Over the last ten to 15 years, pathology has developed into an extremely dynamic and innovation-driven area of medicine. New technologies such as digital pathology, automated image analysis, molecular diagnostics and genomics have fundamentally changed the way pathologists work. The precision of diagnosis that is possible today increases the efficiency of treatments and opens up new avenues for personalized therapies.
“Modern therapy cannot ignore the pathology,” explains Professor Dr. Katharina Tiemann, pathologist and managing director of the Institute of Hematopathology in Hamburg and regional chairwoman of the Federal Association of German Pathologists. “More and better treatments are leading to a growing number of oncological treatments for increasingly older patients with more and more comorbidities and more and more chronic courses. These facts must be taken into account when restructuring the care structures in the healthcare system.”
Access to new knowledge
The current hospital reform of the Federal Ministry of Health pursues ambitious goals. To name just two: Planned changes are intended, on the one hand, to ensure the quality of care and, on the other hand, to achieve better networking between inpatient and outpatient care. In concrete terms, this means that cancer patients should have access to common companion diagnostics with specific medications in combination with chemotherapy and targeted therapies, regardless of where they live.
As a coherent declaration of intent, it poses major challenges in practice. This often involves access to the latest knowledge, as well as financing services and the reliable exchange of information.
Needs-based reform
In total, around 500,000 new cases of cancer are recorded in Germany every year. Around two thirds of all oncology patients are cared for in certified structures, while others are not. Certified structures refer to the care of cancer patients in medical facilities that are specifically equipped and qualified for the diagnosis, treatment and care of cancer patients.
These structures must meet certain standards and quality guidelines established by certifying organizations such as state health authorities, national cancer societies or other medical professional associations. Lung cancer is now one of the most common diseases, with around 57,000 new diagnoses every year. According to the fifth statement of the government commission for modern and needs-based hospital reform, only 39 percent of patients with lung cancer are treated in certified structures.
Uncomplicated cash reimbursement
The intersectoral care aimed at by the hospital reform repeatedly reaches its limits in practice. Prof. Dr. Roland Repp, chief physician in the hematology and oncology department at the Kiel Municipal Hospital, cooperates with the Institute of Hematopathology in Hamburg because his hospital does not have its own molecular pathology department. For example, if he is treating a patient with prostate cancer in whom a tissue sample needs to be tested for BRCA mutations, he sends it to his colleague Katharina Tiemann. “Today, taking the molecular causes of an illness into account is standard medical practice,” says Roland Repp.
However, this service is not financed in the inpatient area according to the applicable standards. However, if the request for tissue analysis came from a practicing doctor, the health insurance companies would easily reimburse the service. “In the future, it must be ensured that necessary examinations such as molecular diagnostics – regardless of whether they are commissioned by a doctor in private practice or in a hospital – are equally refinanced,” says chief physician Repp. “The same applies to approved medications. Depending on the health insurance provider, the reimbursement of costs is sometimes straightforward and sometimes complicated.”
Advantage of the “EPA”
Data transfer has so far been confusing or uncertain in many places. For example, if a patient in Kiel is diagnosed with colon cancer and the diagnosis is carried out in Hamburg, further treatment should take place close to home. However, when the oncologist there takes over the treatment, he does not have automatic access to the information that is already available, but has to spend a lot of time collecting it. This takes up time that is missing elsewhere.
The electronic patient record (EPR) offers an opportunity to reliably store important findings and information for everyone involved. It could answer questions such as: Where are the most recent CT scans or current laboratory and pathology results? But the e-file still has a long way to go before it is completed. The risks of incomplete information flow are obvious. If an important finding is missing, the treatment decision may be wrong at the expense of the patient's health, or unnecessary additional costs arise due to multiple examinations.
Avoid breaks in the treatment chain
“The exchange of data between the inpatient and outpatient sectors is definitely a huge problem at the moment,” says Repp. “Among other things, there is a lack of uniform documentation with defined formats and interfaces so that, for example, certain information about a tumor patient is transmitted automatically and effortlessly to the responsible tumor board.” Structured information is necessary to avoid loss of quality and breaks in the treatment chains.
The aim of the hospital reform is to provide care close to home. People with cancer often go through a long period of medical support, from initial diagnostic tests to diagnosis by a specialist, treatment in a hospital or cancer center, to outpatient procedures such as radiation or immunotherapy or stays in rehabilitation facilities.
After treatment, regular follow-up care is required to monitor the recovery process and possible complications. The process can take years, which is why short routes to a trusted doctor are extremely important.
Pooling skills and knowledge
A solution has been found between Hamburg and Kiel to provide patients with the best possible treatment. “The more disciplines work on a patient, the better communication has to be,” emphasizes Katharina Tiemann. The Hematopathological Institute and the Kiel Municipal Hospital therefore founded a molecular tumor board in 2022 that is open to all interested doctors. Pathologists, oncologists, human geneticists, pharmacologists and molecular biologists meet here with local practitioners online every two weeks.
Everyone takes a specific look at the patient and brings in their experiences. “What is important is the presence of the practitioner who knows the patient best. For example, if a patient has difficulty swallowing, we choose a medication that can be dissolved. It’s about what’s best for the individual and not necessarily about the best oncological solution,” says Tiemann.
So far, Tiemann and Repp agree, the hospital reform is not really cross-sectoral. Their demand: “Practiced physicians also belong in the core team of a tumor center so that individual patient concerns are taken into account in the treatment decision.” Creed of the initiative: collect information from practice and learn for the future.
Positive balance of the first bridge-building
Pathologist Tiemann uses an example to explain what the “knowledge-generating care” of the tumor board means: “We determine resistance to a certain drug A in a patient and then test another substance, which causes a gene change and thus the drug A in combination “If a different preparation works for the affected person, we are recording this new know-how for the treatment of future patients.”
Regular exchange, flexible staffing, openness to necessary changes – the Tumor Board’s experiences so far have been positive. The conclusion and recommendation: It is worth investing in new structures that make all relevant skills available regionally and provide important diagnostic skills.
The results of the Hamburg-Kiel bridge are promising – also from a cost perspective. “Tumor therapies cost up to 10,000 euros per month. If we can prevent a patient from receiving incorrect therapy for several months, this saves enormous amounts of money. Money that can be invested in sensible structures and necessary training.”
Necessary further training
The high pace of innovation in pathology brings a lot of new things to all players in healthcare. Everything has to be processed and integrated. This is where further training becomes more important. However, fewer and fewer Germans are taking part in further training or international conferences. Fresh momentum is needed. “It takes learning how to deal with rapidly growing knowledge,” say the specialists.
“More and more treatment options require us to look at alternatives. Questioning the tried and tested, exploring new things, weighing up patient interests – that is the direction for the future.” Active action is often a better choice than waiting a long time for solutions from above. The Hamburg-Kiel project proves this. So why not simply swap jobs as a hemato-oncologist with a hemato-pathologist or form a regional network with a regional clinic or an outpatient provider?
