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      Shifting cancer care towards Multidisciplinarity: the cancer center certification program of the German cancer society

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          Abstract

          Background

          Over the last decades numerous initiatives have been set up that aim at translating the best available medical knowledge and treatment into clinical practice. The inherent complexity of the programs and discrepancies in the terminology used make it difficult to appreciate each of them distinctly and compare their specific strengths and weaknesses. To allow comparison and stimulate dialogue between different programs, we in this paper provide an overview of the German Cancer Society certification program for multidisciplinary cancer centers that was established in 2003.

          Main body

          In the early 2000s the German Cancer Society assessed the available information on quality of cancer care in Germany and concluded that there was a definite need for a comprehensive, transparent and evidence-based system of quality assessment and control. This prompted the development and implementation of a voluntary cancer center certification program that was promoted by scientific societies, health-care providers, and patient advocacy groups and based on guidelines of the highest quality level (S3). The certification system structures the entire process of care from prevention to screening and multidisciplinary treatment of cancer and places multidisciplinary teams at the heart of this program. Within each network of providers, the quality of care is documented using tumor-specific quality indicators. The system started with breast cancer centers in 2003 and colorectal cancer centers in 2006. In 2017, certification systems are established for the majority of cancers. Here we describe the rationale behind the certification program, its history, the development of the certification requirements, the process of data collection, and the certification process as an example for the successful implementation of a voluntary but powerful system to ensure and improve quality of cancer care.

          Conclusion

          Since 2003, over 1 million patients had their primary tumors treated in a certified center. There are now over 1200 sites for different tumor entities in four countries that have been certified in accordance with the program and transparently report their results from multidisciplinary treatment for a substantial proportion of cancers. This led to a fundamental change in the structure of cancer care in Germany and neighboring countries within one decade.

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          Most cited references 18

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          Multidisciplinary team working across different tumour types: analysis of a national survey.

          Using data from a national survey, this study aimed to address whether the current model for multidisciplinary team (MDT) working is appropriate for all tumour types. Responses to the 2009 National Cancer Action Team national survey were analysed by tumour type. Differences indicate lack of consensus between MDT members in different tumour types. One thousand one hundred and forty-one respondents from breast, gynaecological, colorectal, upper gastrointestinal, urological, head and neck, haematological and lung MDTs were included. One hundred and sixteen of 136 statements demonstrated consensus between respondents in different tumour types. There were no differences regarding the infrastructure for meetings and team governance. Significant consensus was seen for team characteristics, and respondents disagreed regarding certain aspects of meeting organisations and logistics, and patient-centred decision making. Haematology MDT members were outliers in relation to the clinical decision-making process, and lung MDT members disagreed with other tumour types regarding treating patients with advanced disease. This analysis reveals strong consensus between MDT members from different tumour types, while also identifying areas that require a more tailored approach, such as the clinical decision-making process, and preparation for and the organisation of MDT meetings. Policymakers should remain sensitive to the needs of health care teams working in individual tumour types.
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            Survival of women with breast cancer in Europe: variation with age, year of diagnosis and country. The EUROCARE Working Group.

            Breast cancer is the most frequent malignancy among women in developed countries. Prognosis is better than for other major cancers, and an improvement in survival has been reported for several populations in recent decades. Within the framework of EUROCARE, a population-based project concerned with the survival and care of cancer patients in Europe, we analysed data from 119,139 women diagnosed with breast cancer between 1978 and 1985 in 12 countries and followed for at least 6 years. Multiple regression models of relative survival, which take mortality from all other causes in each area into account, were used to estimate the effect of age, period of diagnosis and country on survival. For the comparison between countries, survival rates were age-standardised to the age structure of the entire study population. Women aged 40-49 years at diagnosis had the best prognosis in all countries and throughout the study period. Women younger than 30 years at diagnosis had a worse prognosis than those aged 30-39. The highest relative survival at 5 years was in Finland and Switzerland (about 74%), intermediate levels were found for Italy, France, The Netherlands, Denmark and Germany (about 70%) and the lowest rates were in Spain, the United Kingdom, Estonia and Poland (55-64%). During the 6 months following diagnosis, survival was highly dependent on age and was sharply lower in women older than 49 years. For women surviving more than 6 months after diagnosis, survival was similar for all ages, although women aged 40-49 still had the better prognosis. The average rate of death from breast cancer fell by about 2.5% for each year of diagnosis between 1978 and 1985. This improvement manifested mainly in younger and older women, for whom survival was initially less good. The largest improvement was seen in Poland (-15% death risk per year). We suggest that the better survival of women aged 40-49 at diagnosis is related to lower levels of circulating sex hormones, resulting in reduced stimulation of tumour cell growth. Early diagnosis may also be important in the peri-menopausal period due to increased diagnostic attention. Low survival in the United Kingdom may be due to inadequate adherence to consensus treatment guidelines and greater variation in treatment.
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              Benchmarking the quality of breast cancer care in a nationwide voluntary system: the first five-year results (2003–2007) from Germany as a proof of concept

              Background The main study objectives were: to establish a nationwide voluntary collaborative network of breast centres with independent data analysis; to define suitable quality indicators (QIs) for benchmarking the quality of breast cancer (BC) care; to demonstrate existing differences in BC care quality; and to show that BC care quality improved with benchmarking from 2003 to 2007. Methods BC centres participated voluntarily in a scientific benchmarking procedure. A generic XML-based data set was developed and used for data collection. Nine guideline-based quality targets serving as rate-based QIs were initially defined, reviewed annually and modified or expanded accordingly. QI changes over time were analysed descriptively. Results During 2003–2007, respective increases in participating breast centres and postoperatively confirmed BCs were from 59 to 220 and from 5,994 to 31,656 (> 60% of new BCs/year in Germany). Starting from 9 process QIs, 12 QIs were developed by 2007 as surrogates for long-term outcome. Results for most QIs increased. From 2003 to 2007, the most notable increases seen were for preoperative histological confirmation of diagnosis (58% (in 2003) to 88% (in 2007)), appropriate endocrine therapy in hormone receptor-positive patients (27 to 93%), appropriate radiotherapy after breast-conserving therapy (20 to 79%) and appropriate radiotherapy after mastectomy (8 to 65%). Conclusion Nationwide external benchmarking of BC care is feasible and successful. The benchmarking system described allows both comparisons among participating institutions as well as the tracking of changes in average quality of care over time for the network as a whole. Marked QI increases indicate improved quality of BC care.
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                Author and article information

                Contributors
                +49(0)30 / 322 932 955 , kowalski@krebsgesellschaft.de
                Ullrich.graeven@mariahilf.de
                christof.kalle@NCT-Heidelberg.de
                hauke.lang@unimedizin-mainz.de
                Matthias.Beckmann@uk-erlangen.de
                jens.blohmer@charite.de
                martin.burchardt@uni-greifswald.de
                michael.ehrenfeld@med.lmu.de
                jan.fichtner@evkln.de
                Stephan.grabbe@unimedizin-mainz.de
                hans.hoffmann@urz.uni-heidelberg.de
                heinrich.iro@uk-erlangen.de
                stefan.post@umm.de
                scharl.anton@klinikum-amberg.de
                uwe.schlegel@kk-bochum.de
                thomas.seufferlein@uniklinik-ulm.de
                walter.stummer@ukmuenster.de
                dieter.ukena@klinikum-bremen-ost.de
                j.ferencz@onkozert.de
                wesselmann@krebsgesellschaft.de
                Journal
                BMC Cancer
                BMC Cancer
                BMC Cancer
                BioMed Central (London )
                1471-2407
                14 December 2017
                14 December 2017
                2017
                : 17
                Affiliations
                [1 ]German Cancer Society, Department for Certification, Kuno-Fischer-Strasse 8, 14057 Berlin, Germany
                [2 ]Kliniken Maria Hilf GmbH, Viersener Strasse 450, 41063 Mönchengladbach, Germany
                [3 ]NCT University Hospital, Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
                [4 ]GRID grid.410607.4, University Hospital, ; Langenbeckstrasse 1, 55131 Mainz, Germany
                [5 ]ISNI 0000 0000 9935 6525, GRID grid.411668.c, University Hospital, ; Universitätsstrasse 21-23, 91054 Erlangen, Germany
                [6 ]ISNI 0000 0001 2218 4662, GRID grid.6363.0, Charité University Hospital, ; Charitéplatz 1, 10117 Berlin, Germany
                [7 ]University Hospital, Fleischmannstrasse 42, 17489 Greifswald, Germany
                [8 ]ISNI 0000 0004 0477 2585, GRID grid.411095.8, University Hospital, ; Lindwurmstrasse 2a, 80337 Munich, Germany
                [9 ]Johanniter Krankenhaus, Steinbrinkstr. 96, 46145 Oberhausen, Germany
                [10 ]University Hospital, Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
                [11 ]University Medical Center, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
                [12 ]GRID grid.440273.6, Klinikum St. Marien, ; Mariahilfbergweg 7, 92224 Amberg, Germany
                [13 ]ISNI 0000 0004 0490 981X, GRID grid.5570.7, Knappschaftskrankenhaus, Dept. of Neurology, , Ruhr-University Bochum, ; In der Schornau 23, 44892 Bochum, Germany
                [14 ]GRID grid.410712.1, Ulm University Hospital, ; Albert-Einstein-Allee 23, 89081 Ulm, Germany
                [15 ]ISNI 0000 0004 0551 4246, GRID grid.16149.3b, University Hospital, ; Albert-Schweitzer-Campus 1, 48149 Münster, Germany
                [16 ]Hospital Ost, Züricher Strasse 40, 28325 Bremen, Germany
                [17 ]OnkoZert GmbH, Certification Institute of the German Cancer Society, Gartenstrasse 24, 89231 Neu-Ulm, Germany
                Article
                3824
                10.1186/s12885-017-3824-1
                5731059
                29241445
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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                © The Author(s) 2017

                Oncology & Radiotherapy

                multidisciplinarity, certification, quality of care, quality indicators

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