Lung cancer is the most common cancer type worldwide and has the highest and second highest mortality rate for men and women respectively in Germany. Yet, the role of comorbid illnesses in lung cancer patient prognosis is still debated. We analyzed administrative claims data from one of the largest statutory health insurance (SHI) funds in Germany, covering close to 9 million people (11% of the national population); observation period was from 2005 to 2019. Lung cancer patients and their concomitant diseases were identified by ICD-10-GM codes. Comorbidities were classified according to the Charlson Comorbidity Index (CCI). Incidence, comorbidity prevalence and survival are estimated considering sex, age at diagnosis, and place of residence. Kaplan Meier curves with 95% confidence intervals were built in relation to common comorbidities. We identified 70,698 lung cancer incident cases in the sample. Incidence and survival figures are comparable to official statistics in Germany. Most prevalent comorbidities are chronic obstructive pulmonary disease (COPD) (36.7%), followed by peripheral vascular disease (PVD) (18.7%), diabetes without chronic complications (17.4%), congestive heart failure (CHF) (16.5%) and renal disease (14.7%). Relative to overall survival, lung cancer patients with CHF, cerebrovascular disease (CEVD) and renal disease are associated with largest drops in survival probabilities (9% or higher), while those with PVD and diabetes without chronic complications with moderate drops (7% or lower). The study showed a negative association between survival and most common comorbidities among lung cancer patients, based on a large sample for Germany. Further research needs to explore the individual effect of comorbidities disentangled from that of other patient characteristics such as cancer stage and histology.
Lung cancer is the most common cancer type worldwide with close to 2.1 million incident cases in year 2019 [
There is a consensus that the comorbidity burden among lung cancer patients is high [
Nevertheless, researchers have not yet fully agreed on the impact comorbidities might have on lung cancer patient chances of survival. Some studies have indicated a no significant to small effect [
In this context, the objective of this study is threefold: first, to estimate lung cancer incidence based on administrative claims data that is validated with the statistics from the national cancer registry in Germany; second, to recognize the prevalence of comorbidities among lung cancer patients in relation to individual characteristics and their evolution over time; and third, to analyze the association between comorbidities and survival rates for lung cancer patients.
We analyzed administrative claims data from Barmer health insurance, one of the largest statutory health insurance (SHI) funds in Germany, covering close to 9 million people (11% of the national population) [
We identified incident cases on a year-by-year basis. In accordance to McGuire et al. [
Following guidance in Edwards et al. [
Lung cancer incidence was estimated after relating the identified incident cases with the entire Barmer population. Comorbidity prevalence was calculated for each comorbidity group as the percentage of lung cancer patients diagnosed with that particular comorbidity. Survival rates were obtained for three and six months after the diagnosis date, as well as for one, three and five years after. Incidence, comorbidity prevalence and survival rates were retrieved for each year and also by sex, age at diagnosis and place of residence. Time trends in these metrics were recognized by observing three year averages across the period of analysis. If estimated averages were consistently (i.e., without exception) increasing throughout the sample, the trend was then labeled as increasing, likewise for decreasing averages. Kaplan Meier curves were estimated by censoring the sample at December 31, 2019 and excluding the patient population that terminated their insurance affiliation for reasons different than death. Confidence intervals (CI) at the 95% levels were built around the curves in order to compare surviving probabilities across subpopulations. The analysis were performed using R software, version 3.6.0.
The number of new lung cancer diagnoses identified was 70,698 during the period of analysis.
2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Total cases | 5,108 | 5,247 | 5,496 | 5,681 | 5,664 | 5,721 | 6,047 | 6,209 | 6,288 | 6,406 | 6,504 | 6,327 |
Sex | ||||||||||||
Men | 56.0 | 56.0 | 55.2 | 55.1 | 55.3 | 53.1 | 54.5 | 53.0 | 53.0 | 51.9 | 51.1 | 49.7 |
Women | 44.0 | 44.0 | 44.8 | 44.9 | 44.7 | 46.9 | 45.5 | 47.0 | 47.0 | 48.1 | 48.9 | 50.3 |
Age group | ||||||||||||
18–35 | 0.3 | 0.2 | 0.2 | 0.3 | 0.4 | 0.3 | 0.3 | 0.2 | 0.3 | 0.2 | 0.3 | 0.3 |
35–50 | 6.0 | 5.5 | 5.5 | 5.1 | 4.9 | 4.5 | 4.2 | 4.2 | 3.5 | 2.9 | 3.0 | 2.8 |
50–65 | 32.1 | 33.1 | 31.4 | 30.4 | 29.6 | 31.6 | 31.2 | 31.0 | 31.3 | 29.9 | 30.1 | 28.1 |
65–80 | 48.1 | 47.9 | 48.4 | 49.8 | 50.5 | 49.8 | 50.2 | 50.7 | 52.1 | 52.5 | 52.0 | 52.7 |
80+ | 13.5 | 13.3 | 14.5 | 14.4 | 14.6 | 13.8 | 14.2 | 14.0 | 12.8 | 14.6 | 14.5 | 16.1 |
Place of residence | ||||||||||||
Baden-Wurttem. | 7.0 | 6.9 | 7.2 | 7.5 | 6.7 | 7.1 | 7.3 | 7.0 | 6.6 | 7.0 | 7.1 | 7.1 |
Bavaria | 10.3 | 10.5 | 9.5 | 10.4 | 10.9 | 9.8 | 9.7 | 9.8 | 10.3 | 9.4 | 10.1 | 10.0 |
Berlin | 6.1 | 5.8 | 5.2 | 6.0 | 5.6 | 5.5 | 6.1 | 6.1 | 5.9 | 5.7 | 5.7 | 5.7 |
Brandenburg | 3.2 | 3.5 | 3.7 | 3.7 | 3.8 | 4.4 | 4.4 | 4.6 | 4.4 | 4.4 | 4.6 | 4.4 |
Bremen | 0.5 | 0.5 | 0.6 | 0.4 | 0.7 | 0.4 | 0.5 | 0.5 | 0.4 | 0.5 | 0.5 | 0.6 |
Hamburg | 2.5 | 2.3 | 2.4 | 2.1 | 2.2 | 2.4 | 2.7 | 2.7 | 2.7 | 2.8 | 3.0 | 2.6 |
Hesse | 8.1 | 7.8 | 7.2 | 7.9 | 7.0 | 7.5 | 8.1 | 8.0 | 7.4 | 7.9 | 7.1 | 8.0 |
Mecklenburg-Vor. | 1.9 | 2.1 | 1.9 | 2.4 | 2.3 | 2.0 | 2.4 | 2.2 | 2.3 | 2.4 | 2.6 | 2.1 |
Lower Scaxony | 8.4 | 8.7 | 9.0 | 8.6 | 8.4 | 8.2 | 8.1 | 8.8 | 8.7 | 9.2 | 8.8 | 8.5 |
North rhine-West. | 31.3 | 30.8 | 31.0 | 30.0 | 30.0 | 30.6 | 29.1 | 29.9 | 30.6 | 29.5 | 29.3 | 30.3 |
Rhineland-Palat. | 5.6 | 5.6 | 5.7 | 5.4 | 5.8 | 6.2 | 5.7 | 4.8 | 5.5 | 5.8 | 5.8 | 5.6 |
Saarland | 1.5 | 1.8 | 1.5 | 1.5 | 1.4 | 1.5 | 1.7 | 1.7 | 1.4 | 1.3 | 1.8 | 1.7 |
Saxony | 4.1 | 3.5 | 4.1 | 4.2 | 4.3 | 4.4 | 3.8 | 3.7 | 3.6 | 3.2 | 3.5 | 3.5 |
Saxony-Anhalt | 2.8 | 2.7 | 3.1 | 2.8 | 3.0 | 2.7 | 3.1 | 3.2 | 2.7 | 2.8 | 2.7 | 2.9 |
Schleswig-Hols. | 4.5 | 5.3 | 5.1 | 4.8 | 5.0 | 4.5 | 4.7 | 5.1 | 4.9 | 5.4 | 5.0 | 4.8 |
Thuringia | 2.1 | 2.2 | 2.5 | 2.3 | 2.8 | 2.8 | 2.5 | 2.0 | 2.5 | 2.7 | 2.4 | 2.4 |
2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Total (+) | 60.3 | 62.0 | 65.0 | 67.0 | 66.2 | 66.4 | 70.3 | 72.6 | 74.4 | 77.2 | 79.3 | 78.4 |
Sex | ||||||||||||
Men (+) | 82.7 | 84.7 | 87.3 | 89.4 | 88.4 | 84.8 | 91.9 | 91.8 | 93.7 | 94.9 | 95.7 | 91.8 |
Women (+) | 57.1 | 58.9 | 61.0 | 62.9 | 62.5 | 60.4 | 65.8 | 66.3 | 68.1 | 69.3 | 70.4 | 67.7 |
Age group | ||||||||||||
18–35 | 0.9 | 0.8 | 0.6 | 1.0 | 1.3 | 1.0 | 1.0 | 0.6 | 1.2 | 0.7 | 1.5 | 1.3 |
35–50 (−) | 16.4 | 15.8 | 17.0 | 16.8 | 16.1 | 15.4 | 15.6 | 16.4 | 14.6 | 12.7 | 13.7 | 12.9 |
50–65 | 93.6 | 98.6 | 97.5 | 94.9 | 89.2 | 93.9 | 96.5 | 97.8 | 100.1 | 98.1 | 100.7 | 92.4 |
65–80 (+) | 171.3 | 170.5 | 176.4 | 187.7 | 188.0 | 183.0 | 191.8 | 197.8 | 206.2 | 213.6 | 216.5 | 215.9 |
80+ | 156.5 | 152.8 | 170.3 | 169.8 | 169.1 | 158.2 | 170.5 | 164.8 | 145.4 | 159.3 | 152.5 | 154.9 |
Place of residence | ||||||||||||
Baden-Wurttem. (+) | 48.0 | 48.4 | 52.6 | 56.1 | 49.8 | 53.2 | 57.6 | 57.4 | 55.1 | 60.6 | 63.2 | 62.9 |
Bavaria (+) | 50.3 | 52.4 | 50.1 | 56.7 | 59.1 | 53.0 | 56.1 | 58.2 | 62.0 | 58.3 | 64.4 | 62.7 |
Berlin (+) | 77.1 | 74.8 | 70.5 | 84.5 | 78.3 | 75.9 | 89.3 | 92.1 | 92.0 | 92.1 | 93.7 | 92.7 |
Brandenburg (+) | 44.8 | 50.3 | 55.8 | 56.7 | 57.1 | 64.3 | 68.2 | 72.5 | 71.0 | 73.5 | 78.3 | 73.2 |
Bremen | 74.9 | 75.5 | 91.9 | 67.5 | 103.0 | 65.6 | 82.6 | 88.9 | 72.7 | 99.9 | 90.0 | 104.0 |
Hamburg | 72.3 | 68.7 | 76.9 | 69.2 | 70.6 | 76.1 | 94.6 | 95.4 | 99.4 | 104.7 | 115.3 | 98.9 |
Hesse (+) | 58.5 | 57.3 | 55.5 | 62.7 | 55.0 | 58.8 | 66.8 | 68.0 | 64.3 | 69.9 | 64.9 | 71.0 |
Mecklenburg-Vor. (+) | 41.1 | 44.6 | 43.9 | 54.3 | 51.5 | 44.9 | 55.5 | 52.1 | 53.5 | 58.9 | 62.7 | 49.8 |
Lower saxony (+) | 58.9 | 62.2 | 68.0 | 66.0 | 64.2 | 63.0 | 65.6 | 73.4 | 74.4 | 82.3 | 82.2 | 80.4 |
North rhine-West. (+) | 76.0 | 77.4 | 81.8 | 81.8 | 81.3 | 83.6 | 84.4 | 89.7 | 93.7 | 93.1 | 94.4 | 96.0 |
Rhineland-Palat. (+) | 69.5 | 72.3 | 76.6 | 75.4 | 80.6 | 85.7 | 84.1 | 73.2 | 85.1 | 91.7 | 94.4 | 88.5 |
Saarland | 57.1 | 70.6 | 61.9 | 63.2 | 59.3 | 61.2 | 73.9 | 76.3 | 66.2 | 61.3 | 87.8 | 79.6 |
Saxony | 50.3 | 44.5 | 54.4 | 57.2 | 58.0 | 59.6 | 55.7 | 55.6 | 59.2 | 56.7 | 66.6 | 66.5 |
Saxony-Anhalt (+) | 47.6 | 48.3 | 58.1 | 53.3 | 55.8 | 50.8 | 61.1 | 65.8 | 59.0 | 65.1 | 64.6 | 69.5 |
Schleswig-Hols. (+) | 131.6 | 159.7 | 162.3 | 155.7 | 160.6 | 146.6 | 162.5 | 182.2 | 179.0 | 204.1 | 196.0 | 183.8 |
Thuringia | 45.6 | 48.9 | 59.9 | 55.6 | 65.8 | 66.5 | 62.5 | 51.9 | 70.0 | 81.1 | 76.2 | 76.7 |
Note: If the three year average is always higher (lower) than the three year average of the period immediately before, the trend is labeled as increased (decreasing). An increasing trend in incidence is denoted by (+), a decreasing trend by (−).
Comorbidity prevalence statistics can be found in
2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Comorbidity | ||||||||||||
Myocardial infarction | 6.6 | 5.6 | 5.6 | 6.2 | 6.1 | 5.5 | 6.2 | 6.9 | 6.6 | 6.8 | 7.0 | 6.3 |
CHF (+) | 15.6 | 15.3 | 15.4 | 15.2 | 15.8 | 15.5 | 17.6 | 17.5 | 16.6 | 17.7 | 17.6 | 17.5 |
PVD (+) | 13.4 | 14.5 | 16.3 | 17.1 | 17.5 | 19.0 | 20.2 | 20.1 | 20.6 | 21.3 | 21.0 | 20.8 |
CEVD (+) | 9.0 | 8.3 | 8.0 | 8.6 | 8.7 | 8.9 | 9.2 | 10.0 | 9.1 | 10.6 | 10.8 | 10.3 |
Dementia | 3.3 | 3.3 | 3.1 | 3.5 | 3.1 | 3.3 | 2.9 | 3.4 | 2.9 | 2.8 | 2.9 | 3.3 |
COPD (+) | 35.1 | 34.1 | 34.7 | 35.9 | 37.0 | 36.4 | 35.6 | 38.3 | 37.4 | 38.8 | 38.1 | 37.9 |
Rheumatoid disease (+) | 1.6 | 1.8 | 1.8 | 1.9 | 1.8 | 2.1 | 2.0 | 2.8 | 2.3 | 2.5 | 2.5 | 2.5 |
Peptic ulcer (−) | 3.1 | 3.1 | 3.0 | 2.8 | 2.8 | 2.9 | 2.6 | 2.4 | 2.4 | 2.5 | 2.6 | 2.2 |
Mild liver disease | 4.7 | 4.5 | 4.4 | 4.6 | 5.0 | 4.9 | 4.4 | 4.6 | 5.1 | 5.2 | 5.7 | 6.1 |
Diab. without chron. compl. | 15.8 | 15.8 | 16.0 | 16.1 | 17.4 | 17.8 | 19.0 | 18.5 | 18.0 | 17.5 | 18.3 | 17.9 |
Diab. with chron. comp. | 4.2 | 4.0 | 4.1 | 3.9 | 4.1 | 4.2 | 4.3 | 4.7 | 4.5 | 4.5 | 5.0 | 4.7 |
Hemiplegia or paraplegia | 5.3 | 5.1 | 4.7 | 5.4 | 5.4 | 5.5 | 5.3 | 5.3 | 5.3 | 5.2 | 5.6 | 5.6 |
Renal disease (+) | 11.5 | 11.4 | 12.4 | 12.9 | 14.1 | 14.8 | 16.1 | 15.8 | 15.8 | 16.7 | 16.3 | 16.6 |
Moderate or severe liver dis. | 0.6 | 0.7 | 0.5 | 0.5 | 0.7 | 0.6 | 0.6 | 0.8 | 0.8 | 0.8 | 0.6 | 0.8 |
AIDS | 0.1 | 0.1 | 0.1 | 0.0 | 0.1 | 0.1 | 0.1 | 0.1 | 0.1 | 0.2 | 0.1 | 0.0 |
Number of comorbidities | ||||||||||||
0 (−) | 34.4 | 35.6 | 33.8 | 33.1 | 31.6 | 30.9 | 29.7 | 27.8 | 29.6 | 27.9 | 28.9 | 27.2 |
1 or 2 | 49.4 | 48.6 | 50.3 | 49.5 | 50.2 | 50.9 | 50.7 | 52.2 | 50.3 | 51.1 | 49.6 | 52.3 |
3 or 4 (+) | 13.8 | 13.3 | 13.5 | 14.6 | 14.8 | 14.7 | 16.4 | 16.4 | 16.5 | 17.2 | 17.5 | 17.0 |
5 or more (+) | 2.3 | 2.5 | 2.4 | 2.7 | 3.4 | 3.5 | 3.2 | 3.6 | 3.5 | 3.8 | 4.0 | 3.5 |
Note: Comorbidities are classified with the categories listed in the Charlson Comorbidity Index (CCI). COPD stands for chronic obstructive pulmonary disease, PVD for peripheral vascular disease, CHF for congestive heart failure and CEVD for cerebrovascular disease. If the three year average is always higher (lower) than the three year average of the period immediately before, the trend is labeled as increased (decreasing). An increasing trend in incidence is denoted by (+), a decreasing trend by (−).
Men | Women | 18–35 | 35–50 | 50–65 | 65–80 | 80+ | |
---|---|---|---|---|---|---|---|
Comorbidity | |||||||
Myocardial infarction | 8.6 | 3.7 | 0.0 | 1.6 | 4.1 | 7.5 | 8.3 |
CHF | 19.1 | 13.5 | 2.2 | 4.4 | 9.5 | 18.4 | 28.9 |
PVD | 21.4 | 15.5 | 7.1 | 10.8 | 16.3 | 21.2 | 17.4 |
CEVD | 10.5 | 8.0 | 2.2 | 2.7 | 6.4 | 10.7 | 13.1 |
Dementia | 3.2 | 3.1 | 0.0 | 0.0 | 0.6 | 3.0 | 10.1 |
COPD | 38.7 | 34.4 | 16.9 | 24.6 | 36.2 | 39.8 | 30.9 |
Rheumatoid disease | 1.4 | 3.0 | 0.6 | 1.2 | 2.1 | 2.3 | 2.0 |
Peptic ulcer | 3.0 | 2.3 | 1.6 | 1.6 | 2.4 | 2.9 | 3.1 |
Mild liver disease | 5.3 | 4.6 | 1.6 | 5.1 | 5.9 | 4.9 | 3.2 |
Diab. without chron. compl. | 20.9 | 13.4 | 3.3 | 4.8 | 13.1 | 20.6 | 19.4 |
Diab. with chron. compl. | 5.7 | 2.8 | 0.0 | 0.6 | 2.5 | 5.4 | 6.1 |
Hemiplegia or paraplegia | 5.5 | 5.1 | 2.2 | 3.8 | 5.6 | 5.4 | 4.9 |
Renal disease | 17.2 | 11.7 | 2.2 | 3.0 | 6.8 | 16.7 | 28.1 |
Moderate or severe liver dis. | 0.9 | 0.4 | 0.0 | 0.6 | 0.8 | 0.7 | 0.4 |
AIDS | 0.1 | 0.0 | 0.5 | 0.4 | 0.2 | 0.0 | 0.0 |
Number of comorbidities | |||||||
0 | 26.2 | 35.8 | 68.3 | 54.8 | 36.4 | 26.6 | 24.8 |
1 or 2 | 50.9 | 50.0 | 30.6 | 41.5 | 52.2 | 51.1 | 47.7 |
3 or 4 | 18.8 | 12.0 | 1.1 | 3.2 | 10.0 | 18.2 | 22.3 |
5 or more | 4.2 | 2.2 | 0.0 | 0.4 | 1.5 | 4.0 | 5.2 |
Note: Comorbidities are classified with the categories listed in the Charlson Comorbidity Index (CCI). COPD stands for chronic obstructive pulmonary disease, PVD for peripheral vascular disease, CHF for congestive heart failure and CEVD for cerebrovascular disease.
The survival rate is presented in
2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | |
---|---|---|---|---|---|---|---|---|---|---|---|
5-year survival | |||||||||||
Total (+) | 19.0 | 18.6 | 18.9 | 19.7 | 18.8 | 19.8 | 19.7 | – | – | – | – |
Sex | |||||||||||
Men (+) | 14.9 | 15.6 | 15.2 | 16.9 | 15.4 | 16.7 | 17.9 | – | – | – | – |
Women (−) | 24.2 | 22.5 | 23.4 | 23.2 | 22.9 | 23.4 | 21.9 | – | – | – | – |
Age group | |||||||||||
18–35 (−) | 71.4 | 75.0 | 88.9 | 62.5 | 52.4 | 68.8 | 56.2 | – | – | – | – |
35–50 (+) | 28.3 | 27.7 | 29.6 | 28.9 | 30.9 | 32.8 | 38.6 | – | – | – | – |
50–65 | 22.0 | 22.4 | 22.9 | 24.6 | 22.4 | 24.4 | 22.2 | – | – | – | – |
65–80 (+) | 18.5 | 18.0 | 17.9 | 19.2 | 18.5 | 18.6 | 20.1 | – | – | – | – |
80+ (−) | 8.3 | 6.6 | 8.5 | 7.0 | 7.2 | 8.4 | 6.6 | – | – | – | – |
3-year survival | |||||||||||
Total (+) | 24.4 | 24.7 | 25.3 | 26.1 | 25.4 | 26.7 | 26.2 | 26.9 | 27.8 | – | – |
Sex | |||||||||||
Men (+) | 20.5 | 21.2 | 21.1 | 22.8 | 22.1 | 23.7 | 24.0 | 23.5 | 23.9 | – | – |
Women (+) | 29.3 | 29.2 | 30.5 | 30.2 | 29.5 | 30.1 | 28.9 | 30.8 | 32.1 | – | – |
Age group | |||||||||||
18–35 | 71.4 | 75.0 | 88.9 | 62.5 | 57.1 | 68.8 | 56.2 | 80.0 | 66.7 | – | – |
5-50 (+) | 33.2 | 33.2 | 34.9 | 34.0 | 37.5 | 38.2 | 41.7 | 45.0 | 47.5 | – | – |
50–65 | 27.2 | 28.5 | 29.6 | 30.2 | 28.3 | 31.0 | 28.9 | 29.3 | 31.3 | – | – |
65–80 (+) | 24.3 | 24.7 | 24.4 | 26.1 | 25.7 | 26.0 | 26.9 | 27.5 | 27.5 | – | – |
80+ | 12.8 | 10.8 | 14.8 | 14.1 | 13.8 | 15.2 | 12.7 | 13.9 | 13.9 | – | – |
1-year survival | |||||||||||
Total (+) | 48.5 | 48.6 | 48.8 | 49.9 | 49.3 | 50.5 | 49.5 | 50.7 | 51.4 | 50.6 | 51.2 |
Sex | |||||||||||
Men | 45.0 | 45.2 | 45.0 | 45.7 | 46.0 | 47.5 | 47.1 | 47.6 | 48.1 | 46.1 | 48.1 |
Women | 53.0 | 52.7 | 53.6 | 55.1 | 53.4 | 53.9 | 52.3 | 54.3 | 55.1 | 55.5 | 54.4 |
Age group | |||||||||||
18–35 | 92.9 | 83.3 | 88.9 | 93.8 | 85.7 | 75.0 | 75.0 | 80.0 | 83.3 | 90.0 | 72.7 |
35–50 | 60.6 | 60.2 | 54.5 | 59.5 | 64.7 | 62.2 | 62.6 | 69.0 | 67.7 | 59.1 | 69.9 |
50–65 (+) | 51.8 | 53.5 | 55.0 | 53.9 | 55.2 | 55.9 | 55.1 | 55.0 | 56.1 | 57.0 | 56.6 |
65–80 (+) | 49.4 | 49.2 | 48.1 | 50.6 | 49.2 | 50.5 | 49.5 | 50.8 | 51.4 | 51.0 | 51.0 |
80+ (+) | 31.1 | 28.6 | 35.2 | 34.8 | 31.5 | 33.5 | 32.5 | 35.1 | 35.0 | 34.2 | 36.1 |
6-month survival | |||||||||||
Total | 67.5 | 67.0 | 67.3 | 68.3 | 67.2 | 68.1 | 67.4 | 68.1 | 68.1 | 68.4 | 67.4 |
Sex | |||||||||||
Men | 65.7 | 64.5 | 64.5 | 65.2 | 65.1 | 65.7 | 66.2 | 66.8 | 65.7 | 64.7 | 65.2 |
Women | 69.9 | 70.3 | 70.8 | 72.1 | 69.8 | 70.8 | 68.8 | 69.5 | 70.8 | 72.4 | 69.7 |
Age group | |||||||||||
18–35 | 100.0 | 100.0 | 88.9 | 93.8 | 95.2 | 93.8 | 87.5 | 100.0 | 88.9 | 100.0 | 90.9 |
35–50 | 77.5 | 78.9 | 76.4 | 80.8 | 79.3 | 80.7 | 80.7 | 83.7 | 82.5 | 79.0 | 82.1 |
50–65 (+) | 73.0 | 72.9 | 72.4 | 73.9 | 73.3 | 74.1 | 73.6 | 74.2 | 73.6 | 76.1 | 72.6 |
65–80 | 67.5 | 66.9 | 67.8 | 67.9 | 67.6 | 67.9 | 67.2 | 67.7 | 68.2 | 68.2 | 67.4 |
80+ | 49.3 | 47.4 | 51.1 | 53.2 | 48.7 | 50.3 | 50.3 | 51.1 | 49.9 | 50.9 | 52.8 |
3-month survival | |||||||||||
Total | 0.81 | 0.81 | 0.81 | 0.81 | 0.81 | 0.81 | 0.81 | 0.81 | 0.82 | 0.81 | 0.81 |
Sex | |||||||||||
Men | 0.80 | 0.79 | 0.79 | 0.79 | 0.80 | 0.80 | 0.80 | 0.80 | 0.81 | 0.79 | 0.80 |
Women | 0.82 | 0.84 | 0.84 | 0.84 | 0.82 | 0.83 | 0.82 | 0.82 | 0.84 | 0.84 | 0.82 |
Age group | |||||||||||
18–35 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 0.94 | 1.00 | 1.00 | 0.94 | 1.00 | 1.00 |
35–50 | 0.87 | 0.89 | 0.88 | 0.91 | 0.91 | 0.92 | 0.89 | 0.93 | 0.92 | 0.89 | 0.92 |
50–65 (+) | 0.85 | 0.86 | 0.84 | 0.86 | 0.86 | 0.85 | 0.85 | 0.85 | 0.87 | 0.87 | 0.85 |
65–80 | 0.82 | 0.81 | 0.81 | 0.81 | 0.81 | 0.81 | 0.81 | 0.81 | 0.82 | 0.81 | 0.80 |
80+ (+) | 0.65 | 0.67 | 0.71 | 0.70 | 0.67 | 0.70 | 0.69 | 0.70 | 0.70 | 0.68 | 0.72 |
Note: If the three year average is always higher (lower) than the three year average of the period immediately before, the trend is labeled as increased (decreasing). An increasing trend in survival is denoted by (+), a decreasing trend by (−).
Moreover, Kaplan-Meier curves by the number of comorbidities are shown in
The present study identified 70,698 lung cancer incident cases covering all of Germany and across a 12-year period between 2007 and 2018, making it the largest lung cancer patient sample—to which we are aware—in Germany. We validated the representativeness of the sample by comparing our obtained age-standardized incidence figures with those from the German Centre for Cancer Registry Data, which is responsible for pooling and assessing every reported cancer case it receives from the population based cancer registries in each German federal state. Our incidence for women was nearly identical to national statistics over the 12 years analyzed; though, our incidence for men was higher [
Comorbidity prevalence in our sample was in line to that found in Islam et al. [
The most prevalent concomitant diseases in our study were similar to those in the Annual Report to the Nation on the Status of Cancer, based on a sample of more than 160,000 lung cancer patients in the US [
With respect to survival, time trends for the short- and long-term, as well as divergence across sex, found in this study, were also identified by the German Centre for Cancer Registry Data for the whole of Germany [
A greater probability of survival among lung cancer patients without comorbidities was also observed in Islam et al. [
Overall, this study provides a detailed picture on the comorbidity profile of lung cancer patients in Germany with a representative sample covering all sixteen federal states and a period of time longer than a decade. It is necessary to supply figures in this matter, as the German Centre for Cancer Registry Data does not collect information on comorbidities, a crucial element in understanding lung cancer survival. In this respect, we have delivered evidence on its association with most common comorbidities, and thereby a clearer characterization of lung cancer prognosis. This could facilitate improvement in treatment selection and strategies that enhance survival and quality of life in lung cancer patients.
The main limitation of our analysis was the inability to control for individual characteristics that might influence lung cancer patient survival. This is because administrative data does not include information on, for instance, tumor stage and histology. We cannot, therefore, disentangle the effect of comorbidities on survival rates by means of multivariate regression methods. Tumor stage and histology have been shown to explain most variation in lung cancer survival, and by excluding them, an econometric analysis would inevitably suffer from omitted variable biases [
The present study reveals the epidemiological picture of lung cancer incidence and comorbidity prevalence, as well as provides evidence on the relationship between survival and comorbidities among lung cancer patients, based on administrative claims data from a health insurance company in Germany. The sample was large and the patient identification strategy delivered incidence and survival figures that were comparable to official statistics for lung cancer patients in Germany. Comorbidities are prevalent in around 70% of lung cancer patients and usually associated with lower probability of survival. The largest impact on survival from common comorbidities is observed in lung cancer patients with CHF, CEVD or renal disease, and a more moderate impact in those with PVD or diabetes without chronic complications. Further research for Germany is needed to disentangle the effect of comorbidities on survival from other patient characteristics such as cancer stage and histology.
We are grateful for the collaboration with the Statutory Health Insurance Company Barmer, especially to Ursula Marschall and Helmut L’hoest for the conception of the article, to Beata Hennig for data analysis support and to Martial Mboulla and Joachim Saam for technical assistance. We thank as well Rachel Eckford for her proofreading of the manuscript.
This research received no specific grant from any funding agency in the public, commercial, or non-profit sectors.
The authors confirm contribution to the paper as follows: study conception and design: all authors; data collection: Diego Hernandez; analysis and interpretation of results: Diego Hernandez, Karla Hernandez-Villafuerte, Chih-Yuan Cheng; draft manuscript preparation: Diego Hernandez, Karla Hernandez-Villafuerte. All authors reviewed the results and approved the final version of the manuscript.
This study is supported by Barmer, with whom the Division of Health Economics has a Data Use and Transfer Agreement. Personal data of the beneficiaries were pseudonymized through Barmer before data sharing. Personal identifiers were masked or deleted prior to receiving the data. Quasi-identifiers were generalized (year of birth only, deletion of the last two digit of the zip code, etc.) The processing and analysis of sensitive data took place by remotely accessing the servers at the Scientific Data Warehouse of Barmer under special data protection conditions. The Data Use and Transfer Agreement does not contemplate data distribution to third parties and it is therefore not available.
Not applicable.
The authors declare that they have no conflicts of interest to report regarding the present study.
2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Barmer sample | ||||||||||||
Women | 26.0 | 26.6 | 27.4 | 28.0 | 27.1 | 28.3 | 28.3 | 29.8 | 30.8 | 31.0 | 32.5 | 31.7 |
Men | 53.2 | 53.7 | 53.5 | 54.0 | 52.5 | 50.6 | 53.7 | 52.7 | 53.3 | 52.6 | 52.5 | 49.1 |
Germany | ||||||||||||
Women | 25.9 | 26.4 | 26.6 | 27.4 | 28.4 | 29.1 | 29.8 | 30.4 | 31.3 | 31.6 | 31.7 | 31.5 |
Men | 65.8 | 65.2 | 64.7 | 63.3 | 62.9 | 61.5 | 61.1 | 59.8 | 59.6 | 58.1 | 58.2 | 55.3 |
Note: Age standardized incidence is calculated for the sample with the European Standard Population 1976. Figures for Germany are retrieved from [
2007–2008 | 2009–2010 | 2011–2012 | 2013–2014 | 2015–2016 | 2017–2018 | |
---|---|---|---|---|---|---|
Barmer sample | ||||||
5-year survival | ||||||
Women | 23 | 23 | 23 | 22 | – | – |
Men | 15 | 16 | 16 | 18 | – | – |
3-year survival | ||||||
Women | 29 | 30 | 30 | 30 | 32 | – |
Men | 21 | 22 | 23 | 24 | 24 | – |
1-year survival | ||||||
Women | 53 | 54 | 54 | 53 | 55 | 55 |
Men | 45 | 45 | 47 | 47 | 47 | 47 |
Germany | ||||||
5-year survival | ||||||
Women | 18 | 19 | 18 | 19 | 19 | 20 |
Men | 12 | 13 | 13 | 13 | 13 | 15 |
3-year survival | ||||||
Women | 23 | 24 | 24 | 25 | 25 | 27 |
Men | 17 | 19 | 18 | 18 | 18 | 21 |
1-year survival | ||||||
Women | 48 | 48 | 48 | 49 | 48 | 49 |
Men | 41 | 43 | 41 | 41 | 40 | 43 |
Note: Figures for Germany are retrieved from [
2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | |
---|---|---|---|---|---|---|---|
Barmer sample | |||||||
5-year survival | 20.8 | 19.8 | 20.7 | 21.3 | 20.8 | 21.9 | 22.6 |
CONCORD-3 | |||||||
5-year survival | 18.3 |
Note: Age standardized survival probability is calculated for the sample with the European Standard Population 1976. Figures for Germany are retrieved from [