A breast cancer scandal broke in the 1990s in the city of Essen, North-Rhine (1), Germany (Koch, 2000). Qualifications of a local pathologist came into question after a review of the clinical histories of 76 patients revealed recurring inconsistencies. Arson in the pathologist's laboratory prevented a retrospective histological review. Based on the pathology reports in clinical records at least 300 females had been diagnosed with breast cancer. In the absence of a second opinion, many of these females had undergone mastectomy.

In 2000 the Allgemeine Ortskrankenkasse (AOK) Rheinland, a large regional German statutory health insurance company, conducted a survey among females with breast cancer to recognize deficiencies of therapy and identify specific patient's needs (Dusseldorf, 2000). Only 71 percent of females felt that they had received sufficient medical information, and only 52 percent had been given information concerning the availability of psychosocial counseling. A year later, in 2001, the Advisory Council for Concerted Action in Health Care (2) at the Federal Ministry of Health and Social Security analyzed health care deficits in chronic diseases affecting large numbers of the population. Data were obtained with specific questionnaires for medical societies, patient support organizations, health insurance companies, and social agencies. A report by the Advisory Council for Converted Action in Health Care demonstrates a dominance of acute medical care and a neglect of prevention and rehabilitation, both indicative of a lack of awareness of the social, psychological, environmental, and biographic references of chronically ill patients.
Lack of a quality-assured program for early detection of cancer (breast screening according to the European guidelines of 1994) (DeWolf and Perry, 1996).

* Inadequate diagnostic procedures (too many mammograms for females under age 50) and inexperienced radiologists (too many operators of mammography equipment see too few cases).

* Too many breast amputations (mastectomy instead of lumpectomy).

* Too many cases with high-dose chemotherapy with or without stem cell support.

* Too often expensive conventionally equipped technical post-operative care instead of symptom-oriented care.

Based on these and the findings for the chronic diseases, the Advisory Council formulated a series of recommendations for treatment of chronically ill patients and outlined requirements for quality assurance, patient contributions, coordination, evidence-based care, prevention, and training and education of patients and care providers. In response, the Federal health authority outlined structured disease management programs under the responsibility of the statutory health insurance companies and regulated the admission to such programs. The risk-structure compensation scheme was modified to assure statutory health insurance companies promoting disease management programs for patients with chronic diseases do not face disadvantages compared to statutory health insurance companies that do not introduce disease management programs. Admission criteria were defined for the disease management programs of diabetes type 2 and breast cancer; followed by those for chronic obstructive lung disease, diabetes type 1, and coronary heart disease. Described here are the design and experiences of the first disease management program for breast cancer