Incidence of malignant mesothelioma in Germany 2009-2013

Our plain-English summary of Incidence of malignant mesothelioma in Germany 2009-2013, by M. Lehnert, K. Kraywinkel, E. Heinze, et al (Cancer Causes & Control, 2017).

The study

• Authors: M. Lehnert, K. Kraywinkel, E. Heinze, T. Wiethege, G. Johnen, J. Fiebig, T. Brüning, D. Taeger
• Journal: Cancer Causes & Control
• Published: 2017;28(2):97-105
• Cited by: 26 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Purpose: The malignant mesothelioma is a rare malignancy and mainly caused by occupational exposure to asbestos. German cancer registries are providing a national database to investigate temporal and regional patterns of mesothelioma incidence. These may be of interest for healthcare planning and for surveillance programs aiming at the formerly exposed workforce.

Methods: We analyzed population-based incidence data of malignant mesothelioma by site, type, sex, age, as well as district and state of patient's residence. Age-standardized incidence rates (AIRs40+) were calculated according to the European standard population truncated to the age of 40 years and older. We present rates at national, state, and district level and trends of incidence of northern states of Germany.

Results: In total, 7,547 malignant mesotheliomas were reported to German cancer registries diagnosed between 2009 and 2013-90% located to the pleura. On average, 1,198 men and 312 women were affected each year. We estimated AIR40+ of 4.77 in 100,000 German men and 0.98 in 100,000 German women. Regional clusters were predominantly located to the seaports of West Germany. The highest regional AIR40+ was 20 per 100,000 men. Corresponding rates in northeast Germany were between 2 and 4 per 100,000 men.

Conclusion: Regional clusters of high incidence indicate districts with former shipyards and steel industry, but predominantly in the western part of Germany. The West-to-East difference corresponds to patterns of mortality. Twenty years after banning asbestos in Germany, Bremen and Hamburg are presenting the highest mesothelioma incidence but show steadily decreasing trends.

In plain English

This study used German cancer registry data on malignant mesothelioma diagnosed from 2009 to 2013, by sex, age, body site and district. It had no individual asbestos exposure data. Registries reported 7,547 cases (5,989 in men, 1,558 in women), and the median age at diagnosis was 73. The pleura was the site in 91.2% of men's cases, and the peritoneum in 15.3% of women's cases. 17% were known only from death certificates. Excluding Baden-Württemberg, age-standardized rates for ages 40 and over were 4.78 per 100,000 person-years in men (95% CI 4.64 to 4.90; 4.77 in the table) and 0.98 in women (95% CI 0.92 to 1.04). In men, the highest state rates were Bremen (16.82; 95% CI 14.35 to 19.28) and Hamburg (9.96; 8.74 to 11.18), and district rates ranged from 0 to 20.2. From 2003 to 2013, male rates fell significantly in Bremen and Hamburg but not in four other northern states. The authors concluded that clusters lay around former shipyards and steel industry in the West but not the East. They noted their area-level design cannot establish causes.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Population-based analysis of cancer registry incidence data, which the authors describe as an ecological approach. It calculated age-standardized incidence rates at national, state and district level and analyzed time trends with linear regression.
• Who was studied: All malignant mesothelioma cases reported to German cancer registries with diagnosis from 1 January 2009 to 31 December 2013: 7,547 cases (5,989 men, 1,558 women). Baden-Württemberg was excluded from national rates because its registry was incomplete. Trends from 2003 to 2013 covered six northern states: Schleswig-Holstein, Hamburg, Bremen, Niedersachsen, Mecklenburg-Vorpommern and Brandenburg.
• Exposure: No individual exposure data. Asbestos exposure was considered only indirectly, by comparing district incidence patterns with the locations of past industrial asbestos processing, such as shipyards, iron and steel industry, and asbestos cement production.
• Main results:
  • The median age at diagnosis was 73 years in both men and women. On average there were 1,198 cases in men and 312 in women each year, a male-to-female ratio of 3.8 to 1.
  • The pleura was the site in 5,461 (91.2%) of men's cases and 1,244 of women's cases (79.8% in the text, 79.9% in the table). The peritoneum followed, at 5.5% in men and 15.3% in women. Only 8 cases (0.1%) were in the pericardium.
  • Epithelioid was the most frequent subtype (43.1%), and 41% were not otherwise specified (Table 3, pleural cases). 72% were diagnosed from a tissue sample of the primary cancer. 17% were known from a death certificate only.
  • National age-standardized rates for ages 40 and over (Baden-Württemberg excluded) were 4.78 per 100,000 person-years in men (95% CI 4.64 to 4.90), given as 4.77 in Table 4 and the abstract. In women the rate was 0.98 (95% CI 0.92 to 1.04).
  • State rates (ages 40 and over, per 100,000) in men were lowest in Thüringen (1.62) and Mecklenburg-Vorpommern (1.92). They were highest in Bremen (16.82; 95% CI 14.35 to 19.28) and Hamburg (9.96; 95% CI 8.74 to 11.18). In women they were lowest in Thüringen (0.60) and highest in Bremen (2.38).
  • District rates for 2009 to 2013 ranged from 0 to 20.2 per 100,000 men and 0 to 3.7 per 100,000 women. Higher rates in men appeared in the northwest (Bremen and adjacent districts, Hamburg, Emden, Kiel, Lübeck), the Ruhr district, the Salzgitter region and the Rhine-Main area.
  • Clusters were assigned to the western shipbuilding cities of Emden and Kiel, but not to the eastern shipbuilding cities of Wismar, Rostock or Stralsund.
  • In men, 2003 to 2013 trends showed significant downward slopes in Bremen (minus 0.67, 95% CI minus 1.10 to minus 0.24) and Hamburg (minus 0.57, 95% CI minus 0.88 to minus 0.26), but not in the other northern states. Annual rates in women varied without a clear trend.
  • District rates in women were correlated with those in men (Pearson correlation 0.28; 95% CI 0.18 to 0.37).
• The authors' conclusion: The authors concluded that there were clusters of mesothelioma around former shipyards and steel industries in western Germany but not in the East. They said the higher incidence in the West matches the reported mortality pattern and may be due to different exposure profiles. They also said a decrease in incidence can be seen in the regions with the highest rates and well-established registration.
• Limitations the authors state:
  • The ecological design cannot establish causes for the East-West difference.
  • District-level analysis may miss local clusters, which can be diluted in large populations.
  • Formerly exposed East German workers who moved after reunification could have affected regional patterns.
  • Regional differences in awareness of asbestos hazards could bias diagnosis and reporting.
  • The higher share of peritoneal mesothelioma in women could partly reflect misclassified ovarian carcinoma.
  • There was a high proportion of death-certificate-only cases and incomplete subtyping.
  • Data for Baden-Württemberg, whose registry was still being set up, must be interpreted with special caution.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Malignant Mesothelioma, Occupational Exposure, Mesothelioma, Incidence, Pleura.

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• Trends in suspected and recognized occupational respiratory diseases in Germany between 1970 and 2005 — V. van Kampen, R. Merget, et al. (2008)
• Mesothelin Gene Variants Affect Soluble Mesothelin-Related Protein Levels in the Plasma of Asbestos-Exposed Males and Mesothelioma Patients from Germany — H.P. Rihs, S. Casjens, et al. (2022)
• Lung cancer risk and welding: results from a case-control study in Germany — K.H. Jöckel, W. Ahrens, et al. (1998)
• Occupational cancer in Germany — I. Brüske-Hohlfeld (1999)

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