Breast Cancer: Early Detection and Modern Treatments Save Lives — Expert Interview with Prof. Dr. med. Hans-Christian Kolberg

Prof. Dr. med. Kolberg is Chief of the Department of Gynecology and Obstetrics at Marienhospital Bottrop, an academic teaching hospital affiliated with the University of Duisburg-Essen. He has headed the department there since 2005, focusing on the treatment of malignant tumors of the female breast and female reproductive organs. Prior to that, he was a senior attending physician and director of the Breast Center at the University Women’s Hospital in Lübeck. In addition to gynecologic oncology, his expertise includes the treatment of fibroids, the management of pelvic organ prolapse and incontinence, and the care of patients in the field of high-risk obstetrics. Prof. Dr. Kolberg is known for his exceptional skill in performing complex gynecologic surgeries. He is internationally recognized in the field of breast diagnostics.

An important part of his work involves the use of modern, minimally invasive procedures. These include highly focused ultrasound therapy for uterine fibroids and fibroadenomas, as well as intraoperative radiation therapy for breast cancer. In treatment, he follows a de-escalation approach aimed at making procedures as minimally invasive and individually tailored as possible. His clinic has been certified as a Breast Center by the German Cancer Society and the German Society for Senology since 2007, and as a Genital Cancer Center since 2010. Together with the University Hospital Essen, the Breast Center at Marienhospital Bottrop forms the Essen 1 Breast Center at the West German Cancer Center. Both centers meet the highest standards of professional expertise, technical equipment, and treatment experience.

In the field of research, Prof. Dr. Kolberg is active as a member of numerous national and international professional societies, on the scientific advisory board of Brustkrebs Deutschland e.V., and as the 1st Chair of the Working Group of Certified Breast Centers, which he also represents on the S3 Guidelines Commission for Breast Cancer and the Certification Commission for Breast Centers. He publishes regularly in recognized journals, gives national and international lectures—particularly on the topic of breast cancer—and serves as an investigator in over 80 clinical trials. In addition, he has previously served as a visiting professor of breast surgery at the First School of Clinical Medicine in Nanjing, China, and at the University of Malaya in Kuala Lumpur, Malaysia. Despite his specialization and focus on high-performance medicine, Prof. Dr. Kolberg places great importance on being a trusted point of contact for his patients, treating them as equals.

On the topic of breast cancer, the editorial team of the Leading Medicine Guide was able to learn more about the latest developments in breast cancer treatment during a conversation with Prof. Dr. Kolberg.

Breast cancer is the most common cancer among women in Germany. Approximately 70,000 women are newly diagnosed with it each year. Thanks to modern diagnostic and therapeutic methods, the chances of recovery have improved significantly in recent years. Nevertheless, for many patients, the disease remains a life-altering event that requires comprehensive medical care and personal support. Early detection and individually tailored treatment strategies play a decisive role in treatment success.

Breast cancer is a disease defined not only by its location in the mammary gland but also by the highly varied biological characteristics of individual tumors. These biological differences are crucial in determining how the tumor behaves in the body and which treatment is most appropriate.

Prof. Dr. Kolberg explains: “Fundamentally, as I said, breast cancer is not a single disease but an umbrella term for many different types of tumors. For practical treatment and clinical significance, they are roughly divided into three, sometimes four, subtypes. There are additional classifications based on genomic tests, which are primarily important for prognosis; however, for daily practice and for patients’ understanding, classification based on biological parameters is most helpful—that is, based on characteristics determined during routine examinations. The largest group consists of hormone receptor-positive, HER2-negative tumors. These tumors are sensitive to anti-hormone therapies and are generally treated with them. Chemotherapy is only considered if additional risk factors, such as a high grade or a high cell division rate (proliferation rate), are present. Overall, these tumors do not respond particularly well to chemotherapy, so they are primarily treated with anti-hormonal therapies. Then there are HER2-positive breast cancers, which exhibit a specific surface characteristic. The hormone receptor is also a surface characteristic that makes tumor cells sensitive to hormonal influences—and, accordingly, to anti-hormone therapies. HER2 status, in turn, indicates sensitivity to certain antibodies. Patients with HER2-positive tumors who are in a curable situation usually receive a combination of chemotherapy and antibody therapy. Today, this treatment is typically administered before surgery, a process known as “neoadjuvant” therapy. This allows for monitoring the tumor’s response to treatment during therapy. Particularly encouraging: In cases of HER2-positive carcinomas, approximately 60 to 65 percent of patients achieve complete remission—meaning no tumor is detectable at the time of surgery. The third group consists of what are known as triple-negative carcinomas. These tumors are neither hormone-sensitive nor do they respond to HER2 antibodies. For small tumors, they are treated with chemotherapy prior to surgery. If they are larger or have already spread to lymph nodes, chemotherapy is combined with immunotherapy using an immune antibody. “These are the main therapeutic implications resulting from the different subtypes,” he adds, and continues:

“In fact, we have long been conducting research aimed at providing breast cancer patients with comprehensive oncological treatment without the need for surgery. What we currently lack is the ability to use imaging to reliably distinguish which patients truly no longer have any tumor cells. In studies to date, the best that has been achieved is a false-negative rate of about 20 percent—which means that for one in five patients, we would mistakenly assume the tumor has disappeared, even though cancer cells are still present. That would, of course, be unacceptable, because it would mean leaving tumor tissue untreated. That is why intensive work is underway on new imaging techniques and tracers to make this distinction more reliably. At the moment, however, it is not yet possible to completely do without surgery. Our goal remains to treat the tumor so effectively that it disappears completely and surgery is no longer necessary, but unfortunately, we’re not there yet. I expect that we could make decisive progress within the next ten years, making this vision a realistic possibility.”

An important aspect of today’s breast cancer treatment is that tumor biology not only provides information about which therapy a patient might respond to but also serves as a prognostic factor. 

“Generally speaking, for example, triple-negative carcinomas have a poorer prognosis without appropriate therapy than hormone receptor-positive tumors. However, we administer chemotherapy not only because the prognosis is poor, but also because we know that certain tumors respond well to it. A fundamental paradigm shift has taken place here in recent years: In the past, the principle of risk assessment—that is, evaluating the risk in order to select an appropriate therapy—prevailed. Today, the focus is on responsiveness—that is, the likelihood that a specific therapy will actually be effective. This means that a poor prognosis alone no longer justifies intensive therapy; rather, the decisive factor is whether the patient will truly benefit from the treatment. Even in cases with a poor prognosis, we now avoid therapies if the chance of a response is low. These considerations are now incorporated into completely individualized treatment planning—a “one-size-fits-all” approach has long since ceased to exist in breast cancer,” Prof. Dr. Kolberg clarifies, and goes on to elaborate on the topic of immunotherapy:

“Traditional immunotherapy for breast cancer works differently than is often assumed. It does not involve highly personalized cell therapies, such as CAR-T cell therapies, which are produced individually for each patient and are extremely expensive. Instead, we use standard antibodies that target specific mechanisms in the immune system. Cancer cells can normally evade the immune system by donning a sort of ‘cloak of invisibility.’ Immunotherapy helps remove this camouflage and make the tumor visible and vulnerable to the body’s own defenses. While biomarkers such as PD-L1 play a role, treatment—especially in the early stages of the disease—is currently often still administered independently of such markers. When we talk about genetic predispositions, BRCA1 and BRCA2 are at the forefront—they are, so to speak, the tip of the iceberg. In practice, however, we do not examine just these two genes, but rather a whole panel of mutations that can increase the risk of breast or ovarian cancer. What is particularly relevant with BRCA1 and BRCA2 mutations is not only the increased risk of breast cancer, but above all the significantly increased risk of ovarian cancer, which is more aggressive and has poorer survival rates. About 5–6% of all breast cancers are caused by a genetic predisposition. For patients who have already been diagnosed, we perform genetic testing to determine both treatment options (such as the use of specific medications, including PARP inhibitors) and preventive measures for the patient, as well as recommendations for testing within the family. This is distinct from women seeking counseling—that is, women who have not been diagnosed with the disease but have a family history of risk. For them, we create family trees and use a scoring system to assess their risk. Genetic testing is recommended when the risk is approximately 10% or higher—for example, in cases where there has been one breast cancer diagnosis before age 35, two diagnoses before age 50, or three diagnoses after age 50 within a family.”

If a mutation is detected, the individual’s lifetime risk of breast and ovarian cancer is calculated based on that specific mutation. Patients with a BRCA1 or BRCA2 mutation are generally advised to undergo prophylactic removal of the ovaries to drastically reduce their risk. 

Prof. Dr. Kolberg comments on this: “The decision to undergo prophylactic mastectomy is made on a more individual basis, but the lifetime risk of breast cancer in such cases is as high as 70%, which is why many women opt for this procedure. A prominent example of this is the actress Angelina Jolie, who attracted a great deal of public attention with her decision to undergo preventive removal of both breasts. This has greatly increased awareness of such options. It is important to note that even after a mastectomy or oophorectomy, the risk is significantly reduced but never eliminated entirely. Nevertheless, these measures are often an important and sensible decision for the women affected. For patients who have already been diagnosed with breast cancer, considerations regarding the removal of the opposite breast also take into account the individual risk profile resulting from the current disease—this makes the decision even more complex, but it also follows the principle of individualization.”

In the future, even more tumors could receive targeted therapies that achieve high efficacy with very few side effects. This represents one of the most promising developments in the treatment of breast cancer and improves both the prognosis and the quality of life for affected patients.

Young women with a family history of an increased incidence of breast or ovarian cancer should not schedule frequent gynecological examinations on their own initiative simply out of a sense of security. 

“My advice to young women with a family history of breast or ovarian cancer is not to schedule frequent gynecological exams on their own initiative simply out of a desire for reassurance. Instead, they should take a structured approach. The first step is to assess the risk, which a gynecologist can do in just a few minutes using a family tree. If an increased risk is identified, the question arises as to whether the affected mother or aunt is still alive. If so, she should be examined first, not the young woman herself. This is because the likelihood of detecting a genetic predisposition is significantly higher in a person who has already developed the disease. Whether a young woman has actually inherited the risk is an entirely different question. Only if no affected relatives are still alive would an examination of the young woman herself be considered. And intensified early detection measures would be initiated only if a genetic predisposition were actually confirmed. “The best points of contact for such structured approaches are the specialized centers organized within the Consortium for Familial Breast and Ovarian Cancer,” says Prof. Dr. Kolberg, who also offers recommendations regarding breast cancer screening:

“As far as early detection methods are concerned: Tomosynthesis is not yet widespread enough to play a significant role in general early detection. MRI presents a difficult alternative—while it does detect abnormalities, it has not yet been conclusively proven that these findings actually improve patients’ prognosis. Therefore, MRI remains a supplementary, but not a routine, screening method. As gynecologists, we would like to see ultrasound used more widely and no longer offered as a so-called ‘individual health service’ (IGeL), since ultrasound can also detect carcinomas at an early stage. Nevertheless, mammography screening remains the gold standard. It has been proven to be the most effective means of reducing breast cancer mortality in the general population, as cancers are detected significantly earlier through screening than by manual palpation alone. In fact, the reduction in breast cancer mortality achieved through screening is currently even more effective than many advances in treatment. In Germany, preventive mammograms are not offered outside of the structured screening program. Currently, women between the ages of 50 and 75 receive an official invitation to participate in the screening, and it is crucial to accept this invitation, as it can save lives. In the future, the age range will even be lowered: Women aged 45 to 75 are to be invited for a mammogram every two years. Anyone who receives such an invitation should take it seriously and act on it.”

In recent years, minimally invasive surgical treatment for breast cancer has made significant progress, particularly in the areas of breast-conserving surgery and reconstruction methods. These advances aim to preserve patients’ quality of life by avoiding the loss of the breast while still allowing for the complete removal of the tumor.

A major advance in breast cancer surgery has been the further development of breast-conserving procedures. In the past, mastectomy—that is, the complete removal of the breast—was the standard treatment for many forms of breast cancer. “The basic principle is: as little as possible, but as much as necessary.” Today, approximately 70 to 75% of patients in Germany undergo breast-conserving surgery. It remains standard practice to administer radiation therapy following breast-conserving surgery. Sometimes, part of the radiation therapy is administered during the surgery itself. Particularly for older patients, doctors are now also considering whether radiation therapy can be omitted, especially if targeted (“intraoperative”) radiation has been administered. Increasingly, surgeons are also foregoing the removal of lymph nodes in the armpit. In the past, it was common practice to remove at least ten lymph nodes. Today, the so-called sentinel lymph node biopsy is the new standard. In this procedure, a tracer—a medication that is stored in lymph nodes and can be detected using special probes—is injected into the breast. The lymph nodes that take up this substance are considered sentinel lymph nodes, which represent the entire axilla. If these lymph nodes are not affected, it can be assumed that the remaining ones are also free of tumor cells,” says Prof. Dr. Kolberg, adding:

“For patients over 50 years of age with small tumors under 2 cm, sentinel lymph node biopsy is increasingly being omitted. For a significant proportion of patients, axillary surgery is no longer performed at all. This significantly reduces the risk of long-term complications, such as lymphedema in the arm or limited mobility. This development means a significantly lower burden for patients and represents a major advance. Another change concerns the options for reconstruction following a mastectomy. A wide range of options is now available, using both the patient’s own tissue and implants. The decision is made on a case-by-case basis and agreed upon together with the patient. In Germany, these procedures are generally covered by statutory health insurance. International comparisons consistently show that Germany is very well positioned in the care of breast cancer patients. There is no medically appropriate treatment for breast cancer that is reserved for privately insured patients and not available to those with public health insurance. Everything that is necessary and appropriate is made available to all patients.”

Psychosocial factors play a significant role in the healing process and in patients’ quality of life during and after breast cancer treatment. A breast cancer diagnosis and the subsequent treatment are often associated with enormous psychological stress, which can influence the entire healing process. 

At Marienhospital, great importance is placed on taking psychological factors into account during treatment, particularly in the sensitive areas of loss, femininity, and hormonal changes. “Psycho-oncologists work closely with the treating physicians as part of a team. Every patient receives psycho-oncological care, regardless of whether the disease is in an early or advanced stage. In addition, case managers and social services are available. A specially trained full-time “Best Nurse” is dedicated exclusively to caring for breast cancer patients. This ensures intensive psychosocial care. In addition to individual care, patients also have the option to participate in group sessions following inpatient treatment. Furthermore, regular counseling sessions with the in-house cancer counseling service are offered. Overall, a wide range of services is available, some voluntary and others mandatory as part of quality assurance. An important aspect is that every certified breast center in Germany—and that is nearly all of them—is required to offer psycho-oncological support. As chair of the Working Group of Certified Breast Centers and a member of the Certification Commission, I can only emphasize the immense importance of this standard. This also demonstrates that the medical community clearly recognizes how indispensable the involvement of psycho-oncologists and psychologists in treatment teams is. The duration of the accompanying psychological care is determined on an individual basis according to each patient’s specific needs. Already during the inpatient stay, a standardized tool is used to assess the need for psychosocial support. Further care is then tailored based on this assessment. Long-term psychological support spanning several months cannot be provided within the centers themselves, as these services are not covered under the current reimbursement system. “As soon as patients have completed inpatient treatment and there is a continued need for psychotherapy, they are transitioned to outpatient care. In this process, patients are actively supported in finding suitable therapists,” emphasizes Prof. Dr. Kolberg.

At Marienhospital, there is a particular focus on participation in clinical trials. For a non-university hospital, an exceptionally high volume of clinical research is conducted there. 

Prof. Dr. Kolberg explains: “64% of patients are enrolled in clinical trials, giving them access to new therapies that are not yet available in the standard of care. The hospital is very proud of this intensive scientific work. It forms the scientific focus of the Marienhospital. Another key area concerns the early detection of breast cancer. Participation in the screening program is essential. Women who are invited should definitely take advantage of this opportunity. In addition, it is recommended to see a gynecologist at least once a year. During these visits, both breast cancer screening and cervical cancer screening are performed. In Germany, only about 50% of women currently participate regularly in these preventive screenings—an alarmingly low figure. Therefore, it is strongly advised to undergo these important examinations. In addition, regular breast self-exams are of great importance. They should ideally be performed on the last day of your period. “This simple measure can reduce the average tumor size at the time of detection by nearly two centimeters, thereby significantly improving the chances of recovery,” and with that, we conclude our conversation.

Thank you very much, Prof. Dr. Kolberg, for this encouraging information!