Tumorzentrum Regensburg

Institut für Qualitätssicherung und Versorgungsforschung

FAKULTÄT FÜR MEDIZIN

Dr. Max Mustermann Referat Kommunikation & Marketing Verwaltung

Tumorzentrum Regensburg

Institut für Qualitätssicherung und Versorgungsforschung

Universität Regensburg

Was können wir von

Krebsregistern lernen?

What can we learn from

cancer registries? Dr. med. Michael Gerken

Institute for quality assurance and health care research University Regensburg

„Krebsfrüherkennungs- und Registergesetz“

9. April 2013

Cancer Screening and Registry Act

Basic regulations and criteria for clinical cancer registries

Common contents and data („Basisdatensatz“) Data interfaces for exchange („Schnittstellen“) Analyses and reports for doctors and hospitals („Rückmeldungen“) Collaboration with Gemeinsamer Bundesausschuss („Qualitätssicherung“) Collaboration with cancer centers („Zertifizierte Zentren“) Data collection for epidemiologic cancer registries („Registeraustausch“) Providing data for health care research („Versorgungsforschung“)

Basisdatensatz

TUDOK Relational Database patients

id name first_name birth_name date_of_birthsex title …

icds

id code name …

diagnoses

id fk_patient date_of_diagnosis fk_icd …

chemotherapies

id fk_diagnosis intention started_at finished_at …

surgeries

id fk_diagnosis …

ops

id code name …

surgery_positions

id fk_surgery date_of_operation fk_ops …

… total: 283 tables

Data sources

Importing and Exporting Interfaces to other registries and systems

Tumorboard (- conferences)

ADT XML Import ADT XML Export

AQUA/IQTIG Export XML Oncobox Darm, Prostata, Brust

XML Health Insurances

ADT Arbeitsgemeinschaft Deutscher Tumorzentren AQUA Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH IQTIG Institut für Qualitätssicherung und Transparenz im Gesundheitswesen

Auswertung der erfassten klinischen Daten und

die Rückmeldung der Auswertungsergebnisse an die

einzelnen Leistungserbringer

KFRG § 65c (1) 2 und 4,

Evaluation of registry data and response of results to doctors

(general practitioners, specialised doctors, clinicians)

Standardized and automatic

evaluation routine generates…

… a general public report

(„reference“) and …

… individual reports for doctors

and hospitals („Rückmeldung“)

Rückmeldung

General report Individual report

Quality indicator 26:

Adjuvant chemotherapy: colon (UICC stage III) Quality indicator 6 of the Level 3 Guideline on Colorectal Carcinoma

Specified value: ≥ 70%

Numerator: Patients with UICC stage III colon carcinoma who received adjuvant chemotherapy

Denominator: Patients with UICC stage III colon carcinoma who had a R0 resection of the primary tumour

adjuvant

chemotherapy

adjuvant

chemotherapy

planned

adjuvant

chemotherapy

refused

contraindication no adjuvant

chemotherapy

n = 9/16 = 56,3%

num

ber

Bundesweite Auswertung Krebskongress 2016

2000-2014

n = 29.177

2014:

n = 1673

%: 58,0

chemotherapy

yes

no

year of diagnosis

German Cancer Congress 2016

rela

tive f

req

ue

ncy (

%)

64,7%

88,2%

72,7%

62,5% 66,7% 66,7%

86,7% 87,5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

DZ1 DZ2 DZ3 DZ4 DZ5 DZ6 DZ7 DZ8

pe

rcen

tag

e

Benchmarking of Colorectal Cancer Centres Adjuvant chemotherapy: colon (UICC stage III)

Example Cancer Centre No. 3 Specified value: ≥ 70%

Numerator: Patients with UICC stage III colon carcinoma who received

adjuvant chemotherapy

Denominator: Patients with UICC stage III colon carcinoma who had a R0

resection of the primary tumour

n = 8/11 = 72,7%

adjuvant

chemotherapy

adjuvant

chemotherapy

planned

adjuvant

chemotherapy

refused

contraindication no adjuvant

chemotherapy

num

ber

Neoadjuvant radio- or radiochemotherapy: rectum (UICC stage II and III)

Example Cancer Centre No. 3 Specified value: ≥ 80%

Numerator: Patients who received neoadjuvant radiotherapy and radiochemotherapy

Denominator: Patients with rectal cancer of the middle and lower third

(= up to 12 cm form anus) and TNM categories cT3,4/cM0

and/or cN1,2/cM0 who underwent elective surgery

(= clinical UICC stages II and III) (without transanal wall resection))

n = 8/8 = 100%

100,0% 95,8% 100,0% 90,0%

75,0%

85,7% 90,9%

85,7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

DZ1 DZ2 DZ3 DZ4 DZ5 DZ6 DZ7 DZ8

pe

rcen

tag

e

Benchmarking of Colorectal Cancer Centres 2014

neoadjuvant

radio/chemotherapy

planned

neoadjuvant

radio/chemotherapy

neoadjuvant

radio/chemotherapy

rejected

contraindication no neoadjuvant

radio/chemotherapy

2000-2014

n = 17.181

2014

n = 1164

%: 69,8

German Cancer Congress 2016

no therapy

adjuv. RCTX

neoadjuv. RCTX –

adjuv. CTX

neoadjuv. RCTX +

adjuv. CTX

year of diagnosis

rela

tive f

req

ue

ncy (

%)

primary radio-

chemotherapy num

ber

8,3% 7,7% 12,5%

6,7% 9,5% 8,8%

4,1% 8,3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

DZ1 DZ2 DZ3 DZ4 DZ5 DZ6 DZ7 DZ8

perc

en

tag

e

Benchmarking: Indicator 15

Revision operations in the colon

Specified value: ≥ 15%

Numerator: Revision operations due to perioperative complications within 30 d after an elective operation

Denominator: Elective colon procedures

6,6%

0,0% 2,9%

11,9% 7,0%

3,0% 0,0%

4,5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

DZ1 DZ2 DZ3 DZ4 DZ5 DZ6 DZ7 DZ8

perc

en

tag

e

Benchmarking: Indicator 18

Anastomotic insufficiencies in the colon Quality indicator 9 of the Level 3 Guideline on Colorectal Carcinoma

Specified value: ≥ 6%

Numerator: Colon anastomotic insuffuciencies requiring repeat intervention after elective surgery

Denominator: Patients with colon cancer in whom anastomosis was performed in an elective tumour resection

n = 75/77 = 97,4%

Indicator 4.1:

Recommended RT after breast conserving therapy in cases of invasive BC

Specified value: ≥ 90%

Numerator: Primary cases with inv. breast cancer and breast conserving

therapy, in which a radiotherapy was recommended

Denominator: Primary cases with invasive breast cancer with BCT

(excluding patients with metastases at initial presentation)

100,0% 99,5% 95,8% 99,2% 100,0% 98,0% 96,8% 98,0% 97,4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

BZ1 BZ2 BZ3 BZ4 BZ5 BZ6 BZ7 BZ8 BZ9

perc

en

tag

e

Benchmarking of Breast Cancer Centres 2014

German Cancer Congress 2016

Breast cancer (breast conserving therapy, primary M0, invasive)

Trend of radiotherapy after breast conserving therapy

(< 70 y, n = 123.495; ≥ 70 y. n = 39.171)

< 70 years

≥ 70 years

radiotherapy

planned

radiotherapy radiotherapy

rejected

contraindication no radiotherapy

num

ber

Indicator 7.1:

Recommended chemotherapy in cases of steroid

receptor negative patients

Specified value: ≥ 90%

Numerator: All steroid receptor neg. primary cases with invasive breast cancer,

for which chemotherapy was recommended

Denominator: Primary cases with invasive breast cancer with steroid receptor

negative diagnosic finding (excluding patients with metastases at

initial presentation)

n = 12/12 = 100%

77,8%

94,1% 87,5% 87,5%

100,0% 92,3%

81,8% 83,9%

100,0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

BZ1 BZ2 BZ3 BZ4 BZ5 BZ6 BZ7 BZ8 BZ9

perc

en

tag

e

Benchmarking of Breast Cancer Centres 2014

German Cancer Congress 2016

Breast cancer (HR-, primary M0, invasive)

Trend of chemotherapy HR- (< 70 y. n = 32.708; ≥ 70 y. n = 10.039)

≥ 70 years

< 70 years

num

ber

radiotherapy

planned

radiotherapy radiotherapy

rejected

contraindication no radiotherapy

Examples for analyses in health care research (§ 65c (1) 8) – regional, nation-wide

5772 CRC patients

diagnosed 2002-2007

1426 (24.7 %)

hepatic metastases 1019 (71.4%) synchronous

407 (28.5%) metachronous

4346 (75,3%) no

hepatic metastases

374 of 1426 patients

(26.2%) hepatic resection

1052 of 1426 patients

(73.8%) no hepatic resection

Overall survival after resection of metastases in patients with colorectal liver metastases (n= 1 426/5772, Diagnoses 2002 – 2007, Follow-up – 2012, regional) Hackl C, Neumann P, Gerken M, Loss M, Klinkhammer-Schalke M, Schlitt HJ. Treatment of colorectal liver metastases in Germany: a ten-year population-based analysis of 5772 cases of primary colorectal adenocarcinoma. BMC Cancer. 2014 Nov 4;14:810.

Overall survival after resection of metastases inpatinets with colorectal liver metastases(n= 1 426 LM / 5772 CRC, Diagnosen 2002 – 2007, Follow-up – 2012, regional)

Patients with vs without liver metastases Comparison with vs without resection (all) HR 0,355 (95%CI 0.305-0.414)

Comparison with vs without resection (singulary)

Resection rates – colorectal liver metastases (CLM)

Annual resection rates (all CLM)

resection rates according to center vs no-center (all CLM)

Annual resection rates (1-3 CLM)

Overall survival after recurrence therapy in patients with relapsed

ovarian carcinoma 300 patients with diagnosis of relapsed ovarian carcinoma

tumour spread recurrence

tumour spread

yes

number row-%

peritoneum 118 39,3%

liver 77 25,7%

intestine 25 8,3%

other abdominal 61 20,3%

abdominal wall 13 4,3%

spleen 13 4,3%

suprarenal gland 1 0,3%

lung 27 9,0%

pleura 13 4,3%

brain 12 4,0%

bones 4 1,3%

distant lymph nodes 50 16,7%

extra-abdominal other 6 2,0%

other 109 36,3%

over-all-survival after diagnosis of recurrence

time after recurrence (years)

cu

mu

lative

su

rviv

al

over-all-survival

censored

Overall survival after recurrence therapy in patients with relapsed

ovarian carcinoma

145 patients with surgery and recurrence of ovarian carcinoma

substances of chemotherapy

(patients with surgery)

over-all-survival after chemotherapy

Log-Rank (Mantel-Cox)

number %

chemo

recurrence

+ Platin + Taxol 55 37,9%

+ Platin - Taxol 46 31,7%

other substance 20 13,8%

no chemo 24 16,6%

over-all 145 100,0%

chemo recurrence

+ Platin

+ Taxol

+ Platin

- Taxol

other

substance

no

chemo

p p p p

+ Platin + Taxol - 0,009 0,231 <0,001

+ Platin - Taxol 0,009 - 0,580 0,023

other substance 0,231 0,580 - 0,077

no chemo <0,001 0,023 0,077 -

over-all-survival after chemotherapy

(patients with surgery)

time after recurrence (years)

cu

mu

lative

su

rviv

al

chemo recurrence

+ Platin + Taxol

+ Platin – Taxol

other substance

no chemo

+ Platin + Taxol

censored

+ Platin – Taxol

censored

other substance

cencored

no chemo

cencored

Neoadjuvant radio- or radiochemotherapy in rectum cancer

(UICC stage II and III, lower and middle rectum) (n=12 498, Diagnoses 2000 – 2014, Germany) Bundesweite onkologische Qualitätskonferenz, Deutscher Krebskongress

Benz et al 2016 and German Cancer Registries Group 2016

Variable Kategorie p-Wert Hazard Ratio 95%-KI

unten

95%-KI

oben

Alter bei Diagnose Alter stetig ,000 1,052 1,050 1,054

Geschlecht m 1,000

w ,000 ,786 ,759 ,815 Lokalisation unteres Rektumdrittel 1,000

mittl.Rektumdrittel ,695 ,990 ,941 1,042

oberes Rektumdrittel ,001 ,905 ,855 ,957

Rektumdrittel nnb ,017 1,056 1,010 1,105 Stadium UICC I 1,000

II ,000 1,658 1,580 1,740

III ,000 2,387 2,278 2,502 Grading G1 1,000

G2 ,719 ,985 ,910 1,067

G3/4 ,000 1,226 1,124 1,337

GX/kA ,464 1,040 ,937 1,155

Anzahl LK untersucht Grp

LK >0-<12 1,000 LK >=12-<24 ,000 ,887 ,848 ,928

LK >= 24 ,000 ,888 ,836 ,944

LK keine Angabe ,211 ,962 ,905 1,022

Residual-klassifikation

R0 1,000 R1/2 ,000 2,645 2,446 2,860

RX/kA ,224 ,967 ,915 1,021

Operation lokal Rektumresektion unter Sphinktererhalt

1,000

Rektumresektion ohne Sphinktererhalt

,000 1,336 1,282 1,392

OP-Zugang Offen-chirurgisch 1,000 Laparoskopisch ,000 ,813 ,747 ,885

Sonstige/.k.A. ,442 1,014 ,979 1,051

Primäre RCTX neoadjuv. RCTX + adjuv. CTX

1,000

neoadjuv. RCTX - adjuv. CTX

,000 1,373 1,280 1,473

adjuv. RCTX ,000 1,257 1,174 1,346

Therapie nein/k.A. ,000 1,599 1,498 1,708

Overall Survival rectum carcinoma „risk adjustment“ UICC I-III incl. R1/2 (N=42 914) ohne 30-Tage-Mortalität Multivariable Cox-Regression

Arbeitsgemeinschaft Deutscher Tumorzentren e.V.

Benz, Gerken, Barlag, Fürst, Klinkhammer-Schalke Surg Endosc. 2016

Colorektal Cancer – Trends in therapy

laparoscopic vs open-surgical

Percentage of patients with laparoscopic surgery

(stage I-III, year of diagnosis) (Colon carcinoma with partial resection)

perc

enta

ge

(%

)

year of diagnosis

UICC stage

Percentage of patients with laparoscopic surgery

(stage I-III, year of diagnosis) (rectum carcinoma with sphincter-saving resection)

perc

enta

ge

(%

)

year of diagnosis

UICC stage

Benz, Gerken, Barlag, Fürst, Klinkhammer-Schalke Surg Endosc. 2016

open-surgical

laparoscopic

open-surgical censored

laparoscopic censored

cu

mu

lati

v s

urv

ial

relapse-free-survial-time (month)

surgical technique

Survival – Colon carcinoma UICC stage: III; surgery: OPS 5-455 - partial resection of colon

Outcome after adjuvant chemotherapy in colon carcinoma UICC II T4N0M0 R0-resected patients (N = 4 047) exclusion of 90-days mortality Overall and recurrence-free survival: Benefit persist after multivariable analysis Bundesweite onkologische Qualitätskonferenz, Deutscher Krebskongress

Log-Rank p < 0,001 Hazard ratio: 0,69 (95%-KI 0,60 - 0,78)

Adjusted for age, sex, grading

Log-Rank p < 0,001 Hazard ratio: 0,70 (95%-KI 0,62 - 0,80)

Adjusted for age, sex, grading

Benz et al 2016 and German Cancer Registries Group 2016

Outcome after adjuvant chemotherapy in colon cancer, stage UICC III

Dependency of over-all-survival and time between surgery and start of chemotherapy

(steps: 0-14, 15-29, 30-44 days etc.) n = 23592

days after surgery hazard ratio lower 95%-CI

upper 95%-CI p-value

0-14

1,000

15-29 0,827 0,719 0,950 ,007

30-44 0,859 0,751 0,984 ,028

45-59 1,033 0,890 1,199 ,671

60-74 1,044 0,874 1,248 ,634

75-89 0,967 0,768 1,217 ,774

Benz et al 2016 and German Cancer Registries Group 2016

What can we learn from cancer registries?

Common contents and data („Basisdatensatz“) Data interfaces for exchange („Schnittstellen“) Analyses and reports for doctors and hospitals („Rückmeldungen“) Collaboration with Gemeinsamer Bundesausschuss („Qualitätssicherung“) Collaboration with cancer centers („Zertifizierte Zentren“) Data collection for epidemiologic cancer registries („Registeraustausch“) Providing data for health care research („Versorgungsforschung“)

Thank you!

Vielen Dank!