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Colorectal cancer screening by colonoscopy and trends in disease-specific mortality: a population-based ecological study of 358 German districts

  • Joachim HübnerEmail author
  • Philip Lewin
  • Ron Pritzkuleit
  • Nora Eisemann
  • Werner Maier
  • Alexander Katalinic
Original Article
  • 36 Downloads

Abstract

Purpose

Screening for colorectal cancer (CRC) by colonoscopy was implemented in Germany in 2002. Although the procedure has proven to be effective in reducing disease-specific mortality in numerous clinical studies, its effect at the population level is unclear. We performed an ecological study at the level of 358 German districts, testing the hypothesis that a higher participation rate in screening colonoscopy is associated with a stronger decline in CRC mortality from 2001 to 2012.

Methods

Information on the use of colonoscopy in each district was extracted from settlement data, used for the remuneration of physicians of the ambulant sector from 2008 to 2011. Yearly mortality rates for each district from 2001 to 2012 were derived from the official mortality statistics. A spatial model was fitted, considering other factors which might influence early detection of CRC (fecal occult blood test (FOBT), diagnostic colonoscopy, material and social area deprivation, and rural-urban disparities).

Results

The population-weighted mean annual participation rate during 2008–2011 in screening colonoscopy was 2.0% (range 0.6 to 3.9%). The weighted mean annual percentage change (APC) of CRC mortality was − 2.9% (range − 7.8 to 1.2%). According to the fully adjusted model, a 1% higher annual participation rate in colonoscopy screening was associated with an additional annual change in CRC mortality rate of − 0.34% (p = 0.015). Given an annual 2.0% participation rate, colonoscopy screening attributed 23% to the observed decline.

Conclusions

Our real-world data from Germany provide first evidence that colonoscopy screening for CRC is effective in reducing disease-specific mortality at the population level.

Keywords

Colorectal cancer Screening Colonoscopy Mortality Epidemiology 

Notes

Acknowledgments

We thank the Central Research Institute of Ambulatory Health Care in Germany for providing data on use of colonoscopy and FOBT and financial support.

We thank Anne Starker (Robert Koch Institute, Berlin) for providing data from the GEDA 2010 Survey and Klaus Kraywinkel (Robert Koch Institute, Berlin), Karla Geiss and Martin Meyer (Cancer Registry of Bavaria), Andrea Eberle and Sabine Luttmann (Cancer Registry of Bremen), Roland Stabenow (Cancer Registry of Berlin and the New Federal States), Stefan Hentschel and Alice Nennecke (Hamburg Cancer Registry), Joachim Kieschke and Eunice Sirri (Cancer Registry of Lower Saxony), Bernd Holleczek (Saarland Cancer Registry), Katharina Emrich (Cancer Registry of Rhineland-Palatinate), Hiltraud Kajueter and Volkmar Mattauch (Cancer Registry of North Rhine-Westphalia), and Anke Richter and Miriam Holzmann (Cancer Registry of Schleswig-Holstein) for providing data on CRC mortality.

Funding

This study was funded by the Central Research Institute of Ambulatory Health Care in Germany.

Compliance with ethical standards

This article does not contain any studies with human participants or animals performed by any of the authors.

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Robert Koch-Institut (2017) www.krebsdaten.de/database. Accessed 02.08.2018
  2. 2.
    Holme O, Bretthauer M, Fretheim A, Odgaard-Jensen J, Hoff G (2013) Flexible sigmoidoscopy versus faecal occult blood testing for colorectal cancer screening in asymptomatic individuals. Cochrane Database Syst Rev 9:CD009259.  https://doi.org/10.1002/14651858.CD009259.pub2 Google Scholar
  3. 3.
    Brenner H, Stock C, Hoffmeister M (2014) Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies. BMJ 348:g2467.  https://doi.org/10.1136/bmj.g2467 CrossRefGoogle Scholar
  4. 4.
    Wiegering A, Ackermann S, Riegel J, Dietz UA, Gotze O, Germer CT, Klein I (2016) Improved survival of patients with colon cancer detected by screening colonoscopy. Int J Color Dis 31(5):1039–1045.  https://doi.org/10.1007/s00384-015-2501-6 CrossRefGoogle Scholar
  5. 5.
    Kuipers EJ, Lansdorp-Vogelaar I (2017) Colorectal cancer screening in Australia. Lancet Public Health 2(7):e304–e305.  https://doi.org/10.1016/S2468-2667(17)30121-4 CrossRefGoogle Scholar
  6. 6.
    Loffeld R, Dekkers PEP, Liberov B (2018) The first results of the “bevolkingsonderzoek” in the Zaanstreek region in the Netherlands. Int J Color Dis 33(10):1485.  https://doi.org/10.1007/s00384-018-3073-z CrossRefGoogle Scholar
  7. 7.
    Schnoor M, Waldmann A, Eberle A, Holleczek B, Katalinic A (2012) Colorectal cancer incidence in Germany: stage-shift 6 years after implementation of a colonoscopy screening program. Cancer Epidemiol 36(5):417–420.  https://doi.org/10.1016/j.canep.2012.04.008 CrossRefGoogle Scholar
  8. 8.
    Dufault B, Klar N (2011) The quality of modern cross-sectional ecologic studies: a bibliometric review. Am J Epidemiol 174(10):1101–1107.  https://doi.org/10.1093/aje/kwr241 CrossRefGoogle Scholar
  9. 9.
    Blach A, Jacek J (1999) Die Gebietsreform der neuen Länder: Folgen für die Laufende Raumbeobachtung des BBR. Arbeitspapiere 5. BonnGoogle Scholar
  10. 10.
    www.gbe-bund.de. Accessed 02.08.2018
  11. 11.
    Starker A, Bertz J, Saß A (2012) Inanspruchnahme von Krebsfrüherkennungsuntersuchungen [Utilization of cancer screening tests]. In: Koch-Institut R (ed) Daten und Fakten: Ergebnisse der Studie ‘Gesundheit in Deutschland aktuell 2010’. Berlin, pp 27–38Google Scholar
  12. 12.
    Clegg LX, Hankey BF, Tiwari R, Feuer EJ, Edwards BK (2009) Estimating average annual per cent change in trend analysis. Stat Med 28(29):3670–3682.  https://doi.org/10.1002/sim.3733 CrossRefGoogle Scholar
  13. 13.
    Maier W, Scheidt-Nave C, Holle R, Kroll LE, Lampert T, Du Y, Heidemann C, Mielck A (2014) Area level deprivation is an independent determinant of prevalent type 2 diabetes and obesity at the national level in Germany. Results from the National Telephone Health Interview Surveys ‘German Health Update’ GEDA 2009 and 2010. PLoS One 9(2):e89661.  https://doi.org/10.1371/journal.pone.0089661 CrossRefGoogle Scholar
  14. 14.
    Maier W (2017) Indices of multiple deprivation for the analysis of regional health disparities in Germany : experiences from epidemiology and healthcare research. Bundesgesundheitsbl, Gesundheitsforsch, Gesundheitsschutz 60(12):1403–1412.  https://doi.org/10.1007/s00103-017-2646-2 CrossRefGoogle Scholar
  15. 15.
    Bivand R, Pebesma E, Gómez-Rubio V (2013) In: Applied spatial data analysis with R. pp 293–298Google Scholar
  16. 16.
    R Core Team (2017) R: a language and environment for statistical computing. Vienna, AustriaGoogle Scholar
  17. 17.
    Bivand R, Hauke J, Kossowski T (2013) Computing the Jacobian in Gaussian spatial autoregressive models: an illustrated comparison of available methods. Geogr Anal 45(2):150–179CrossRefGoogle Scholar
  18. 18.
    Bivand R, Piras G (2015) Comparing implementations of estimation methods for spatial econometrics. J Stat Softw 63(18):1–36CrossRefGoogle Scholar
  19. 19.
    Wickham H (2009) ggplot2: elegant graphics for data analysis. New YorkGoogle Scholar
  20. 20.
    Altenhofen L, Heringer M, Blaschy S, Fischer M, Schäfer M, Pilgermann I, Lichtner F, Folle J, Schmidt A (2010) Projekt Wissenschaftliche Begleitung von Früherkennungs-Koloskopien in Deutschland. Berichtszeitraum 2008 - 6. Jahresbericht, Version 1.1Google Scholar
  21. 21.
    Chen C, Stock C, Hoffmeister M, Brenner H (2018) How long does it take until the effects of endoscopic screening on colorectal cancer mortality are fully disclosed? : a Markov model study. Int J Cancer 143:2718–2724.  https://doi.org/10.1002/ijc.31716 CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Institute of Social Medicine and EpidemiologyUniversity of LübeckLübeckGermany
  2. 2.Institute of Cancer EpidemiologyUniversity of LübeckLübeckGermany
  3. 3.Institute of Health Economics and Health Care ManagementHelmholtz Zentrum München - German Research Center for Environmental HealthNeuherbergGermany

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