the overall sample, more than half of patients (55%) reported symptoms of anxiety and 39% reported symptoms of depression. Patients with a change in cancer care were more likely to report symptoms of depression than those with no change (AOR: 2.18; 95% CI: 1.26-3.76). Concern about the pandemic affecting the quality of health care was a predictor of both anxiety (AOR: 2.76; 95% CI: 1.75-4.35) and depression (AOR: 2.15; 95% CI: 1.43-3.23). Results showed that the majority of cancer patients in our study did not experience a change in their cancer care. However, the level of anxiety and psycho-social burden of cancer patients during the pandemic was high throughout the study period. Our findings underscore the need for health care services and policy makers to assess and to attend cancer patients' medical needs, with added emphasis on patients' psychological and social well-being. This applies particularly in situations where the healthcare system is strained and prioritization is necessary., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Eckford, Gaisser, Arndt, Baumann, Kludt, Mehlis, Ubels, Winkler, Weg-Remers and Schlander.)

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., (© 2021. The Author(s).)

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., (© 2021. The Author(s).)

Background: Inpatient rehabilitation therapy (IRT) is commonly offered to cancer patients during or after cancer treatment in Germany. However, little is known about utilization and long-term effects of this offer in colorectal cancer (CRC) patients. We aimed to assess IRT utilization, determinants of utilization and the association between IRT and survival in CRC patients., Materials and Methods: CRC patients diagnosed in 2005-2014 recruited in the population-based DACHS study in South West Germany were included. Determinants of IRT utilization were assessed by multivariable logistic regression. Hazard ratios (HRs) of the association of IRT with overall and disease-specific survival were estimated by adjusted Cox proportional hazards models. Modified landmark approach was applied to avoid immortal time biased results., Results: Among the included CRC patients ( n  = 3704), 43.6% underwent IRT. Patients who did not live in a relationship with a partner, worked as employee and who reported higher levels of physical activity were more likely to undergo IRT. Patients were less likely to undergo IRT if they had private health insurance, were diagnosed with cancer stage IV, received no or laparoscopic cancer surgery or were treated in a hospital with medium vs. high surgical volume. The median follow-up time was 4.4 years (post-landmark). Utilization of IRT was associated with better overall (HR 0.81, 95% confidence interval 0.72-0.92) and disease-specific survival (HR 0.72, 95% confidence interval 0.61-0.85)., Conclusion: Almost every other CRC patient underwent IRT. Next to clinical characteristics, identified social and lifestyle characteristics seemed to play an essential role in the decision-making. Use of IRT was associated with better overall and disease-specific survival.

Background: Lip, oral cavity, and pharynx cancers (ICD-10: C00-C14) describe a heterogeneous group of tumors with strong variations in incidence, mortality, and survival by entity., Objectives: This work provides a detailed overview of epidemiologic measures for these tumor entities, taking into account heterogeneity in age, sex, location, and stage., Material and Methods: Incidence and mortality data for Germany for the years 1999-2016 were extracted from the interactive database of the Center for Cancer Registry Data (ZfKD). Age and stage distributions and five-year relative survival were calculated on the pooled ZfKD data set (diagnosis years 1999-2017)., Results: In 2016, overall incidence and mortality for all entities were 17.6 and 7.0 per 100,000 men and 6.5 and 1.8 per 100,000 women, respectively. The five-year relative survival in 2015-2017 was 53 and 63%, respectively. There were marked differences in survival as well as age and stage distributions between entities. Trend analyses showed an increase in age at diagnosis, particularly in male patients, and no change in stage distributions. However, five-year relative survival increased from 45% (men) and 59% (women) in 1999-2002 to 52% and 63% in 2013-2017., Conclusion: The marked heterogeneity of the studied tumors highlights the need to differentiate the analysis by sex and entity for meaningful interpretation of epidemiologic metrics. With the expansion of clinical cancer registration in Germany, additional analyses including other important clinical factors will be possible in the future., (© 2021. The Author(s).)

Background: Fatigue prevalence and severity have been assessed in a variety of studies, yet, not in a standardized way, and predominantly in breast cancer patients. Systematic, comparative investigations across a broad range of cancer entities are lacking., Methods: The FiX study systematically enrolled 2244 cancer patients across 15 entities approximately 2 years after diagnosis. Fatigue was assessed with the multidimensional EORTC QLQ-FA12 questionnaire. Physical, emotional, cognitive, and total fatigue were compared across entities and with normative values of the general population. Differences in patients' characteristics and cancer therapy between entities were taken into account using analyses of covariance models., Results: Across all entities, mean physical fatigue levels were significantly higher than age- and sex-matched means of the general population for all cancer entities (all Bonferroni-Holm adjusted P < .01). For most entities also emotional and cognitive fatigue levels were significantly higher than normative values. Age- and sex-standardized physical fatigue prevalence ranged from 31.8% among prostate to 51.7% among liver cancer patients. Differences between entities could not be fully explained by sex, age, BMI, or cancer therapy. Adjusted for these factors, mean physical fatigue was higher for stomach (P = .0004), lung (P = .034), kidney (P = .0011), pancreas (P = .081), and endometrium (P = .022) compared to breast cancer patients. Adjusted means of emotional fatigue were also lowest in breast cancer patients and significantly higher in stomach (P = .0047), bladder (P = .0036), and rectal (P = .0020) cancer patients., Conclusions: Physical, emotional, and cognitive fatigue is prevalent in all 15 investigated cancer entities even 2 years after diagnosis. Fatigue in breast cancer patients, the so-far most studied group, is in the lowest range among all entities, suggesting that the extent of fatigue is still insufficiently determined. Entity-specific problems might need to be considered in the treatment of fatigue., (© 2020 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

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., (© 2020 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Evidence suggests that physical activity (PA) is positively associated with (health-related) quality of life (QOL) in colorectal cancer survivors. However, little is known regarding long-term effects of PA on QOL and if prediagnosis PA is associated with QOL in the years after diagnosis. Our study aimed to investigate the association of prediagnosis and postdiagnosis PA with long-term QOL in colorectal cancer survivors.This study is based on a population-based cohort from Germany of 1,781 newly diagnosed colorectal cancer survivors over a 5-year period. PA was assessed at diagnosis and at 5-year follow-up (5YFU). Quality of life was assessed by the European Organisation for Research and Treatment of Cancer C Quality of Life Questionnaire QLQ-C30 at 5YFU. Multivariable linear regression was used to explore associations between prediagnosis and postdiagnosis PA and QOL at 5YFU.No evidence of a positive association between higher levels of prediagnosis PA and better long-term QOL was found. Higher levels of prediagnosis work-related PA and vigorous PA were even associated with decreased QOL in domains such as cognitive [Beta(β) = -2.52, 95% confidence interval (CI) = -3.77, -1.27; β = -1.92, CI = -3.17, -0.67) and emotional functioning (β = -2.52, CI = -3.84, -1.19; β = -2.12, CI = -3.44, -0.80). In cross-sectional analyses, higher postdiagnosis PA was strongly associated with higher QOL. Survivors physically active at both prediagnosis and postdiagnosis as well as survivors who increased their PA between prediagnosis and postdiagnosis reported significantly higher long-term QOL compared with survivors who remained inactive at prediagnosis and postdiagnosis. In this study, higher prediagnosis PA does not appear to be associated with higher QOL among long-term colorectal cancer survivors but our results support the importance of ongoing PA throughout survivorship., (©2020 American Association for Cancer Research.)

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.

Background: Evidence suggests that physical activity (PA) is beneficial for reducing fatigue in colorectal cancer (CRC) survivors. However, little is known regarding long-term effects of PA on fatigue and whether pre-diagnosis PA is associated with less fatigue in the years after diagnosis. Our study aimed to investigate the association of pre- and post-diagnosis PA with long-term fatigue in CRC survivors., Methods: This study used a German population-based cohort of 1781 individuals, diagnosed with CRC in 2003-2014, and alive at five-year follow-up (5YFU). Physical activity was assessed at diagnosis and at 5YFU. Fatigue was assessed by the Fatigue Assessment Questionnaire and the EORTC Quality of Life Questionnaire-Core 30 fatigue subscale at 5YFU. Multivariable linear regression was used to explore associations between pre- and post-diagnosis PA and fatigue at 5YFU., Results: No evidence was found that pre-diagnosis PA was associated with less fatigue in long-term CRC survivors. Pre-diagnosis work-related PA and vigorous PA were even associated with higher levels of physical (Beta (ß) = 2.52, 95% confidence interval (CI) = 1.14-3.90; ß = 2.03, CI = 0.65-3.41), cognitive (ß = 0.17, CI = 0.05-0.28; ß = 0.13, CI = 0.01-0.25), and affective fatigue (ß = 0.26, CI = 0.07-0.46; ß = 0.21, CI = 0.02-0.40). In cross-sectional analyses, post-diagnosis PA was strongly associated with lower fatigue on all scales., Conclusions: In this study, pre-diagnosis PA does not appear to be associated with less fatigue among long-term CRC survivors. Our results support the importance of ongoing PA in long-term CRC survivors. Our findings might be used as a basis for further research on specific PA interventions to improve the long-term outcome of CRC survivors.

Population-based cancer registries have a long-standing role in cancer monitoring. Scientific use of cancer registry data is one important purpose of cancer registration, but use of cancer registry data is not restricted to cancer registries. Cancer registration in Germany is currently heading towards population-based collection of detailed clinical data. This development together with additional options for record linkage and long-term follow-up will offer new opportunities for health services and outcome research. Both regional population-based registries and the German Centre for Cancer Registry Data (ZfKD) at the Robert Koch-Institute as well as international cancer registries and consortia or organizations may provide external researchers access to individual or aggregate level data for secondary data analysis. In this review, we elaborate on the access to cancer registry data for research purposes, availability of specific data items, and options for data linkage with external data sources. We also discuss as well as on limitations in data availability and quality, and describe typical biases in design and analysis., Competing Interests: The authors declare that they have no conflict of interest., (Eigentümer und Copyright ©Georg Thieme Verlag KG 2019.)

Background: Despite the increasing number of younger individuals diagnosed with colon and rectal cancer, research on the long-term disease-specific health-related quality of life of younger (<50 years) survivors of colon and rectal cancer is scarce., Objective: Our study aimed to compare disease-specific functional deficits and symptoms of survivors of colon and rectal cancer 5 to 16 years postdiagnosis, stratified by age at diagnosis and by sex., Design: This is a cross-sectional study., Setting: We used data from the population-based CAncEr Survivorship-A multi-Regional study in collaboration with 5 population-based German cancer registries., Patients: Survivors of colon and rectal cancer were included in the study., Main Outcome Measures: Respondents completed the disease-specific European Organization for Research and Treatment of Cancer Quality of Life colorectal cancer module. Age at diagnosis categories were <50, 50 to 59, 60 to 69, and ≥70 years. Least square mean health-related quality of life scores, derived from linear regression, were adjusted for sex, education, time since diagnosis, cancer site, cancer stage, and treatment, where appropriate., Results: The sample comprised 697 survivors of colon cancer and 479 survivors of rectal cancer. In general, survivors of colon and rectal cancer diagnosed at <50 years of age reported lower functioning and higher symptom burden in comparison with survivors diagnosed at an older age. When stratified by sex, female survivors of colon cancer tended to report more concerns with hair loss but fewer sexual problems when compared with male survivors of colon cancer of the same age. Female survivors of rectal cancer in all age groups tended to report lower levels of sexual interest than male survivors of rectal cancer of the same age., Limitations: This was a cross-sectional study with findings that could be biased toward healthier long-term survivors. The generalizability of results is limited to survivors diagnosed before 2005., Conclusions: Our results suggest that supportive care for survivors of colon and rectal cancer to improve their self-management of symptoms should be adapted according to cancer type, age at diagnosis, and sex. See Video Abstract at http://links.lww.com/DCR/B29. LA EDAD AL DIAGNÓSTICO Y EL GÉNERO ESTÁN ASOCIADOS CON DÉFICITS A LARGO PLAZO EN LA CALIDAD DE VIDA RELACIONADA CON LA SALUD ESPECíFICA DE LA ENFERMEDAD DE LOS SOBREVIVIENTES DE CÁNCER DE COLON Y RECTO: UN ESTUDIO BASADO EN LA POBLACIÓN:: A pesar del creciente número de individuos jóvenes diagnosticados con cáncer de colon y recto, la investigación sobre la calidad de vida relacionada con la salud específica de la enfermedad a largo plazo de los sobrevivientes de cáncer de colon y recto jóvenes (<50 años) es escasa.Nuestro estudio tuvo como objetivo comparar los déficits funcionales específicos de la enfermedad y los síntomas de los sobrevivientes de cáncer de colon y recto 5-16 años después del diagnóstico, estratificados por edad al momento del diagnóstico y por género.Transversal.Utilizamos datos del estudio Supervivencia de CAncEr basada en la población: Un estudio multirregional en colaboración con cinco bases de datos alemanas de cáncer basados en la población.Sobrevivientes de cáncer de colon y recto.Los encuestados respondieron el módulo de calidad de vida específica para la enfermedad en cáncer colorrectal de la Organización Europea para la Investigación y Tratamiento del Cáncer. Las categorías de edad al diagnóstico fueron <50, 50-59, 60-69 y ≥70 años. Los puntajes de CVRS (calidad de vida relacionada a la salud) medios mínimos cuadrados, derivados de la regresión lineal, se ajustaron por género, educación, tiempo desde el diagnóstico, sitio del cáncer, etapa del cáncer y tratamiento, cuando apropiado.La muestra comprendió 697 y 479 sobrevivientes de cáncer de colon y de recto, respectivamente. En general, los sobrevivientes de cáncer de colon y recto diagnosticados con <50 años de edad reportaron una menor funcionalidad y una mayor carga de síntomas en comparación con los sobrevivientes diagnosticados a una edad más avanzada. Cuando se estratificaron por género, las mujeres sobrevivientes de cáncer de colon tendieron a informar más preocupaciones sobre la pérdida de cabello pero menos problemas sexuales en comparación con los hombres sobrevivientes de colon de la misma edad. Las mujeres sobrevivientes de cáncer rectal en todos los grupos de edad tendieron a informar niveles más bajos de interés sexual que los hombres sobrevivientes de cáncer rectal de la misma edad.Estudio transversal con hallazgos que podrían estar sesgados hacia sobrevivientes a largo plazo más saludables. La generalización de los resultados se limitó a los sobrevivientes diagnosticados antes de 2005.Nuestros resultados sugieren que los cuidados de soporte para los sobrevivientes de cáncer de colon y recto para mejorar su automanejo de síntomas deben adaptarse según el tipo de cáncer, la edad en el momento del diagnóstico y el género. Vea el resumen en video en http://links.lww.com/DCR/B29.

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.

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. Chi 2 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.

Background: Previous research suggests an age differential in health-related quality of life (HRQOL) among long-term (5-10 years post-diagnosis, LTS) colorectal cancer (CRC) survivors. Few studies have specifically addressed the association of age differentials with HRQOL for very long-term CRC survivors (>10 years post-diagnosis, VLTS) and non-cancer population controls. We aimed to assess possible deficits in HRQOL of disease-free CRC-LTS and CRC-VLTS in comparison with non-cancer population controls, and whether the observed pattern varies by age and time since diagnosis. Methods: We used data from the CA nc E r S urvivorship - A multi- R egional (CAESAR+) study in collaboration with five population-based German cancer registries. HRQOL from controls was accessed from the L ebensqualität in DE eutschland (LinDE) study. All respondents completed the European Organization for Research and Treatment of Cancer Quality of Life Core-30 questionnaire. We calculated least square means of HRQOL scores. Analyses were adjusted for age, sex, and education, where appropriate. Results: The sample included 862 CRC-LTS, 400 CRC-VLTS and 1689 controls. CRC survivors reported overall good HRQOL but significantly poorer social functioning and more problems with dyspnea, constipation, diarrhea and finances than controls. When stratified by age, deficits in functioning and global health, and more problems with symptoms and finances were noted mainly among younger CRC survivors. Further stratification by time since diagnosis showed that similar deficits in HRQOL and symptoms were noted mainly among the younger CRC-LTS group when compared with controls. Generally, CRC-VLTS reported comparable HRQOL to controls. An exception was noted for diarrhea, whereby CRC survivors, regardless of age and time since diagnosis, reported significantly more problems with this symptom than controls. Conclusions: In comparison with non-cancer controls, disease-free CRC survivors reported overall good HRQOL but experience persistent specific detriments in HRQOL many years after diagnosis. In age stratified analyses, HRQOL deficits were noted mainly among younger CRC-LTS.

Several studies have suggested that the anticancerogenous effects of vitamin D might be modulated by genetic variants in the vitamin D receptor (VDR) gene. The association of VDR polymorphisms with breast cancer-specific and all-cause mortality after a breast cancer diagnosis remains, however, largely unexplored. We assessed the association of genetic variants in VDR (rs731236, rs1989969, rs2228570, and 11568820) with breast cancer survival in a sample of 498 patients with breast cancer with a mean age at diagnosis of 61 years from Saarland, Germany, who were followed for up to 5 years with respect to total and breast cancer-specific mortality (56 and 48 events, respectively). Adjusted HRs with 95% confidence intervals (CI) were estimated by Cox regression models. We found that patients with breast cancer homozygous for the rare allele of rs731236 (15% of the women in our cohort) had a tendency toward an increased risk for breast cancer-specific mortality. The HR (95% CI) adjusted for age and breast cancer stage was 2.8 (1.1-7.2) for breast cancer-specific mortality and 2.1 (0.9-4.9) for total mortality. Additional adjustment for family history of breast cancer, radical mastectomy, and body mass index only marginally changed the estimates. No association was found for rs1989969, rs2228570, and rs11568820. Our analysis suggests that VDR polymorphism rs731236 might be associated with breast cancer-specific mortality, and if our findings are confirmed in future bigger studies rs731236 might deserve consideration as a prognostic factor in clinical care of patients with breast cancer.

Background: Implementation of mammography screening and advances in breast cancer treatment are considered as main reasons for the decline in breast cancer mortality observed in many industrialized countries during the past two decades. The purpose of this study was to provide a comprehensive assessment of trends in breast cancer incidence, mortality and survival by age and stage in Germany., Methods: Data from the population based Saarland Cancer Registry including patients diagnosed with breast cancer from 1972 to 2007 were used. Period analysis methods were employed to calculate 5-year relative survival and its trends., Results: Mortality started to decline during the 1990s, and a previous increase in incidence levelled off in the early 21st century. Overall age-standardized 5-year relative survival of invasive breast cancer steadily increased during the past three decades to 83% in 2004-2008. This increase was mostly due to an increase in survival for patients with localized cancers and locally or regionally spread tumours (increase of age-standardized 5-year relative survival from 92% to 98% and from 65% to 80%, respectively, between 1992 and 2008), whereas age-standardized 5-year relative survival essentially remained unchanged at levels close to 21% in patients with metastasized cancer. For women aged 70 years or older 5-year relative survival and its increase over time were inferior compared to younger patients., Conclusions: The observed trends in population based survival suggest that advances in treatment of early breast cancer have substantially contributed to the gain in prognosis. The poor prognosis of metastasized breast cancer patients and the increasing age gradient in 5-year relative survival call for enhanced efforts for early detection and more rigorous treatment of elderly patients., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background & Aims: Associations of serum gamma-glutamyltransferase levels with a variety of incident diseases and mortality have been suggested. The present study attempted to expand the body of evidence to especially relevant occupational cohorts in which exposure to established γ-GT determinants may greatly differ from the general population., Methods: The study was based on occupational health examinations conducted from 1986 to 1992 in 19,090 German male workers from the construction industry, aged 25-64years. Sociodemographics and other health-related information were collected during the exam. Vital status follow-up was conducted through 2008. Associations of baseline γ-GT levels (measurements at 25°C) with all-cause and cause-specific mortality were examined by Kaplan-Meier plotting and multiple adjusted Cox regression models., Results: A total of 2170 deaths occurred during 303,198 person-years of follow-up. The risk of death due to any cause was 2.5-fold increased in subjects in the highest (⩾39U/L) versus lowest (<11U/L) γ-GT quintile. To varying extents, elevated γ-GT was associated with higher mortality due to cancer, circulatory, respiratory, and digestive causes, as well as accidents/poisoning., Conclusions: The findings in this cohort provide evidence for γ-GT being associated with a broad range of causes of death, including less investigated outcomes. Some characteristics of the observed patterns need to be seen in the context of our cohort, featuring particularly high γ-GT levels., (Copyright © 2011 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Background & Aims: Screening recommendations for colorectal cancer (CRC) commonly take family history but no other risk factors into account. We compared and assessed risk factors of colorectal polyps in a large population undergoing screening colonoscopy., Methods: We conducted a population-based cross-sectional study that included 3349 subjects, 55 years or older (mean ages of men and women, 63.6 and 63.4 years, respectively), who underwent colonoscopy for the first time within the nationwide colonoscopy screening program in Germany. We calculated prevalences of colorectal polyps and estimated multivariate prevalence ratios (PRs) and population attributable fractions (PAFs)., Results: Overall, 654 subjects had hyperplastic polyps (20%), 675 had non-advanced adenomas (20%), 343 had advanced adenomas (10%), and 40 had CRC (1%). Risk factor prevalences and adjusted PRs were higher for male gender and smoking than for family history of CRC. PAFs for prevalence of non-advanced and advanced neoplasia were highest for male gender (23% and 23%, respectively), followed by smoking (7% and 9%, respectively), and family history of CRC (2% and 4%, respectively)., Conclusions: Male gender and smoking have a larger impact on the prevalence of colorectal neoplasia than family history, suggesting an extensive evaluation of additional risk stratification in population-based screening, particularly by sex., (Copyright © 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: The role of serum uric acid (UA) as an independent risk factor for several health outcomes remains controversial. However, given the accumulating evidence that UA is related to predictors of occupational disability such as obesity, excessive alcohol consumption, hypertension, and diabetes mellitus, UA may represent a relevant risk indicator for occupational disability, which has emerged as an important public health problem., Methods: The association between UA and occupational disability was examined in a cohort of 16,532 male construction workers in Germany who underwent occupational health examinations from 1986 to 1992 and were followed until 2005. Cox regression analysis was employed with adjustment for established risk factors., Results: A total of 3,002 cases of disability pension occurred during the followup. Risk of all-cause occupational disability was significantly increased for UA concentration in the top quartile (hazard ratio [HR] 1.25, 95% confidence interval [95% CI] 1.12-1.40) after adjustment for potential confounders when compared with UA levels in the lowest quartile (≤ 5.23 mg/dl). Cause-specific analysis revealed a significant association between increased UA and occupational disability due to cardiovascular diseases (HR 1.62, 95% CI 1.20-2.17). In addition, positive but statistically nonsignificant associations were observed for occupational disabilities due to respiratory diseases (HR 1.78, 95% CI 0.99-3.23), musculoskeletal disorders (HR 1.16, 95% CI 0.98-1.37), diseases of the digestive system (HR 1.59, 95% CI 0.69-3.67), and mental disorders (HR 1.40, 95% CI 0.95-2.06)., Conclusion: Our study is the first to our knowledge to indicate that increased UA might also serve as a potential independent risk indicator for occupational disability, in particular due to cardiovascular diseases.

Background & Aims: Screening colonoscopy is an effective method to reduce the incidence of and mortality from colorectal cancer (CRC). There is little empirical evidence available about the optimal interval for screening, making this a subject of debate. We associated the prevalence of advanced colorectal neoplasms with time since negative colonoscopies., Methods: In a study of participants in the German colonoscopy screening program, we determined the prevalence of colorectal neoplasias detected at screening colonoscopy among subjects who had undergone a previous colonoscopy without detection of polyps (negative colonoscopy). Data were compared with that from subjects who had not received colonoscopies., Results: No CRCs were detected in participants who had a previous negative colonoscopy an average of 11.9 years previously (n = 553), compared with the 8.4 CRC cases expected based on age- and gender-specific prevalences among participants who had not received a colonoscopy (n = 2701; standardized prevalence ratio [SPR] = 0.00; 95% confidence interval [CI]: 0.00-0.55). Prevalence of advanced adenoma was also much lower among subjects who had previous colonoscopies (SPR = 0.42; 95% CI: 0.25-0.68). Adjusted prevalence ratios (95% CIs) for detecting an advanced adenoma were 0.38 (95% CI: 0.16-0.90), 0.34 (95% CI: 0.15-0.74), 0.38 (95% CI: 0.16-0.90), and 0.53 (95% CI: 0.27-1.04) among participants with a negative colonoscopy conducted 1-5, 6-10, 11-15, and >16 years ago, respectively, compared to participants with no previous colonoscopy., Conclusions: The low risk of CRC and advanced adenomas after a negative colonoscopy supports suggestions that screening intervals be extended to > or =10 years., (Copyright 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Given the accumulating evidence that gamma-glutamyltransferase (gamma-GT) is not merely a sensitive marker for liver and bile disorders but also a risk marker for a multiplicity of other chronic diseases, gamma-GT may represent a promising risk indicator for occupational disability, which has emerged as an important public health problem. The association between gamma-GT and disability pension was examined in a cohort of 16,520 male construction workers in Württemberg, Germany, who participated in routine occupational health examinations from 1986 to 1992 and who were followed until 2005. Using the Cox proportional hazards model, hazard ratios were calculated with gamma-GT concentrations in the lowest quartile (1 to 24 U/L) as reference category after adjustment for age and further adjustment for potential confounding factors such as nationality, type of occupation, smoking, alcohol consumption, cholesterol, and body mass index (BMI). Overall, a monotonically increasing association of gamma-GT with all-cause disability pension (total number: n = 2,998 cases) was observed, with the steepest increase at lower levels of gamma-GT. Particularly strong associations were observed for participants in the highest quartile (>67 U/L) and disability pension due to musculoskeletal disorders, diseases of the digestive system, and cardiovascular as well as mental diseases (age-adjusted hazard ratios with 95% confidence intervals: 1.53, 1.27-1.85; 9.68, 3.10-30.21; 1.76, 1.28-2.42; and 1.83, 1.23-2.72, respectively)., Conclusion: gamma-GT is a strong risk indicator of all-cause occupational disability even at levels of gamma-GT in the "normal range" and is in particular associated with disability pension due to diseases of the digestive system, musculoskeletal disorders, cardiovascular, and mental diseases.

Objectives: Although smoking causes a variety of diseases and both, a high smoking prevalence and permanent occupational disability are a great burden on the population level, data about the impact of smoking habits on occupational disability are sparse. The objective of this study was to examine the influence of smoking habits on occupational disability among construction workers, an occupational group with particularly high smoking prevalence., Methods: The association between smoking and occupational disability was examined during a mean follow-up of 10.8 years in a cohort of 14,483 male construction workers in Württemberg, Germany. The cohort was linked to the regional pension register of the German pension fund to identify workers who were granted a disability pension during the follow-up. HRs (Hazard Ratios) were calculated with non-smokers as reference by the Cox proportional hazards model adjusting for potential confounding factors such as age, nationality, type of occupation, alcohol consumption and body mass index., Results: Overall, 2643 cases of occupational disability were observed, with dorsopathy (21%) being the most common cause. Clear dose-response relationships were seen between smoking and occupational disability due to all causes, as well as occupational disability due to respiratory, cardiovascular and mental diseases, cancer and dorsopathy. Particularly strong associations were seen between heavy smoking (> or =20 cigarettes/day) and occupational disability due to mental and respiratory diseases (HR 3.25, 95% CI 1.93 to 5.46 and HR 3.26, 95% CI 1.69 to 6.27, respectively)., Conclusion: Smoking is associated with increased risk of occupational disability among construction workers, in particular occupational disability due to respiratory, cardiovascular and mental diseases, cancer and dorsopathy.

Background: Colonoscopy is used for early detection and prevention of colorectal cancer, but evidence on the magnitude of overall protection and protection according to anatomical site through colonoscopy performed in the community setting is sparse. We assessed whether receiving a colonoscopy in the preceding 10-year period, compared with no colonoscopy, was associated with prevalence of advanced colorectal neoplasms (defined as cancers or advanced adenomas) at various anatomical sites., Methods: A statewide cross-sectional study was conducted among 3287 participants in screening colonoscopy between May 1, 2005, and December 31, 2007, from the state of Saarland in Germany who were aged 55 years or older. Prevalence of advanced colorectal neoplasms was ascertained by screening colonoscopy and histopathologic examination of any polyps excised. Previous colonoscopy history was obtained by standardized questionnaire, and its association with prevalence of advanced colorectal neoplasms was estimated, after adjustment for potential confounding factors by log-binomial regression., Results: Advanced colorectal neoplasms were detected in 308 (11.4%) of the 2701 participants with no previous colonoscopy compared with 36 (6.1%) of the 586 participants who had undergone colonoscopy within the preceding 10 years. After adjustment, overall and site-specific adjusted prevalence ratios for previous colonoscopy in the previous 10-year period were as follows: overall, 0.52 (95% confidence interval [CI] = 0.37 to 0.73); cecum and ascending colon, 0.99 (95% CI = 0.50 to 1.97); hepatic flexure and transverse colon, 1.21 (95% CI = 0.60 to 2.42); right-sided colon combined (cecum to transverse colon), 1.05 (95% CI = 0.63 to 1.76); splenic flexure and descending colon, 0.36 (95% CI = 0.16 to 0.82); sigmoid colon, 0.29 (95% CI = 0.16 to 0.53); rectum, 0.07 (95% CI = 0.02 to 0.40); left colon and rectum combined (splenic flexure to rectum, referred to as left-sided elsewhere), 0.33 (95% CI = 0.21 to 0.53)., Conclusion: Prevalence of left-sided advanced colorectal neoplasms, but not right-sided advanced neoplasms, was strongly reduced within a 10-year period after colonoscopy, even in the community setting.

Aim: To review and summarize evidence from longitudinal studies on the association between serum 25-hydroxyvitamin D (25(OH)D) and the risk of prostate cancer (PC)., Methods: Relevant prospective cohort studies and nested case-control studies published until July 2009 were identified by systematically searching Ovid Medline, EMBASE, and ISI Web of Knowledge databases and by cross-referencing. The following data were extracted in a standardized manner from eligible studies: first author, publication year, country, study design, characteristics of the study population, duration of follow-up, PC incidence/PC mortality according to serum vitamin D status and the respective risk ratios, and covariates adjusted for in the analysis. Due to the heterogeneity of studies in categorizing serum vitamin D levels, all results were recalculated for an increase in serum 25(OH)D by 10ng/ml. Summary odds ratios (ORs) were calculated using meta-analysis methods., Results: Overall, eleven original articles were included, ten of which reported on the association between serum vitamin D levels and PC incidence and one article reported on the association with PC mortality. Meta-analysis of studies on PC incidence resulted in a summary OR (95% confidence interval, CI) of 1.03 (0.96-1.11) associated with an increase of 25(OH)D by 10ng/ml (P=0.362). No indication for heterogeneity and publication bias was found., Conclusions: According to available evidence from longitudinal studies, serum 25(OH)D is not associated with PC incidence.

Infection with Helicobacter pylori is a major cause of gastric cancer (GC). The association likely has been underestimated in the past due to disease-related clearance of the infection. On the other hand, only a minority of the infected individuals develop GC, and better risk stratification is therefore highly desirable. We aimed to assess the association of GC with antibodies to 15 individual H. pylori proteins, determined by novel multiplex serology, to identify potentially relevant risk markers. This analysis was based on 123 GC cases aged 50 to 74 years and 492 age-matched and sex-matched controls from Saarland, Germany. Eight of the antibodies were significantly associated with noncardia GC and seven of them were significantly related to GC at any site. More pronounced associations were observed for noncardia GC; adjusted odds ratios (95% confidence intervals) ranged from 1.60 (1.01-2.54) for HyuA to 5.63 (3.20-9.91) for cytotoxin-associated antigen A (CagA). A dose-response relationship was found between the number of seropositivities and GC (P < 0.001). The seropositivities of CagA and GroEL were found to be independent predictors of GC, which were strongly related to GC risk in a dose-response manner (P < 0.001). In conclusion, GroEL was identified as a new independent risk marker that may contribute to enhanced quantification of H. pylori-related GC risk.

Objectives: Although obesity and permanent work disability impose a great burden on the individual and are very costly for society, data on the impact of being overweight on occupational disability are sparse, especially in men who work hard physically. The aim of this study was to investigate the association of body mass index (BMI) with work disability among construction workers., Methods: The association between BMI and work disability was examined during a mean follow-up period of 10.8 years in a cohort of 16,875 male construction workers in Württemberg, Germany, who participated in routine occupational health examinations from 1986 to 1992. Hazard ratios were calculated with normal weight (20.0-22.4 kg/m(2)) as reference using the Cox proportional hazards model, after adjustment for potential confounding factors., Results: Overall, a U-shaped association of BMI with all-cause work disability (total number = 3064 cases) was observed, with the lowest risk of disabilities at BMI levels between 25 and 27.4 kg/m(2). Strong positive associations were observed between BMI and work disability due to osteoarthritis or cardiovascular diseases, whereas BMI was inversely related to work disability due to cancer, even after exclusion of the first 3 years of follow-up., Conclusions: Moderate overweight is not associated with increased risk of work disability among construction workers, but obesity increases the risk of work disability due to osteoarthritis and cardiovascular disease.

Purpose: Breast-conserving therapy (BCT) was developed to improve quality of life (QOL) in early stage breast cancer patients. Except for differences in body image, literature comparing the psychosocial sequelae of BCT with mastectomy is ambiguous and shows a lack of substantial benefits. However, knowledge regarding long term effects of treatment on QOL in breast cancer is very limited as most of the pertinent studies have been performed in the early post-operative period. Therefore we compared QOL in women with breast cancer undergoing BCT versus women undergoing mastectomy over a 5-year period following primary surgery., Methods: QOL was assessed at 1, 3, and 5 years after diagnosis in a population based cohort of 315 women with early stage breast cancer (UICC stage I-II) from Saarland (Germany) using the EORTC QLQ-C30 questionnaire and the breast cancer specific module BR23., Results: Breast-conserving therapy was performed in 226 women (72%). After control for potential confounding, women with BCT reported better physical and role functioning, were sexually more active and more satisfied with their body image already at 1 year after diagnosis (all P values < 0.05). Differences in overall QOL and social functioning were gradually increasing over time and became statistically significant only at 5 years., Conclusions: Whereas some, very specific benefits of BCT, such as a better body image, are already visible very timely after completion of therapy, benefits in broader measures such as psychosocial well-being and overall quality of life gradually increase over time and become fully apparent only in the long run.

Objective: Although obesity is clearly associated with diabetes and cardiovascular disease, health consequences of being mildly or moderately overweight are less clear in physically heavily working men., Methods: The association between body mass index (BMI) and mortality was assessed over a 10-year period in a cohort of 19,513 male construction workers, who underwent routine occupational health examination during 1986 to 1992., Results: Among never smokers normal and overweight men experienced similar mortality. Among smokers, we observed a strong U-shaped association between BMI and all-cause mortality, which was lowest for BMI levels between 25 and 35 kg/m after control for potential covariates., Conclusions: BMI levels commonly considered to reflect overweight may not necessarily be associated with increased mortality in physically heavily working men.

Transatlantic cancer survival comparisons are scarce and involve mostly aggregate European data from the late 1980s. We compare the levels of cancer patient survival achieved in Germany and the United States (US) by the beginning of the 21st century, using data from the Cancer Registry of Saarland/Germany and the SEER Program of the US. Age-adjusted 5- and 10-year relative survival for 23 common forms of cancer derived by period analysis for the 2000-2002 period were calculated, with additional detailed age- and stage-specific analyses for cancers with the highest incidence. Among the 23 cancer sites, 5 (10) year relative survival was significantly higher for 1 (2) and 8 (5) cancers in Germany and the US, respectively. In Germany, survival was significantly higher for patients with stomach cancer, whereas survival was higher in the US for patients with breast, cervical, prostate, colorectal and oral cavity cancer. Among the most common cancers, age-specific survival differences were particularly pronounced for older patients with breast, colorectal and prostate cancer. Survival advantages of breast cancer patients in the US were mainly due to more favorable stage distributions. This comprehensive survival comparison between Germany and the US suggests that although survival was similar for the majority of the compared cancer sites, long-term prognosis of patients continues to be better in the US for many of the most common forms of cancer. Among these, differences between patients with breast and prostate cancer are probably due to more intensive screening activities., ((c) 2007 Wiley-Liss, Inc.)

Background: The ageing of populations makes outcome monitoring among elderly cancer patients particularly important., Patients and Methods: Using data from the population-based Cancer Registry of Saarland, we examined age-specific trends in 5-year relative survival from 1979 to 2003 for patients with 15 common cancers in Germany. Model-based period analysis was applied to estimate 5-year relative survival for four age groups (15-54, 55-64, 65-74, 75+) in the periods 1979-1983, 1984-1988, 1989-1993, 1994-1998, and 1999-2003., Results: Overall, 5-year relative survival improved steadily from 42.2% in 1979-1983 to 56.7% in 1999-2003. From the youngest to the oldest age group, 5-year relative survival increased by 14.5, 12.1, 12.5, and 8.4 percent units, respectively, after adjusting for changes in the spectrum of cancer sites, and survival significantly improved for 10, 12, 11, and 5 cancer sites, respectively. The age gradient particularly increased for cancer sites with major progress in chemotherapeutic treatment regimens, such as ovarian cancer, non-Hodgkin's lymphoma and leukemia., Conclusions: Relative survival of cancer patients increased considerably for many forms of cancer in Germany from 1979 to 2003. Increases were much less pronounced among elderly patients, leading to an increasing age gradient in prognosis.

Aims: Most industrialised countries have public income maintenance programmes to protect workers in case of disability but studies addressing disability risk of specific professional groups are rare. The objective of this study was to establish a detailed pattern of the nature and extent of occupational disability among construction workers., Methods: A cohort study was set up including 14,474 male workers from the construction industry in Württemberg (Germany) aged 25-64 years who underwent occupational health exams between 1986 and 1992. The cohort was linked to the regional pension register of the manual workers' pension insurance institution to identify workers who were granted a disability pension during the 10 year follow up. All-cause and cause specific standardised incidence ratios (SIR) and 95% confidence intervals (CI) were calculated using disability rates from the general workforce and from all blue collar workers in Germany as references., Results: In total, 2247 (16%) members of the cohort were granted a disability pension. Major causes of disability were musculoskeletal (45%) and cardiovascular diseases (19%). In comparison with the general workforce, construction workers experienced a higher risk of disability from cancer (SIR = 1.26; 95% CI 1.08 to 1.47), respiratory diseases (SIR = 1.27; 95% CI 1.03 to 1.55), musculoskeletal diseases (SIR = 2.16; 95% CI 2.03 to 2.30), injuries/poisoning (SIR = 2.52; 95% CI 2.06 to 3.05), and all causes combined (SIR = 1.47; 95% CI 1.41 to 1.53). When compared with the blue collar reference group, increased risks of disability among construction workers were found for musculoskeletal diseases (SIR = 1.53; 95% CI 1.44 to 1.63), injury/poisoning (SIR = 1.83; 95% CI 1.50 to 2.21), and all causes combined (SIR = 1.11; 95% CI 1.07 to 1.16)., Conclusions: Musculoskeletal diseases and external causes are major factors limiting the work capability of construction workers and lead to an increased proportion of occupational disability.

Purpose: Numerous epidemiological studies on middle aged men suggest that moderate alcohol consumption lowers all-cause mortality. Uncertainty exists whether this finding also applies to younger adults., Methods: The authors studied the age specific association between alcohol consumption and all-cause mortality in a cohort of 19,943 male employees in the German construction industry (age range 25-64 years) who underwent an occupational health examination between 1986 and 1992 and were followed with respect to vital status over an average period of 10 years. Information on alcohol consumption at baseline examination relied on self report and strongly correlated with biological markers of alcohol consumption. Covariates considered in the proportional hazard regression analysis included age, nationality, smoking status, and comorbidity., Results: Age specific analysis revealed that the J/U-shaped association between alcohol consumption and all-cause mortality is limited to men aged 35 years and above. In contrast, a linear positive dose-response relationship was observed for men aged 25 to 34 years (p-trend=0.02)., Conclusions: Recommendations regarding alcohol consumption and potential health benefits should not be generalized to all ages.

Background: Construction workers are potentially exposed to many health hazards, including human carcinogens such as asbestos, silica, and other so-called "bystander" exposures from shared work places. The construction industry is also a high risk trade with respect to accidents., Methods: A total of 19 943 male employees from the German construction industry who underwent occupational health examinations between 1986 and 1992 were followed up until 1999/2000., Results: A total of 818 deaths occurred during the 10 year follow up (SMR 0.71; 95% CI 0.66 to 0.76). Among those were 299 deaths due to cancer (SMR 0.89; 95% CI 0.79 to 1.00) and 312 deaths due to cardiovascular diseases (SMR 0.59; 95% CI 0.51 to 0.68). Increased risk of mortality was found for non-transport accidents (SMR 1.61; 95% CI 1.15 to 2.27), especially due to falls (SMR 1.87; 95% CI 1.18 to 2.92) and being struck by falling objects (SMR 1.90; 95% CI 0.88 to 3.64). Excess mortality due to non-transport accidents was highest among labourers and young and middle-aged workers. Risk of getting killed by falling objects was especially high for foreign workers (SMR 4.28; 95% CI 1.17 to 11.01) and labourers (SMR 6.01; 95% CI 1.63 to 15.29)., Conclusion: Fatal injuries due to falls and being struck by falling objects pose particular health hazards among construction workers. Further efforts are necessary to reduce the number of fatal accidents and should address young and middle-aged, semi-skilled and foreign workers, in particular. The lower than expected cancer mortality deserves careful interpretation and further follow up of the cohort.

Although the association between Helicobacter pylori infection and gastric cancer is well established, this association might have been underestimated in epidemiologic studies because of possible clearance of the infection in the course of disease development. The authors addressed this hypothesis in a case-control study from Saarland, Germany (68 cases first diagnosed between 1996 and 1998 and 360 controls), with serologic assessment of H. pylori infection in which various exclusion criteria were used to minimize potential bias from this source. Joint application of three such exclusion criteria (blood sample taken more than 90 days after gastrectomy, advanced (T4) gastric cancer, and CagA positivity in Western blot analysis despite a negative result in anti-H. pylori immunoglobulin G enzyme-linked immunosorbent assay) increased the odds ratio of noncardia gastric cancer from 3.7 (95% confidence interval (CI): 1.7, 7.9) to 18.3 (95% CI: 2.4, 136.7) for any H. pylori infection and from 5.7 (95% CI: 2.6, 12.8) to 28.4 (95% CI: 3.7, 217.1) for CagA-positive H. pylori infections. Furthermore, there was no single H. pylori-negative patient out of 32 patients with noncardia gastric cancer left after additional exclusion of subjects with borderline levels in immunoglobulin G enzyme-linked immunosorbent assay. The H. pylori-gastric cancer relation may be much stronger than previously thought, and H. pylori infection may even be a (close to) necessary condition for development of noncardia gastric cancer.

Purpose: Delaying the diagnosis and initiation of treatment of cancer is likely to result in tumor progression and a worse prognosis. We examined sources and consequences of provider delay among female breast cancer patients in a population-based study in Germany., Patients and Methods: Three hundred eighty women, who were ages 18 to 80 years and who had invasive breast cancer, were interviewed with respect to the diagnostic process. Provider delay was defined as time from first presentation to a health care provider until initiation of cancer treatment., Results: Median provider delay was 15 days and did not substantially differ by the specialty of first consulted physician. Delays in the diagnostic work-up were mainly because of erroneous initial suspicion of a benign breast disease or because of time constraints by patients or physicians. Provider delay over 3 months was found in 11% of all breast cancer cases and was associated with patient characteristics such as higher education (odds ratio [OR] = 2.6; 95% confidence interval [CI], 1.3 to 5.4), full-time employment (OR = 2.5; 95% CI, 1.1 to 5.5), family history of breast cancer (OR = 2.8; 95% CI, 1.2 to 6.2), and presenting with a non-breast symptom (OR = 4.3; 95% CI, 1.7 to 10.9). The association between duration of diagnostic work-up and stage at diagnosis was U shaped, with the highest proportions of metastasized breast cancer tumors among women with very short (< 7 days) or very long (> 3 months) duration., Conclusion: Diagnostic work-up is within reasonably short time limits among most patients with breast cancer in Germany. Although the association between delay and tumor stage seems to be complex, any delay in diagnostic work-up should be kept to a minimum.

MaeIII Restriction Fragment Length Polymorphism in exon 3 of the alcohol dehydrogenase II was assessed in serum from 467 randomly selected German women and 278 women with invasive breast cancer to evaluate the interaction between a polymorphism of the alcohol dehydrogenase II gene, alcohol consumption and risk for breast cancer. In both groups, usual consumption of different alcoholic beverages was asked for using semiquantitative food frequency questionnaires. We used multivariable logistic regression to separately estimate the association between alcohol consumption and alcohol dehydrogenase II polymorphism in the population sample and women with breast cancer. The alcohol dehydrogenase II polymorphism was detected in 14 women from the population sample (3.0%) and in 27 women with invasive breast cancer (9.7%). Frequency of alcohol consumption was independent of the genotype in the population sample. In women with breast cancer, there was a significant inverse association between the alcohol dehydrogenase II polymorphism and frequency of alcohol consumption (adjusted case-only odds ratio over increasing frequency of alcohol consumption=0.5; P for interaction=0.02). We observed a gene-environment interaction between the alcohol dehydrogenase II polymorphism, alcohol consumption, and risk for breast cancer. Breast cancer risk associated with alcohol consumption may vary according to the alcohol dehydrogenase II polymorphism, probably due to differences in alcohol metabolism.

Early diagnosis is a tenet in oncology and should enable early treatment with the expectation of improved outcome. Extent and determinants of patient delay of diagnosis in breast cancer patients and its impact on stage of disease were examined in a population based study among female breast cancer patients in Germany. Two hundred and eighty-seven women, aged 18 to 80 years with newly diagnosed invasive symptomatic breast cancer, were interviewed with respect to the diagnostic process. Patient delay was defined as time from onset of first symptoms to first consultation of a doctor. Median patient delay was 16 days among symptomatic patients. Eighteen per cent of all breast cancer patients waited longer than 3 months before consulting a physician. Long patient delay was associated with old age, history of a benign mastopathy, obesity, and indices of health behaviour such as not knowing a gynaecologist for out-patient care and non-participation in general health screening examinations. A strong association between patient delay and stage at diagnosis was observed for poorly differentiated tumours. These results suggest that at risk groups for delaying consultation can be identified and that a substantial proportion of late stage diagnoses of poorly differentiated breast cancer cases could be avoided if all patients with breast cancer symptoms would present to a doctor within 1 month.

Late-stage diagnosis of breast cancer is associated with poor survival. Identification of individuals at high risk of late-stage diagnosis could be an effective step to reduce breast cancer mortality. We examined the association of socio-demographic factors and health behavior with breast cancer stage in a population-based sample of 380 female breast cancer patients in Saarland, Germany. Overall, 182 women (47.9%) were diagnosed with late-stage (regional or distant) breast cancer. After control for potential confounding by multivariate logistic regression, an increased risk of late-stage diagnosis was observed for older age (OR = 1.8; 95% CI 1.0-3.2), foreign nationality (OR = 3.9; 95% CI 0.7-20.8), living in large households (OR = 1.7; 95% CI 1.0-2.9), non-participation in general health check-up (OR = 1.5; 95% CI 0.9-2.4) and low interest in health care (OR = 1.6; 95% CI 1.0-2.7). The proportion of late-stage cancer was clearly decreased when tumors were detected by screening (OR = 0.4; 95% CI 0.2-0.8). Certain socio-demographic factors and characteristics of health behavior seem to represent independent risk indicators of late-stage diagnosis.

Background: Gamma-glutamyl transferase (GGT), alanine transaminase (ALT), and aspartate transaminase (AST) are widely used as markers of hepatobiliary disorders in occupational health surveillance. Little is known, however, about the prevalence and occupational and non-occupational determinants of elevated levels of these enzymes in specific occupational groups or about the prognostic value of elevated levels with respect to long-term outcomes such as all-cause mortality and vocational disability., Methods: A cohort study was conducted among 8,043 male construction workers aged 25-64 years who had undergone occupational health examinations in 6 centers in southern Germany from 1986 to 1988 and had been followed until 1994. The prevalence of elevated levels of GGT, ALT, and AST, depending on the sociodemographic and medical characteristics determined at the baseline examination and the risk of vocational disability and all-cause mortality in relation to elevated liver enzyme activity at baseline were assessed. Covariates considered in multivariate analysis included age, nationality, occupation, body mass index (BMI), smoking, and alcohol consumption., Results: The baseline prevalence of elevated activity levels of GGT (>28 U/1 at 25 degrees C), ALT (>22 U/1), and AST (>18 U/1) was 32%, 22%, and 12%, respectively. Factors most strongly related to elevated serum activity levels for all three enzymes were self-reported alcohol consumption, diabetes, and hypertension. BMI was strongly associated with elevations in GGT and ALT but not in AST. Elevated levels of AST and GGT were strongly related to early retirement and all-cause mortality. Men with AST levels exceeding 18 U/1 had a 2-fold risk of early retirement and a 3 times higher risk of all-cause mortality as compared with men with lower AST levels. No significant association was observed between ALT and either of the long-term outcomes., Conclusions: Our findings suggest that screening for elevated GGT and AST levels, which are a common finding among construction workers, may be a powerful tool for the identification of individuals at increased risk of early retirement and preterm mortality and may be helpful in targeting of prevention efforts.

Little is known about the relation of cigarette smoking and early retirement due to permanent disability. We conducted a cohort study among 4796 construction workers aged 40 to 59 who underwent occupational health examinations in 1986-1988 in occupational health centers located in the southern region of Germany. They were followed up with respect to working status until July 1994. The effect of smoking on early retirement due to permanent disability was assessed using the Cox proportional hazard model. Overall, smoking prevalence at baseline was 52%. The relative rate (RR) for permanent disability was 1.3 (95% CI 1.0-1.8) for all current smokers, compared with never-smokers. A positive dose-response relationship between smoking and the rate of early retirement due to permanent disability was found after adjustment for covariates. RR ranged from 1.3 in persons who reported smoking 1-19 cigarettes a day to 1.6 in persons who reported smoking > or = 30 cigarettes a day (P value for trend = 0.02). These findings underline the need for comprehensive efforts at the workplace to reduce smoking and its negative consequences for the individual, as well as to limit the associated social burden for society.

The impact of body weight on all-cause mortality is subject to ongoing debate. We assessed the relation between body mass index (BMI) and all-cause mortality in a cohort of 8043 male employees in the German construction industry who underwent detailed occupational health examinations at ages 25-64 and who were followed for all cause mortality over an average period of 4.5 years. Overall, there was a negative, graded relation between BMI and all-cause mortality, which persisted after controlling for multiple covariates including age and cigarette smoking, and after excluding the initial two years of follow-up. There was a strong positive cross-sectional relationship between BMI and a medical diagnosis of diabetes, hypertension, and ischemic heart disease at the baseline examination. While BMI showed a strong negative relation with all-cause mortality among men with such diseases, the association was much weaker and non-monotonic for mean free of these diseases. Our results underline the importance of preexisting diseases for the prognostic value of body weight.

Study Design: A cohort study on back-related morbidity and its impact on early retirement resulting from disability among employees in the construction industry., Objective: To describe the prevalence of back-related morbidity according to different measures in various occupational groups and to assess the prognostic value of these measures for early retirement resulting from disability., Methods: The results of occupational health examinations conducted in 1986-1988 among 4,958 employees of the German construction industry aged 40-64 years were analyzed. Active follow-up evaluation was carried out between October 1992 and July 1994 to ascertain employment status., Results: Compared with that of white-collar employees, no excess risk for self-reported back pain or sciatica was seen for any of the manual professions. In contrast, the age-adjusted prevalence of clinical findings of the spine was elevated among all employees in manual professions, and the prevalence of a recorded diagnosis related to disorders of the back and spine (ICD-9 position 720-724) was elevated among bricklayers compared with white-collar employees. The relative risk of being granted a disability pension in the follow-up period was 1.6 (95% Confidence Interval [Cl], 1.3-2.1) for persons reporting back pain or sciatica, 1.8 (95% Cl, 1.4-2.2) for persons with an abnormal clinical finding of the spine, and 1.5 (95% Cl, 1.2-1.8) for persons with a recorded medical diagnosis related to disorders of the back or spine (ICD-9 720-724)., Conclusion: Patterns of morbidity varied according to the evaluated morbidity measure. All three measures qualified as significant predictors of disability and helped to identify high-risk occupations and high-risk employees.

Background: Serum gamma-glutamyltransferase (GGT) is commonly measured as a marker of hepatobiliary disorders in clinical practice, but little is known about its distribution and prognostic value for all-cause mortality., Methods: Distribution and determinants of serum GGT levels were assessed among 8,043 construction workers ages 25-64 who underwent occupational health examinations in six centers in Southern Germany from 1986 to 1988. Study participants were followed for all-cause mortality until 1994., Results: Serum GGT levels were considerably higher in this cohort than among male employees examined in a national survey conducted during the same period. The factors most strongly related to serum GGT were self-reported alcohol consumption, body mass index, diabetes, and hypertension, but relations of GGT levels were also found with nationality, occupation, and smoking. There was a strong dose-response relation between serum GGT levels and all-cause mortality (P value for trend < 0.001). Compared with men with GGT levels below 15 U/liter (measured at 25 degrees C), relative risks (95% CI) were 1.46 (0.86-2.49), 1.78 (1.08-2.94), 2.09 (1.26-3.45), and 3.44 (2.20-5.38) for men with GGT levels of 15-19, 20-29, 30-49, and > or = 50 U/liter, respectively. This relation was reduced but not eliminated by control for body mass index, diabetes, hypertension, alcohol consumption, and other covariates in multivariable analysis., Conclusion: Serum GGT is a strong risk indicator of all-cause mortality.