Abstract

Background:

Until recently, population-based data of cancer survival in Germany mostly relied on one registry covering ∼1 million people (1.3% of the German population). Here, we provide up-to-date cancer survival estimates for Germany based on data from 11 population-based cancer registries, covering 33 million people and compare them to survival estimates from the United States.

Patients and methods:

Cancer patients diagnosed in 1997–2006 were included. Period analysis was employed to calculate 5-year relative survival for 38 cancers for 2002–2006. German and USA survival rates were compared utilizing the Surveillance, Epidemiology and End Results 13 database.

Results:

Five-year relative survival >80% was observed for testicular cancer (93.5%), skin melanoma (89.4%), cancers of the prostate (89.1%) and thyroid (87.8%), Hodgkin’s lymphoma (84.5%) and cancers of the breast (83.7%) and endometrium (81.0%), which together account for almost 40% of cases. For the majority of cancers, German survival estimates were close to or below those in the United States. Exceptions with higher survival in Germany were cancers of the stomach, pancreas and kidney and Hodgkin’s lymphoma.

Conclusions:

German cancer survival estimates are mostly higher than the 2000–2002 pan-European estimates. Further research is needed to investigate causes responsible for differences between German and USA cancer survival rates.

introduction

Three of the 10 leading causes of death in Germany are cancers of the lung, colorectum and breast [1], which emphasize the importance of monitoring survival of cancer patients. Population-based cancer survival data provide important prognostic information for clinicians, patients and public health decision makers.

Until recently, population-based data on cancer survival in Germany mostly relied on the Saarland Cancer Registry, which covers only ∼1 million people (1.3% of the German population) [2]. In particular, Germany was represented in international comparative studies (EUROCARE, EUNICE) so far by the Saarland and occasionally by the Munich Cancer Registry only [3–6]. By now, population-based cancer registries have been built up in all federal states of Germany and a collaborative project funded by the German Cancer Aid was set up between 13 population-based German cancer registries and the Division of Clinical Epidemiology and Aging Research at the German Cancer Research Center (DKFZ) in order to provide comprehensive monitoring of cancer survival in Germany.

This article gives an overview of the data collection and provides the most comprehensive report available to date on overall and age-specific 5-year relative cancer survival in Germany for the period of 2002–2006 for the 25 most common forms of cancer representing >95% of the cancer cases in the pooled dataset. In addition, 5-year relative survival is provided for 13 rare cancers for which population-based survival estimates are generally sparse. Furthermore, comparisons of cancer survival in Germany and the United States are provided. In order to achieve up-to-date monitoring of cancer survival, period analysis was used allowing the exclusive use of the most recent available follow-up information [7].

materials and methods

data sources

Data were submitted for the present project from cancer registries covering 12 out of the 16 German federal states and the Münster administrative district of North Rhine-Westphalia. According to the estimations from the Robert Koch Institute (Germany’s central public health institute), the completeness of cancer registration was >80% in all states and >90% in most states in 2004–2006 [8]. Degree of completeness was calculated using incidence/mortality ratio. Expected incidence data were initially retrieved from the Saarland Cancer registry, the only population-based cancer registry in Germany working continuously for >40 years. The development of the age-specific quotients over time is modeled in a log-linear approach with polynomial trends. Further registries successively contribute to the data pool of reference registry, once the completeness of these registries has been confirmed in a comparison with the Saarland [8].

In two federal states of Germany (Baden-Württemberg and Hesse), cancer registration is still in an early phase of build-up; data from Berlin were not delivered due to known major deficiencies in the completeness of registration. After detailed additional datachecks, data from two registries (Saxony-Anhalt and Thuringia) were excluded from further survival analysis because they did not meet the following criteria: percentage of death certificate only (DCO) cases <20% throughout the study period or decrease by at least two percentage points per year to levels <20% by the end of the study period. The latter criterion was chosen as high DCO rates in initial years of registration of young registries occur even in cases of high completeness of registration. For the states of Bavaria, Schleswig-Holstein and Rhineland-Palatinate, data were used from those administrative regions where these criteria were met. Finally, data from 11 cancer registries, covering a population of 33 million people, were retained (Table 1).

Table 1.

Overview of participating cancer registries in the present analysis

Registry Underlying population in 2006 (million) Diagnosis period Date of last follow-up Cases diagnosed (1997–2006) (NMicroscopically confirmed cases (%) Exclusions based on
 
Available cases (1997–2006) (N
DCO casesa (%) Otherb (N
Brandenburg 2.55 1961–2006 2006 130 080 96.3 16.0 99 109 207 
Mecklenburg-Vorpommern 1.69 1961–2006 2006 87 647 96.2 14.3 46 75 095 
Saxony 4.25 1961–2006 2006 232 993 95.8 14.0 50 200 230 
Bremen 0.66 1998–2006 2006 34 196 96.7 15.3 28 958 
Hamburg 1.75 1991–2007 2007 87 146 95.2 14.8 12 74 264 
Bavariac 8.13 2002–2006 2006 209 624 99.3 19.0 169 729 
Saarland 1.04 1970–2006 2006 60 723 97.3 6.8 13 56 554 
Lower Saxony 7.98 2001–2006 2008 249 975 90.5 19.3 55 201 716 
North Rhine-Westphaliac 2.62 1988–2004 2004 99 214 97.1 9.5 30 89 770 
Schleswig-Holsteinc 1.85 1999–2006 2006 95 228 98.4 21.8 16 74 488 
Rhineland-Palatinatec 0.52 1998–2006 2006 26 200 94.4 18.5 21 347 
Total 33.04       1 101 358 
Registry Underlying population in 2006 (million) Diagnosis period Date of last follow-up Cases diagnosed (1997–2006) (NMicroscopically confirmed cases (%) Exclusions based on
 
Available cases (1997–2006) (N
DCO casesa (%) Otherb (N
Brandenburg 2.55 1961–2006 2006 130 080 96.3 16.0 99 109 207 
Mecklenburg-Vorpommern 1.69 1961–2006 2006 87 647 96.2 14.3 46 75 095 
Saxony 4.25 1961–2006 2006 232 993 95.8 14.0 50 200 230 
Bremen 0.66 1998–2006 2006 34 196 96.7 15.3 28 958 
Hamburg 1.75 1991–2007 2007 87 146 95.2 14.8 12 74 264 
Bavariac 8.13 2002–2006 2006 209 624 99.3 19.0 169 729 
Saarland 1.04 1970–2006 2006 60 723 97.3 6.8 13 56 554 
Lower Saxony 7.98 2001–2006 2008 249 975 90.5 19.3 55 201 716 
North Rhine-Westphaliac 2.62 1988–2004 2004 99 214 97.1 9.5 30 89 770 
Schleswig-Holsteinc 1.85 1999–2006 2006 95 228 98.4 21.8 16 74 488 
Rhineland-Palatinatec 0.52 1998–2006 2006 26 200 94.4 18.5 21 347 
Total 33.04       1 101 358 
a

Including also cases that were not registered as death certificate only case, but cancer diagnosis was made on the day of death.

b

Other: conversion problem from International Classification of Diseases for Oncology (ICD-O)-3 to ICD-10 or inconsistent incidence/death date or missing sex.

c

Selected administrative districts only.

Patients with primary malignant tumors diagnosed in 1997–2006 who were at least 15 years old at the time of diagnosis with follow-up date until the end of December 2006 were included in the analysis. Cancer topography, morphology and behavior were originally coded in accordance with the International Classification of Diseases for Oncology (ICD-O)-3 guidelines and later converted into ICD-10 using ‘IARC crgTools’ [9].

The registries were recording cancer cases according to rules set up by the International Agency for Research on Cancer (IARC). Cancer patient follow-up was carried out via linkage to death certificates of the respective state and in some registries, additional linkage to population registries in order to get information about deaths or migration to another state. Two of the cancer registries (Hamburg and Bremen) registered out-migrations by record linkage with population registries. Out-migration rates leading to the loss of follow-up were 1.7% in Hamburg and 2.8% in Bremen.

Cases were excluded if they were identified only by death certificate or the diagnosis was issued on the day when the patient died (Table 1). Cases whose cancer diagnosis could not be converted from ICD-O-3 to ICD-10 were not included in survival analysis. Very few cases were removed because of additional problems (e.g. inconsistency of date of diagnosis or date of last follow-up). The percentage of diagnoses that were microscopically confirmed was >90% in all registries (Table 1).

Primary malignant tumors diagnosed in 1997–2006 were selected from the Surveillance, Epidemiology and End Results (SEER) 13 database for comparative analysis. Patients identified by DCO were excluded.

statistical methods

Five-year relative survival estimates for the time period of 2002–2006 were calculated. Relative survival, which quantifies cancer-related excess mortality in the cancer patient population, was calculated as the ratio of the observed survival in the patient group divided by the expected survival of a comparable group in the general population [10]. Expected survival was estimated according to the Ederer II method using life tables stratified by age, sex, calendar period and region as obtained from the participating cancer registries and the German Federal Statistical Office [11]. All relative survival estimates are period estimates, considering only the survival experience in 2002–2006, the most recent 5-year interval for which data were available. Period analysis has been shown to provide more up-to-date estimates of cancer survival than traditional cohort-based analysis [7, 12]. The differences between the survival estimates of the German and American cancer populations were tested for statistical significance by model-based period analysis [13].

For the 25 most common forms of cancer, 5-year overall relative survival estimates were calculated with age adjustment according to the International Cancer Survival Standards using the following age groups: 15–44, 45–54, 55–64, 65–74 and 75+ years [14]. In addition, 5-year survival was estimated for two major age groups: <75 years (age-adjusted estimate using four age groups: 15–44, 45–54, 55–64, 65–74 years) and 75+ years (age-specific estimate). For additional 13 less common cancers, only overall age-adjusted 5-year relative survival is shown.

All calculations were carried out with SAS software (version 9.2; SAS Institute, Cary, NC), using macros developed for period analysis [15].

results

Table 2 shows the number of cases of the 25 most common cancers jointly representing >95% of the total cases of the pooled- German dataset. The most frequent cancer sites (each contributing at least 10% and >100 000 cases to the pooled dataset) were the colorectum, lung, breast and prostate. Another 13 cancer sites that are not among the 25 most frequent ones but contributed at least 500 cases to the pooled dataset are shown in Table 3.

Table 2.

Number of cases for the 25 most common cancers in 1997–2006 in the pooled-German dataset

Cancer site ICD-10 code Number of cases % of the pooled dataset 
Oral cavity 0–14 32 868 3.0 
Esophagus 15 14 532 1.3 
Stomach 16 44 867 4.1 
Colorectum 18–21 168 409 15.3 
Liver 22 13 254 1.2 
Gallbladder 23–24 11 632 1.1 
Pancreas 25 26 191 2.4 
Larynx 32 10 307 0.9 
Trachea, lung, bronchus 33–34 113 936 10.4 
Skin melanoma 43 37 129 3.4 
Connective and soft tissue 49 6083 0.6 
Breast (female) 50 165 615 15.0 
Cervix 53 15 685 1.4 
Corpus uteri 54 30 906 2.8 
Ovary 56 21 651 2.0 
Prostate 61 141 412 12.8 
Testis 62 11 504 1.0 
Kidney 64 37 520 3.4 
Bladder 67 45 208 4.1 
Brain and nervous system 71–72 14 051 1.3 
Thyroid 73 12 419 1.1 
Hodgkin’s lymphoma 81 5 283 0.5 
Non-Hodgkin’s lymphoma 82–85 33 009 3.0 
Multiple myelomaa 90 11 922 1.1 
Leukemia 91–96 23 064 2.1 
Total  1 048 457 95.3 
Cancer site ICD-10 code Number of cases % of the pooled dataset 
Oral cavity 0–14 32 868 3.0 
Esophagus 15 14 532 1.3 
Stomach 16 44 867 4.1 
Colorectum 18–21 168 409 15.3 
Liver 22 13 254 1.2 
Gallbladder 23–24 11 632 1.1 
Pancreas 25 26 191 2.4 
Larynx 32 10 307 0.9 
Trachea, lung, bronchus 33–34 113 936 10.4 
Skin melanoma 43 37 129 3.4 
Connective and soft tissue 49 6083 0.6 
Breast (female) 50 165 615 15.0 
Cervix 53 15 685 1.4 
Corpus uteri 54 30 906 2.8 
Ovary 56 21 651 2.0 
Prostate 61 141 412 12.8 
Testis 62 11 504 1.0 
Kidney 64 37 520 3.4 
Bladder 67 45 208 4.1 
Brain and nervous system 71–72 14 051 1.3 
Thyroid 73 12 419 1.1 
Hodgkin’s lymphoma 81 5 283 0.5 
Non-Hodgkin’s lymphoma 82–85 33 009 3.0 
Multiple myelomaa 90 11 922 1.1 
Leukemia 91–96 23 064 2.1 
Total  1 048 457 95.3 
a

Includes malignant plasma cell neoplasms as well.

Table 3.

Number of cases for 13 rare cancers in 1997–2006 in the pooled-German dataset

Cancer site ICD-10 code Number of cases % of the pooled dataset 
Small intestine 17 3248 0.3 
Nasal cavity, middle ear and accessory sinuses 30–31 1726 0.2 
Heart 38 750 0.1 
Bone 40–41 1970 0.2 
Mesothelioma 45 3465 0.3 
Peritoneum 48 1310 0.1 
Breast cancer in males 50 1261 0.1 
Vulva 51 5281 0.5 
Vagina 52 1162 0.1 
Penis 60 1516 0.1 
Renal pelvis 65 3325 0.3 
Ureter 66 1865 0.2 
Eye 69 1769 0.2 
Total  28 648 2.7 
Cancer site ICD-10 code Number of cases % of the pooled dataset 
Small intestine 17 3248 0.3 
Nasal cavity, middle ear and accessory sinuses 30–31 1726 0.2 
Heart 38 750 0.1 
Bone 40–41 1970 0.2 
Mesothelioma 45 3465 0.3 
Peritoneum 48 1310 0.1 
Breast cancer in males 50 1261 0.1 
Vulva 51 5281 0.5 
Vagina 52 1162 0.1 
Penis 60 1516 0.1 
Renal pelvis 65 3325 0.3 
Ureter 66 1865 0.2 
Eye 69 1769 0.2 
Total  28 648 2.7 

Age-adjusted 5-year relative survival estimates for the 25 most common types of cancer in Germany for the time period of 2002–2006 are shown in Table 4. Survival of cancer patients in Germany ranged from 9.0% (for pancreatic cancer) to 93.5% (testicular cancer). Cases with good prognosis (5-year relative survival >80%) made up almost 37% of the pooled dataset, including women diagnosed with cancers of the breast or endometrium, men with testicular or prostate cancer and patients diagnosed with melanoma, Hodgkin’s disease and thyroid cancer. Survival for patients with non-Hodgkin’s lymphoma and cancers of the connective tissue, colorectum, larynx, cervix, kidney and bladder was between 80% and 60%. These cases contributed almost 30% of the pooled dataset. Survival between 59% and 20% were observed for patients with seven cancers (leukemia, multiple myeloma and cancers of the stomach, gallbladder, ovary, brain and the oral cavity), accounting for ∼15% of the cases. The prognosis was worst (5-year relative survival <20%) for patients with cancers of the esophagus, liver, pancreas and lung, representing ∼15% of the pooled dataset.

Table 4.

Estimates of age-adjusted 5-year relative survival (%) for the period of 2002–2006 utilizing the pooled-German dataset and compared with SEER results

Cancer site 1
 
  2
 
 Germany
 
Difference between (2) and (1) P valuea SEER 
RS (%) SE RS (%) SE 
Oral cavity 48.7 0.6 7.1 <0.001 55.8 0.5 
Esophagus 18.3 0.6 −1.0 0.080 17.3 0.5 
Stomach 31.8 0.4 −4.8 <0.001 27.0 0.4 
Colorectum 63.0 0.2 2.5 <0.001 65.5 0.2 
Liver 13.1 0.5 −0.1 0.866 13.0 0.4 
Gallbladder and biliary tract 20.1 0.7 −3.0 0.002 17.1 1.0 
Pancreas 9.0 0.3 −2.7 <0.001 6.3 0.2 
Larynx 63.4 1.1 −1.9 0.017 61.5 0.8 
Trachea, lung, bronchus 16.5 0.2 0.9 <0.001 17.4 0.1 
Skin melanoma 89.4 0.3 1.6 <0.001 91.0 0.2 
Connective and soft tissue 60.4 1.0 5.7 <0.001 66.1 0.8 
Breast (female) 83.7 0.2 6.1 <0.001 89.8 0.2 
Cervix 64.7 0.6 0.1 0.186 64.8 0.7 
Corpus uteri 81.0 0.4 −0.6 0.006 80.4 0.4 
Ovary 40.7 0.5 −0.7 0.692 40.0 0.5 
Prostate 89.1 0.4 9.9 <0.001 99.0 0.2 
Testis 93.5 1.4 0.3 0.003 93.8 1.6 
Kidney 73.7 0.5 −6.4 <0.001 67.3 0.4 
Bladder 66.3 0.4 12.7 <0.001 79.0 0.3 
Brain and nervous system 25.0 0.5 1.7 0.838 26.7 0.4 
Thyroid 87.8 0.6 5.1 <0.001 92.9 0.4 
Hodgkin’s lymphoma 84.5 0.7 −3.9 <0.001 80.6 0.6 
Non-Hodgkin’s lymphoma 62.8 0.5 2.0 0.378 64.8 0.3 
Multiple myeloma 41.1 0.7 −4.4 <0.001 36.7 0.5 
Leukemia 50.5 0.5 −2.3 <0.001 48.2 0.4 
Cancer site 1
 
  2
 
 Germany
 
Difference between (2) and (1) P valuea SEER 
RS (%) SE RS (%) SE 
Oral cavity 48.7 0.6 7.1 <0.001 55.8 0.5 
Esophagus 18.3 0.6 −1.0 0.080 17.3 0.5 
Stomach 31.8 0.4 −4.8 <0.001 27.0 0.4 
Colorectum 63.0 0.2 2.5 <0.001 65.5 0.2 
Liver 13.1 0.5 −0.1 0.866 13.0 0.4 
Gallbladder and biliary tract 20.1 0.7 −3.0 0.002 17.1 1.0 
Pancreas 9.0 0.3 −2.7 <0.001 6.3 0.2 
Larynx 63.4 1.1 −1.9 0.017 61.5 0.8 
Trachea, lung, bronchus 16.5 0.2 0.9 <0.001 17.4 0.1 
Skin melanoma 89.4 0.3 1.6 <0.001 91.0 0.2 
Connective and soft tissue 60.4 1.0 5.7 <0.001 66.1 0.8 
Breast (female) 83.7 0.2 6.1 <0.001 89.8 0.2 
Cervix 64.7 0.6 0.1 0.186 64.8 0.7 
Corpus uteri 81.0 0.4 −0.6 0.006 80.4 0.4 
Ovary 40.7 0.5 −0.7 0.692 40.0 0.5 
Prostate 89.1 0.4 9.9 <0.001 99.0 0.2 
Testis 93.5 1.4 0.3 0.003 93.8 1.6 
Kidney 73.7 0.5 −6.4 <0.001 67.3 0.4 
Bladder 66.3 0.4 12.7 <0.001 79.0 0.3 
Brain and nervous system 25.0 0.5 1.7 0.838 26.7 0.4 
Thyroid 87.8 0.6 5.1 <0.001 92.9 0.4 
Hodgkin’s lymphoma 84.5 0.7 −3.9 <0.001 80.6 0.6 
Non-Hodgkin’s lymphoma 62.8 0.5 2.0 0.378 64.8 0.3 
Multiple myeloma 41.1 0.7 −4.4 <0.001 36.7 0.5 
Leukemia 50.5 0.5 −2.3 <0.001 48.2 0.4 
a

The differences between relative survival rates were tested using model-based period analysis.

RS, 5-year relative survival; SE, standard error; SEER, Surveillance, Epidemiology and End Results.

Additionally, Table 4 shows comparisons of survival of cancer patients in Germany and in the United States. Five-year relative survival was lower in Germany than in the United States for several cancers, including the most common ones such as colorectal, breast, prostate and lung cancers; as well as melanoma and cancers of the bladder, thyroid, oral cavity and connective tissue. Five-year relative survival was higher in Germany for some of the common cancers, such as Hodgkin’s lymphoma, multiple myeloma and cancers of the stomach, pancreas and kidney.

Five-year relative survival for younger (aged 15–74 years) and older (aged 75 years and older) cancer patients in Germany and in the United States are shown in Table 5. For several cancer sites (cervical, ovarian, thyroid and brain cancer as well as to all hematological malignancies), survival was much worse among older patients than among younger patients in both countries. For Hodgkin’s lymphoma, survival was higher among younger patients in Germany than in the United States, whereas an opposite pattern was seen among the older patients. There was a major age gradient in 5-year breast cancer survival in Germany but not in the United States.

Table 5.

Estimates of five-year relative survival of German and USA cancer patients for the period of 2002–2006 by two major age groups

Cancer site Age 15–74 years
 
Age 75+ years
 
1
 
2
 
  1
 
2
 
  
 Germany SEER Difference between (2) and (1) P valueb Germany SEER Difference between (2) and (1) P valueb 
RSa (%) SE RSa (%) SE RS (%) SE RS (%) SE 
Oral cavity 47.9 0.5 59.6 0.5 11.7 <0.001 50.6 1.8 46.3 1.1 −4.3 0.491 
Esophagus 19.9 0.6 19.3 0.6 −0.6 0.140 14.5 1.4 12.6 0.9 −1.9 0.348 
Stomach 34.0 0.4 28.5 0.5 −5.5 <0.001 26.6 0.7 23.4 0.7 −3.2 0.002 
Colorectum 65.4 0.2 67.8 0.2 2.4 <0.001 57.2 0.4 59.8 0.4 2.6 <0.001 
Liver 14.7 0.6 15.3 0.5 0.6 0.311 9.1 0.9 7.4 0.7 −1.7 0.187 
Gallbladder and biliary tract 21.8 0.9 19.1 1.3 −2.7 0.013 15.7 1.0 12.3 1.4 −3.4 0.080 
Pancreas 10.2 0.4 7.9 0.3 −2.3 <0.001 6.2 0.5 2.6 0.2 −3.6 <0.001 
Larynx 63.1 0.8 62.5 0.8 −0.6 0.044 64.1 3.1 58.9 2.1 −5.2 0.183 
Trachea, lung, bronchus 18.5 0.2 19.4 0.2 0.9 <0.001 11.7 0.4 12.5 0.2 0.8 <0.001 
Skin melanoma 90.2 0.3 92.4 0.2 2.2 <0.001 84.2 1.5 82.2 1.0 −2.0 0.301 
Connective and soft tissue 61.6 1.1 67.7 0.8 6.1 <0.001 53.2 3.0 56.3 2.1 3.1 0.235 
Breast (female) 85.7 0.2 89.9 0.1 4.2 <0.001 78.8 0.6 89.5 0.4 10.7 <0.001 
Cervix 68.6 0.6 68.7 0.7 0.1 0.179 40.7 2.0 41.1 2.3 0.4 0.677 
Corpus uteri 84.7 0.4 84.1 0.3 −0.6 0.058 72.0 1.1 71.4 1.0 −0.6 0.011 
Ovary 47.5 0.6 46.7 0.6 −0.8 0.665 24.2 1.0 23.7 0.9 −0.5 0.588 
Prostate 90.6 0.5 99.9 0.1 9.3 <0.001 85.3 0.7 97.1 0.4 11.8 <0.001 
Testis 95.5 0.6 94.6 0.9 −0.9 0.001 75.1 12.8 86.5 13.5 11.4 0.327 
Kidney 75.6 0.4 71.4 0.4 −4.2 <0.001 69.1 1.3 57.1 1.1 −12.0 <0.001 
Bladder 71.0 0.4 82.7 0.3 11.7 <0.001 55.0 0.8 69.9 0.6 14.9 <0.001 
Brain and nervous system 28.0 0.6 30.6 0.5 2.6 0.161 6.9 1.0 2.8 0.5 −4.1 0.010 
Thyroid 92.4 0.5 95.1 0.3 2.7 <0.001 59.6 2.8 79.5 2.1 19.9 <0.001 
Hodgkin’s lymphoma 89.6 0.6 84.9 0.6 −4.7 <0.001 38.9 4.4 42.1 3.3 3.2 0.406 
Non-Hodgkin’s lymphoma 69.5 0.5 70.2 0.4 0.7 0.004 46.5 1.1 51.7 0.7 5.2 0.036 
Multiple myeloma 47.1 0.9 43.3 0.7 −3.8 <0.001 26.5 1.4 20.5 0.9 −6.0 <0.001 
Leukemia 57.6 0.6 54.0 0.5 −3.6 <0.001 33.1 1.2 33.8 0.8 0.7 0.062 
Cancer site Age 15–74 years
 
Age 75+ years
 
1
 
2
 
  1
 
2
 
  
 Germany SEER Difference between (2) and (1) P valueb Germany SEER Difference between (2) and (1) P valueb 
RSa (%) SE RSa (%) SE RS (%) SE RS (%) SE 
Oral cavity 47.9 0.5 59.6 0.5 11.7 <0.001 50.6 1.8 46.3 1.1 −4.3 0.491 
Esophagus 19.9 0.6 19.3 0.6 −0.6 0.140 14.5 1.4 12.6 0.9 −1.9 0.348 
Stomach 34.0 0.4 28.5 0.5 −5.5 <0.001 26.6 0.7 23.4 0.7 −3.2 0.002 
Colorectum 65.4 0.2 67.8 0.2 2.4 <0.001 57.2 0.4 59.8 0.4 2.6 <0.001 
Liver 14.7 0.6 15.3 0.5 0.6 0.311 9.1 0.9 7.4 0.7 −1.7 0.187 
Gallbladder and biliary tract 21.8 0.9 19.1 1.3 −2.7 0.013 15.7 1.0 12.3 1.4 −3.4 0.080 
Pancreas 10.2 0.4 7.9 0.3 −2.3 <0.001 6.2 0.5 2.6 0.2 −3.6 <0.001 
Larynx 63.1 0.8 62.5 0.8 −0.6 0.044 64.1 3.1 58.9 2.1 −5.2 0.183 
Trachea, lung, bronchus 18.5 0.2 19.4 0.2 0.9 <0.001 11.7 0.4 12.5 0.2 0.8 <0.001 
Skin melanoma 90.2 0.3 92.4 0.2 2.2 <0.001 84.2 1.5 82.2 1.0 −2.0 0.301 
Connective and soft tissue 61.6 1.1 67.7 0.8 6.1 <0.001 53.2 3.0 56.3 2.1 3.1 0.235 
Breast (female) 85.7 0.2 89.9 0.1 4.2 <0.001 78.8 0.6 89.5 0.4 10.7 <0.001 
Cervix 68.6 0.6 68.7 0.7 0.1 0.179 40.7 2.0 41.1 2.3 0.4 0.677 
Corpus uteri 84.7 0.4 84.1 0.3 −0.6 0.058 72.0 1.1 71.4 1.0 −0.6 0.011 
Ovary 47.5 0.6 46.7 0.6 −0.8 0.665 24.2 1.0 23.7 0.9 −0.5 0.588 
Prostate 90.6 0.5 99.9 0.1 9.3 <0.001 85.3 0.7 97.1 0.4 11.8 <0.001 
Testis 95.5 0.6 94.6 0.9 −0.9 0.001 75.1 12.8 86.5 13.5 11.4 0.327 
Kidney 75.6 0.4 71.4 0.4 −4.2 <0.001 69.1 1.3 57.1 1.1 −12.0 <0.001 
Bladder 71.0 0.4 82.7 0.3 11.7 <0.001 55.0 0.8 69.9 0.6 14.9 <0.001 
Brain and nervous system 28.0 0.6 30.6 0.5 2.6 0.161 6.9 1.0 2.8 0.5 −4.1 0.010 
Thyroid 92.4 0.5 95.1 0.3 2.7 <0.001 59.6 2.8 79.5 2.1 19.9 <0.001 
Hodgkin’s lymphoma 89.6 0.6 84.9 0.6 −4.7 <0.001 38.9 4.4 42.1 3.3 3.2 0.406 
Non-Hodgkin’s lymphoma 69.5 0.5 70.2 0.4 0.7 0.004 46.5 1.1 51.7 0.7 5.2 0.036 
Multiple myeloma 47.1 0.9 43.3 0.7 −3.8 <0.001 26.5 1.4 20.5 0.9 −6.0 <0.001 
Leukemia 57.6 0.6 54.0 0.5 −3.6 <0.001 33.1 1.2 33.8 0.8 0.7 0.062 
a

Age adjusted using four age groups (15–44, 45–54, 55–64, 65–74 years).

b

The differences between relative survival rates were tested using model-based period analysis.

RS, 5-year relative survival; SE, standard error; SEER, Surveillance, Epidemiology and End Results.

Age-adjusted 5-year relative survival for patients in Germany and in the United States diagnosed with rare cancers are displayed in Table 6. In Germany, survival for rare cancers ranged from 11.9% (mesothelioma) to 74.7% (male breast cancer). USA survival estimates were higher than those in Germany for cancer sites, such as the heart, eye, vulva and male breast. Mesothelioma patients in Germany had better survival than in the United States.

Table 6.

Estimates of age-adjusted 5-year relative survival and SEs for the period of 2002–2006 utilizing the pooled-German dataset and compared with SEER results

Cancer site 1
 
  2
 
 Germany
 
  SEER
 
 RS (%) SE Difference between (2) and (1) P valuea RS (%) SE 
Small intestine 57.4 1.6 −0.8 0.128 56.6 1.1 
Nasal cavity and middle ear 50.3 2.1 1.1 0.822 51.4 1.8 
Heart 17.5 2.2 10.3 0.008 27.8 4.3 
Bone 53.7 1.7 8.4 0.001 62.1 1.5 
Mesothelioma 11.9 1.0 −1.5 <0.001 10.4 0.9 
Peritoneum 38.9 2.3 −4.7 0.735 34.2 1.2 
Breast (males) 74.7 2.7 12.5 <0.001 87.2 2.1 
Vulva 68.6 1.1 7.7 <0.001 76.3 1.2 
Vagina 47.0 2.4 2.2 0.998 49.2 2.2 
Penis 65.5 2.5 −2.7 0.388 62.8 2.6 
Renal pelvis 53.1 1.5 −0.9 0.586 52.2 1.6 
Ureter 58.4 2.1 −3.3 0.152 55.1 2.2 
Eye 66.0 2.3 12.5 <0.001 78.5 1.8 
Cancer site 1
 
  2
 
 Germany
 
  SEER
 
 RS (%) SE Difference between (2) and (1) P valuea RS (%) SE 
Small intestine 57.4 1.6 −0.8 0.128 56.6 1.1 
Nasal cavity and middle ear 50.3 2.1 1.1 0.822 51.4 1.8 
Heart 17.5 2.2 10.3 0.008 27.8 4.3 
Bone 53.7 1.7 8.4 0.001 62.1 1.5 
Mesothelioma 11.9 1.0 −1.5 <0.001 10.4 0.9 
Peritoneum 38.9 2.3 −4.7 0.735 34.2 1.2 
Breast (males) 74.7 2.7 12.5 <0.001 87.2 2.1 
Vulva 68.6 1.1 7.7 <0.001 76.3 1.2 
Vagina 47.0 2.4 2.2 0.998 49.2 2.2 
Penis 65.5 2.5 −2.7 0.388 62.8 2.6 
Renal pelvis 53.1 1.5 −0.9 0.586 52.2 1.6 
Ureter 58.4 2.1 −3.3 0.152 55.1 2.2 
Eye 66.0 2.3 12.5 <0.001 78.5 1.8 
a

The differences between relative survival rates were tested using model-based period analysis.

RS, 5-year relative survival; SE, standard error; SEER, Surveillance, Epidemiology and End Results.

discussion

The present study provides up-to-date estimates of cancer survival for the time period of 2002–2006 using data from 11 population-based cancer registries covering 33 million people (∼40% of the German population). Five-year survival of cancer patients in Germany varied from 9.0% to 93.5% for the 38 most common cancers. Five-year relative survival >80% were observed for testicular cancer, skin melanoma, cancers of the prostate and thyroid, Hodgkin’s lymphoma and cancers of the breast and endometrium, which together account for almost 40% of cases. Survival estimates in Germany were below those in the United States for several of the more common cancers, including cancers of the colorectum, breast, lung and prostate. On the other hand, 5 years after the diagnosis, German patients diagnosed with Hodgkin’s lymphoma, multiple myeloma and cancers of the stomach, pancreas and kidney had higher relative survival than American patients.

In our analysis, estimates for Saarland were very close to the pooled- German estimates in most cases. For example, 5-year relative survival for colorectal, lung, breast and prostate cancers were 64.6%, 17.9%, 83.8% and 91.7% in Saarland compared with 63.0%, 16.5%, 83.7% and 89.1%, respectively, in the pooled dataset. However, the pooled database covering an ∼30-fold larger population allowed derivation of survival estimates at a much higher precision.

A recent study used data from 47 European cancer registries in order to calculate region weighted pan-European 5-year relative survival estimates for 2000–2002 by period analysis [5]. Comparing these estimates to the results of the present study reveals that 5-year survival estimates for the most common cancers for 2002–2006 in Germany were higher than the pan-European ones for 2000–2002. However, there is strong and persistent variation in cancer survival between European countries, which was shown to be associated with the total national expenditure on health and our survival estimates for Germany are mostly comparable to those of countries with higher expenditure, such as France and Switzerland [5, 16–18].

When examining differences between German and USA survival estimates, it has to be kept in mind that for some cancer sites, the SEER coverage population may not be representative of the USA population [19–21]. There are indications that SEER covers the more affluent areas of the USA [20]. Strong evidence for socioeconomic differences in cancer survival was revealed for many cancers in many populations [22–24]. There are additional complexities involved in interpreting comparisons of survival estimates such as differences in health care systems. In 2002, Germany spent ∼11% of the gross domestic product on health care compared with 14.6% in the United States [25, 26]. German health care secures a universal coverage of the population. In the United States, however, 18% of the non-elderly population was without health insurance in 2006 [27]. Additionally, different multiple primary coding rules were followed by the SEER program and the German cancer registries, which applied the IARC suggestions. Application of the IARC multiple primary coding rules could result in fewer cancer cases [28]. Furthermore, given the number of tests carried out, chance may have operated in some of the findings in the study.

German cancer survival estimates were close to or below those in the United States for the majority of the cancer sites, such as melanoma and cancers of the breast, colorectum, oral cavity, lung and prostate. Higher USA survival estimates compared with Saarland/Germany have previously been documented for cancers of the breast, colorectum and prostate and might be mostly ascribed to earlier detection [2]. For example, in the United States, the percentage of women aged ≥40 years who reported that they have had a mammogram in the previous 2 years reached 70% by 2000 and showed a small decline to 66% by 2005 [29]. Organized breast cancer screening started in Germany in 2005 only [30]. Lower breast cancer survival among women in Germany might therefore reflect differences in the implementation of screening. Similarly, more widespread utilization of prostate-specific antigen (PSA) testing in the United States leading to overdiagnosis might be responsible for the differences in prostate cancer survival [31]. In Germany, ∼1.5 million PSA test were purchased in 2002 (corresponding to ∼12% of the German male population >50 years of age), while in 2001, 57% of the United States male population aged ≥50 years had a PSA test within the previous year [32, 33]. Likewise, earlier detection of colorectal cancer may have improved survival chances of patients in the United States. In 2004–2005, the proportion of the German population aged ≥50 years who had colorectal endoscopy within the previous 10 years was ∼25% compared with almost 50% in the United States as of 2004 [34, 35]. Stage of cancer was reported to be an important factor in explaining differences in of colorectal cancer survival between the Unites States and Europe [36].

Survival estimates in Germany were higher than the USA rates for some of the more common cancers, including stomach cancer and Hodgkin’s lymphoma. For stomach cancer, differences might be explained by differences in the subsite distribution of cancers (considerably worse prognosis for cardia cancers), which is related to the prevalence of Helicobacter pylori infection [37–39]. For Hodgkin’s lymphoma, a large proportion of patients in Germany have been included in randomized trials with substantially advanced care for this malignancy [40–42].

Although age at the time of diagnosis can also influence cancer survival, age standardization and the usage of relative survival methodology through the analysis of the survival data minimized its impact. Worse survival of the older cancer patients compared with the younger ones in Europe has been addressed before [43]. There are several indications that some of the gaps in survival between older and younger patients might be due to the fact that older patients are less likely to get the best available care for their disease [44, 45]. In addition, comorbidity in older cancer patients can have a negative influence on survival due to a higher rate of treatment-related complications [46].

Cancer survival can be influenced by factors such as quality of registration or completeness of follow-up [47, 48]. Completeness of cancer registration is a major concern especially in the build-up phase of new registries. For this study, only cancer registries were selected whose estimated completeness in 2004–2006 exceeded 80% (for most registries, estimated completeness reached 90%) [8]. However, in some of the recently established German registries, the percentage of cases identified through only death certificate was still high. In the initial years of a newly established cancer registry, high proportions of DCO cases can be due to the fact that many dying cancer patients may have had their diagnosis before the establishment of the registry. A high percentage of DCO cases even in the longer run can indicate that the registry did not have access to a number of cancer diagnoses, such as cancer diagnoses at advanced stages among older patients.

Misclassification of cancer cases could be a source of inconsistency in the data. As an example, higher estimates of bladder cancer survival in the United States than in Germany might be partially explained by differences in cancer registration such as separation of in situ/non-invasive and superficially invasive carcinomas as well as papillary and nonpapillary lesions [49].

In the absence of a national death index, most of the cancer registries that have submitted data for the project rely on record linkage with vital statistics from the state they cover, thereby potentially missing deaths among patients who migrated out of the state. Two cancer registries (Hamburg and Bremen, essentially covering the cities of Hamburg and Bremen, respectively) registered such out-migration and censored patients at the date of out-migration. When patients in these two registries were recoded as alive at the end of the study period (December 2006) in order to mimic follow-up procedures in the other federal states, the estimates of 5-year age-adjusted relative survival were only slightly elevated. As an example, 5-year age-adjusted relative survival of lung cancer changed from 13.8% to 13.9% in Hamburg and from 17.5% to 18.3% in Bremen. Potential bias from missed deaths due to out-migration is likely to be of even less concern for the other registries, covering much larger states with both urban and rural areas. Nevertheless, some bias due to incomplete ascertainment of deaths cannot be ruled out and may account for some of the apparent variation between registries in 5-year relative survival for cancer with poor prognosis, such as lung cancer (11.5%–20.9%) or pancreatic cancer (5.2%–11.6%).

The present study with >1 million cancer diagnoses from 11 population-based German cancer registries and with an underlying population of 33 million people is the most comprehensive report on cancer survival in Germany available to date. Furthermore, the study provides estimates of relative survival for rare cancers, which were available previously only for Saarland. Period methodology was used through this project to incorporate the most recent follow-up information into the analysis. Estimates of cancer survival in Germany for 2002–2006 were somewhat lower than in the United States for the same time period for several cancer sites but were higher than most of the pan-European ones estimated for the time period of 2000–2002. German patients diagnosed with Hodgkin’s lymphoma, multiple myeloma and cancers of the stomach, pancreas and kidney had higher relative survival than American patients. Further research is needed to investigate factors that might be responsible for the different cancer survival rates in Germany and in the United States.

funding

German Cancer Aid (Deutsche Krebshilfe) (108257).

disclosure

The authors declare no conflict of interest.

Members of the GEKID Cancer Survival Working Group: Karla Geiss, Martin Meyer (Cancer Registry of Bavaria), Andrea Eberle, Sabine Luttmann (Cancer Registry of Bremen), Roland Stabenow (Cancer Registry of Berlin and the New Federal States), Stefan Hentschel, Alice Nennecke (Cancer Registry of Hamburg); Joachim Kieschke, Eunice Sirri (Cancer Registry of Lower Saxony), Bernd Holleczek (Cancer Registry of Saarland), Katharina Emrich (Cancer Registry of Rhineland-Palatinate), Hiltraud Kajüter, Volkmar Mattauch (Cancer Registry of North Rhine-Westphalia), Alexander Katalinic (Cancer Registry of Schleswig-Holstein), Klaus Kraywinkel (Robert Koch Institute, Berlin), Hermann Brenner, Adam Gondos, Eva Hiripi (DKFZ).

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Author notes

Members of the GEKID Cancer Survival Working Group are listed in acknowledgements.