How it all began - our Breast Center

The idea to establish a specialized breast cancer center in Stade, Lower Saxony, where I have been working as a radiologist-mammologist since 2009, was born as a result of numerous studies from America and Scandinavia. These studies indicated a reduction in breast cancer mortality with early diagnosis – in the United States, a 1.6% reduction per year from 1995, and a 3.4% reduction per year from 1995 to 1998. In Germany, the numbers were discouraging, with only 41.8% of affected women remaining alive after 15 years, while in America, it was up to 58%.

German experts demanded fundamental changes and reforms at all levels of healthcare. The reasons for this catastrophic situation were clear:

• Late breast cancer diagnosis due to a lack of lobbying for screening by pharmaceutical associations.
• Reduced chances for treatment due to the widespread application of evidence-based medicine principles.
• Women were losing their lives because communication between doctors from different specialties involved in breast cancer diagnosis and treatment was not effectively established.
• The absence of a national tumor registry prevented the analysis of statistics, error correction, and drawing conclusions about the effectiveness of diagnosis and therapy.

The early diagnosis indicator for breast cancer is the tumor size – a maximum of 10mm. In the USA, the average tumor size at the time of detection was 11mm, whereas in Germany, until 2002, tumors were often identified at the 2nd stage (2 to 5cm). The ability to detect tumors at an early stage was demonstrated in some individual centers in Germany, where communication between hospital specialists and outpatient radiologists and gynecologists was established. In these centers, most tumors were diagnosed with sizes below 1.5cm. The utility of early detection is reflected in life expectancy – according to the Ministry of Health in Bonn, late diagnosis costs the lives of 4000 women in Germany each year.

The prognosis is particularly favorable in cases of in-situ breast cancer (when the tumor has not spread beyond the milk ducts and has not metastasized). Adequate treatment in such cases can achieve a recovery rate of up to 98%. In countries with functioning screening programs, up to 20% of tumors are detected at this pre-cancerous stage. In some American and British centers, this figure reaches 40%. In the early 2000s, Germany had a discouraging statistic, with only 5% of carcinomas being diagnosed at the pre-cancerous stage (in-situ).

The problem in Germany lay in the low qualification of gynecologists, who were not sufficiently skilled to detect carcinoma at an early stage. They had limited experience in reading mammograms. Outdated mammography machines were used in clinics, which were not regularly calibrated. Additionally, there was a lack of readiness for double-reading mammograms.

After numerous hearings and years of debates, the Bundestag passed a law on the all-German breast cancer screening program in 2003. On December 16, 2003, the Association of Health Insurance Physicians and the Hospital Funds issued a joint statement: "Finally, starting from January 1, 2004, we can offer all women an outpatient early breast cancer detection program. As soon as all the necessary conditions for the launch of this program are met in your region, women aged 50-69 will be invited every 2 years for screening mammography," announced the first head of the Association of Health Insurance Physicians (KBV), Dr. Manfred Richter-Reichhelm. By now, this age group has been determined as breast cancer is most frequently encountered in this age range.

From this moment, an active campaign to popularize screening among radiologists, gynecologists, and the female population began. Our clinic, one of the first, embraced this new wave, and in 2000, the Breast Center was established based at Klinik Dr. Hancken, greatly improving communication and information exchange among outpatient gynecologists, radiologists, radiation therapists, oncologists at Klinik Dr. Hancken, and gynecologists at the city clinic (Elbe Klinik Stade).

Initially, meetings were held with gynecologists in the so-called "informal working group on screening" (arbeitskreis). The pivotal moment was the certification of the center and its approval as a regional screening unit. "We initially met in the parking lot to exchange experiences in the early stages of screening," says Dr. Töllner, the program's responsible physician in our region. Such meetings were necessary because not all colleagues in the region supported the idea put forth by the Association of Health Insurance Physicians. There was resistance, some of it quite significant. In 2002, the German magazine Spiegel, on the eve of the reform, published appeals from medical communities attempting to establish and promote their own screening: "They criticized population-based screening as 'mass production' in mammography centers. X-ray preventive mammography only makes sense when combined with palpation by a doctor and targeted ultrasound examination in case of suspicious findings."

However, such demands should be approached with caution, as skeptics of population-based screening often only want to prevent patients from leaving their practices for mammography centers. The significance of ultrasound is also often exaggerated by office-based gynecologists. For example, in the detection of carcinoma in situ (precancerous condition), ultrasound is practically "blind."

In our center, preparations for the launch of the screening program were in full swing. Center doctors underwent special training designed for screening program physicians, with the review of 5000 mammograms per year and an exam based on 200 mammograms. The screening region was divided with another center in a neighboring city (the "sphere of responsibility" was divided, so to speak). Center doctors spent several weeks learning from colleagues in the United Kingdom to gain experience from those already operating a national screening program. It became clear that screening would succeed if it reached women – the Netherlands' "magic border" – the distance a woman can travel by bicycle to the nearest screening center," explains Dr. Töllner's colleague. Consequently, mobile screening units on wheels began to be introduced in the Netherlands. These "rolling" mobile X-ray units were not cheap, costing 400,000 euros. Our center and neighboring colleagues acquired such a machine.

These were not the only investments made. It was necessary to divide the waiting area for patients being observed in the center for breast cancer and healthy women invited for screening. Centers had to provide a separate entrance for screening women or separate their times from women with complaints undergoing observation in the center for cancer treatment or recurrence prevention.

Not only the facilities but also the equipment was state-of-the-art. Digital mammography was being introduced at the time, replacing the outdated system. Additionally, a Fischer table for conducting stereotactic biopsies of microcalcifications and non-palpable tumors was acquired by our center in 2003 (it was invented and introduced into practice in America in 1996/97). To this day, this method remains the gold standard for the examination of microcalcifications and in cases where biopsy cannot be performed under ultrasound guidance.

Even during the construction phase, Dr. Töllner actively campaigned, presented reports to office-based gynecologist colleagues in our region, preparing them for the start of screening. Dr. Töllner was well-known in these circles, as he continued to give lectures and seminars with a surgeon from the clinic on the topic of thrombosis.

Since 2000, we have already been a Breast Center. Colleagues from our center, office-based gynecologists, and surgeons from the clinic regularly met with each other and conducted joint training seminars. To popularize screening, it was not enough to communicate with doctors alone. Therefore, Dr. Töllner established contacts with women's associations in the region, and the idea of screening and informational meetings were received by them with great enthusiasm. Often, reporters from local newspapers were present at these meetings, spreading information about the upcoming new program. In parallel, other radiologist colleagues from our center attended special courses to participate in the screening program. Each mammogram had to be reviewed by two radiologists independently. Additionally, the nurses conducting mammography underwent special training at courses. During the screening mammography procedure, a doctor is not present; a nurse works alone and is the sole point of contact for the patient, who, in the case of a normal mammogram (without pathology), never sees a doctor.

In 2006, the population-based screening program was officially launched across Germany. Our screening center was one of the first to be certified to conduct breast cancer screening.

At the start of the program, we invited reporters from the local newspaper and the First Deputy Mayor, Mrs. Ignelore Heuck, for an official announcement:

"Women in the high-risk age group of 50-69 years will have the opportunity to participate in the German regular, free early breast cancer diagnosis program. Every 2 years, women in this age group will be invited to undergo mammography at a specially equipped practice based at the Dr. Hancken clinic." Mrs. Heuck gave special praise for the design of the practice rooms: "The rooms are lovingly furnished, which provides women with additional support and confidence," said Mrs. Heuck. Already on Monday, the first 4 women of screening age received invitations to undergo their first mammogram. Additionally, over the next two years, women from the neighboring regions will be gradually invited for mammography, not in our practice but in a mammography mobile unit. This large mobile bus, converted into a mammological practice, was presented at an exhibition in our region the day before. It will gradually travel and stop for 2-4 weeks in all remote areas of our screening region, providing modern diagnostics without prolonged waiting. All mammogram images are evaluated by two specially trained radiologists-mammologists before the woman receives a written report. Mammography had been used before screening, but only when a woman had complaints and was referred by a doctor for a radiological examination. As a result, screening in our region has proven successful; more than 60% of women aged 50-69 accepted the invitation and underwent mammography in 2020 – one of the highest rates in Germany. In 20% of cases, we detect changes at the in-situ (precancerous) stage, which, with appropriate therapy, offers a chance of complete cure of up to 98%.

So, to establish screening, dialogue is needed above all – dialogue among doctors of different specialties: surgeons, radiologists, oncologists, radiation therapists, pathologists, psycho-oncologists. Only the willingness of all to work as a unified team can lead to success and overcome skepticism at the very beginning. Of course, initially, this means an additional workload for all participants in creating a multidisciplinary team. According to German colleagues, such collaborative multidisciplinary work should already be taught at the university.

Positive effects of multidisciplinary collaboration:

• Improved quality of treatment and reduction in advanced disease
• More active patient involvement in therapy decisions
• Reduction in repeat and unnecessary examinations
• Positive impact on the quality of life of chronically ill patients
• Increased life expectancy