Prof. Dr. med. Kolberg is Chief Physician of the Clinic for Gynaecology and Obstetrics at Marienhospital Bottrop, an academic teaching hospital of the University of Duisburg-Essen. He has headed the clinic there since 2005 and focuses on the treatment of malignant tumors of the female breast and female reproductive organs. He was previously Senior Consultant and Head of the Breast Center at the University Women's Hospital in Lübeck. In addition to gynecological oncology, his expertise also includes the treatment of fibroids, prolapse and incontinence as well as the care of patients in the field of high-risk obstetrics. Prof. Dr. Kolberg is known for his special expertise in complex gynaecological operations. He enjoys international recognition in the field of breast diagnostics.
An important part of his work is the use of modern, gentle procedures. This includes highly focused ultrasound treatment for fibroids and fibroadenomas as well as intraoperative radiotherapy for breast cancer. He takes a de-escalating approach to treatment, aiming to make interventions as gentle 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 Essen University Hospital, the Breast Center at Marienhospital Bottrop forms the Breast Center Essen 1 at the West German Tumor Center. Both centers meet the highest standards in terms of expertise, technical equipment and treatment experience.
Prof. Dr. Kolberg is scientifically active as a member of numerous national and international specialist societies, on the scientific advisory board of Brustkrebs Deutschland e.V., as 1st Chairman of the Association of Certified Breast Centers, which he also represents in the S3 Breast Cancer Guidelines Commission and the Certification Commission for Breast Centers. He regularly publishes in recognized journals, gives national and international lectures, particularly on the subject of breast cancer, and is an investigator in over 80 clinical trials. In the past, he has also worked as a visiting professor for breast surgery at the First School of Clinical Medicine in Nanjing, China and at the University of Malaya in Kuala Lumpur, Malaysia. Despite all his specialization and high-performance medicine, Prof. Dr. Kolberg attaches great importance to being a trustworthy contact person at eye level for his patients.
The editorial team of the Leading Medicine Guide was able to find out more about the latest developments in breast cancer treatment in an interview with Prof. Dr. Kolberg.
Breast cancer is the most common cancer in women in Germany. Around 70,000 women are diagnosed with the disease every year. Thanks to modern diagnostic and therapeutic procedures, the chances of recovery have improved significantly in recent years. Nevertheless, the disease remains a drastic event for many of those affected, requiring comprehensive medical care and personal support. Early detection and individually tailored treatment strategies play a decisive role in the success of treatment.
Breast cancer is a disease that is not only defined by its location in the mammary gland, but also by the very different biological characteristics of the individual tumors. These biological differences are decisive for how the tumor behaves in the body and which treatment is most suitable.
Prof. Dr. Kolberg explains: “Basically, as I said, breast cancer is not a single disease, but a collective term for many different types of tumor. For practical therapy and clinical significance, they are roughly divided into three, sometimes four subtypes. There are other classifications based on genomic tests, which are particularly important in terms of prognosis, but for daily routine and for understanding patients, the classification according to biological parameters is most helpful - i.e. according to characteristics that are determined in routine examinations. The largest group are the hormone receptor-positive, HER2-negative findings. These tumors are sensitive to anti-hormone therapies and are usually treated with them. Chemotherapy is only an option if there are additional risk factors such as high grading or a high cell division rate (proliferation rate). Overall, these tumors do not respond particularly well to chemotherapy, so they are primarily treated with anti-hormones. Then there are the HER2-positive breast carcinomas, which have 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. The HER2 status in turn indicates the sensitivity to certain antibodies. Patients with HER2-positive tumors usually receive a combination of chemotherapy and antibody therapy in the curable situation. Today, this treatment is usually carried out before surgery, which is called 'neoadjuvant'. This makes it possible to monitor how the tumor responds to treatment during therapy. Particularly pleasing: in HER2-positive carcinomas, around 60 to 65 percent of patients achieve a complete remission - no tumor is detectable at the time of surgery. The third group are the so-called triple-negative carcinomas. These tumors are neither hormone-sensitive nor do they respond to HER2 antibodies. In the case of small tumors, they are treated with chemotherapy before surgery. If they are larger or already have affected lymph nodes, chemotherapy is combined with immunotherapy using an immune antibody. These are the main therapeutic consequences that result from the different subtypes,” he adds:
“In fact, we have been researching for a long time to be able to treat breast cancer patients completely oncologically without the need for surgery. What we still lack is the ability to use imaging to reliably distinguish which patients really no longer have any tumor cells. So far, studies have only been able to achieve a false negative rate of around 20 percent at best - this means that one in five patients would be wrongly assumed to have a tumor that has disappeared, even though cancer cells are still present. This would of course be unacceptable because tumor tissue would then be left untreated. For this reason, intensive work is being done on new imaging techniques and tracers to make this distinction more reliably. At the moment, however, it is not yet possible to dispense with surgery altogether. Our goal remains to treat the tumor so effectively that it disappears completely and surgery is no longer necessary, but unfortunately we are not there yet. I expect that we could make decisive progress within the next ten years so that this vision becomes realistic."
An important point in today's breast cancer therapy is that tumor biology not only provides information about which therapy a patient might respond to, but is also a prognostic factor.
“In principle, triple-negative carcinomas, for example, have a worse prognosis than hormone receptor-positive tumors without appropriate therapy. However, we don't just administer chemotherapy because the prognosis is poor, but also because we know that certain tumors respond well to it. There has been a fundamental paradigm shift here in recent years: The principle of risk assessment used to apply, i.e. assessing the risk in order to then choose an appropriate therapy. Today, the focus is on responsiveness - i.e. the probability that a particular therapy will actually work. This means that it is no longer the poor prognosis alone that justifies intensive therapy, but rather whether the patient will actually benefit from the treatment. Even with a poor prognosis, we now avoid treatment if the chance of a response is low. These considerations are now incorporated into completely individualized treatment planning - a “one-size-fits-all” approach to breast cancer no longer exists,” explains Prof. Dr. Kolberg and continues on the subject of immunotherapy:
“Traditional immunotherapy for breast cancer works differently than is often assumed. These are not 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 act on specific mechanisms in the immune system. Cancer cells can normally evade the immune system through a kind of 'cloak of invisibility'. Immunotherapy helps to remove this camouflage and make the tumor visible and vulnerable to the body's own defenses. Although biomarkers such as PD-L1 play a role, treatment is currently often carried out independently of such markers, particularly in the early stages of the disease. When we talk about genetic predispositions, BRCA1 and BRCA2 are at the forefront - they are the tip of the iceberg, so to speak. In practice, however, we do not only examine these two genes, but a whole panel of mutations that can increase the risk of breast or ovarian cancer. Particularly relevant in the case of 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 offers poorer chances of survival. Around 5-6% of all breast cancers are caused by a genetic predisposition. We carry out genetic tests on patients who already have the disease in order to determine therapeutic options (such as the use of special drugs, e.g. PARP inhibitors) as well as preventive measures for the patient and indications for testing for the family. This is to be distinguished from women seeking advice - i.e. women who do not have the disease and who are at family risk. We draw up family trees for them and work with a scoring system that assesses the risk. Genetic testing is recommended from a risk of around 10%, for example in the case of breast cancer under 35 years of age, two cases under 50 or three cases over 50 years of age in a family."
If a mutation is detected, the personal lifetime risk of breast and ovarian cancer is calculated based on the individual mutation. Patients with a BRCA1 or BRCA2 mutation are usually advised to have their ovaries removed prophylactically in order to drastically reduce their risk.
Prof. Dr. Kolberg comments: “The decision to have prophylactic breast removal is made on a somewhat individual basis, but the risk of breast cancer is up to 70% over the course of a lifetime, which is why many women opt for such a measure. A prominent example of this is the actress Angelina Jolie, who attracted a lot of public attention with her decision to have both breasts removed as a preventative measure. This has greatly increased awareness of such options. It is important to know that even after breast or ovary removal, the risk is significantly reduced, but never reduced to zero. Nevertheless, these measures are often an important and sensible decision for affected women. For patients who already have breast cancer, the individual risk situation due to the current illness is also taken into account when considering the removal of the opposite side - this makes the decision even more complex, but also follows the principle of “individualization”.
In the future, even more tumors could receive specific therapies that are highly effective 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 of affected patients.
Young women with a family history of breast or ovarian cancer should not arrange for frequent gynecological examinations on their own initiative and out of a sense of security.
“My advice to young women who have an increased incidence of breast or ovarian cancer in their family is not to arrange frequent gynecological examinations on their own initiative and out of a sense of security. Instead, a structured approach should be taken. The first step is to assess the risk, which a gynecologist can do in a few minutes with the help of 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, they should be examined first, not the young woman herself. This is because the probability of discovering a genetic predisposition is significantly higher in a person who already has the disease. Whether a young woman has actually inherited the risk is a completely different question. An examination of the young woman herself would only be considered if no affected relatives were still alive. And intensified early detection measures would only be initiated if a genetic burden had actually been identified. The best contacts for such structured procedures are the specialized centers that are organized in the consortium for familial breast and ovarian cancer,” says Prof. Dr. Kolberg and makes further recommendations for early breast cancer detection:
“As far as early detection methods are concerned, tomosynthesis is not yet widespread enough to play a significant role in general early detection. MRI is a difficult alternative - although it detects findings, it has not yet been clearly proven that these findings actually improve the prognosis of patients. MRI therefore remains a complementary, but not a routine, examination method. As gynecologists, we would like to see ultrasound used more and no longer offered as a so-called “individual health service” (IGeL), as 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 carcinomas are found much earlier with screening than with palpation alone. In fact, the reduction in breast cancer mortality through screening is currently even more effective than many improvements in therapy. In Germany, screening mammography is not offered outside of structured screening. Currently, women between the ages of 50 and 75 receive an official invitation to screening, and it is important to take up this invitation as it can be life-saving. In the future, the age limit will actually be lowered: From the age of 45 to 75, women will be invited for a mammogram every two years. Anyone who receives such an invitation should take it seriously and make use of it."
In recent years, the gentle surgical treatment of breast cancer has made significant progress, particularly in the field of breast-conserving surgery and reconstruction methods. These advances aim to maintain patients' quality of life by avoiding the loss of the breast and at the same time allowing the tumor to be completely removed.
A significant advance in breast cancer surgery is the further development of breast-conserving procedures. In the past, mastectomy, i.e. 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, around 70 to 75 % of patients in Germany undergo breast-conserving surgery. It is still standard practice for breast-conserving surgery to be followed by radiotherapy. Sometimes part of the radiotherapy is carried out during the operation. Particularly in older patients, it is now also considered whether radiotherapy can be dispensed with, especially if targeted (“intraoperative”) radiotherapy has taken place. Increasingly, surgery on the lymph nodes in the armpit is also being dispensed with. 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. A tracer, a drug that is stored in lymph nodes and can be detected with special probes, is injected into the breast. The lymph nodes that absorb this substance are considered sentinel lymph nodes, which represent the entire armpit. If these lymph nodes are not affected, it can be assumed that the other lymph nodes are also free of tumor cells,” says Prof. Dr. Kolberg and adds:
“In patients over 50 and with small tumors under 2 cm, the sentinel lymph node biopsy is increasingly being dispensed with. For a significant proportion of patients, armpit surgery is no longer performed at all. This considerably reduces the risk of long-term consequences, such as lymphoedema in the arm or restricted mobility. This development means significantly less stress for patients and is a major step forward. Another change concerns the reconstruction options following a mastectomy. There is now a wide range of options available, both with autologous tissue and with implants. The decision is made on an individual basis and coordinated with the patient. In Germany, these measures are generally covered by statutory health insurance. An international comparison shows time and again that Germany is very well positioned in the care of breast cancer patients. There is no medically sensible measure in the treatment of breast cancer that would be reserved for a private patient and would not be available to a statutory health insurance patient. Everything that is necessary and sensible is made possible for all patients."
Psychosocial factors play an important role in the healing process and in the quality of life of patients during and after breast cancer treatment. The diagnosis of breast cancer and the subsequent treatment are often associated with enormous psychological stress, which can influence the entire healing process.
At Marienhospital, great importance is attached to taking psychological factors into account during treatment, particularly in the sensitive area of loss, femininity and hormonal changes. “Psycho-oncologists work closely with the treating physicians in the team. Every patient receives psycho-oncological care, regardless of whether the disease is early or advanced. Case managers and social services are also available. A specially trained full-time best nurse looks after breast cancer patients exclusively. This ensures intensive psychosocial care. In addition to individual support, there is also the opportunity to take part in group discussions after inpatient treatment. In addition, regular cancer counseling sessions are held at the clinic. Overall, a wide range of services are available, some of which are voluntary and some of which are mandatory as part of quality assurance. One important aspect is that every certified breast center in Germany - and that is almost all of them - is obliged to offer psycho-oncological support. As Chairman of the Association of Certified Breast Centers and a member of the Certification Commission, I can only emphasize the immense importance of this standard. This means that doctors have also clearly recognized how indispensable it is to integrate psycho-oncologists and psychologists into the treatment teams. The duration of the accompanying psychological care depends on the patient's individual needs. Psychosocial support needs are determined during the inpatient stay using a standardized instrument. Further care is then adapted on this basis. Long-term psychological support over a period of months cannot be provided in the centers themselves, as these services are not provided for in the current remuneration system. As soon as patients have completed inpatient treatment and there is a need for further psychotherapy, they are transferred to the outpatient sector. Patients are actively supported in finding suitable therapists,” emphasizes Prof. Dr. Kolberg.
At Marienhospital, there is a particular focus on participation in clinical studies. For a non-university hospital, an extraordinary amount of clinical research is carried out there.
Prof. Dr. Kolberg explains: “64% of patients are included in clinical trials, giving them access to new therapies that are not yet available in the normal treatment context. The hospital is very proud of this intensive scientific work. It forms the scientific focus of the Marienhospital. Another central point 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. It is also recommended that they visit their gynecologist at least once a year. This includes early detection of breast cancer as well as screening for cervical cancer. In Germany, only around 50% of women regularly take part in screening - an alarmingly low figure. It is therefore strongly recommended that these important examinations are carried out. Regular breast self-examination is also very important. The best time to do this is on the last day of your period. This simple measure can reduce the average tumor size at the time of detection by almost two centimeters and thus significantly improves the chances of recovery,” and with that we end our conversation.
Thank you very much, Prof. Dr. Kolberg, for this encouraging information!
