With gratitude to the American College of Surgeons (ACS) and the German Surgical Society (Deutsche Gesellschaft für Chirurgie, DGC), I report on my experiences as the 2013 Traveling Fellow to Germany. The trip included attendance at the 130th Congress of the German Surgical Society and visits to four different institutions that provide breast surgery services and are involved in oncology clinical trial accrual.
Frankfurt—German Breast Group
The successes in clinical trial completion that European breast oncologists have experienced intrigue me. Clinical trials from Germany and other European countries have been featured prominently at breast oncology meetings in the U.S. To learn more about their efforts, I visited the German Breast Group (GBG), headquartered in Neu-Isenburg near Frankfurt. This cooperative group conducts mostly phase II and III trials. More than 5,000 patients participated in their trials last year. The GBG maintains a robust portfolio that strikes a balance between prevention, neoadjuvant, adjuvant, and palliation studies, with an emphasis on investigator-initiated trials. Although funding comes from a combination of public, philanthropic, and industry sources, the group is committed to preserving its independence and academic orientation.
Concept-to-activation times for trial development are significantly shorter than those reported for oncology clinical trial cooperative groups in the U.S. Trial activation processes at local institutions use central institutional review boards (IRBs). Incentives for local investigator participation include authorship for high recruiters, which is critical for professional advancement; access to the latest treatment agents; and breast center certification requirements of at least 10 percent of patients enrolled in clinical trials.
I shared with GBG some of my research in clinical trial accrual in the cooperative group setting. Our discussion proved to be an informative exchange of experiences and ideas. The friendliness of the GBG staff was much appreciated and made for a welcome reception just a few hours after my arrival in Frankfurt.
Berlin—HELIOS Klinik and the Langenbeck-Virchow-Haus
The following morning I traveled by train to Berlin. The German capital is vibrant and dynamic, offering an abundance of historical and cultural sites. Certainly the city has undergone profound changes in the last 20 years, rendering places I had seen on my first trip there in the summer of 1990 virtually unrecognizable.
A primary focus of my fellowship was to observe multidisciplinary health care delivery for breast cancer in Germany. To this end, I wanted to visit a breast center in both a private clinic setting and a university setting. Today, breast cancer care in Germany is largely delivered in nationally certified breast centers. To improve quality-of-care standards and reduce practice variability in breast cancer care, the German Cancer Society (Deutsche Krebsgesellschaft, DKG) and the German Society of Senology (Deutsche Gesellschaft für Senologie, DGS) developed evidence-based clinical guidelines and a program for breast center certification approximately 10 years ago. More than 70 percent of women with breast cancer in Germany are now estimated to receive their diagnostic and therapeutic interventions in a certified breast center. Continuous quality improvement includes monitoring adherence to guideline recommendations and process quality indicators. Of note, breast cancer surgery in Germany is a clinical domain of gynecology, rather than general surgery as it is in the U.S.
My first clinical visit was at the HELIOS Klinik in Berlin-Buch. Here I was greeted by the chefartz (chief), Prof. Dr. med. Michael Untch, and by oberärztin (attending) Dr. med. Christine Mau. After participating in the morning report, I was thrilled to spend the day in the operating room (OR) assisting Dr. Mau. We performed five breast operations, including one with intraoperative radiation therapy. It was interesting to observe minor differences in technique. However, most fascinating was the rapid OR turnover. With each turnover well below 30 minutes, and some even less than 15 minutes, I saw a very different workflow than I have seen in the U.S. Also impressive was the large amount of natural light in the ORs.
The HELIOS Klinik breast center enrolls many patients in clinical trials. Two of the five patients I saw in the OR were participating in a therapeutic clinical trial.
The following day I visited the Langenbeck-Virchow-Haus to see the DGC’s headquarters (see photo,). I received a very kind reception from Rosmarie Nowoiski, PhD, director of the DGC. She took time away from preparing for the upcoming conference to provide me with historical information about the society and the building in which it is housed. The DGC first began hosting meetings in this building in 1915. Following World War II, the building became the property of the German Democratic Republic. The DGC regained ownership of the building in 2003, along with the original co-owners, the Berlin Medical Society, after a protracted legal battle. Dr. Nowoiski provided a tour of the building and helped arrange additional meetings for me. She and her staff are clearly committed to making the visiting Fellow’s experience a rich and rewarding one.
Munich—Ludwig Maximilian Universität
Munich was the next stop. I was fortunate to spend several days with the Ludwig Maximilian Universität (LMU) Breast Center team at both clinical sites: Campus Innenstadt and Campus Grosshadern. The Women’s Clinic at Campus Innenstadt is housed in buildings dating to 1916 (see photo, this page). Many of the decorations, clocks, and door inscriptions are the originals. The buildings are constructed around a tranquil courtyard and fountain, with patient rooms facing inward to shield against outside noise. Open terraces also invite patients to sit outside and take in fresh air. The more modern Campus Grosshadern constitutes one of the largest hospital complexes and teaching institutions in Germany.
Prof. Dr. med. Nadia Harbeck, director of the Breast Center, made the arrangements for my visit. Through interactions in the clinic and the OR, I was able to observe a high-functioning multidisciplinary team. Interestingly, most of the gynecologists whom I met had developed a particular focus within breast care, enabling them to work together as a team. Some physicians devote their time primarily to medical therapies and clinical trials, others to breast surgery and reconstruction, and one other to image-guided procedures. Again, a robust portfolio of clinical trials was available to patients, and offering clinical trial participation was notably a priority.
In addition to spending considerable time with Prof. Harbeck, I had the pleasure of meeting with Oberärztinnen Dr. med. Rachel Würstlein and Dr. med. Isabelle Himsl. Through their clinics and multidisciplinary tumor board meetings, I learned about the delivery of breast cancer screening, treatment plans, and survivorship care in the German health care system. Our discussions regarding various practice differences between the U.S. and Germany, such as the higher mastectomy rate for early stage breast cancer in the U.S. and the central role of the primary care physician in delivering survivorship care in Germany, were thought-provoking. Furthermore, I am thankful for the time and sample patient resources that Frau Brigitte Ehrl, breast center nurse and patient navigator, provided.
130th Congress of the DGC
The 130th Congress of the DGC took place in Munich this year with more than 8,000 surgeons and surgical trainees in attendance. The first morning, I presented highlights from my research in a talk titled Rethinking Phase III Oncology Clinical Trial Accrual: Predictors of Accrual Success. The session on clinical trials was very interesting, and I learned about the successes and challenges surrounding surgical trials in Germany.
Updates on two surgical studies nearing completion, PROUD and Synchronous, were given, as were presentations on ChirNet and the Studienzentrum der Deutschen Gesellschaft für Chirurgie (SDGC) in Heidelberg. (I would travel to Heidelberg later to learn more about these programs.) Prof. Dr. med. Norbert Senninger, FACS, ACS Governor for Germany, kindly attended my presentation. As the primary contact for the American Traveling Fellows to Germany, Prof. Senninger also met with me at the start of the conference to answer my questions with regard to the conference and to ensure that I was included in all social events (see photo).
Prof. Dr. med. Hans-Joachim Meyer, DGC Secretary-General, also met with me. I very much appreciated his time and our discussion on the challenges of surgical training in the face of work-hour restrictions and the challenges of keeping large, general surgical conferences relevant in the setting of increasing subspecialization.
The opening ceremonies of the DGC Congress took place in the assembly hall of the Ludwig Maximilian University. The presidential address of Prof. Dr. med. Karl-Walter Jauch introduced the themes of the conference. The primary theme focused on strengthening professionalism and retaining public trust through passion and judgment (sachliche Leidenschaft und distanziertes Augenmass). Economic pressures and increased competition were depicted as burdening the specialty’s sense of professionalism and, in part, contributing to a recent scandal among certain transplant centers in Germany. Regaining and maintaining public trust would require greater accountability, more balanced resource distribution, and further emphasis on transparent patient outcomes.
A secondary theme involved care of an aging population. Although many operations have now been shown to be safely performed even in elderly patients, the surgeon must remain forthright about potential complications of and alternatives to surgery. Both themes developed in this excellent address underscored that our profession faces similar challenges in the U.S. and in Germany, despite the differences in health care systems.
The diverse and interesting scientific program concluded with special presentations on navigating risk and uncertainty. Thomas Huber, a professional extreme mountain climber from Bavaria, gave an inspiring yet humorous talk on his experiences seeking out the most challenging peaks and his personal battle with cancer. Prof. Dr. Gerd Gigerenzer, director of the Max Planck Institute for Human Development and former visiting professor and fellow at my home institution of the University of Virginia, Charlottesville, delivered a keynote address on The Illusion of Certainty. Professor Gigerenzer spoke on how common misunderstanding and, in some cases, deliberate misrepresentation of cancer statistics influence medical decision making and resource use.
The conference also featured several memorable social events. I participated in a 6K race through the English Gardens, organized to heighten awareness about organ donation, followed by a festive evening in the Augustinerkeller hosted by the German Society for General and Alimentary Surgery (Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie). The mood remained celebratory throughout the evening not only due to drink and camaraderie, but also the 3–0 victory of FC Bayern over Barcelona in a semi-final game of the European Champions League soccer tournament. At the conclusion of the Congress, I had the honor of attending the president’s dinner at the former royal residence in Munich. Having my father, a Munich native, accompany me to this elegant gala was a once-in-a-lifetime opportunity (see photo).
Heidelberg—Studienzentrum der Deutschen Gesellschaft für Chirurgie
After hearing presentations on the Study Center of the German Surgical Society (Studienzentrum der Deutschen Gesellschaft für Chirurgie—SDGC) and ChirNet at the Congress, I was delighted to obtain an invitation to visit this program at the University of Heidelberg. Now in its 10th year, the SDGC conducts randomized controlled trials investigating surgical therapies, techniques, and materials. ChirNet is a network of eight regional surgical centers providing infrastructure for the implementation of patient-oriented clinical trials in surgery. Inga Rossion, physician and business director of the SDGC, and Dr. med. Markus Diener were my hosts for this visit. I presented my research on cancer clinical trial accrual to their extended team involved in clinical trial design and management, as well as surgery residents learning about clinical trial research. I found our discussions about their processes for trial concept prioritization and design highly informative. Their processes include formal systematic literature reviews for each research question, with staff dedicated to this function. I found this aspect of their operations particularly impressive. Government grant funding is commonly sought to support individual trials. In addition to funding, a challenge for clinical trials in Germany includes improving follow-up compliance. Most patient care after a primary surgical or oncologic treatment is completed reverts to the local primary care physician. I found their efforts to conduct well-designed surgical trials very laudable and anticipate that this visit has initiated an enduring exchange of ideas.
I extend my thanks to the ACS and its International Relations Committee for a motivating and enlightening experience. The professional friendships and collaborative opportunities forged through this fellowship surely represent a highlight in my academic career. I am deeply grateful to Prof. Senninger, the German Surgical Society, and my hosts in Berlin, Munich, Heidelberg, and Neu-Isenburg for welcoming me to their organizations and allowing me to learn about their professional activities. I appreciate the encouragement to pursue a traveling fellowship that my chairman, Irving Kron, MD, FACS, and division chief, Reid Adams, MD, FACS, both of whom are former ACS traveling fellows, provided to me. My gratitude certainly extends to my colleagues at the University of Virginia and my husband for making my month-long absence from work and home possible.
Based on this experience, I strongly encourage my American colleagues to visit surgical institutions in Germany and to participate in the College’s international fellowships. Attending our visiting fellows’ presentations at the ACS annual Clinical Congress, hosting an international fellow, or applying for an ACS traveling fellowship support the important mission of fostering scholarship and forging professional associations.