Entwicklung der Krebsfrüherkennung in Deutschland

Cancer is one of the most relevant chronic diseases in the German population, but not all neoplastic entities are eligible for early cancer detection (ECD) programs. In 1971, ECDs were introduced as population-wide screenings for the first time in the catalogue of benefits of the West German statutory health insurance funds. However, the implementation at that time was rarely systematic. Concurrently, a discussion on the perspectives of ECD arose in the former German Democratic Republic, where a structured program was not prepared in the country until the late 1980s.A national cancer plan (NCP) was initiated in 2008 and its area of action #1 was titled “Further development of ECD”. In April 2013, the law for the development of early cancer detection and quality assurance by clinical cancer registries was passed, which adopted major suggestions of the NCP. Consequently, the pertinent recommendations of the EU guidelines for the screening of the breast, cervix, and colon-rectum are currently being implemented.Public opinion in Germany with regard to ECDs has changed in recent years from unanimous consent to a rather critical distance. While ineffective and inefficient preventive action is being replaced by quality-assured screening procedures, public discussion about the fundamental reasonability of ECDs is controversial as never before.     

Früherkennung des Zervixkarzinoms in Deutschland

Cervical cancer is the third most common cancer among women worldwide, with an estimated 529,000 new cases in 2008. The incidence of cervical cancer in Germany is still among the highest in Western Europe. For more than 40 years women in Germany have had legal and free access to a conventional cytologic smear test starting at the age of 20 years. The introduction of the Pap smear subsequently led to a reduction in the incidence and mortality of cervical cancer. However, the low sensitivity of the Pap smear and the evidence regarding human papillomavirus (HPV) in the context of cervical cancer have led to a critical view of the existing early detection of cervical cancer. In the meantime, new screening methods have been developed and different HPV tests, liquid-based cytology, and novel biomarkers have become available. Several randomized studies have investigated HPV testing as a primary cervical cancer screening test, generating a large body of evidence. It is expected that a combination of HPV testing and cytology will improve cervical cancer screening. In the near future, the early detection of cervical cancer in Germany will be restructured on the basis of the German National Cancer Plan as well as the new Cancer Screening and Registers Act (KFRG). The European guidelines for quality assurance in cervical cancer screening will be taken into account, and an organized, population-based, and quality-assured cervical cancer screening program will be implemented.     

Aktueller Stand der Evidenz und Entwicklung der Darmkrebsfrüherkennung in Deutschland

Colon cancer is currently the third leading cause of cancer death in men and women in Germany, with a total of about 25,000 deaths per year. Established methods for early detection of colorectal cancer include lower gastrointestinal endoscopy and fecal occult blood testing. For both procedures, there is evidence of a reduction in colorectal cancer-specific mortality and for endoscopy a reduction of colorectal cancer incidence has been shown.In Germany, the guaiac test for fecal occult blood has been offered since 1977. Additionally, screening colonoscopy has been offered since 2002 and in 2016, the guaiac test was replaced by the immunological fecal occult blood test, which has an improved diagnostic performance. Overall, participation rates have been low over the past decades and differed between men, women, and age groups.Personal invitations are expected to be sent out starting in 2019 as part of the introduction of an organized colorectal cancer screening program in Germany. The program also provides for measures to systematically monitor and improve the quality of colorectal cancer screening. It remains to be seen which effects these changes will have and whether the trend towards declining colon cancer incidence and mortality that has been observed in Germany will continue in the coming years.     

Die Einführung der elektronischen Gesundheitskarte in Deutschland

Zusammenfassung Ab 2006 erhalten alle Krankenversicherten in Deutschland eine elektronische Gesundheitskarte. Sie löst die bisherige Krankenversichertenkarte ab und wird geeignet sein, neben deren administrativen Funktionen auf freiwilliger Basis auch Gesundheitsdaten verfügbar zu machen. Detaillierte Regelungen zu den Zugriffsrechten und vom Gesetzgeber vorgegebene technische Sicherheitsanforderungen sollen eine weitgehende Patientenautonomie sowie eine größtmögliche Sicherheit der Daten gewährleisten.     

Die zukünftige Entwicklung des Krebsgeschehens in Deutschland

The future as well as the past development of cancer incidents in Germany is of continuous importance for health policy. Cancer incidence data observed over more than 20 years are analysed by log-linear models with polynomial trend components. The estimated trend models are used for a trend extrapolation until the year 2020. Since cancer registration in Germany is not complete yet and does not cover the whole area of the country national incidences are estimated by the data of the existing complete regional cancer registries. In this way it can be assessed that the number of new cancer diseases increased from 270,000 cases in 1980 to 420,000 cases in 2002. Extrapolating the trends and taking into account the demographic prognosis of the German Federal Statistical Office 570,000 (version 1) or 590,000 (version 9) annual cancer cases are predicted for the year 2020. From 1980 to 2002 a decrease of cancer mortality was observed. If this trend continues until 2020, the number of deaths caused by cancer would decrease from 209,000 in 2002 to 153,000 (or 158,000) in 2020, although the number of cancer cases are predicted to increase. Assuming constant mortality rates the number of deaths caused by cancer would be much higher.     

Die GeSiD-Studie „Gesundheit und Sexualität in Deutschland“ – eine kurze Einführung

Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz - Bis zum Jahr 2020 gab es für Deutschland keinen repräsentativen Sex-Survey mit publizierten Daten. Die GeSiD-Studie...     

Schilddrüsenkrankheiten in Deutschland

Background

Diseases of the thyroid gland are a frequent problem in Germany. Of these, iodine deficiency diseases (diffuse and nodular goitre) are the most common.

Results

Screening of the working population has revealed that almost a quarter of the adult German population has a nodular goitre. There are no significant regional differences in the prevalence of the disease.

Conclusion

Medical treatment could be optimized. Only 40% of the patients treated with thyroid hormones have laboratory values within the desirable range. Treatment with iodine alone, or in combination with thyroid hormones, is initiated to seldom. In Germany, autoimmune thyroid diseases are less frequent than diseases due to iodine deficiency. Graves’ disease is the second most common cause of hyperthyroidism after autonomous thyroid dysfunction. Spontaneous hypothyroidism occurs much more commonly in the older population than in young adults.     

Darmkrebsfrüherkennung

Background

Colorectal cancer (CRC) is the second most common cancer among both men and women in Germany. Owing to its relatively slow growth, perspectives for effective early detection are much better than for other forms of cancer.

Aim

To summarize the evidence on effectiveness and cost-effectiveness of CRC screening, and to provide an overview on the current state and perspectives for effective CRC screening.

Materials and methods

Summary and critical review of evidence from randomized trials and observational epidemiological studies.

Results

A reduction in CRC mortality by offering annual fecal occult blood tests or once-only flexible sigmoidoscopy has been demonstrated in randomized trials. Novel fecal immunochemical tests for hemoglobin in stool have been shown to be more sensitive than traditional fecal occult blood tests and could substantially improve noninvasive CRC screening. Epidemiological studies suggest that the majority of CRC cases and deaths could be prevented by colonoscopy and removal of colorectal adenomas. However, adherence to screening offered outside organized screening programs is low. The National Cancer Plan recommends an organized CRC screening program in Germany. The law on the early detection of cancer from April 2013 has paved the way for its implementation.

Discussion

The great potential for CRC prevention by early detection has so far only been realized to a very limited extent in Germany. Introduction of an organized screening program and the offer of enhanced noninvasive screening tests could strongly enhance the utilization and effectiveness of CRC screening in Germany. The political frame has been set, and timely quality-assured implementation is required.     

Die Leitlinie Allergiepr?vention auf dem Prüfstand

The recommendations of the revised guideline Primary Allergy Prevention published in 2009 are summarized and discussed. The updated guidelines do not further recommend reducing house dust mite allergen exposure as a measure of primary prevention. New suggestions include the avoidance of overweight, and reduction of the exposure to indoor and/or outdoor air pollutants. In line with the current guidelines, there is no scientific evidence that prolonged introduction of solid food is an allergy-preventive measure. Consequently, even children with a family history of atopy can introduce solid foods at the beginning of the 5th month. The recommendations on avoiding environmental tobacco smoke, breast feeding over 4 months, avoiding a mold-promoting indoor climate, vaccination according to current recommendations, and avoidance of furry pets (especially cats) in risk babies have remained unchanged.     

Evaluation von organisierten Programmen zur Krebsfrüherkennung: Allgemeine Aspekte und aktueller Stand in Deutschland

In the past decades, it has been increasingly recognized that cancer screening is not always or not exclusively beneficial and, in the case of some measures, the negative effects may even outweigh the benefits. This has fundamentally changed the significance and emphasis placed on the evaluation of cancer screening programs. Generally, there is a distinction between an endpoint evaluation, which assesses the effectiveness or risk/benefit ratio, and a process evaluation, which aims to ensure optimum implementation of the program.Prior to the nationwide introduction of a screening measure, proof of effectiveness should ideally be provided by a randomized controlled trial (RCT), in which persons without a screening offer form the control group. From a scientific point of view, this study design is by far the best method to evaluate the endpoint, as it avoids biases that may distort the results in observational studies. RCT evidence on cancer screening measures currently offered by statutory health insurance providers in Germany – if available at all – originates exclusively from other countries.When mammography screening was introduced as the first organized screening program in Germany, comprehensive measures for process evaluation were taken. In April 2013, the legal basis for the transfer of colorectal and cervical cancer screening into organized programs was created. According to the legal provisions, both a process and an endpoint evaluation are planned for the new programs. It remains to be seen how the necessary data flows will be conceptualized and later implemented in practice.     

Zukünftige Tuberkulinversorgung in Deutschland

Zusammenfassung Der Hersteller des einzigen bisher in Deutschland für Intradermaltests nach Mendel-Mantoux verwendeten Tuberkulins, die Firma Chiron Vaccines Behring, hat 2004 kurzfristig die Produktion von Tuberkulin Behring GT (GT=gereinigtes Tuberkulin) eingestellt. Anfang 2005 waren die Bestände an GT 10 bereits erschöpft, geringe Restbestände existierten noch für die Dosierungen GT 100 und GT 1000. Als Übergangslösung wurde von Chiron Vaccines Behring der Import des von Chiron S.r.l. in Siena hergestellten italienischen Tuberkulins Biocine PPD 5 IE lyophil vorgeschlagen. Da es sich um ein in Deutschland nicht zugelassenes Produkt handelt, ist eine Einzelverordnung nach § 73 Abs. 3 Arzneimittelgesetz (AMG) erforderlich. Langfristig will Chiron Vaccines Behring die Versorgung Deutschlands durch in Großbritannien von Chiron Vaccines Evans produziertes Tuberkulin (PPD Evans) ab Sommer 2006 sicherstellen. Problematisch an diesem Vorgehen ist die damit verbundene zweimalige Umstellung auf ein anderes Tuberkulin sowie die ungeklärte Frage der Bioäquivalenz. Als weitere Möglichkeit können, neben den erwähnten Tuberkulinen der Firma Chiron Vaccines, auch das von der Weltgesundheitsorganisation (WHO) als Standardtuberkulin empfohlene und in vielen europäischen Ländern bereits eingeführte Tuberkulin PPD RT23 SSI des Statens Serum Institut (Kopenhagen, Dänemark) sowie andere Tuberkuline, wie beispielsweise das in den USA verwendete Tubersol (PPD CT68), importiert werden. Zusammen mit dem Robert Koch-Institut (RKI) und dem Paul-Ehrlich-Institut (PEI) bemüht sich das Deutsche Zentralkomitee zur Bekämpfung der Tuberkulose (DZK) intensiv um eine Problemlösung, da eine kontinuierliche Tuberkulinversorgung Deutschlands zu diagnostischen Zwecken und auch im Rahmen von Umgebungsuntersuchungen zwingend notwendig ist. Angestrebtes Ziel sollte zudem die Verwendung eines einheitlichen Tuberkulins in allen Regionen sein, da ansonsten ein standardisiertes Vorgehen und die Vergleichbarkeit auf nationaler Ebene gefährdet sind. Geschätzt kann zukünftig von einem jährlichen Bedarf von etwa 2 Millionen Tuberkulintestdosen für Deutschland ausgegangen werden. Das Statens Serum Institut prüft derzeit die Möglichkeit einer Antragstellung auf Zulassung des PPD RT 23 SSI in Deutschland. Chiron Vaccines Behring teilt mit, dass es keine Zulassung für das Biocine-Tuberkulin anstrebt, hat aber die Absicht, eine Zulassung für das Tuberkulin PPD Evans in Deutschland zu beantragen. Sanofi Pasteur MSD hat derzeit keine Absicht, eine Mendel-Mantoux-Testsubstanz [wie z. B. Tubersol (PPD CT68)] zur Zulassung auf dem deutschen Markt anzumelden. Bis in Deutschland wieder ein zugelassenes Tuberkulin zur Verfügung steht, wäre es, insbesondere in Fällen, in denen ein Lagerbestand an Tuberkulin unverzichtbar ist, wie beispielsweise im öffentlichen Gesundheitsdienst und in Krankenhausapotheken, überaus hilfreich, wenn eine Ausnahmeregelung für den Import erwirkt werden könnte.B. Hauer , Deutsches Zentralkomitee zur Bekämpfung der TuberkuloseW. Haas, Robert Koch-InstitutK. Magdorf, Deutsches Zentralkomitee zur Bekämpfung der TuberkuloseM. Priwitzer, Gesundheitsamt StuttgartR. Loddenkemper, Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose     

Risikoadaptierte Früherkennung

Breast cancer surveillance programs for the general population are not adequate for the small number of women with hereditary breast and ovarian cancer syndrome. Breast cancer screening for women in Germany starts at the age of 50 years, but nearly half of all women with familial risk are already diagnosed with breast cancer at that time. Moreover, mammography alone is not suitable for an early diagnosis of breast cancer in young women from high-risk families. Their typical dense breast tissue causes a high rate of false-negative cases. Therefore, national and international prospective clinical trials were initiated to offer a multimodal breast cancer surveillance program including magnetic resonance tomography for the breast and semi-annual screening intervals to women with BRCA1/2 mutations and those from high-risk families who tested negative for BRCA1/2 mutations. This program will currently be evaluated by the 15 centers of the German Consortium for Hereditary Breast and Ovarian Cancer.     

Obst- und Gemüsekonsum in Deutschland

Until now, the recommendations of the German Nutrition Society on fruit and vegetable intake have not been reached by the majority of the population. In the first wave of the“German Health Interview and Examination Survey for Adults” (DEGS1), which was conducted from 2008 to 2011, food consumption was determined with a validated food frequency questionnaire in a representative random sample of the 18-79-year-old residential population in Germany (n=7116). The number of portions of fruit and vegetables consumed on average every day and the number of persons meeting the recommended five portions of fruit and vegetables per day were calculated. On average, women consume 3.1 and men 2.4 portions of fruit and vegetables per day. 15 % of women and 7 % of men reach the recommended quantity of five portions per day. Fruit intake increases in both men and women up to the age of 60- 69 years. 39 % of women and 25 % of men consume at least three portions of fruit and vegetables every day. The proportion of men and women who consume at least three portions every day tends to increase with rising social status. Although the intake of fruit has increased slightly compared to previous surveys, the percentage of persons who consume five portions of fruit and vegetables per day is still very low. An English full-text version of this article is available at SpringerLink as supplemental.     

Epidemiologie von Schilddrüsenerkrankungen in Deutschland

Background

Germany is an iodine-deficient region. Iodine deficiency was classified as moderate in the North and as severe in mountain regions in Southern Germany. Improved legislation involving the iodization of table salt became effective during the 1990s. This legislation has contributed considerably to an increase in the use of iodized salt for food production.

Current results

The population is currently supplied with iodine at a lower recommended level. From an epidemiological point of view, Germany is a region characterized by the change from iodine deficiency to iodine sufficiency. Typical for this transformation, one might expect a low prevalence of goitre among children and adolescents, while there would still be a high prevalence of goitre, thyroid nodules, and subclinical hyperthyroidism among the elderly. In a representative German sample of children and adolescents, however, relatively large thyroid volumes have been found.

Conclusion

Systematic monitoring programs for thyroid disorders, including measurements of urinary iodine excretion in population samples, allow the detection of deviations in the iodine supply and are thus an obligatory precondition for the effective prevention of iodine deficiency.     

Die telefonische infektionsepidemiologische Bund-Länder-Lagekonferenz in Deutschland

Public health threats are increasingly triggered by events which span across international, national and state level jurisdictions. Innovative surveillance methods are needed to ensure adequate and timely response to such threats. In January 2009 the Department of Infectious Disease Epidemiology at the Robert Koch Institute (RKI) established a system of weekly telephone conferences with all competent authorities of the German federal states to identify, discuss and respond to infectious disease events in real-time. A regular and structured platform was developed for use between participants from state level public health authorities, the military and the RKI. During the first three quarters, 46 infectious diseases were covered, including mandatory reports of measles and meningococcal meningitis and outbreaks of cowpox, which does not have to be notified in Germany. Results of a targeted evaluation and a consistently high attendance rate both indicate that the teleconference has met additional needs for supplemental information exchange among participants. The telephone conference has proven to be a useful resource for rapid and direct communication, coordination and evaluation of signals for public health events in Germany.     

Informationen zur Darmkrebsfrüherkennung

Colorectal cancer is the second most prevalent cancer in Germany. The governmental program for early detection of colorectal cancer intends to increase the chances of recovery by identifying colorectal cancer in an early, more treatable stage. Citizens need quality-assured, balanced, and target-group-specific information to be able to make an informed decision. On the basis of the current state of research, of extensive studies, and of expert and user interviews, the Federal Center for Health Education (BZgA) developed an information module on“early detection of colorectal cancer” for the women’s health portal of the BZgA. The information module contains information on colorectal cancer, on the governmental program for early detection, as well as on the program’s benefits and risks. The information offered is intended to be up to date and is approved by experts. The BZgA approves the quality of this information using methods of process and outcome evaluation.