Advances, challenges and the future of healthcare

Frauke Fiegl, Chair of the Board of DKV Deutsche Krankenversicherung AG and ERGO Krankenversicherung AG, talks to Professor Dagmar Führer-Sakel, MD, Director of the Clinic and Chair at Essen University Hospital, about endocrinology and precision medicine. She is one of our approximately 100 DKV Best Care top experts who are available to our Best Care policyholders with serious illnesses to provide a second opinion and detailed recommendations for further treatment.

Prof. Führer, you are the director and chair of the Clinic for Endocrinology, Diabetology and Metabolism at Essen University Hospital. First of all, to help us understand better, what exactly does endocrinology involve?

Endocrinology is part of internal medicine and is a large field of specialisation. Put simply, endocrinology is everything to do with hormones. Hormones are essential messenger substances produced by organs such as the thyroid, pituitary gland, pancreas, ovaries, testicles and adrenal glands. They regulate a variety of functions, including energy balance, growth, reproduction and mood. Disorders of the endocrine system are also the cause of major widespread diseases that everyone is familiar with, such as obesity, diabetes, high blood pressure and osteoporosis.

We are hearing more and more about personalised, individualised medicine or precision medicine. What exactly does this mean?

Generally speaking, it means that the same therapy is not used for every patient. It is a progressive approach that aims to tailor treatments individually to the genetic and molecular characteristics of a disease. In a broader sense, additional factors such as gender, age, nutritional status and the patient's performance status are also taken into account in the treatment decision. We want to offer each person the treatment that promises the most success and has the fewest side effects.

Can you explain the practical benefits using a specific example?

In medullary thyroid carcinoma (MTC), a very rare form of thyroid cancer, it was discovered in the early 1990s that the tumour has a specific genetic characteristic. The genetic mutation is present in around 60% of all MTC cases. In 25% of cases, it even occurs as a germline mutation, meaning that it is present in every cell of the body and has a 50% chance of being passed on from one generation to the next. It was then discovered that the genetic code can be used to predict the age at which thyroid cancer will occur. With this knowledge, children in families with a RET germline mutation began to undergo surgery at an early stage, before the cancer could even develop properly. These were the beginnings of precision medicine in endocrinology. Of course, research continues. A drug that targets precisely this ‘RET characteristic’ of MTC and effectively combats the cancer has been approved for over a year now. It is a real game changer, not only because the metastases respond very well to the drug, but also because patients tolerate it very well.

Does that mean significantly fewer side effects, and that the cancer will then also be curable?

Looking at cancer medicine as a whole, there are increasing examples of cures, especially in children. In adult cancer patients, it is much more common than in the past to be able to push back the cancer or keep it ‘in check’. This is partly due to advances in molecular medicine, which also ensures a good quality of life. Of course, as doctors, we always want to cure, but how patients live is also important. I would say that we have made immense progress in both areas with precision medicine. Today, it is often possible to live with ‘cancer as a chronic disease’ and continue to enjoy family and professional life.

So precision medicine means that the patient, the individual tumour and the tailored treatment come together. That sounds like a very complex process.

Yes, it is. If we stick with the topic of cancer, it takes a whole team of specialists to really help patients. For example, specialised doctors from various disciplines, specialised nursing staff, nutrition experts, psychologists, sports physicians and a palliative care team. Certified centres, which exist in Germany for common tumours such as colon, breast and prostate cancer, provide structural support.

In this context, contact points for patients with rare cancers are also extremely important. When I took over the clinic at Essen University Hospital in 2011, we set up a specialised centre for endocrine and neuroendocrine tumours. Today, we treat around 3,000 cases of such tumours at the Endocrine Tumour Centre at the WTZ, one of Germany's leading oncology centres and the location of the new NCT West. Patients come to us from all over Germany and, in some cases, from other European countries. We work according to the ‘one-stop shop principle’, i.e. we coordinate patients centrally and, in an interdepartmental approach, provide them with all diagnostics and high-end therapies from a single source at Essen University Hospital. Of course, all this is done in close consultation with the patient's primary care physicians near their home.

We have a wide variety of players in the healthcare system. University hospitals are one of them. In your opinion, what role do they play in our healthcare landscape?

University medicine stands for a triad of research, teaching and patient care. And in my opinion, it should be formulated in exactly that order. Because the primary task of university medicine is to be a driver of innovation, to develop new diagnostics and therapies, to provide blueprints and to maintain a high level of specialisation. University hospitals must be places where experts are trained in the best possible way so that they can then pass on and implement their knowledge elsewhere. By experts, I mean doctors, but also non-medical professions. When it comes to specialisation and dealing with complex and rare diseases, university medicine is, so to speak, ‘the last stop’ – there is nothing else after that! Admittedly, this is a very high standard, but it is precisely what university medicine must achieve and be equipped to do.

My clinic at Essen University Hospital specialises in endocrine oncology, digital diabetology, hormonal disorders related to organ transplants (TREND-E programme), and rare endocrine diseases, for which we are a European reference centre. In all these areas, we combine innovative research – from basic science to clinical application – with close interdisciplinary care in order to improve the prognosis and quality of life of our patients in the long term.

University medicine is a driving force for scientific progress and new concepts. What challenges are we currently facing, and what conditions do you think are crucial for high-performance medicine for all?

On the one hand, we spend too much, and on the other, we are not consistent enough because we want to stick to old structures. We have free access to diagnostics and innovative, sometimes very expensive therapies in Germany – that's great. However, this has also created a sense of entitlement in society. In the long run, this will no longer work because we simply do not have the resources, either financial or human. At the same time, our healthcare system is characterised by considerable parallel structures – both in outpatient and inpatient care. University medicine is actually a national task and requires different structures and funding to ensure progress in medicine in Germany and to remain internationally competitive. But what is also fundamentally lacking in our healthcare system are real incentives for prevention. Finally, we need a society-wide discourse on the topic of prioritisation and personal responsibility. Everyone must also be willing to contribute to maintaining their own health. So we need to change our mindset, our expectations and our demands as a society. That is a really big task.

I share your assessment – promoting personal responsibility is a challenge for society as a whole. In your opinion, what specific changes are necessary to make our healthcare system fit for the future?

Bureaucracy, for example. The documentation requirements in the healthcare system are a reflection of our rigid structures and the pressure to protect ourselves against everything. This is at the expense of interaction with patients, but also between professional groups such as doctors, nurses and physiotherapists. We need to return to a healthy balance. The universal and justified expectation is that digitalisation will help to overcome many of the barriers. Nevertheless, especially in medicine, we need to talk to people and have enough time to be there for them. We must not lose sight of this when shaping the future of medicine.

Thank you very much for the fascinating insight into the topic.