tumorzentrum regensburg dr. max mustermann referat … · numerator: all steroid receptor neg....
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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!