Volker Diehl, MD, Professor of Medicine, Emeritus, University of Cologne, Germany, recently shared a snapshot of his oncologic journey with The ASCO Post.

Career Beginnings

What inspired you to become an oncologist?

I became an oncologist by serendipity. I did my thesis on tissue culture work with monkey kidney cells in an attempt to disprove Warburg’s theory that cancer cells continue to use glycolysis in the presence of oxygen for their energy supply. While culturing cancer cells in vitro, I started research in virology. In 1966, I was invited to the United States to work in the laboratory of Drs. Werner and Brigitte Henle in Philadelphia. There, I succeeded in transforming the first lymphocytes in vitro with the Epstein-Barr Virus (EBV); and by serendipity, once again, I discovered that EBV causes infectious mononucleosis.

An exciting first step—what followed?

I was fortunate to receive a grant to work in East Africa, flying around Kenya, Tanzania, Uganda, and Sudan with the great Dr. Denis Burkitt in the Flying Doctor Service, an air ambulance enterprise established in 1957 as part of the African Medical and Research Foundation. Our mission was to study whether infectious mononucleosis also occurs in children with Burkitt lymphoma, a disease found frequently in East Africa.  While there, I got involved in treating children with Burkitt lymphoma in the radiotherapy department at the Kenyatta Hospital in Nairobi, Kenya.

Following my year in East Africa (the most exciting time of my life) I went to Stockholm, Sweden, and began work at the Karolinska University Hospital, primarily as a radiotherapist. Afterward, I started my training as a medical oncologist, getting involved in clinical and basic research in Hodgkin lymphoma in Sweden, a well-to-do country in which there is an abundance of this disease.

When I started my clinical work at the Radiumhemmet, Karolinska University Hospital in Stockholm, I got very mad at Hodgkin lymphoma. Remember, in 1969 it still killed 70% to 80% of the young patients with advanced stages of “Hodgkin’s disease,” as it was called at that time.

Next Steps

Where did your anger at Hodgkin lymphoma lead?

In 1969, we did not know whether it was a real tumor, an inflammatory process, or an aggressive infectious disease. We discovered that EBV was indeed involved in the pathogenesis of Hodgkin lymphoma, but its role was still blurry at this time—the clinical picture of drenching night sweats, fever, lymph node enlargement, itching, and other signs of infectious processes did not necessarily lead us to consider this disease as a true cancer entity.

I attempted to culture the tumor cells in vitro; the so-called Reed-Sternberg cells—at that time, we did not know their origin, clonality, and cellular identity—to get in closer in the fight with Hodgkin disease. It took me 10 years and 427 failed attempts to grow the first in vitro Hodgkin tumor cell line, the famous L428 cell line. It was the first Hodgkin cell line ever grown in vitro, which later became the “in vitro masterpiece” for thousands of laboratories around the world and was used to elucidate the pathogenic mechanisms behind the transformation of a normal germinal B lymphocyte into a fragile, malignant, monoclonal cell with the capacity to attract “innocent bystander cells” of the innate immunity armamentarium to form its specific protective environment.

German Hodgkin Study Group

How did you apply this growing body of scientific knowledge?

In 1972 I went back to Germany. In 1978, while doing my medical fellowship at the University in Hannover, I was asked by the German Federal Ministry of Research and Technology to initiate a Clinical Cooperative Trial Group and research program for patients with Hodgkin lymphoma. The overriding purpose was to standardize treatment for patients with this disease. To that end, I founded the German Hodgkin Study Group (GHSG), initially with three centers and only five patients recruited to the study in the first year. Today, the GHSG is the largest and most renowned study group in Hodgkin lymphoma research worldwide.

In 2011, about 450 centers all over Europe participate in the 6th generation of GHSG studies, with approximately 20,000 Hodgkin lymphoma patients documented in the computer in Cologne. Of the 2,000 newly diagnosed patients in Germany, about 1,400 to 1,600 per anno are included in the studies; approximately 85% of patients with the diagnosis are treated according to the GHSG protocols every year in Germany, in private hematology practices and in small and large community hospitals.

Research and Health Care in Germany

What do you see as differences between the practice landscapes in Germany and the United States?

In Germany, the government supports university hospitals. Each director of a university clinic oversees from 20 to 30 doctors, each of whom has a regular salary granted by the state government (16 states in Germany). Research efforts are supported by the Federal Research Foundation (Deutsche Forschungsgemeinschaft) and third-party donations from cancer societies, philanthropic foundations, private sponsors, or industry. Every doctor working at an academic institution is expected to engage in basic or clinical research.

There are 260 health insurance companies in Germany; every person must be insured. About 15% of your salary is withdrawn automatically for health insurance and 18% for retirement funds. Only 10% of German citizens are privately insured. There are around 250 private hematology-oncology practices in Germany; every large community hospital and university hospital has medical oncology and radiotherapy departments.

Most patients with cancer are diagnosed and treated in 1 of 12 comprehensive cancer centers in close cooperation with regional referring cancer centers and private hematology-oncology practices.

For the hematologic cancers, up to 80% of patients are treated in clinical trials according to protocols. For solid tumors, this number is much lower, about 5% to 20%.

Future of Oncology

Do you have any last thoughts about the state of oncology moving forward?

Continued progress in oncology is only possible when we join forces globally in health research, health management, and basic and clinical research. We need to conduct clinical trials on a global scale, not only in orphan cancers, like pediatric tumors, but also in rare adult tumors such as Hodgkin lymphoma, myeloma, and others.

Breakthroughs in the big killer-cancers like lung, breast, colorectal, and prostate can only be achieved by an intimate liaison between the pharmaceutical industry, basic biogenetic research labs, bioinformatics institutions, and visionary clinicians who have conquered their egos. And last but not least, we need more patients who are willing to cooperate by enrolling in clinical trials, from phase I to phase III.

ASCO and ASH are mediators and the Societies provide wonderful arenas in which to foster and promote these various ideas and endeavors. ■