Breast cancer (breast cancer): Overview
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Breast cancer (breast cancer): Overview
Breast cancer, the most common cancer in women, is produced in the mammary gland. Information on risk factors, pre-cancerous lesions, diagnosis and current therapies
Breast Cancer - turning point in life
Diagnosis: Breast Cancer. Who gradually tried after this shocking message, to bring order into his thoughts, often is faced with a tough job: mobilize our own forces to take life into their own hands, create confidence. To deal with the treatment recommendations, make important decisions. But also accept aid: All this is extremely important in order to survive the coming hardships without too many injuries.
The future? Later, please. First, it is about the here and now. The goal: to gain valuable life years. In fact, this is now often and for a long time realistic in breast cancer. Despite the stress that often makes the therapy itself, but many sufferers acknowledge that they can lift. And the cancer? Once defeated and over.
This article provides an overview of breast cancer. It provides information on risk factors such as hormones and genes on benign findings in the chest , bring an increased breast cancer risk, through non-invasive (non-destructive growing) cancer precursors such as ductal carcinoma in situ (DCIS), through early detection, diagnosis, prognosis and therapy.
With the chapter list in the box above or the bar at the bottom allows you to navigate quickly, just on the chapter links in the text.
Breast Cancer: The most common cancer in women
In Germany every year receive more than 71,000 women are diagnosed with breast cancer. Breast cancer is the most frequent cancer in women.
Around half of those affected are old at diagnosis less than 65, about one in ten sick woman even under 45 years.
By the way: Even men can get breast cancer, but very rarely. Only about one in a hundred breast cancer patient is a man.
Early shows success
However, the undoubtedly alarming numbers can be a positive development to face: breast cancer is no longer now the most threatening tumor in women. Meanwhile, he has been among women in the industrialized countries of lung cancer surpassed (in men lung cancer tops the list of cancers with the highest mortality rates - both in industrialized and development countries Ling - on). The main cause is considered smoking .
Diagnosis and treatment have steadily improved just in breast cancer. This includes current assessment also introduced in Germany in 2005 mammography screening, ie, the X-ray examination of the breast as part of the free screening program for women between 50 and 69 years of age. Furthermore informs the chapter "early detection, diagnosis, prognosis, "detail.
The relative 5-year survival rates of breast cancer patients, considered over all stages of the disease are, now more than 83 percent. The term "relative 5-year survival rate" is a statistic that is often used for cancers.
It says how many patients affected by hundred live five years after establishing the diagnosis, based on the survivors in the same period the general population of the same age and sex.
The vast majority of breast cancer sufferers is five years after the diagnosis alive, many even ten or fifteen years later. Nevertheless, the disease develops differently in each woman.
What determines the prognosis depends on?
First of all, the earlier breast cancer is detected, the better are generally the treatment prospects.
Crucial for the prognosis is next to the tumor size and lymph node involvement of a possible armpit of biological character of cancer. From this, conclusions can be drawn regarding its growth behavior. For the therapy is becoming increasingly important.
However, the type of treatment, the age of the patient, possible personal risk factors for breast cancer and comorbidities play a role in the prognosis.
Therefore, statistical figures are ultimately always be considered relative and with regard to the individual course of the disease with caution.
What are the risk factors for breast cancer, there are?
Breast cancer is very diverse - there are known only about thirty forms. Meanwhile it is even the view that any patient "their" breast cancer. The determining cause simply does not exist.
Among the important risk factors include effects of female sex hormones and lifestyle, then the age and genetic factors.
In some families, breast cancer occurs more frequently. But only some of them there is a clear genetic predisposition. Thus, for example, certain changes (mutations) of the two genes BRCA1 and BRCA2 (BRCA is derived from the English term for breast cancer: Br east Ca ncer) responsible for about five percent of all breast cancers. In another five percent there are changes in other genes, including similarly influential as the BRCA genes. Some researchers increased cancer potential in interaction with environmental factors such as alcohol have also been found.
What symptoms indicate breast cancer?
Breast cancer often develops over many years. Possible signs are nodes in the breast tissue, dimples or redness of the skin , a unilateral increase in breast size, rarely chest pain . The nipple may be retracted or liquid secrete (more on this in chapter "symptoms ")
A swelling or hardening of the breast with redness and pain may occur, for example, even with a blocked duct or mastitis developing therefrom. These changes typically occur at the beginning of lactation. When a breast infection, the pain is even more pronounced, individuals feel uncomfortable and also have a fever. For an engorgement usually help against local measures, such as regular emptying of the breast as well as local heating and cooling after breastfeeding . There is evidence of infection , the doctor will also treat the woman with antibiotics. Then the inflammation subsides generally.
Otherwise - and outside of pregnancy and lactation in principle - is an inflammation with redness and swelling or hardening of the breast always suspect and in need of clarification. Rarely, as in one to four percent of the cases, a so-called inflammatory (inflammatory) breast cancer are present. The average age of patients is 57 years, and fever is not a typical symptom. Breast cancer should always be promptly detected and treated. This is especially true for an inflammatory breast cancer because it tends to progress rapidly.
Breast cancer: early detection - diagnosis
Still, breast cancer is mainly an incidental finding. Often women discover the changes in the breast itself - by accident or conscious when scanning (self-examination).
The instructions for self-investigation is part of the breast cancer screening examination by the gynecologist.
It is recommended for every woman to use the regular basic cancer screening rates.
The assumption of costs by the national health insurance in women with no increased risk provides:
Women from 20 years receive an annual free early detection test for cervical cancer .
For women over 30 years a free early detection test for breast cancer is annually provided.
The doctor examines the breasts carefully and thereby scans the lymphatic drainage of the breast from. For specifics, he will quickly follow up on.
The most important for the diagnosis of breast cancer, in addition to the palpation mammography, ie, the X-ray examination of the breast.
There are essentially two ways: volunteers series X-ray examinations of the breast should contribute to earlier detection and better prognosis of breast cancer.
For this mammography s creening be "breast health" women between 50 and 69 years - ie until the end of the 70th year of life - invited every two years. For more information, see the chapter "Early detection, diagnosis, prognosis". Occurs between screening appointments or any time an obscure change in the breast, the doctor is a so-called Abklärungs- or curative if necessary mammography cause.
Other imaging techniques such as ultrasound (sonography Mamma), in some cases, the magnetic resonance imaging ( MRI ) of the breast can additionally be needed - both for the clarification of incurred on the curative mammography screening as well as a suspicious finding. Modern imaging is constantly evolving, what is proving to be useful in the diagnosis of breast cancer.
Ultimately, however, may a tissue sample (biopsy) confirm the diagnosis only the histological analysis. For this, the doctor takes samples as needed from a suspicious area of the breast. The tissue is then examined in detail.
It focuses first on the fundamental question of whether a destructive growing, invasive cancer or a non invasive, certain tissues limits not exceeding tissue change as ductal carcinoma in situ (DCIS; see among others the chapter "breast cancer (breast carcinoma) suspected: Even benign or even cancer? ") is present.
In both cases, the determination of specific proteins on the cell surface follows. Among them are those which docking sites for sex hormones such as estrogen or progesterone form, and the molecule HER2. Doctors refer to in the context of hormone receptors and HER2 receptors. About these receptors receive both normal cells and cancer cells signals to divide. Cancer cells can have a particularly large number of them. Then they grow faster. At the same time here are starting points for therapy (see below).
Which diagnostic procedures may come in detail, this also more in the chapter "early detection, diagnosis, prognosis".
Breast Cancer Therapy: by guidelines
Basically affects the spread of the tumor - the stage at which the cancer is at diagnosis - treatment planning. Often the first step in treatment consists of surgical removal of the tumor, and possibly also of axillary lymph nodes (more on this in chapter "therapy "). During surgery, the breast can often be retained. Does it need to be removed, the surgeon can they. Using an implant with autologous tissue or both rebuild (breast reconstruction)
In addition are the radiation, anti-hormone therapy, chemotherapy and so-called targeted therapies, such as an antibody therapy.
Which treatment sequence is selected ultimately depends on various factors. So breast cancer may be different aggressive. Certain variants as HER2-positive tumors treated doctors usually in advance with an antibody therapy and / or chemotherapy. But in other cases in which chemotherapy is indicated, this is now preceded by increasingly surgery.
And: hormone-sensitive tumor cells respond to female sex hormones, thus a hormone withdrawal. The use doctors for therapy (anti-hormone treatment). The key here is, among other things, whether the tumor in a woman before or after menopause has occurred. When a hormone-sensitive breast cancer overall has a favorable prognosis, sufficient for its complete removal followed by radiation usually a sole anti-hormonal treatment.
Important: The treatment of breast cancer today follows scientific guidelines and is also tailored to the individual patient.
Medical guidelines are recommendations for physicians on the basis of clinical trial results secured. Here the highest possible level of agreement is aimed at the broadest possible expert level.
The guidelines are intended to provide adequate health care. The aim in the medium and long term, reduced in breast cancer mortality and quality of life are improved. The recommendations are regularly adjusted to current developments.
What are breast units?
Breast (cancer) centers are recognized by the German Cancer Society and the German Society for Senology (certified) clinics to diagnose and treat breast cancer.
The name derives from the French word senology for the female breast, "le be" off.
They therefore meet the requirements of a breast cancer treatment in full. And they ensure the necessary quality of treatment because of their medical equipment and technical qualification. More information in the section "Consulting expert, specialist literature" .
The health insurance companies have developed structured treatment programs for chronic diseases such as breast cancer, based on the guidelines. Participation is voluntary.
Such programs are aimed at breast cancer from it, to ensure that standards of care and to accompany the person concerned in the follow-up after initial treatment.
They should also help to ensure that the woman is left at this critical juncture is not alone and learns the necessary psychosocial support.
Finally, the program is designed to help improve the coordination of doctors responsible for each other and the family doctor.
With the growth of knowledge is also the treatment of breast cancer varies in a relatively short time. Inform yourself. Before making important decisions in which it comes to your health, including to the relevant research and advisory facilities
Literature and more information:
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More on that below and in Chapter: "Consulting expert, specialist literature" .
This article provides only general information and may not be used for self-diagnosis or treatment. He can not replace a doctor's visit. The answer individual questions by our experts is not possible.
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Breast cancer (breast cancer): Structure of the breast - and what changes in the tissue
Millions of women feel the hormones with each monthly cycle: Before menstrual chest begins to tighten or feels nodular. After menopause settles that. Therefore, the shape of the breast after
So the breast is constructed
The female breast (latin "Mamma") consists of glandular, fat, connective tissue and skin . It also has nerve, blood - and lymph vessels . About this tracks the breast is the nerve -, immune and vascular system of the body connected.
The mammary gland itself is composed of about 15 to 20 branched, different sized glands (lobules) together. They are each surrounded by connective and supporting tissue. Each of these glands lobe consists of several lobules, the smallest units of the mammary gland.
There each small milk ducts have their origin. Towards the nipple they unite to form larger corridors (see drawing).
What do the sex hormones
In the fertile phase of life, the breast tissue is subject to the changing influence of female sex hormones, estrogen and progesterone .
After ovulation at midcycle, the milk ducts wide easily, and the lobules enlarge temporarily. The connective tissue takes up more liquid, the breast is bigger, stronger, spanning perhaps something.
Sense of it all: preparation for the production of milk and the breast-feeding , the actual tasks of the chest. Places that feel somewhat uneven, bumpy or even knotty, may increase in the second half of the cycle and be sensitive to pain.
These cyclical problems, even the somewhat nodular character of the fabric to go with the onset of menses, often back.
The glandular cells of the breast mature way, only during pregnancy completely. You zoom in and then multiply even more. Pregnancy and breast-feeding over a certain total duration may affect breast cancer risk low.
This Age also plays in the first pregnancy a role. Women who have their first child at the age of under 20 years, appear to have a lower risk of breast cancer than women without children or those who are first time with more than 30 mother.
Breast disease: Benign conversion
Sometimes the reason for the symptoms described earlier, is a cyclical mastopathy. This refers to specific remodeling of the breast tissue.
They are often linked to the imbalances of sex hormones during the menstrual cycle. Interactions with other hormones are believed to play a role.
After the menopause, the glandular and connective tissue developed back, the shape of the breast strength decreases. Often then the mastopathischen changes weaken also. Sometimes, however, also leads the regression of the breast tissue in the age to mastopathischen findings. A breast disease can therefore occur throughout the adulthood of women.
Possible symptoms, especially in the childbearing years, are pain , leakage of secretions from the nipple and breast lumps. Rarely show signs of inflammation. All in all, can be represented very differently in their course a breast disease.
Important: Neither is the remodeling of the tissue necessarily morbid, still must therefore go hand in hand complaints. But if, for example, is leaking from the nipple or notice a nodular change, the gynecologist should necessarily clarify.
If, in the context of breast disease to pathological changes, then they are assigned to the benign breast disease.
There are three degrees of severity of fibrocystic breast disease (I, II and III). In grade III breast cancer risk is slightly increased.
Certainty about the nature of a lesion can be only a fine tissue examined tissue sample. When it is recommended that you read the chapter "early detection, diagnosis, prognosis" .
Breast cancer: malignant growth
In a malignant tumor of the breast cells to change in the glandular tissue and can fundamentally uncontrolled and destructive grow into the surrounding tissue. The starting point is damage in the genetic material of these cells.
Affected are either cells in the region of a lobule (lobular), more commonly, in a milk duct (ductal). By the female sex hormones - estrogens and progestin progesterone - and other factors affect the glandular cells of the breast, they can also promote irregular growth processes.
The tumor grows and can be palpated as a node. Malignant cells can migrate through the lymphatic and blood vessel system, reach other organs and form secondary tumors (metastases).
Breast cancer (breast cancer): causes, risk factors, prevention
Hormones, lifestyle and heredity influence the development of breast cancer. The personal risk of cancer usually depends on several factors not always tangible
Cancer cells grow in an uncontrolled manner
Every now and then spontaneously degenerate cells in the body, but are separated. In the development of cancer , the genetic program and a cell line changed. There are developing new cell structures which deviate more and more from normal.
Has this trend prevailed, start the degenerated cells - now cancer cells - to be strengthened multiply. It grows a tumor. As a so-called carcinoma in situ (non-invasive cancer) and is restricted to its "natural tissue boundaries," as invasive cancer it grows destructively into the environment. Important limitations in the tissue - in breast cancer about the so-called basement membrane under the glandular cells - can command him unable to control.
Sex "blessing and a curse" at the same time
Female sex hormones - estrogens and progestins - play a tangible role in breast cancer. That the hormone levels fluctuate during each menstrual cycle and affect the structure of the mammary gland, is first of all very normal.
Yet sustainable change a pregnancy and the menopause the breast tissue (see section "Structure of the chest ..." ). Put simply, the female hormones exert a growth stimulus on the gland cells. In breast cancer, this process gets out of control. In addition to the natural, endogenous hormones and the "outside" fed hormone preparations are relevant.
The links between hormone exposure and breast cancer can be summarized as follows:
Time between the first and last menstrual period (menarche and menopause): The earlier the menstrual period and the later the menopause begin, the longer the breast is exposed to hormonal influences. This circumstance is considered as a factor that increases the risk of breast cancer.
Multiple pregnancies with subsequent lactation periods: You can reduce the risk of breast cancer - the younger the person concerned at the time of pregnancy and breastfeeding, the better. Affordable: a total standstill period of more than a half to two years.
Birth Control Pill & Co: The hormonal contraception, in the form of birth control pills or short pill that breast cancer risk increases hardly. At the same time the pill reduces the risk of other cancers, such as uterine (body) - and ovarian cancer. Other malignant diseases, including cervical cancer , take turn to light. Overall, the risk-benefit profile of the pill in healthy women with regard to the risk of cancer truncates positive.
Hormone therapy for menopause symptoms: It increases the risk of breast cancer and ovarian cancer. This applies especially to the combined treatment with estrogens and progestins. After completion of the hormone it drops back and does not differ more within a few years from the risk of women who have never done a hormone therapy.
In healthy women who have pronounced symptoms such as severe hot flashes, keep gynecologist a temporary, low-dose hormone replacement therapy for justifiable.
Vegetable materials against menopausal symptoms: Dietary supplement with so-called soy isoflavones can act as estrogen-like. Hence the name phytoestrogens. Findings as to whether they affect the risk of breast cancer favorable or unfavorable, are contradictory.
Let yourself before taking the safe side of your gynecologist advise you, particularly in hormone-dependent breast cancer. People who eat a balanced and occasionally also consumed natural soy foods, his health certainly does not hurt.
Preparations that black cohosh extract contains, do not increase the risk of breast cancer. However, they may be able to interact with administered drugs. Talk Again definitely with your gynecologist before you apply these and other herbal remedies, especially during a breast cancer therapy.
Pregnancy after breast cancer treatment is complete: There are no known adverse effects on the development of the disease.
Is a preventive anti-hormone treatment possible?
There are indications that most women at increased risk of breast cancer can reduce their risk of illness by means of preventive anti-hormone therapy. In Germany, however, has so far not a drug for breast cancer prevention admitted. It is currently being explored yet intense, in which women of the expected benefits of such preventive therapy outweighs the potential damages associated with the (early) hormone withdrawal
Lifestyle, environment, X-rays
Certain risk factors can be influenced very well as lack of exercise and obesity . That they can increase the risk of breast cancer, is made in particular during and watch after menopause. Apparently, here plays an unbalanced metabolic state, which is also generally harmful to health, a role.
An example: the so-called metabolic syndrome , which work closely with the diabetes (diabetes mellitus) and heart disease -cycle is connected. From lifestyle related metabolic disorders such as type 2 diabetes can be very well avoid or detect in time and have to get to grips with. A key role to play in weight control. Both - the increased risk of breast cancer as well as breast cancer disease in its course - are thus favorable influenced.
Also risky: frequent consumption of alcohol. The risk increases to bring it to a common denominator, with the amount. As low as 18 grams of alcohol daily (equivalent for example a glass with about 150 milliliters of wine, Alcohol 13 Vol .-%) takes it to clear.
Also smoking promotes studies by the World Health Organization (WHO), the development of breast cancer. Stress , however, has no discernible effect. However, night and shift work in the modifiable risk factors for breast cancer is sometimes mentioned.
Finally, numerous chemicals are discussed as possible risk factors for breast cancer, such as mold toxins, then harmful substances produced during grilling and roasting meat and fish (as polycyclic aromatic hydrocarbons, PAHs), benzene and other substances in car exhaust or cigarette smoke. The list (see section "Consulting expert, specialist literature ") long.
An earlier radiation treatment in the area of the thorax may increase the risk of breast cancer. Of course, doctors perform radiotherapy only when it is medically necessary. This also applies to the treatment of breast cancer. In addition, modern radiation techniques are helping to keep the radiation dose as low as possible.
Conclusion: Direct causes of breast cancer are not known. And: A healthy lifestyle can help reduce breast cancer risk.
The role of genes in breast cancer
Sometimes the predisposition to breast cancer is the change of a single gene underlying (breast cancer genes or high-risk genes). Much more common, however, affect a number of factors, including genetic, together. In sum, they then contribute to the fact that fundamental changes in the genetic material of a cell and sneak it comes to degeneration.
If appropriate genetic modifications in someone present, various factors (environmental, lifestyle) can easily cause the cancer develops. In other words: The sufferers are more sensitive than people with "normal" Genausstattung.
These factors include in particular the female sex hormones and an unhealthy lifestyle with lack of exercise, obesity and increased alcohol consumption (see sections above).
More and more well-known breast cancer genes
Scientists have mid-nineties, two breast cancer genes, namely discovered BRCA1 and BRCA2, which are often changed in hereditary predisposition to breast cancer families.
BRCA stands for "Breast Cancer", ie breast cancer. The mutations responsible are inherited via the egg or sperm cell and are found in all body cells. What does it mean when a woman has a Hochrisikogen for breast cancer? It states that their risk of developing breast cancer during her lifetime, is high. Also the risk that the other breast is ill, then increased, as the risk for ovarian cancer.
There is also evidence that in families with familial breast cancer risk is increased for other cancers.
A change in the BRCA genes is but only about five percent of all breast cancer sufferers. In another five percent other genes play a role.
In fact, now been further genes, including the high risk gene RAD51C, also referred to as BRCA3 discovered. Mutations of this gene may also hereditary breast and ovarian cancer trigger. Are known today no less than 49 different genes whose changes affect the risk of breast cancer, and probably in the future come to some.
What to do in case of suspected familial breast cancer?
Women, in their families breast cancer occurs more frequently are, rightly concerned and want to know what they can do to prevent it.
If there is suspicion of an inherited burden on a woman, it can to a specialized human genetics center or at one of 16 university centers "Hereditary Breast and Ovarian Cancer" call (for more information see the links at the bottom and in the chapter "Consulting expert, literature " ). You can also obtain advice from her gynecologist, which point is suitable.
Concrete examples: If the mother or sister has had breast cancer before age 36. or if two first-degree relatives have ovarian cancer, this may indicate a genetic predisposition. There are in breast and ovarian cancer, of course, other family disease patterns that may suggest a heritability.
If certain family constellations present, recommends the consortium "Hereditary Breast and Ovarian Cancer" at the time a test for BRCA mutations. The list of criteria can also be found in the section "Consulting expert, specialist literature".
What does the BRCA gene test?
The test can establish whether the disease accumulation underlies a change in the BRCA genes and, where appropriate, whether the person tested this genetic alteration also possesses or not at heaped incidence of breast cancer in a family clarity. However, the theme "Hereditary breast cancer" is very complicated. To take advantage of the advisory services and expertise of specialists before deciding for or against a genetic test is all the more important. One has to also of the consequences - for themselves as well as possibly affected family members - be aware.
If applicable, do not question a genetic test. That would be the case if the calculated risk was not high enough to accept a certain probability of a BRCA mutation. If at a correspondingly high risk of the test is performed, it may still happen that no BRCA mutation is found. Then one would assume that the risk is very likely caused by changes in the family in other genes.
Because breast cancer can occur more frequently in some families, without being charged with any of the previously known hereditary gene mutations for breast cancer. It may also be that they have a (BRCA -) - have gene variant that is still unclear in its meaning. This affects about five to 30 percent of the BRCA mutations.
In addition, for example, not a negative result when tested a healthy person from a hereditary risk of breast cancer. By contrast, the announcement that the test is positive, not only for the sufferers consequences (see below), but for all relatives in the family or on the affected family page. They would have but henceforth in the stressful living consciousness, part of a "cancer family" to be and possibly even have the gene mutation and thus a high risk of disease. It applies, however, important to note that not everyone who has inherited the predisposition actually suffering from breast cancer or ovarian cancer.
More meaningful is the test if it is possible an already diseased family member, a so-called "index patient" test: If the test that if this person is present a high-risk gene mutation, other related family members can be examined at the request of the gene back.
If the test would demonstrate that when a family member, this change does not occur, the person in question would have no increased risk of breast cancer - he or she would be "relieved" by the test.
Before the test is carried out at the center always only a pedigree analysis as well as medical and psychological counseling. Then there is enough time to deal with the issue and to make well-founded his own decision. Until the test result is available, by the way can take a long time - if it is in a hurry, then it goes even faster.
Important: The test is voluntary. Who can be tested, has a right not to know. He or she may also choose not to know the result after the analysis.
What are the other consequences of a positive test result?
For a more early: For women with a BRCA1 - / - 2 mutation there is a project financed by various health insurance companies and private health insurance companies, to the specialized centers "Hereditary Breast and Ovarian Cancer" bound program for intensified screening for breast cancer. This should of course then actually take place in such a center.
The program can, incidentally, be taken even without genetic testing to complete if the pedigree analysis indicates a high-risk situation. This program is then but a little less intense than that in women with proven BRCA mutation.
That the program envisages the intensified breast cancer screening:
From the age of 25 or five years before the youngest age of onset in the family every six months medical Tastuntersuchungen and Sonografien and annual contrast-enhanced magnetic resonance imaging of the chest.
From the age of 40 every one to two years to come mammograms added. Once a month, the person concerned should perform a breast self-examination. The mammograms should be continued at least until the age of 50 and no longer than until the age of 70 or as long as the recordings are easily evaluated.
Women without proven BRCA mutation (see above), have the virtue of other genetic constellations an increased lifetime risk of breast cancer (about 30 percent), offered a little less intensive screening measures. Annual MRIs are for example only provided here from the age of 30 years. From 50 years the victims the usual screening measures (the "screening") will be accessible.
Engagingly, but more security: preventive operations
On the other hand come with a positive BRCA test preventive operations into consideration. This allows reduce cancer risk sustainably.
Removal of the ovaries and fallopian tubes: healthy BRCA mutation carriers it is recommended to the age of 40 or after completion of family planning - in addition to intensified screening. The measure has a double benefit to be: The risk of ovarian cancer, also increased significantly in BRCA mutation carriers, decreases by about 85 percent, and the risk of breast cancer is halved. Against early onset menopause symptoms as a result of the procedure, a low-dose hormone therapy be used.
Complete removal of the breasts: To reduce the increased risk of breast cancer up to a very low residual risk, there are only one, but radical solution, namely, the complete removal of the breast on both sides, so the mastectomy. The chest can be rebuilt (see section "Therapy" , the "breast reconstruction"). The minimum age for this preventive operation is 25 years. There are different methods with different advantages and disadvantages. Meanwhile, techniques have been developed to obtain in the amputation the breast skin and in some cases the nipples and areolas. What does this mean for the balance of risks, is not yet clear.
That in particular the mastectomy - despite the breast reconstruction option - is perceived as disfiguring and therefore often meets with rejection, not surprised. But there are women who want to put in a breast cancer high-risk situation to the greatest possible safety and take the burden upon himself.
The decision on the own way is easy for any person concerned. You can also here recourse to competent medical and psychological counseling where you already famous center for "Familial Breast and Ovarian Cancer".
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Breast cancer (breast cancer): Symptoms
Hardening or lumps in the breast are common. Who scans a node or unusual symptoms observed, this should always be to clarify by a doctor
At the initial stage causes breast cancer usually no discomfort. Possible warning signs are tissue induration, nodules and secretions from the nipple.
The majority of the nodes in the breast are benign. Nevertheless, a newly established change you should always get to the bottom.
The following symptoms may be a sign of breast cancer:
The breasts are in their size or shape recently differently.
When scanning the breast or armpit fall on unusual knots or lumps.
The nipple is retracted.
The nipple secretes clear or bloody secretions.
At a certain point the skin of the breast appears grübchenartig drawn (so-called orange peel).
There you will find redness or flaking of the skin that does not regress again, sometimes associated with pulling in the chest, pain or swelling.
Possibly the physician in the regular early detection (see also Chapter "Early detection, diagnosis, prognosis" ), in which it scans not only both breasts, but also the associated lymphatic carefully and systematically, a little swelling in the armpit area determined. It has probably points to an enlarged lymph node. This may in turn be related to a previously hidden change in the chest, so that the findings should be further investigated in a timely manner.
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Breast cancer (breast cancer): screening, diagnosis, prognosis
Screening tests to the gynecologist, imaging, especially mammography and ultrasound, tissue samples - in this context moves the diagnosis of breast cancer
Inspect the breasts regularly yourself
Every woman should have one at the same time their monthly breast self-sampling, pre-menopausal best in the first ten days of the cycle, so on the days after the menstrual period.
The self-examination has the particular advantage of a feel for the nature of the breast to develop and perceive abnormalities conscious. How it works best, you can ask to see the doctor in the early detection and then reconstruct at home alone.
Breast cancer screening at the doctor
The statutory cancer screening breast examination is aimed at women over 30. The doctor considered in this study both breasts and examined it with his preferred tactile technology. The woman takes various postures one: standing, sitting, arms on hips, lifted over his head.
He also inspected the lymphatic drainage and scans them off: the underarms and the ranges above and below the clavicle. With eye-catching Tastbefunden in the second half of the cycle should be a check in the first half of the next cycle.
The gynecologist also noted the important points of the individual and family medical history and information about occupied drugs .
The gold standard: Mammography
For 50- to 69-year-old women is currently available in addition every two years voluntary X-ray screening of breast available mammography screening.
When mammography in its current form, the breast is held by two plates and compressed, so that it is as flat as possible, and then illuminated by X-rays - a bit unpleasant and sometimes painful, but brief moment. Each breast is imaged in two directions.
Mammography screening: organization, procedure
Because the breast tissue is more sensitive to radiation in younger women, the screening mammography begin until the age of 50 years.
Women of that age group will receive every two years an invitation to mammography in a qualified mammography unit. One or more such units form a so-called qualified screening unit along with units for diagnostic evaluation. In Germany there are currently more than 90 of them with a total of 400 locations.
The images of the breast are evaluated by at least two doctors independently (double reading). The doctors involved found among other mammograms per year of at least 5000 women. The result follows in writing after about seven working days.
When a suspicious or unclear findings, the party has been given an invitation again. The situation will be discussed in detail with the woman and, for example by means of a ultrasound scan (see below) clarified. Sometimes even includes a specific magnification mammography. Perhaps the recommendation, a tissue sample from the resulting chest to take (more on that later too).
The person may be, to vote on the proposed follow-up examinations at any time with the doctor of their choice, which will be informed on request. The studies for the clarification of suspicious mammography findings can be carried out with the screening unit in the screening unit or to other qualified, in consultation.
Advantages and disadvantages of mammography screening
Advantages: The screening is naturally not foolproof. It should identify as early as possible any existing tumors already. Because then is breast cancer treated very well and the chances of getting a permanent cure are high. Screening protects but of course not before that breast cancer arises at all. The latest data for the evaluation of screening refer to the year 2010: At about seven to eight in 1000 women with breast cancer detected by a Früherkennungsmammografie before he was conspicuous by symptoms.
Prior to the introduction of the program there were two or three. Around 80 percent of tumors are now recognized at an early stage. Before the screening, there were 49 per cent. In other words: In the meantime, to halve the proportion of larger tumors in the participants was recorded. Discussed, however, that the main reason is that small, little aggressive tumors were found, which would anyway never been noticed (see below: cons).
The also increasingly discovered breast cancer precursors, such as the ductal carcinoma in situ (DCIS), are sometimes those which may later develop into an invasive, so destructive growing into the surrounding tissue breast cancer.
That the breast cancer screening can save lives, is proven. It is estimated that about three to four of 1000 women participating more than 20 years on regular screening, can be cured by early detection of her breast cancer.
Worse quantify, but certainly also to be observed is the benefit of the women concerned arises that can obtain a less burdensome treatment by the early discovery of their tumor.
Disadvantages: It is possible that a breast cancer is detected and treated in the screening that would never have made the women's problems (overdiagnosis). The frequency of diagnosis is highly controversial from experts. According to the Euro Screen Working Group estimated that about three percent of all breast cancer diagnoses in screening overdiagnosis. In addition, in some women up examinations are necessary, which can burden the affected physically and mentally.
As with any imaging examination may become a smaller part of false negative (incorrectly inconspicuous) findings arise that outweigh the woman in question falsely in safety.
In the course of screening the woman an increased radiation exposure is exposed. However, this is thanks to modern digital technology as a relatively small and is compared to the renunciation of the investigation by the majority of experts are currently considered to be less risky. One approach: The single dose of mammography corresponds roughly to the natural radiation that in a week's stay in the mountains over 2000 meters altitude hits the body (source: University Women's Hospital, 2014).
Currently: Check trials currently considering whether further improvements of the current screening or additional new screening techniques, such as by means of ultrasound, bring benefits to uncover some hitherto undetectable changes early in the screening and the rates of unnecessary diagnostic measures to biopsies can reduce. Accurate long-term data for the reduction of breast cancer mortality of nationwide screenings are expected in 2018.
Conclusion: Every woman should consider whether they want to participate in mammography screening. You should obtain advice from a doctor exactly, in detail inform themselves and then make your choice. Your decision may reconsider again. More information on the subject is the attending gynecologist or the Cancer Information Service (see link at the bottom and in the chapter "Consulting expert, specialist literature" ).
Small reading aid in the imaging findings: The Bi-RADS system
Developed in the US Breast Imaging Reporting and Data System (BI-RADS) is used mainly in the Abklärungs mammography to classify mammography findings to detail. Here's a little reading aid.
BI-RADS system
BI-RADS 0: The diagnosis is incomplete; an additional imaging is necessary to complete the evaluation
BI-RADS I: No pathological findings
BI-RADS II: Benign changes, no suspicion of cancer
BI-RADS III: Unclear change, rather benign, re-evaluation after six months
BI-RADS IV: Unclear, suspicious changes, further investigation by histological examination ( biopsy )
BI-RADS V: Great probability of breast cancer, the diagnosis must be clarified through a tissue sample
BI-RADS VI: Histologically assured breast cancer
Imaging methods without radiation exposure: ultrasound and magnetic resonance imaging
Women who are younger than 40 years, often have a very dense breast tissue. Similarly, if after menopause hormones are taken is.
In order to clarify a suspicious palpable mass in the breast, lends itself in these cases initially an ultrasound (high-frequency ultrasound ) to.
This is true even if the radiation exposure should be avoided by mammography as possible, especially in young women, even during pregnancy . In lactation focused ultrasound is also the first investigative measure.
Harmless changes such as fluid-filled blisters ( cysts ) recognizes the physician using sonography particularly well.
Even with eye-catching signs in mammography or if this is poorly assessed because very dense glandular tissue, the ultrasound is connected. Lymph nodes in the armpit can be represented very well mitttels ultrasound also.
As early detection is the ultrasound examination also - in addition to the scanning of the chest and investigation of abdominal organs by the doctor - used in semi-annual basis in women aged 25 or over who have a significantly increased hereditary risk of breast cancer (see chapter "Causes, Risk Factors" ).
To help diagnose the ultrasound but not enough. It is an additional method of investigation and complements mammography in the clarification of suspicious or unclear, especially non-palpable findings. In other words: If in doubt, a mammogram should be performed.
Meanwhile sometimes come even newer techniques such as ultrasound acoustic wave elastography - sort of a sampling of the breast with ultrasound - and 3D procedure in specialized centers in addition to the application.
As the ultrasound brings the magnetic resonance imaging ( MRI ) no radiation exposure with it. Here magnetic fields and radio waves come to fruition. However, it is usually necessary a contrast medium through the bloodstream. This does not contain iodine in breast examinations.
The doctor will examine in advance whether there are risks in terms of the contrast agent. In young women at increased hereditary risk of breast cancer, especially at a BRCA1 or BRCA2 mutation, the program provides early from the age of 25 years, among other things, an annual MRI before.
While mammography for example has its strengths in the preparation of so-called microcalcifications, the MRT very dense breast tissue forms better.
The MRI can clearly show some changes, including scars after surgery. But it is expensive and often results in a false positive result. That is, they are not specific enough: The changes shown may be ambiguous and give unnecessary additional examinations occasion. Therefore, the MRT for the routine is not suitable. For specific questions in the clarification striking mammography findings or follow-up MRI, however, can be very useful. She belongs in young women with a significantly increased hereditary risk of cancer to the statutory early, because at this age because of the dense glandular tissue, the X-ray mammography is often not descriptive enough.
It is also important that at a Abklärungs MRI - as with a diagnostic mammogram or ultrasound examination of the breast well - technically it is possible, a biopsy to connect.
Important: The MRI is not paid in all cases by health insurance. The physician must justify the need.
Nevertheless, the woman should first check with their health insurance company if the costs are covered - otherwise it can happen that you have to pay the examination itself (about 400 to 600 euros). Some funds are now offering to the reimbursement in the course of certain programs.
In addition to the aforementioned cases, the health insurance companies cover the cost mainly in the following situations:
To the local recurrence (local recurrence) of breast cancer after breast conserving therapy (surgery and radiotherapy) exclude when mammography and sonography are not enough to clarify.
Tumor looking at cellular level backed lymph node metastasis of breast cancer in the armpit when the primary tumor (primary tumor in the breast) neither clinically nor can be shown with the imaging standard methods mammography and sonography. Otherwise, a single application must be made at the expense of acquisition.
Even when ultrasound and magnetic resonance imaging, the above-described BI-RADS system is applied. For the ultrasound then the abbreviations mean US BI-RADS, for magnetic resonance imaging MRI BI-RADS.
In BI-RADS IV and -V findings, including those with no palpable mass, the removal of a tissue sample (biopsy) and a histologic examination is necessary.
Suspicious findings chest: How is going on the doctor?
In a striking change in the chest - if the mammography screening (see above) stated spontaneously or as a palpable mass - led the doctor a Abklärungs mammography.
In addition, most other studies, all follow ahead an ultrasound (sonography). The final diagnosis usually provides only the control of a tissue sample (biopsy) under the microscope.
In a malignant development, the cells are studied extensively. More on this in the text sections below.
The biopsy of the breast
In cases of suspected breast cancer doctors take a tissue sample from the node or suspicious area. Various methods are possible:
High-speed punch biopsy
Under local anesthesia be a about two millimeters thick hollow needle several tissue samples, so-called punching cylinder, taken from the breast. The withdrawal itself is done using a special punching machine.
Previously, the doctor placed a guide cannula in the suspected area. He is guided primarily by ultrasound or palpation. As a "guidance method" but is also the mammography possible when it comes to microcalcifications.
However, when the vacuum-assisted biopsy microcalcifications (see below) is increasingly recommended as the only abnormality.
In any case, there is only a single puncture from the outside. The small procedure is performed on an outpatient basis. Sometimes then forms a small bruise, but hardly a scar.
Vacuum biopsy
This also for ambulatory method is especially suitable when in the breast microcalcifications was found without visible or palpable tumor. After the doctor has to finding located by a mammogram or an MRI, the correct positioning of about three millimeters thick hollow needle automatically controls a computer.
Also it is inserted only once after local anesthesia. Tissue - significantly more than in the punch biopsy - is sucked by the vacuum and taken around by a cutting-turning operation. Following the biopsy, the doctor may use a small clip at the donor site. You can thus recognize in later steps.
Initially, the doctor puts local anesthetic to a small incision, the later leaves only a tiny scar. After the procedure a pressure dressing is applied. A sometimes occurring bruising usually goes back soon.
Was the suspect tissue area actually noticed by microcalcifications, x-rays, the doctor's chest and the removed tissue to control after the biopsy yet.
Both the core biopsy and the biopsy vacuum are referred to in the jargon as an imaging-controlled, interventional or minimally invasive diagnosis of breast.
Open biopsy
In exceptional cases, such as when one of the processes outlined above has not helped to clarify the findings or not feasible, the possibility of open biopsy (excisional biopsy). It is a small outpatient procedure, performed under local anesthesia, depending on the scope or a short-term anesthesia.
About a skin incision, the surgeon removes the previously marked by suspicious imaging area completely out of my chest. Possibly the removal area is also still marked with a small steel clip in order to understand the place later. The imaging is performed previously by a mammogram or MRI and thereby placed marking wire. This procedure does not apply to palpable findings that stand only as microcalcifications.
The primary, open diagnostic excisional biopsy should warden carried out only in exceptional cases where an image-guided intervention is impossible or risky.
If more tissue - virtually the entire "nodes" or tumor or suspicious area, such as one already established in a minimally invasive biopsy DCIS (ductal carcinoma in situ, see below) - is removed, has become a therapeutic intervention from the biopsy.
In tissues formed after a biopsy a small scar, of course, outside of the skin . In an excisional biopsy, it is slightly larger.
More rarely performed: the fine needle aspiration
A fine needle aspiration, so the puncture of the tissue with a very thin needle under ultrasound guidance, provides much less information about the tissue under examination and is not normally used to clarify a suspicious findings in the chest. It occurs only in certain situations, to apply, for example when in a cyst liquid contained has to be sucked.
If a lymph node at the keys or at the ultrasound examination in the armpit pathologically altered appear, doctors put too fine needle aspiration, but also ultrasound-guided high-speed punch biopsies.
Possible Biopsy Results
A specialized on diseases of the breast tissue pathologist examines the samples from the breast tissue. Apart from a commonly occurring fortunately benign findings the following results are sometimes possible:
Tissue changes with uncertain biological growth behavior (preinvasive lesions) and ductal carcinoma in situ (DCIS)
There are tissue changes that bring an increased risk of breast cancer with and partially applicable as breast cancer precursor, known as preinvasive lesions. Präinvasiv means: you remain a certain extent within their "natural limits". Sometimes they are also called neoplasms. The term neoplasia is a neoplasm tissue, caused by a dysregulated cell growth. About goodness or evilness that says nothing. May be mentioned here include forms such as lobular neoplasia (as LN or LIN abbreviated) and atypical ductal hyperplasia (ADH).
In particular, as the growths called ductal carcinoma in situ (DCIS) are classified as a precursor of invasive breast cancer. The addition of "in situ" takes off that the cells contained, although cancer cells are quite similar, have stayed at source. In contrast to an invasive carcinoma, it has not come to an aggressive growth in the surrounding area. More on this in chapter "breast cancer (breast carcinoma) suspected: Even benign or even cancer?".
Invasive cancer (breast cancer, breast cancer)
If cancer cells outgrow destructive over predetermined tissue boundaries, is an invasive carcinoma. In breast cancer cells of the lobules or either milk ducts transform into cancer cells.
Accordingly, a distinction is made between the invasive Läppchenkarzinom (lobular) and invasive ductal carcinoma (ductal).
Staging of breast cancer
If the diagnosis of breast cancer histological secured and detects the location of the tumor exactly Further studies are needed to determine the stage of cancer. Doctors talking about the so-called staging (staging). Usually this is done in advance clinically based on touch and ultrasound findings.
First, the doctor asks the patient to their medical history and any complaints (outside the breast). The findings on palpation it rises mostly as part of a physical examination . Here, the state of the lymph nodes in the armpit area and in other lymph drainage in the collarbone area and the sternum is particularly checked. For smaller tumors (T1, T2, see below) the doctors dispense mostly on further investigations.
When chemotherapy is planned before the breast surgery (neoadjuvant or primary chemotherapy), can check-ups after a few weeks tell if the tumor responds to the therapy. Even before the chemotherapy, so-called sentinel lymph nodes are often removed in the armpit and examined (Sentinellymphknotenexzision, see chapter "therapy").
Sometimes it is, however, a matter to exclude distant metastases (secondary tumors). The risk that such metastases have formed is, for example, increases with larger tumors. In order to clarify whether the main target organs for secondary tumors - lung, liver and skeleton - are healthy, an x-ray of the chest, an ultrasound of the liver and a bone scan are performed in these cases.
After completion of the staging measures the breast cancer disease is based on the so-called (c) TNM system - and then after the operation on the basis of p TNM system - associated with a particular stage.
The upstream letter p indicates that the results on investigation of the removed tissue during surgery are based by the pathologist. Sometimes y precedes. This means that the operation was preceded by a drug (systemic) therapy. The addition c is clinically.
The individual letters stand for the tumor size (in millimeters or centimeters, T), the lymph node status (N, derived from English. Node) and the presence or absence of metastases (secondary tumors, M). Here is an abridged, limited to the tumor size version.
The TNM system
Tis: Carcinoma in situ (see above)
T1mic: Slightly (0.1 cm) into the environment ingrown tumor (called microinvasion)
T1: The tumor size of less than two centimeters
T2: The tumor size is between two and five centimeters
T3: The tumor is larger than five centimeters
T4: The tumor has grown into the chest wall or skin
With regard to the lymph nodes, there is the gradation N1 to N3, which divides the number of neighboring miterkrankten (regionären) lymph nodes in three groups N0 means. No infection. If the doctor has determined, for example, on the basis of touch and ultrasound examination of the armpit no abnormalities, this corresponds to the clinical evaluation cN0. Confirms the pathologist that removed lymph nodes are fine tissue healthy, that's a pN0 -Befund. The addition sn assigns the findings to the Wächerlymphknoten, so for example: pN0 (sn).
If no metastases found in other organs, the doctor documented this with M0, M1 otherwise. Another division leads the TNM stages together new groups. The result is then stages from 0 to IV.
This so-called UICC classification of the International Association against cancer is as follows:
Stage 0: In situ carcinoma, N0, M0
Stage IA: T1, N0, M0
Stage IB: T2, N0, M0
Stage IIA: T3, N0, M0
Stage IIb: T4 N0, M0
Stage IIIa: Any T N1, M0
Stage IIIb: Each T with N2, M0
Which prognostic factors are there?
The tumor stage influences the therapy and prognosis. The forecast, however, play other aspects involved, namely the so-called grading and the content of specific tissue receptors.
Grading: Ausreifungsgrad and speed of growth
The pathologist also examined how much cancer cells differ in appearance and growth behavior of normal mammary gland cells. This is described with the degree of differentiation (Ausreifungsgrad, grading).
Going to the Grading three factors: the speed with which share the tumor cells, and the deviation of the tumor cells and the milk ducts in the tumor from the normal glandular tissue. The higher the grading, the more aggressive the tumor is growing. There are three degrees: In G1, the tumor cells resemble largely the healthy cells; they are "well differentiated" and divide more slowly. In G3 soak most of its original form from and divide rapidly. G2 in between.
Information about the growth activity is also the Ki-67 antigen, which can be represented by dyeing the fabric with the pathologist Ki-67 also finds its way in the classification of luminal breast cancer. (See section below "Breast cancer is not the same as breast cancer") ,
Pathologists perform today a tumor grading also in breast cancer precursors such as ductal carcinoma in situ (DCIS) by.
Risk Forecast: Important for therapy decisions
On fresh breast tissue can be - taken by punch biopsy or surgery - that determine the proteins uPA and PAI-1. Affected women should consult their doctor and be informed as to whether the analysis is useful in their case and will be offered in the competent office or clinic.
Furthermore, should the eventual assumption of costs previously clear (clinic? Health insurance?). In addition, the procedure must be agreed before the tissue sampling / operation, even with the pathologist.
In addition, the new predictive genetic testing Multi help the doctor in the risk assessment and support the jointly taken by doctor and patient decision for or against chemotherapy. This especially when the standard criteria do not allow treatment decision. More also section below "Breast cancer is not the same as breast cancer."
Receptors determination
Finally, it is important to determine whether the tumor cells - that goes for invasive breast cancer as well as for a DCIS - are hormone sensitive or increased wear a protein (a receptor) called HER2 on their surface.
In general, the fabric is already possible from the biopsy from the pathologist for the presence of binding sites (receptors) for hormones investigated and on the HER2 receptor.
The hormone receptors it comes to those of estrogens (Abbreviation:. ER) and progesterone (PgR or PR; Progesterone is the corpus luteum hormone, a naturally occurring progesterone, as the estrogen include progestins to the female sex hormones).
The growth of many breast cancers is promoted by estrogens. If at least one percent of the tumor cell nuclei hormone receptors wear on the surface, the tumor is considered to be hormone-sensitive. Consequence: It provides an anti-hormone therapy to, in a sense a hormone withdrawal treatment.
HER2 receptor is human epidermal growth factor receptor 2. The more receptors of this type are on the breast cancer cells, the stronger these tend to divide and multiply.
Whether the cells are HER2-positive or not, is also relevant for subsequent treatment: In the positive case is an antibody therapy in question.
A tumor is HER2-positive,
if the immunohistochemistry (IHC) test is triple positive (3+).
Is he just a double positive (2+), further investigations are necessary.
If the IHC test only a single positive (1+), the tumor is considered HER2-negative and an anti-HER2 therapy is not an option.
Breast cancer is not the same as breast cancer
There is now growing evidence that breast cancer is a diverse disease. Ideally, orient the treatment as individual as possible, and they deliberately use where it is really needed and promising would.Thus overtreatment could be avoided. In fact, breast cancer can now classify more precisely into the tumor cells by analysis of gene activity. Doctors refer to this as the "molecular signature" and derive increasing decision support for therapy. But is this concept still in its possibilities.
Currently, at least four breast cancer subtypes (subtypes) are defined, which differ in their gene pattern, their biological and clinical characteristics and therefore also in the therapy:
Luminal A type: ER and / or PgR highly positive, HER2-negative, growth activity low (low risk of relapse): General Therapy Recommendation *: in addition to surgery (breast-conserving plus radiotherapy) usually only anti-hormonal therapy.
Luminal B type: ER and / or PgR positive growth activity high (medium to high risk of relapse): General Therapy Recommendation *: in addition to surgery (breast-conserving plus radiation therapy) is currently chemotherapy and anti-hormone therapy
HER2-positive ER / PgR positive or negative; Growth activity high (high risk of relapse): General Therapy Recommendation * : in addition to surgery (breast-conserving plus radiotherapy) chemotherapy (neoadjuvant often, so before the operation), antibody therapy and anti-hormone therapy if ER / PgR positive.
Basalzellartiger type: cells immature (if, in addition ER / PgR and HER2 negative, even triple-negative = triple-negative called; high in this combination relapse risk): General Therapy Recommendation *: in addition to surgery (breast-conserving plus radiotherapy) Chemotherapy (often neoadjuvant); More optionally after the recommendations of the high-risk group (see section "Therapy" section: "In particular, women should be treated in the following situations with chemotherapy"). Non-basalzellartige, triple-negative tumors may also have favorable biological properties. In rare cases, there may also be receptor-positive tumors with basalzellartigen properties.
* Note: The therapy is always designed the doctor at each woman individually based on the conditions present in person with her. The general requirements and guidelines serve him as a framework for action. For more detailed information about treatment in the relevant chapter "therapy".
About two-thirds of all breast cancer patients are diagnosed with Luminal A-like breast cancer. Luminal refers to cancer cells that are derived from glandular cells and in sufficient quantity have hormone receptors. While for patients from the luminal low-risk group (Luminal A) often satisfies an anti-hormone therapy, women need with high risk of relapse (Luminal B) usually chemotherapy. A first approximation allows the receptor and Ki-67 determination (see above: Grading) in the tumor tissue. However, lacking a fixed threshold in order to distinguish accurately between Luminal-A-like and luminal-B-like breast cancer can. New molecular tests, known as multi-gene tests , can help to better delineation and shed light on this, if a woman concerned without can survive chemotherapy. The Working Group Gynecologic Oncology eV Mamma (AGO) currently recommends two tests for women after menopause, who are suffering from luminal breast cancer and have tumor-free lymph nodes. Further tests are in clinical evaluation (evaluation). Dealing with such predictive testing (predictive testing) requires a thorough knowledge and great care. The assumption of costs should be clarified. Outside of clinical trials, the tests are used only in m justified individual cases, which also applies to the reimbursement by the national health insurance (only on medically justified request in individual cases). In some breast cancer centers, the tests are used in studies. If the validity is finally resolved, they will come primarily in front of adjuvant therapy for use. Also decisive for the prognosis: The operation result after the operation is, among other things, an indication as PR0 important stating that the malignant tissue completely in healthy area was removed. If PR1 result can be found under the microscope, even tumor cells at the cut edge. The doctor will then often suggest a reoperation.
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Breast cancer (breast carcinoma) suspected: Even benign or even cancer?
Some benign changes in the breast are associated with an increased risk of breast cancer. There are also precursors of invasive breast cancer such as ductal carcinoma in situ (DCIS)
A breast biopsy is for many women a disturbing measure, because it is necessary to go to one of unclear findings on the ground. The majority of the results are benign, as well as so-called microcalcifications often corresponds to a benign finding.
However, some changes must be monitored and / or removed tighter, because the risk for breast cancer may increase or be a precancerous condition.
Absolutely benign
Among the clearly benign changes that do not affect the risk of breast cancer a woman, for example, include simple fibroadenomas and remodeling of the connective tissue of the breast.
Special case papilloma?
Papillomas are actually benign: small, finger-like or wart-like, also highly vascular growths of cells that line the milk duct system. The problem: Sometimes atypical cells are included (atypical papilloma). Or the papilloma occurs along with other tissue changes as a atypical ductal hyperplasia (ADH) or ductal carcinoma in situ (DCIS; see each below), possibly even with an invasive breast cancer. This is shown at times until the tissue was completely removed. Against this background, arrange doctors papillomas today described below "tissue changes with uncertain biological behavior" to.
Papillomas can occur individually (solitary papilloma), approximately in the center of the chest , in a large duct, brustwarzennah. There they can be felt as a node, possibly with pain and bloody discharge from the nipple. If they are more peripherally in the chest - while they sometimes spread among several small milk ducts and their end sections (multiple papillomas) -, they can be generally not keys and are otherwise asymptomatic.
Therapy: In order to examine a tissue zone with a papilloma to the extent necessary, the area is now mostly removed minimally invasively.
Papillomas, which already in the biopsy can be regarded as completely eliminated - mostly they are then very small - and do not contain atypical cells, increase the risk of breast cancer most likely not. Then usually satisfy the usual screening mammograms to check. In other cases, may be about two to three fold increased risk of breast cancer. The further procedure the physician is clear from the findings and in consultation with the patient.
Tissue changes with uncertain biological behavior
Some tissue changes in the mammary gland be classified at this stage, similar to the papillomas previously described as benign. But you can continue to develop under certain conditions to invasive breast cancer. Generally one can say that a higher cell division activity (proliferation) and a deviation (atypia) of proliferating cells of its "normal" appearance in the relevant tissue changes usually associated with an increased risk of breast cancer. The deviations or atypia may vary greatly. In a ductal carcinoma in situ (DCIS), for example, the cells contained already very similar to cancer cells (more on that below).
Another technical term that is more common in this context, is preinvasive lesion. He says that the change or growth (lesion) is not destructive waxing at present in other tissues, including it has the potential, but to a certain extent even within their "natural limits" remains. Preinvasive lesions may be direct precursors of invasive breast cancer. You can also show a generally increased risk of breast cancer.
Often such findings are asymptomatic, thus not palpable. However, when mammography screening dunk increasingly common (more on this in chapter "Early detection, diagnosis, prognosis , "the" mammography screening "). Sometimes they show up just by chance in a tissue biopsy.
Depending feingeweblichem results and other individual risk factors of the woman concerned, the consequences can be very different. Sometimes there is the Council to examine the breast in greater detail with reference to a excisional biopsy (diagnostic excision, excision of a larger tissue part in a outpatient procedure). Either takes place in the local anesthesia or in a short-term anesthesia.
Sometimes, such as when there is a DCIS, for safety's sake surgery like breast cancer may be necessary. But often it is only at the usual regular mammography every two years -screening studies. Partial surveillance mammograms (so-called curative mammography) recommended at shorter intervals.
Preinvasive lesions: Two groups
The pre-invasive lesions can be divided into two groups: those that emanate from the milk ducts of the mammary gland (ductal) and those that arise in the lobules (lobular). The ductal lesions include atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS). The atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LN / LCIS) are lobular preinvasive lesions.
Originate in the milk ducts
- Atypical ductal hyperplasia (ADH): The cell proliferation increases the risk of breast cancer depending on the extent about three to five times for both breasts after ten years. Beyond a certain size, a ADH is assessed as low-gradiges DCIS (see below). An ADH is also seen as a possible precursor of breast cancer.
- Flat epithelial atypia (FEA): One of the ADH related change is the so-called flat epithelial atypia (FEA). Epithelial refers to the epithelium - the lining here, the cells, the milk ducts and lobules. Are formed new, very flat cell layers. A FEA is considered earliest possible neoplastic change with very little risk of malignancy (neoplastic: Declaration under neoplasia in the next section).
Therapy: The changes must be removed only in special cases (for more information see section "aftercare" at the end of this chapter). Frequently satisfy the normal screening checks every two years.
Originate in the lobules
These changes are summarized as lobular neoplasia. A neoplasm is a formation of new tissue, caused by dysregulated cell growth. Lobular neoplasia (often the abbreviations LN or LIN are used here) are formed in the lobules or in the transition zone between lobules and milk duct. They include all variants of atypical epithelial proliferation of the atypical lobular hyperplasia (ALH) to their expanded form, the lobular carcinoma in situ (LCIS or CLIS).
In particular, simple, classic forms of LN are benign. In about half the cases they occur, however, in several places (multifocal) in the breast on, in one-third in both breasts simultaneously. The risk of developing invasive cancer is increased about 7-fold in ten years at this, also known as "risk lesions" for a later breast changes (applies to both breasts). It is currently not clear whether it is in the LN to direct breast cancer precursors. Many affected women are not breast cancer.
Therapy: Sometimes lobular neoplasia can contain very distinct cellular changes. Sometimes they occur together with a DCIS or invasive breast cancer with. Therefore, the affected breast is carefully checked for abnormalities and other suspicious areas are optionally removed. In a pure, classical LN, however it is usually not necessary to remove more tissue from the breast, especially not when the imaging findings after the biopsy is no longer recognizable.
Important: Sometimes can not safely distinguished from a ductal carcinoma in situ (DCIS) a LN, ADH or FEA. In cases of doubt, the change is regarded as a DCIS. To prevent breast cancer later, is then recommended as the DCIS individually matched with the patient, adequate intensive therapy (more on that below).
Ductal carcinoma in situ (DCIS)
A DCIS arises in milk ducts and has seen many changes typical for breast cancer on. Sometimes it is even classified under "breast cancer". The present, often described as malignant or malignant cells have not yet developed the ability to "spread" over their natural tissue boundaries in other tissues.
Often a DCIS forms although only in a breast area (quadrant), but there may have several foci. The doctors call multifocal. On the other hand, it may occur (multicentric) in more than one quadrant of the breast. And it may, but need not be palpable. The exact delimitation if not yet already there is an invasive cancer is sometimes based on the biopsy difficult because they only reflects a very small part of the breast or of the tissue change.
Pathologists distinguish the DCIS essentially three forms: growths with low, medium or highly modified cells. In addition, can be - as with invasive breast cancer - recognize different biological properties. These are also taken into account in treatment planning because DCIS is now being treated like an invasive breast cancer.
The risk of invasive (certain tissue boundaries aggressive border) breast cancer is even higher than for the aforementioned changes in DCIS. It is clear as a precursor of invasive breast cancer. If left untreated, about going up to half of the cases in an invasive cancer in the affected breast DCIS in one third. But this possible development may take different lengths. And: After a DCIS therapy relapses (relapses) possible - as DCIS or invasive breast cancer as well. Nevertheless, the prognosis of affected patients is very good overall.
Therapy: Because DCIS is not yet grown beyond the natural borders into the surrounding tissue, is usually only a less burdensome treatment of here. In many cases, the doctor can operate the overgrowth breast conserving and only the affected part of the breast. Usually followed by a radiation. It reduces the risk significantly, a local relapse (relapse) suffer.
If the tissue is hormone sensitive, an adjuvant anti-hormonal treatment with the therapy as additional drug tamoxifen are eligible. This also weigh the doctors at every question from individually. The risk that the DCIS occurs again, can be explained by the combined hormone and radiation therapy reduce further. Tamoxifen is a so-called selective estrogen receptor modulator (abbreviated SERM): It works by blocking estrogen receptors without then to the breast (cancer) cells as an estrogen to act; in other tissues, it may on the other hand have an estrogen-like effect.
Come for an Affected tamoxifen not eligible for medical reasons, it may be optionally treated with an aromatase inhibitor, if you already the menopause has been reached (more about these therapies in chapter "therapy ", the" anti-hormone therapy - After menopause ").
Sometimes when DCIS the entire breast must be removed for safety's sake but. Then there is the possibility surgically reconstruct the breast (see again Chapter "therapy", the "breast reconstruction"). If necessary, the surgeon removes the sentinel lymph node and the histological examination (so-called Sentinel Lymph Node; more on that also in the section "Early detection, diagnosis, prognosis," "What is a sentinel lymph node?").
It is always important that the changed or diseased area has been completely removed. Otherwise, the breast has to be reoperated.
Aftercare after removal of a pre-invasive lesion
It has already been said: Both after removal of a pre-invasive lesion and after treatment of DCIS may recur change or create a new, up to a breast cancer. Therefore, (50 to 69 years age group) are provided in the first five years after treatment follow-up actions at certain intervals, and from the sixth year screening examinations for the women concerned.
In a FEA satisfy the usual yearly medical Tastuntersuchungen in connection with the doctor's advice and the usual screening mammograms every two years. After treatment of ADH against Kontrollmammografien are recommended every twelve months.
After breast-conserving surgery and radiation for DCIS medical palpation of both breasts and the consultation with the patient is provided for five years every six to twelve months, at yearly intervals thereafter. The same applies to a correspondingly treated LN (LCIS). Kontrollmammografien and Sonografien both breasts offered patients with DCIS / LN (LCIS) at yearly intervals.
For example, if the breast had to be removed with a DCIS, the doctor samples the chest wall on the operated side and the chest on the opposite side in the first five years after surgery every six to twelve months from, every twelve months thereafter. The remaining breast, he also controls every twelve months by means of mammography and sonography . Only when there are new symptoms or changes in the breast area, further studies are indicated.
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Breast cancer (breast cancer) therapy
For the treatment of breast cancer, there are various therapies: surgery, radiation, anti-hormone therapy, chemotherapy, antibody therapy and new targeted therapies for advanced disease
Treatment of breast cancer: What we need is a team of specialists
In the treatment of breast cancer , different specialists are involved, for example, gynecologists, oncologists, surgeons, pathologists, radiotherapists. They shall consult each other on (interdisciplinary conference, tumor board the certified breast center) and discuss the steps with the patient.
The choice of treatment depends inter alia on the type of tumor, the stage of the disease, the age of the patient (before or after menopause) and on whether the cancer is hormone-sensitive, ie hormones react. Even biological characteristics of the tumor, the growth characteristics, play an important role.
There are several pillars of therapy
Operation
Radiotherapy
Anti-hormonal therapy
Chemotherapy
Targeted therapies, including treatment with antibodies
Operation: Custom made and Security
In the majority of cases of breast cancer surgery is necessary. But that does not necessarily mean that the entire breast must be removed (mastectomy). Nowadays can be in many women with breast cancer who received breast (breast-conserving surgery, BET). In the subsequent microscopic inspection the pathologist the removed tissue should have tumor-free cut edges.
The doctor also speaks then of a PR0 resection. This means that the tumor was visually and fine tissue removed "in healthy individuals". If differences are found in the tissue sample under a microscope tumor cells in the peripheral region, the surgeon removes the tumor remains usually at a subsequent surgery (resection).
It marks both the removal edges and the former tumor area, so that in case of reoperation and is taken care of during irradiation for orientation.
If the tumor is located in several places or if it could not be removed in healthy tissue area, even during a reoperation, the doctor removes the breast. The chest wall muscles that form the chest wall remain, in particular the large chest muscle obtained.
If a patient wishes can remove the breast because of cancer, although it is possible to get them during surgery, so doctors respect the desire of course.
In focus: the lymph nodes and the sentinel lymph node
The breast tissue is rich in lymphatics. They carry tissue fluid, fat, protein, pathogens, cellular material (lymph). On their way the lymph passes several lymph nodes: control stations of the immune system. Suspect components lymph defused here of the immune defense. Especially in the armpit, there are many lymph nodes as we just hurt us to hands and arms often and so can penetrate all possible germs and impurities. Therefore, at this point a high hurdle defense is necessary.
Above all, a lymph node category have doctors in breast cancer in their sights: the so-called sentinel lymph node or the (technical term: sentinel lymph node). These are the ones who reached the lymphatic drainage of the breast first. If a tumor in the lymph spreads, the sentinel lymph node is the one who is attacked in the first rule.
Important: It has been found that most likely the local (regionären) lymph nodes that follow the sentinel lymph node, are tumor-free when it is itself also free of tumor. This fact speaks for being able to keep the tumor throughout the treatment even without any further intervention on the armpit well under control.
And to know the status of / the sentinel lymph node (s), as relevant for the more accurate staging of cancer after surgery and for further therapy planning. If there are no lymph nodes, usually a less invasive therapy is sufficient.
Prior to surgery or before neoadjuvant chemotherapy (see below, section "chemotherapy") are checked, the lymph nodes in the armpit by palpation and an ultrasound. Were anticipated no abnormalities, the doctor usually during breast surgery after or seek the sentinel lymph node is. He can track it by using a low-level radioactive and / or a colored substance which he injected into the vicinity of the tumor.
Advanced armpit surgery: Yes or no?
Then the doctor removes the / the entire sentinel lymph nodes for histological examination (Sentinel Lymph Node, SNE). In the workup of the tissue by the pathologist is proven whether the sentinel lymph node is tumor-free. If it contains tumor cells, it may be necessary, a sufficient number of lymph nodes, at least ten, in the armpit to remove (or axillary lymph node dissection).
But doctors are thus now more cautious than before. Because the procedure is potentially stressful. For example, after such an armpit surgery, a swelling of the arm, lymphedema develop and affect the woman permanently. In an SNE the corresponding risk is lower.
Important: If a breast-conserving surgery planned and are loud histologic analysis only one or two sentinel lymph nodes infected, the doctor may consider in early breast cancer, together with the patient, to dispense with the removal of additional lymph nodes from the armpit.
Whilst it might be only microscopically detect small metastases in sentinel lymph nodes, it is possible to dispense with the larger armpits intervention, provided a drug treatment in addition to surgery takes place. In this case, it is particularly important that patients then carry out the planned follow-up.
An operation of the axilla must, for example, but in the rare cases occur, in which previously could not find the sentinel lymph node. Even from a T3 tumor size (see chapter "Early detection, diagnosis, prognosis ") or if the physician already has clinical evidence that lymph nodes of the axilla are miterkrankt, it is not useful to determine sentinel lymph node. Instead, then mostly multiple lymph nodes, at least ten, drawn from the armpit. This applies also when the chest and / or shoulder was operated on the affected side for other reasons.
Breast reconstruction
Is much breast tissue or the whole breast removed, can already be started during the same surgery to rebuild the breast (immediate reconstruction). But Dr reconstruction is also possible at a later date - as the second engagement after the drug treatment and / or radiation therapy (interval reconstruction).
Building a Implant
If he chooses the woman for an implant, there are several ways. Frequently first an expander is used. This is a silicone shell that is filled gradually over a valve from the outside with salt. If after a few months, the skin stretched sufficiently, the expander is in a second procedure under general anesthesia through the final implant ("Silikongelkissen") exchanged. Can be a sufficiently large skin layers get to take the implant, it can be used immediately (skin-sparing mastectomy, skin-sparing technique). Sometimes you can even the nipple and the surrounding areola they receive, at least in part (nipple-sparing technique): for example when the tissue just under the nipple is free of tumor and the tumor was far enough away.
Reconstruction with autologous tissue
There is also the option to reconstruct the breast from its own tissue. For example, from skin and fat - a so-called "tissue flap" along with blood vessels -. With and without muscle percentage for a reconstruction with autologous tissue that can be removed from the abdomen, buttocks, back or thigh instead of a tissue flap, the physician may in some cases. aspirate and fat cells from the abdomen, legs or buttocks and transplant (lipofilling). But this is a longer procedure in which, after a pre-strain of the breast skin envelope in many meetings over several months small portions fat be added, which then finds connection to vessels and can heal.
Even putting doctors, currently mainly in studies, proportionally tissue replacement material as so-called acellular dermis.
The surgical techniques, there are several variants that differ consuming and productive. For the reconstruction of small breasts, other methods are eligible as for the construction of large breasts . In addition, combined methods are possible, ie prosthesis plus own tissue.
Adapting the healthy breast
The reconstructed breast implant means is fixed and does not fall as the healthy breast. However, the skin is still a little stretch. A chest built with own tissue sometimes descends still. That is, until the final result is achieved, it always takes a few months. A significant side difference has arisen, may be a plastic-surgery on the healthy breast to improve symmetry. Either a lift (mastopexy) or downsizing comes (reduction surgery) or an enlargement (augmentation) into consideration. As expected, increased an aesthetically satisfactory operation result, the quality of life of those affected.
Construction of nipple and areola
The nipple can be rebuilt. This is done but only if the breast rebuilt completely healed and a matching operation of the healthy breast is complete.
The new nipple can be shaped from a skin portion of the restored chest or abdominal skin. Also there is the possibility of "Nipple Sharing": Here, the surgeon removes a small portion of healthy nipple and put him on the reconstructed breast. In order to replicate the areola, also there are several options available: For example, a graft from the slightly darker pigmented skin of the groin may be used. Or there is a medical tattoo.
Possible problems with breast reconstruction
- Structure with an implant: Although the quality of the implants is steadily improving, keep not permanently. An implant rupture, for example by the action of external forces or fatigue, may well happen. The latter happens sometimes unnoticed. Suspicious symptoms may deformation of the chest or pain be.
That forms with time around the prosthesis a thin capsule of connective tissue, is a normal response of the body. In some women, the capsule can thicken, possibly even contract (capsular contracture). Depending on the severity that is visible and palpable, often painful. The breast may be harder and deform the implant shifting. Saline or silicone implants are but as a health hazard.
The doctor controls the prosthesis in regular intervals. If it has come in the meantime to changes and breast symptoms, the woman should go to the doctor in advance to determine the cause. If necessary, a surgical correction is necessary, possibly also a replacement of the prosthesis. Information on the safety of breast implants, please visit: www.bfarm.de, Keyword: breast implants. (Www.apotheken-umschau.de assumes no liability and is not responsible for the content of external websites).
- Reconstruction with autologous tissue: Every operation has its risks, as well as the breast reconstruction of body tissue. It takes longer than the reconstruction with a prosthesis and is already burdensome hence. Add to this the additional wound and the tissue defect at the donor site. An important, though not the only factor in the success of an intervention is the experience of the surgeon. Against this background, it will talk to the patient in detail about the advantages and disadvantages as well as the appropriate time as part of breast cancer treatment and recommend you the optimum method for them.
Possible problems include bleeding, collections of wound fluid (seroma), infection and wound healing problems. Own tissue flap - as so-called free grafts without vascular supporting tissue stem - must be microsurgically, vessel for vessel reconnected. They are more prone to circulatory disorders and tissue damage as stalked grafts, hanging on a vascular bundle and let therefore anchor itself more easily to the new location.
Smokers have a higher risk of circulatory problems. Those affected - as well as severely obese women and diabetics - should therefore be quite in depth advice from the doctor about the best procedure for breast reconstruction. Doctors recommend women smokers necessarily the smoking set at least six weeks prior to surgery.
About the various options for breast reconstruction informs the article " Breast Reconstruction "accurate.
Radiotherapy in breast cancer: as much as necessary, as little as possible
The irradiation (radiation therapy or radiotherapy) in breast cancer aims by means of high-energy rays to destroy cancer cells. The beams are used as specifically as possible, sparing surrounding tissue and adjacent organs as far as possible.
There is a local therapy, which is usually carried out by a breast-conserving surgery (adjuvant radiotherapy). Possibly in the tumor bed remaining cancer cells to be destroyed. Has been proven that this will lower the risk for local recurrence of the tumor and so the chances of survival can be improved. Here also the stage of cancer at diagnosis plays a role.
Breast irradiation
Is irradiated usually the entire breast. The standard dose is 50 Gray (Gy). In addition, the "tumor bed" often still specially irradiated (Engl. Boost, boost). All in all, this enables the local risk of relapse significantly reduce.
Meanwhile recommend some rays physicians called hypofractionated radiation for patients in early stage breast cancer after complete removal of the tumor. The total dose of radiation is generally lower. The women concerned have rarely go for irradiation, since the duration of treatment is shortened. However, this means the gift of a slightly higher single dose per day. They may affect the healthy tissue a little more. But she is also true presumably remaining cancer cells accordingly. Again, an additional boost irradiation of the tumor bed is often provided.
The hypofractionated radiation seemed to comparative studies as well as to act the conventional irradiation. However, has been shown only for women over 50. Long-term results for possible late side effects are still pending.
Possible irradiation but also during operation: Immediately after the tumor has been removed, a radiation source is placed in the wound cavity. They are over about 30 minutes from radiation (50 kV). Various new forms of radiation, including the so-called accelerated partial breast irradiation of advanced tumor bed are not yet assessed in clinical trials (see also section "Consulting expert, specialist literature ")
Irradiation of the breast is also particularly important when the tumor tissue completely not in the operation - not even by a reoperation - could be removed or if surgery is not possible.
Irradiation of the chest wall after removal of the breast
When the tumor was rather high, about T3 or T4, and the chest was removed (mastectomy), often followed by a irradiation of the chest wall. In addition, there are other situations in which doctors recommend to irradiate the chest wall after a mastectomy, as if more than three lymph nodes were miterkrankt. The aim is always to reduce the risk of relapse and improve survival.
Irradiation of the axilla
In miterkrankten, but not completely removable lymph nodes in the armpit or in a remaining there residual tumor and it is irradiated. This applies also if no armpit surgery was performed, although urgent suspicion that corresponding lymph nodes are mitbefallen.
In addition, the lymphatic drainage can be irradiated in the collarbone area.
Chronology of therapy
Radiation therapy usually starts a few weeks after surgery, when the surgical wound has healed, or after adjuvant chemotherapy.
About the optimal operation, the doctor will advise the affected exactly. He will start the irradiation only as early as is feasible without risk of local complications at the breast.
An anti-hormone therapy such as the treatment with the HER2 antibody trastuzumab (see further below) can take place simultaneously with the radiotherapy. If chemotherapy is planned, the irradiation usually takes place afterwards.
Drugs against breast cancer
As already mentioned, there are several drugs for the treatment of breast cancer:
Anti-hormonal therapy (Anti-hormonal treatment). Technical term: endocrine therapy
Chemotherapy
Targeted therapies, such as antibody therapy
The drugs can come before or after breast cancer surgery are used: one at a time, sometimes in combination. Unlike locally-faceted therapy as surgery and radiation, they act throughout the body.
Therefore, the drug treatment is also known as systemic therapy. The throughout the body acting therapy reduces relapse and been shown to improve survival rates.
Anti-hormonal therapy
Many breast cancers are hormone sensitive. This means that these tumors are stimulated by the female sex hormones to growth. This is what makes you look and therapeutic advantage: Assign the breast cancer cells receiving agencies for the hormones to (hormone receptors: ER = estrogen receptor and / or PgR- = progesterone receptor-positive), the tumor is called hormone receptor-positive (again, see Chapter "Early detection, diagnosis, prognosis "). Here is recommended in most cases, an anti-hormone therapy.
The antihormonal therapy is also used to treat women who are weakened by other diseases or old age. For this, the breast cancer must naturally have hormone receptors.
Sometimes an anti-hormone therapy is also before the operation, ie neoadjuvant, into consideration. This will be the doctors turn to weigh very carefully because with this procedure have any further questions.
Before menopause
Women are usually treated before menopause than five years of tamoxifen. Tamoxifen is a so called selective estrogen receptor modulator (SERM). It works by blocking estrogen receptors without then to the breast (cancer) cells to act like an estrogen. On other fabrics, it acts against estrogenic. When the anti-hormonal therapy is continued more than ten years, which may be an additional advantage.
There is also in pre-menopausal women the opportunity to the ovaries - and thus also the body's own estrogen production - by administering so-called GnRH agonists artificially eliminating. GnRH agonists, which are also called GnRH analogues are the body's neurohormone GnRH (gonadotropin releasing hormone) similarly formed in the brain. In the short term applied (as in fertility treatment, see below, section "supportive therapy") rise to the hormone levels. For the treatment of breast cancer a longer handover is necessary. Because then comes the hormone production in the ovaries to a standstill, and account for the hormonal growth impetus to the cancer cells.
GnRH agonists are used as a monthly injections under the skin or as an implant once every three months. After completion of therapy, which usually takes at least two years, the ovaries can theoretically return to work.
The anti-hormone therapy takes place usually after surgery, therefore adjuvant. At high risk of relapse of endocrine therapy is also preceded by a chemotherapy, for example, if the tumor was larger than two centimeters, axillary lymph nodes were mitbefallen or the cancer cells have a significantly increased growth rate or corresponding other features. Then the anti-hormone therapy follows in the next step.
After menopause
Another group of drugs with anti-hormonal effect are known as aromatase inhibitors. They block the enzyme aromatase, which is necessary for the production of estrogen in the body. To use come anastrozole, exemestane or letrozole - which is the so-called third-generation aromatase inhibitors.
The aromatase inhibitor is taken for five years. Or he followed two to three years of tamoxifen, which is then replaced for another two to three years by the aromatase inhibitors (so-called "switch"). The total duration of successive or sequential therapy is five years.
After an exclusive five-year tamoxifen treatment, however, can still be achieved an increased therapeutic effect by an aromatase inhibitor which is occupied for another three to five years. That is, the total duration of the anti-hormone therapy is then up to ten years.
In women with high risk of relapse and the less common lobular breast cancer, which arises in the lobules, an aromatase inhibitor should be used first as antihormonal therapy after menopause. He is taken for a maximum of five years.
If an aromatase inhibitor is not an option, it stays with tamoxifen (total: five to ten years).
Again back to treat pre-menopausal: aromatase here offer themselves rare. If another disease militates against taking tamoxifen, for example, certain disorders of the bone marrow, an aromatase inhibitor may however questioned. Are aromatase inhibitors used before menopause, normally the ovarian function must be switched off in addition.
Chemotherapy
In breast cancer, in addition to an operation chemotherapy be necessary to fight the tumor cells intensely. The chemotherapy may, for example, after the operation, so adjuvant, take place.
Due to this subsequent treatment, the risk of relapse and metastasis can be significantly reduced. The benefit of chemotherapy is the greater, the higher the individual risk of relapse of a woman.
In particular, if the risk is very high that the cancer recurs, women should receive chemotherapy. The risk of relapse may be increased, for example in the following situations:
If a woman is ill at the age under 35 years
If a HER2-positive tumor is present
In negative breast cancer (see "Early detection, diagnosis, prognosis," sections "receptors-determination" and "Breast cancer is not the same as breast cancer")
When a tumor grade 3 (G3 grading; on the grading also refer to "early detection, diagnosis, prognosis"), probably from grade 2 (G2 Grading)
In miterkrankten axillary lymph nodes
If chemotherapy surgery is preceded by it is called neoadjuvant chemotherapy.
Important: The neoadjuvant chemotherapy is now considered equivalent to adjuvant chemotherapy. If possible, it is recommended by some experts to use them preferred. Other technical terms here: preoperative or primary systemic chemotherapy.
Advantages: The tumor can be significantly reduced and made inoperable, the safety margin of healthy tissue often to the point that the person concerned will be spared the removal of the breast. In addition, it can be checked in this way the tumor response to chemotherapy.
Even at a neoadjuvant treatment - preferably before, sometimes only after that - axillary lymph nodes examined (Sentinel Lymph Node or removal of multiple axillary lymph nodes = axillary dissection, see above).
What medications are eligible?
In the chemotherapy come substances are used which inhibit cell division and destroy the cancer cells: cytotoxic drugs, also called chemotherapeutics. This type of systemic therapy is also aimed at cancer cells that may have spread outside the breast within the body.
There are several drug classes and agents
In breast cancer, preferably so-called anthracyclines such as doxorubicin or epirubicin (also known as Adriamycin), and taxanes (paclitaxel, docetaxel) applied in different combinations, as well as cyclophosphamide and 5-fluorouracil. Other substances in chemotherapy such as gemcitabine, capecitabine, or platinum salts may be useful in specific situations.
Even in older women (over 65 years) chemotherapy is possible in principle. If certain comorbidities before, about a heart disease, which can mean that the therapy would have to be lower doses in order to avoid serious side effects. Doctors who specialize in the treatment of cancer patients, but most are of the opinion that chemotherapy is only useful in high enough doses. If this is not ensured, should rather be waived.
As the chemotherapy work?
Cytostatics are often as an infusion into the vein administered less frequently than tablet. Chemotherapy is carried out in cycles with breaks in between, for example, every three weeks (= q3w), a total of 4 to 6, sometimes even to 8 times. Neoadjuvant therapy should necessarily include 6 cycles. The treatment usually takes then a total of about 12 to 24 weeks.
For each cycle, the fixed combination of drugs is given. After a few cycles, it can be replaced by a new combination.
The doctors grab here back to specific sequences that have been subjected to extensive testing in trials or will be. In special cases, such as in the neoadjuvant therapy of receptor negative breast cancer, putting doctors, so-called dose-dense therapies in shorter rhythm and dose-intensified therapy, a higher dose of medication.
How many cycles are necessary in breast cancer, and whether the chemotherapy is outpatient or inpatient, aimed primarily to the health of the patient, the severity of the disease and then the selected regimen. Today, however, can run most outpatient therapies and the intermediate controls.
Targeted Antibody Therapy
A further possibility of treatment of breast cancer is the so-called therapy with anti-HER2 antibodies. Approximately every fifth patient with breast cancer have tumors with many HER2 receptors on their surface (see "Early detection, diagnosis, prognosis"): The tumor is HER2-positive.
Then can be selectively intervene: in addition to chemotherapy, the antibody trastuzumab is used. This is already the longest applied in breast cancer drug from relatively new group "targeted" drugs. A Trastuzumab Treatment is aimed generally at all HER2-positive breast cancers.
The antibody may parallel to chemotherapy in different stages of early treatment be given either before the first breast surgery, so neoadjuvant or after surgery, therefore adjuvant. Sometimes the chemotherapy and antibody therapy is also used in succession.
The begun before surgery antibody therapy should then be continued to a treatment period of one year. They can be administered every three weeks as an injection under the skin.
It has been found that in HER2-positive patients neoadjuvant treatment with trastuzumab and chemotherapy the tumor in the first-line treatment can even make completely disappear. This can be seen then the surgical specimen (technical term: pathological complete response, pCR short).
Trastuzumab can also be combined with another antibody called pertuzumab zielgericheten - to neoadjuvant treatment in Germany is not yet approved, but by the Working Group Gynecological Oncology (AGO) is recommended as part of studies.
The therapy with two active principles - chemotherapy and anti-HER2 therapy - improves the clinical course and the prognosis. Under the current therapy the doctor regularly checked heart and lungs to detect in time any adverse effects of trastuzumab on these organs.
The OP is carried out in any case within the original dimension after the tumor has been previously labeled by biopsy for the surgeon.
In patients with HER2-positive breast cancer who also has hormone receptors (HER2-positive Luminal B-type; again, see Chapter "Early detection, diagnosis, prognosis"), is a combination of trastuzumab with an anti-hormonal therapy possible.
Even with advanced HER2-positive breast cancers may trastuzumab slow tumor growth and extend survival. Here doctors combine trastuzumab partly again with other targeted agents (see section: "Targeted therapies with different drugs" under "Advanced breast cancer - distant metastasis" in the text below).
Side effects of the therapy
To the cancer fight as completely as possible, intensive treatment is often necessary. The therapy can have side effects. But the extent of side effects is very different from woman to woman and from therapy to therapy. Whether and what side effects occur in advance can not be estimated. In some cases, treatment may be changed if a patient feels the current therapy as too onerous. However, since the chances of recovery from breast cancer are low to non-existent without treatment outweighs usually of benefit risks. Some of the best-known side effects of chemotherapy, such as nausea , can nowadays be well controlled or avoided the same (see below, section "Supportive therapies"). Complications of surgery Possible complications can occur during an operation to bleeding, inflammation or wound healing. Depending on how extensive tissue had to be removed, the result can be very visually disturbing or unacceptable to the woman. An initially not planned breast reconstruction (more on that in the earlier section "breast reconstruction") can also be made up, but should always be integrated into the overall treatment at the Breast Center. Problem lymphedema Sometimes sooner or later after surgery developed lymphedema at Arm ("thick arm"). Because today operates increasingly gently or if possible to the removal of axillary lymph nodes (axillary dissection) is omitted, the corresponding hazard is no longer so great. Lymphedema is caused by a backlog of lymphatic fluid. This can happen, if restricted or overloaded after the removal of lymph nodes in the armpit of the lymphatic drainage. Already in the clinic is cautiously with an exercise treatment for arms started and shoulders to improve blood circulation and lymph flow and relieve tension. Such exercises are actually getting a good companion in everyday life, such as when the neck, shoulders and arms by working independently are braced on the computer. After breast surgery, it is strongly recommended to continue the exercises at home: you will help to prevent lymphedema. Some women check at certain intervals the circumference of the upper and lower arm (always measure at the same places!) To detect a swelling time. Symptoms that may indicate an incipient lymphedema, heaviness or tingling in the arm, pain can in the armpit and his swelling of the arm and the fingers in loads. At the first sign that person should go to the doctor. He will review the cause and begin treatment as soon possible. In the certified breast center, patients receive a lot of tips and information for the prevention of lymphedema. Important: On the operated side, no pressure on the arm should be exercised - either through massage or by medical procedures such as blood pressure measurement and blood samples. Moderate physical activity, as well as tennis is allowed after some time certainly. A moderate exercise the arm muscles affects swelling favorable than conservation. side effects of radiation in the radiation field lying healthy tissue, such as lung and heart are so well protected during irradiation it is to avoid damage such as hardened tissue (fibrosis). On the skin can cause irritation and discoloration. Irradiation of the axilla can there hair loss occur. Some patients also suffer from constant fatigue. More information in the section "Fatigue in cancer ..." below. Side Effects of Chemotherapy Chemotherapy is known, can often cause unpleasant symptoms, such as hair loss, mucositis, anorexia , nausea and vomiting, diarrhea , anemia, malaise and fatigue (Fatigue, see below). Possibly also occur nervous disorders such as tingling and numbness on or skin and nail changes. . Sometimes heart damage and allergic reactions are possible Some of the side effects, in addition to nausea, for example, an excessive drop of blood cells, however, can be very well absorbed by other medicines (see below: section "Supportive therapies"). And: The majority of complaints goes back after treatment, many sufferers feel better soon. Some women wear but still more to the side effects, such as damage to nerves (neuropathy) or other organs, premature onset of menopause, infertility (more on that below, "What opportunities can help to maintain the fertility?").
What does frequency of side effects?
* Very common side effects: affect more than one in ten patients treated (ten percent)
** Common side effects: occurrence in a treated to ten of 100 patients (less than ten percent)
Side effects of anti-hormone therapy
Typical adverse reactions in pre-menopausal women in hormone deficiencies, as they can in the "natural" menopause and occur thereafter. Very often patients complain * as hot flashes. Many of those affected face a cycle changes, possibly menstruation remains from all over. Important: Irregular bleeding (after menopause: emerging bleeding) you should be checked by the gynecologist to rule out changes in the tissue of the uterine lining. Other symptoms that may occur with an anti-hormonal therapy (for example):
- Tamoxifen: headaches and leg cramps, clot formation in the veins ( venous thrombosis ), pulmonary embolism and stroke. If, for example, a visual disturbance , which have eyes to be examined immediately. - GnRH agonists: The bone system can lose beyond the ordinary to substance. After the end of therapy it brings the loss usually go on, at least partially. - Aromatase inhibitors: headache , joint and muscle pain, depression. Also and especially here, osteoporosis is a problem (see section "What's up with bisphosphonates to?" Below). Side effects of the HER2 antibody trastuzumab
The antibody trastuzumab often leads among others ** headache, diarrhea and heart problems.
Fatigue in cancer: constantly tired, depressed, powerless
Sometimes it is as if the tumor, even if it is overcome as such, individuals downright paralyzing. So do not suffer a few patients - in Germany, there are well over one-third - in the course of their disease on a type leaden tiredness and exhaustion. Sometimes these Fatigue begins already during therapy, sometimes afterwards. The disease is tumor-related fatigue syndrome. The causes effects of breast cancer treatment themselves are not to be underestimated: In particular, chemotherapy and radiation contribute greatly to fatigue at. In addition, inflammatory processes, genetic factors, a tendency to depression and other comorbid conditions play a role. The person concerned does not recover even while resting. You sleep poorly, have no appetite, are kraftos and no longer function properly. This amplifies the discomfort, leading to inactivity and social withdrawal. The diagnosis includes a detailed and at the same time targeted survey for the complaints, physical examination, various laboratory tests and, if necessary further investigations. It is important to have a (co-) inducing depression and possible organic causes such as an infection to identify and treat or anemia. Depression is one in breast cancer the most common comorbidities: Approximately 20-30 percent of patients suffer during their breast cancer disease also a depressive episode. Specific questionnaires for self-assessment of the patient can help to identify a psychological background. The diagnosis of depression is a medical specialist. He also makes a treatment proposal.
Often already relieve lifestyle changes like exercise, lots of exercise in the fresh air or relaxing exercises like yoga fatigue and upset. This is not sufficient, even certain medications can be used. These are aimed at once possible organic causes, such as pain. Even an herbal remedy such as ginseng may be considered against fatigue in hormone receptor negative breast cancer. Questions Always, always tell your doctor if you pull a "self-therapy" into consideration (see also the last paragraph: "Alternative Therapies").
Supportive therapies
So-called supportive or supportive measures are intended to prevent side effects of cancer therapy or alleviate them. Chemotherapeutics behave very differently in the body (see above), as many antidotes. When collecting side effects of cancer therapy such persons can even help a little. It is, for example, extremely important to stick to the prescription and to follow dosage instructions. Find out the safe side always in the package insert and read the information from the pharmacy. - nausea, vomiting: Here prevention does become quite good. Against vomiting give doctors as medications such as so-called 5-HT3 receptor antagonist, corticosteroid, and neurokinin-1 receptor antagonist prior to the start of chemotherapy or and / after radiotherapy. Other drugs are dopamine receptor antagonists, such as metoclopramide, or antihistamines.
- Stomatitis: Recommended once a good oral care before chemotherapy. The teeth, for example, you should remediate quickly and seek treatment gingivitis. Eat during chemotherapy as little sour, avoid strong spices and alcohol. Regular mouthwashes with sage and Pinselungen with myrrh tincture or with others recommended by the physician preparations from the pharmacy have a disinfecting and anti-inflammatory. Local anesthetic agents, such as mouthwash can Benzocainlösung, pain relieve. A fungal infection insulate a locally applied anti-fungal agent. Frequently also be herpesviruses active again. You can fight with locally effective antiviral agents. Sucking ice cubes and mouthwashes with dexpanthenol during and after chemotherapy can protect something the mucosa. Depending on the used cytostatics prescribe doctors also special mouth therapeutics. - Infections: Often, the white blood cells fall significantly from because some chemotherapeutics meet the formation of blood cells in bone marrow. As a result, it can lead to infections and fever come. Based on certain decision criteria, administration of so-called G-CSF (is preventive granulocytes -Kolonie-stimulating factors) possible. These special growth factors accelerate the formation of white blood cells in the bone marrow. Even doctors start if necessary a pathogen diagnostics and treatment with antibiotics. - anemia: You often causes fatigue and weakness. The causes of anemia (anemia) in cancers and their treatments are varied and should be evaluated carefully. If possible, the treatment takes account of the trigger. Thus comes about in cases of proven iron deficiency taking iron questioned. Sometimes that is iron injected. If a lack of vitamin B12 or folic acid before, the corresponding transfer makes sense. Whether in a particular case a blood transfusion (red blood cell concentrate) is necessary, the attending physicians of the findings and complaints of the patient are addictive. Possibly the doctor administered turn special growth factors: Erythropoietin stimulates the bone marrow to produce red blood cells. The doctor will control the therapy so that the hemoglobin ( hemoglobin is the red blood pigment) does not exceed 11 to 12 g / L. Note: Under erythropoietin as well as vitamin B-12 administration (each spraying, for example under the skin ) increases the thrombosis risk. The doctor will inform the patient about this and possible warning signs such as swelling and pain in the leg.
What opportunities can help to maintain the fertility?
For many couples, who are confronted with breast cancer at a young age, this question is quite an important issue. In particular, chemotherapy in young women can cause your menstrual periods temporarily suspend or entirely or premature in the menopause occur.
Meanwhile, some methods are available to these women after completion of therapy the chance of a pregnancy to allow. All those involved - the competent oncologist, reproductive medicine and the woman concerned or the couple - will be matched carefully about whether a particular measure for fertility preservation should be carried out.
Relatively new and not yet widely used method to remove ovarian tissue as a fertility Reserve is to freeze (cryopreserve to) and the woman later replant. This is done each by means of a laparoscopy . The chances of success are not yet sure assessable.
Another approach is hormonally stimulating the ovaries as a fertility treatment (assisted fertility or fertility treatment) and trigger ovulation. Thereafter, the eggs - are removed and frozen - unfertilized or fertilized. Assisted fertility treatment in hormone-sensitive breast cancer, however, is often regarded as not safe, because the hormone signals cancer cells may provide an incentive to multiply (see above, section "hormone therapy before menopause"). The process expensive and are usually not covered by health insurance.
What's up with bisphosphonates to be?
Bisphosphonates are drugs that primarily used to treat osteoporosis are (brittle bones), in addition to vitamin D and calcium in accordance with doctor's orders. To play in the treatment of bone loss in breast cancer patients an important role: Osteoporosis can develop, for example as an adverse effect of the anti-hormonal breast cancer therapy. Bisphosphonates support the prevention and treatment of osteoporosis.
Another field of application of bisphosphonates in cancer are diseases with increased bone loss or elevated calcium levels in the blood (hypercalcaemia) as part of a skeletal metastasis. In the treatment of pain caused by tumor foci in bone caused, they also show a good efficacy.
In addition, studies have shown that bisphosphonates can probably improve the prognosis also in breast cancer: You may be able to contribute to the prevention of bone metastases and so and improve our survival rates overall. Therefore, experts recommend bisphosphonates now in adjuvant therapy in women after menopause. For this application, however, bisphosphonates are not (yet) approved. What does this mean in individual cases for reimbursement by the health insurance, the doctor, the patient will explain exactly.
In metastatic breast cancer, however bisphosphonates are approved. The dentist should check the teeth carefully before starting treatment, because the drug can attack the jawbone (osteonecrosis of the jaw).
And if the cancer recurs?
After breast-conserving surgery and adjuvant therapy of tumor may again in the chest, after removal occur on the chest wall or skin. The armpit may be affected. . This means that there has been a local recurrence or loco-regionären recurrence, as doctors say to check if the cancer has spread to other organs, the patient is first again in more detail with imaging - mammography, x-ray of the lungs, Ultrasound of the upper abdominal organs, scintigraphy of the skeleton - examined. In a relapse in the chest this often needs to be removed. But there are sometimes small tumors that can be removed safely and still cosmetically acceptable without sacrificing the breast. However, this approach usually see doctors but as uncertain and therefore less advisable to. When lymph nodes in the armpit it is operated. The aim is always to remove the tumor tissue completely (PR0-resection). This is also true for a tumor that has returned after removal of the breast - either on the chest wall, either in the armpit or in the wider community, including in the area of scar: it should be completely removed also, if possible. The pathologist takes each turn a grading (see "Early detection, diagnosis, prognosis," section: "prognostic factors") before and receptors determination (hormone and HER2 receptors) of the tumor cells. In hormone sensitivity of the tissue may again be proposed or hormone therapy but the doctor is an ongoing hormonal therapy. Based on the individual situation of the patient, he also checks for the recurrence-operation and chemotherapy should be done. This is, for example, for patients in an elevated risk situation in question, as at a young age or when certain tumor characteristics are present. Here, however, prior therapies should be considered. If the tumor is HER2-positive, the antibody trastuzumab can also be used, especially if the person concerned has not previously been treated with it. A second time operated breast after removal of the breast, the chest wall or a diseased lymphatic drainage of the breast are - if possible - again irradiated. Even with localized recurrences a cure is possible. This largely depends on the same factors as in the forecast Ersttumor. A role playing, was how large the disease-free time windows: The larger, about more than two to three years, the better chances.
Locally advanced, inoperable breast cancer - distant metastases
Can a localized tumor can not be completely removed or distant metastases can be identified, there is an advanced cancer. This also applies when distant metastases are already present at the time of diagnosis. Fernmetatasen are metastases of the tumor that occur far away from the chest. They develop from cancer cells that have migrated through the blood and lymph vessels and elsewhere to settle in the body. Although the therapy from the outset aimed at meeting also detached tumor cells, some sometimes escape the clutches. In breast cancer affecting metastasis most frequently the skeleton, but also the liver, lungs, brain and skin, in very rare cases, other organs. In the skeleton are in descending order of frequency vertebrae, femur, pelvis, ribs, sternum, skull (the bony skullcap) and humerus affected. Depending on the type and location of a metastasis symptoms such as painful bone fractures, can back pain , pain in the upper abdomen, pain when breathing, shortness of breath , blurred vision, headache, or dizziness may occur. Weight loss can weaken the body as a whole. A cure is not very likely in this situation. However, under certain conditions, the disease may be some time well be influenced in this phase through special therapies. That is, for example, a total of more favorable characteristics of the tumor tissue of the case. Or if metastases occur in isolation or exclusively present bone metastases. Speaking of medical palliative treatment, so making it a treatment meant that is aimed at alleviating or eliminating symptoms, prolong the life, increase the quality of life and prevent complications. It is important to weigh the burden of side effects of the therapy to the advantage for the further prognosis, adequate quality of life and the patient's wishes. Some therapies found in studies instead (more on studies in "Therapy Studies" section below).
Treatment Planning: Contain metastatic growth
First, the localization of metastases by imaging methods is necessary for the treatment of metastases (see above, section: "And if the cancer recurs?"). It is also important to determine the tissue type of metastasis, since compared to the Ersttumor changes may have occurred, especially in the hormone and HER2 receptors. This can affect the therapy. With bone metastases the determination, however, is technically more difficult. As a medication, the physician may, depending on medical constellation and the wishes of the person concerned is either a (new) anti-hormonal or chemotherapy or targeted therapy initiated. They all act again on the whole body, so systemic. Anti-hormone therapy
The anti-hormone therapy is effective normally requires proof of hormone receptors. Which drug is used in each case will depend among other things on whether the person concerned is before or after menopause, also of the previous treatment. Which therapy individually comes to a patient in question, their doctors will discuss with her. In principle, in women after menopause as in the adjuvant tamoxifen and aromatase into account. The aromatase inhibitors can be optionally combined with the targeted substance everolimus, to improve the response. Also, the estrogen antagonist fulvestrant is in this phase of treatment a possibility.
Women before menopause is often recommended therapy with tamoxifen and the ligation of the hormone production in the ovaries. This can, for example, by means of drugs such as the so-called GnRH agonists (see section "drugs / anti-hormone therapy" above) done.
Later or if tamoxifen is not tolerated, the treatment can also be converted to an aromatase inhibitor together with a suppression of ovarian function (GnRH agonist). Possibly is also used fulvestrant, optionally together with a GnRH agonist. come then questioned high-dose progestins Again ,
About the side effects of the substances used in the anti-hormone therapy most commonly see "side effects of therapy / drugs / anti-hormone therapy," earlier information. Chemotherapy as chemotherapy consult doctors in this treatment situation usually single substances to (monochemotherapy) to the to limit side effects. Very frequently, for example, anthracyclines or taxanes employed individual, but especially when the victims are thus not treated. There are also alternatives. A role always played by the general condition of the patient, as well as the question of where the metastases are located, whether they have receptors and which, moreover, the course of the disease. If the tumor too fast, a combined chemotherapy (chemotherapy) with various can offering substances. Which selects the doctor here also depends on the pre-treatment.
Targeted therapies with various medications
also for the advanced stage of breast cancer, there are now drugs that slow the growth of tumors in a targeted and so can prolong survival. The term "targeted therapies" derives from the English word "target" from (the target). Treatment comes in at specific structures in the cell (target). Metastases can be, for example HER2 receptor-positive. If we find this feature on the cancer cells, they tend to be faster divide and multiply. Then can be selectively intervene: In addition to the chemotherapy used in the treatment of the antibody trastuzumab. He was mentioned several times in this article, for example, in the initial treatment of early breast cancer. Depending on the pre-treatment and other individual requirements suitable for the purposes of targeted therapy various substances, including combinations of antibodies and chemotherapeutic agents . If the metastases have hormone receptors simultaneously, an aromatase inhibitor or fulvestrant can happen. The targeted drugs are constantly evolving. Currently approved and launched for the treatment of advanced or metastatic breast cancer in Germany: - Trastuzumab: use in HER2-positive metastatic breast cancer including hormone receptor-positive forms; Infusion into the bloodstream through a catheter port or port (= venous access with longer retention periods), together with an anti-Allergikum. The administration under the skin (subcutaneously) is possible. Among the very common side effects * (explanation * see above): allergic reactions, flu-like symptoms, palpitations, chest pain, dyspnea, headache, diarrhea, facial swelling, nail damage. - pertuzumab: In combination with trastuzumab and a taxane (particularly docetaxel ), currently in HER2-positive breast cancer in locally advanced (tumor relapse, inoperable) or metastatic disease; Infusion into the bloodstream. Also recommended as part of neoadjuvant breast cancer treatment in studies. As a very common side effects * occur, for example, respiratory infections, blood disorders with anemia and decrease in white blood cells, as well as fever, further oral mucosal inflammation, nail disorder, disturbances of cardiac function, fatigue (see section "Fatigue in cancer" above). - T-DM1 (trastuzumab emtansine): So-called antibody-drug conjugate for women with locally advanced or metastatic HER2-positive breast cancer. The preparation contains the aforementioned antibody trastuzumab (T), the stable through a connecting another active agent has been attached (DM1 or emtansine). DM1 is a cytostatic agent that inhibits cell division. The antibody trastuzumab causes a targeted enrichment of cytostatic directly in HER2-positive tumor. Again, side effects can occur: about drop in platelet count (thrombocytopenia), increase in liver enzymes, fever, headache, cough, epistaxis. - Lapatinib: For advanced or metastatic HER2-positive breast cancer, and hormone receptor positive; Application as tablets. Very common side effects * include diarrhea, nausea, vomiting, rash, blistering and redness on the palms and soles (hand-foot syndrome), disorders of cardiac function. - Bevacizumab: Metastatic stage in HER2 negative breast cancer; Infusion into the bloodstream (Port). Common side effects **: hypertension, joint pain, fever, headache, eye disorders, altered taste. - Everolimus: Sogenannter mTOR kinase inhibitor, which inhibits the mTOR protein; Approved for HER2 negative , thereby also hormone receptor-positive advanced breast cancers; Application as tablets, currently approved in combination with the aromatase inhibitor exemestane. Frequently ** it comes to side effects such as respiratory infections, anemia, oral mucositis, diarrhea, weight loss, venous thrombosis, heart failure, kidney disorders. Other substances are approved in Europe or are currently being examined in the context of studies.
Metastases: tackle specifically Depending on location
Individual secondary tumors, for example in the liver or lung, for example, be surgically removed. Not operationally let liver metastases turned off by a so-called radio frequency ablation (RFA). This electrodes are inserted under ultrasound guidance in the metastasis and those placed under high-frequency current. The evolving heat destroys the tissue. couches spread to the bones before, it can be prevented by the use of bisphosphonates or a so-called Rankligand inhibitor as denosumab bone fractures. Bone pain go back. For stabilization and pain relief was diagnosed with metastatic skeletal regions are also irradiated or treated surgically. This is especially true when a vertebral fracture or if the risk of spinal cord contusion is by an unstable spine.
Single or few brain metastases can ("radiosurgery") are surgically or through a targeted radiotherapy treated.
In addition, the entire brain can be irradiated. The latter is a way even in the presence of many brain metastases. If the underlying disease HER2-positivity, treated with trastuzumab breast cancer, so can a treatment with the small molecule lapatinib (see above, section "Targeted therapies"), possibly in combination with capecitabine are eligible. suppress pain lasting
If pain occurs as a result of tumor growth, can help a very specifically designed pain management today. Pain into the background, without having to take strong side effects by the drugs in purchasing. Permanent pain, however, are grueling and can lead to chronic insomnia, to the development of depression and social withdrawal. Therefore, a pain management is very important to increase the quality of life of affected women.
When pain medications come or analgesic interventions into consideration. A supplementary adjuvant, for example, antidepressants (agents for depression) can support the effects of painkillers. These can then be lower dosage, so that fewer side effects occur. The pain therapy is more effective, the better it is tailored to the needs and wishes of those affected and their daily routines. The schedule of intake should be strictly adhered to. The doctor can check at any time and adjust the medication to a changed situation but him. In severe cases, the attending physician will consult a pain management physician. With good management of therapy and pain management can improve your grip.
Therapy trials
Without studies no therapeutic progress - this is true for breast cancer as well as for any other disease. Only when new, potentially better therapy with existing could be compared with a sufficient number of patients, doctors know if your assumption is correct and the alleged progress worthy of the name. In cancers , especially breast cancer, more and more sufferers are now ready to be treated as part of studies. This is accompanied by a tighter supply and control. In addition, the participants, if appropriate, have the opportunity to benefit in a clinical trial of a new, innovative therapy. Participation is voluntary and can be canceled anytime. The treatment is then continued in the manner customary for the corresponding disease situation manner. In breast cancer, there are various studies -. For adjuvant therapy after surgery, neoadjuvant before, for the treatment of hereditary breast cancer and for the treatment of metastatic breast cancer or locally advanced stage but one should before making a decision whether or not to participate fully with inform conditions. In general, the doctors who care available at the competent certified Breast Center as a contact person.
Alternative Therapies in Breast Cancer
In general, from a scientific perspective none of the alternative therapies can replace the traditional medical standard procedure for breast cancer and should. For homeopathy or mistletoe therapy in breast cancer, for example, are so far insufficient scientific evidence before. Green tea is a lot of sympathy; adverse effects are unknown, favorable not backed up. If you want to use homeopathic, herbal or other alternative therapies, discuss this in any case with your treating physician. This also applies to the use of so-called dietary supplements. There are substances that can, in combination with the drugs used in breast cancer therapy for interactions. If alternative means and medicaments of the cancer therapy, for example, over the same path in the liver are metabolized, the effect can increase or decrease of the drugs. In addition, herbal medicines are not without side effects.
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Breast cancer (breast cancer): Special situations
This is about breast cancer in pregnancy in older women and in men
Breast - Pregnancy - Birth Control
Breast cancer is a dangerous and extremely stressful diagnosis for any woman. Even more so if the frightening message falls in the period of pregnancy.
But even here, the disease can be fought - and without harming the child. The treatment can be scheduled at rest, when the diagnosis has been made. She turns out similar to non-pregnant women.
Surgery and chemotherapy are in the pregnancy possible, the chemotherapy can be carried out in the second and third trimesters.
• In need radiation or hormone - and antibody therapy is a time from two to three weeks after childbirth relocated. This should be done when the fetus has attained sufficient maturity. Between chemotherapy and childbirth should be at least three weeks. Four weeks after completion of cancer treatment can make your child a woman breast-feeding .
Hormonal contraception after first-line treatment of breast cancer is considered risky. There are alternative methods, for example, inserting a copper IUD in the uterus .
However, may be impaired fertility after chemotherapy.
Pregnancy after completion of first-line treatment of breast cancer does not increase the risk of a recurrence of the tumor. We recommend a minimum two-year distance.
Breast Cancer in old age
When planning the treatment of health of the patient as a whole is decisive, not so much the age. With sprightly women no compromises in the treatment must be made.
If a patient but older and frail, the doctor will schedule the treatment in a reasonable manner shall individually.
Breast cancer in men: possible but rare
The male mammary gland are compared to those of mature woman underdeveloped, but otherwise created very similar. Therefore, they also respond to estrogens .
When enlarged, the male chest and a feeling of tension occurs, it must not have to be breast cancer - it may be behind a so-called gynecomastia. It is a benign enlargement of the mammary gland, which is probably caused by hormonal changes. Breast augmentation by the formation of fatty tissue called "pseudogynecomastia".
Only every hundredth breast cancer affects a man. This breast cancer in men is indeed a rare disease, but it is not excluded.
Those affected are at the time of diagnosis, on average, slightly older than women, such as between 60 and 70 years.
Important: Any change in the chest - if the juvenile or adult male - should be studied for safety's sake. This applies especially to any unilateral magnification. First contact is, for example, the general practitioner.
Risk factors come in men, among other things questioned diseases associated with an excess of estrogen or a lack of testosterone , accompanied, the male sex hormone.
In addition to the already mentioned obesity (adiposity) are the example of the testes, the adrenal glands, diseases thyroid and liver.
In a genetic disease such as Klinefelter's syndrome sufferers have one or more additional X chromosomes in the genes. It comes to testosterone deficiency and various aberrations. Also, the risk of breast cancer is increased.
Hereditary changes (mutations) in particular the risk of breast cancer gene BRCA2 and other, as yet unknown breast cancer genes (more about these genes in the chapter "Causes, Risk Factors" , which may carry and pass on in men also play a potential role.
In women, only a minority of breast cancers with hereditary predisposition is related. In male patients, the true in one of five or six cases.
The breast cancer risk for men with a BRCA2 mutation is life-long ten percent (with a significant increase from the age of 50).
Thus, it reaches at least about the level of normal breast cancer risk of women. Hereditary burdened men are at the time of the disease usually younger than 60 years.
Increased radiation exposure, for example, after an earlier radiation treatment in the area of the thorax, the breast cancer risk also increases. This is also true for women.
Symptoms generally occur in one breast and are the same as in women (see section "symptoms" ). The breast forms are also the same.
The prognosis for treated breast cancer are similar to those in women, going from comparable conditions from.
As the doctor goes on before?
The family doctor will consider whether a urologist or andrologist should continue to pursue the issue. Andrologist deal with disorders of male fertility. But it may also be that he has the same affected to a certified breast center.
Diagnosis, treatment and aftercare run in men with breast cancer in the Broad as in women, with the removal of the diseased breast is in the foreground and the breast reconstruction naturally does not matter.
The conditions and the use of chemotherapy and radiation therapy are the same.
In course of the (anti-) hormone therapy eliminates the differentiation in terms of age, so the distinction "before or after menopause."
As a medicine primarily Tamoxifen is used to treat hormone-sensitive breast cancer in men. Aromatase inhibitors currently in metastatic breast cancer are more likely to use (only in adjuvant studies), as well as other anti-hormonal therapies.
Also, trastuzumab can be used with HER2-positive tumors (information about this therapy in women in the chapter "therapy" ).
Important: In addition to the actual breast cancer aftercare individuals should always use the cancer screening tests currently offered for men with the urologist and dermatologist. Let specific advice, which offers free care available to you. If a / s continued / s direct / r Related / r also be suffering from breast cancer, genetic counseling is recommended. More information in the section "Consulting expert, specialist literature"
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Breast cancer (breast cancer): aftercare
After the treatment of breast cancer sufferers are regularly re-examined to identify a recurring or new cancer as early as possible
Breast Cancer: follow-up according to schedule
The follow-up is focused primarily on a possible relapse in time to discover. For example, the tumor when it occurs again in the original position, be very effectively treated (see section "Therapy "section: And if the cancer recurs?").
In addition, possible side effects of cancer therapy are to be found and treated.
This involves, for example, problems such as menopausal symptoms, osteoporosis or lymphedema of the arm. Signs of fatigue ssyndroms (tumor Fatigue, see chapter each "therapy"), you should not try to put away, but to address to the doctor.
In addition, rehabilitation and psycho-social assistance can be promoted and coordinated at the time of initial treatment concluded in the context of follow-up.
Info Mieren your doctor therefore also independent of the designated check points with unusual symptoms or if you abnormalities of the breast or notice on the chest.
The check-ups take place in the first three years after completion of breast cancer treatment at intervals of three months.
Until the fifth year, the checks take place every six months, annually thereafter.
The focus of the events is the conversation with the doctor - usually that's the attending gynecologist - who asks the woman at length to her physical and mental condition, and the physical examination. This means that the physician also checks the abdominal organs.
Technical follow-up examinations in women
After breast-conserving therapy is the treated breast in the first three years also mammografiert least once a year and sonografiert, from the fourth year annually.
If the operated breast with this method is difficult to assess, there is a magnetic resonance imaging . The healthy breast is mammografiert once a year, possibly also sonografiert.
Even after removal of the breast is a once a year mammography provided the other breast. The operated side examined the doctor also at least annually with ultrasound .
Additional diagnostic measures are usually reserved special issues, such as in cases of suspected relapse, metastasis or of course a different disease.
If the physician determines that certain investigations necessary to the costs, apart from few specific exceptions, also be covered by health insurance.
Once a month, individuals should think about the breast self-examination.
Breast Cancer aftercare in men
Even men are after initial treatment of breast cancer (for more information in the chapter "Special situations ", the" breast cancer in men, "and in the section "Consulting expert, specialist literature "; see also below, KID) regular follow-ups provided. Also possible are rehabilitation - stationary as an outpatient. Self-help organizations provide further assistance.
Live well and healthy
The main recommendations for this purpose can be summed up in a few words: eat healthy, exercise as much as possible, maintain normal weight - that's the best way to keep fit and to feel comfortable. Normal weight and movement, possibly even a healthy diet can likely reduce the breast cancer risk of relapse.
Concretely, this means, for example, in the diet a sufficient proportion of fresh fruits, vegetables to use, salads and whole grains. Except vitamins and minerals, they also provide other valuable components such as dietary fiber.
Sweets and high fat foods from animal sources, such as meat and cold cuts, as well as alcohol and nicotine are against unfavorable and should disregard stand.
If you are physically active at least three hours per week, so this increases according to experience well-being and is conducive to health. You can approach your performance limit calmly to achieve a training effect
Mental coping with the breast cancer
Many sufferers put their lives after breast cancer treatment in order to live more consciously, pay more attention to your body and let your own needs space. The physical fitness is often even better than before.
More difficult to grasp, let alone in a few words is abzuhandeln the mental side of the disease.
The confrontation with the diagnosis " cancer ", the" overthrow of normality ", days of fear and despair, the feeling that they can no longer rely on their own bodies, nerve-wracking waiting for medical findings, strains and suffering of therapy - the everything leaves deep scars.
Many sufferers feel even for a long time subliminally "alarmed". It is also not always easy to find the right balance between too little and too much attentiveness to one's own body.
Gelingende coping takes time and understanding accompaniment in private and professional environment. A person may be looking for advice and help and externally.
Competent contacts in breast centers are psycho-oncologists, the mainly cancer patients manage psychological.
Psychosocial Cancer counseling centers and psycho-oncologists outpatient active offer professional psychological help.
Addresses and links can be found at the Cancer Information Service (KID) of the German Cancer Research Centre (contact details see chapter "Consulting expert" , "psychosocial support", for example, "KID-sign". You will also find information on self-help groups).
A positive attitude towards life, fulfilling tasks and interests, the conversation in the family, with the partner and with friends, the exchange with other stakeholders, possibly in a support group locally, experiencing solidarity and assistance, including the experience of the recovered body strength - everything This also strengthens the mind and helps to accept the disease and to deal with.
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Breast Cancer: Advisory expert literature
This text was written with generous support from the Cancer Information Service of the German Cancer Research Center
Sources and further Internet addresses:
Comprehensive information about breast cancer:
German Cancer Information Centre, Cancer Information Service KID:
Free Hotline: 0800 - 420 30 40, daily 8-20 clock
Internet: www.krebsinformationsdienst.de
and www.facebook.com/krebsinformationsdienst
Email: krebsinformationsdienst@dkfz.de
Centre for Cancer Registry Data at the Robert Koch Institute, Berlin: http: //www.krebsdaten.de/Krebs/DE/Home/homepage_node.html
Guidelines of the Working Group Gynecological Oncology (AGO) eV:
- Diagnosis and Threapie of patients with primary and metastatic breast cancer: http://www.ago-online.de/fileadmin/downloads/leitlinien/mamma/maerz2014
/de/2014D_Alle_aktuellen_Empfehlungen.pdf (recall: 28/05/2014)
- Information for patients: http://www.ago-online.de/de/fuer-patienten/allgemeines/
German Cancer Society (DKG) German Society of Gynaecology and Obstetrics (DGGG) eV: German Cancer Aid, AWMF:
Interdisciplinary S3 guideline for the diagnosis, treatment and aftercare of breast cancer
Long Version 3.0, update 2012 AWMF register number 032-045OL:
http://leitlinienprogramm-onkologie.de/uploads/tx_sbdownloader/S3-Brustkrebs-v2012-OL-Langversion.pdf
German Cancer Society (DKG) and the German Society for Gynaecology and Obstetrics (DGGG) eV: Interdisciplinary Level 3 (S3) guideline (AWMF 015/062) hormone therapy in the peri- and postmenopause (HT), 2009 (valid until 1.9 .2014)
Radiotherapy (DEGRO):
http://www.ncbi.nlm.nih.gov/pubmed/24306068
Other:
St. Gallen Consensus Conference early breast cancer 2013:
http://www.medinfo-verlag.ch/upload/File/onko_2_2013/06_onko_2-13_WA_Kongress_Breast%20Cancer.pdf
Janni W, Kuhn T, Schwentner L et al .: Sentinel node biopsy and axillary dissection in breast cancer - evidence and its limitations. Dtsch Ärztebl 2014; 111 (14): 244-9. DOI 10.3238 / arztebl.2014.0244
Harbeck N: Breast Cancer: Tumor Biology-based concepts for surgical and drug therapy. Dtsch Med Wochenschr 2013; 138: 180-182, Georg Thieme Stuttgart. DOI 10.1055 / s-0032-1327410
Rudel RA: Environmental Exposures and Mammary Gland Development: State of the Science, Public Health Implications, Research and Recommendations; Environ Health Perspect 119: 1070-1076 (2011). http://dx.doi.org/10.1289/ehp.1002741 (online April 18, 2011; demand: 05/16/2014)
Aluminum in deodorants:
http://www.bfr.bund.de/cm/343/aluminiumhaltige-antitranspirantien-tragen-zur-aufnahme-von-aluminium-bei.pdf (Polling: 19/07/2014)
Familial breast cancer:
Information sheet with key facts and responses of the KID (see above):
http://www.krebsinformation.de/wegweiser/iblatt/iblatt-familiaerer-brustkrebs.pdf.
http://www.krebshilfe.de/fileadmin/Inhalte/Downloads/PDFs/Praeventionsfaltblaetter/444_familienangelegenheit.pdf
http://www.brca-netzwerk.de/risikofaktoren-brustkrebs.html (polling 06/04/2014)
www.mammamia-online.de (polling 04/06/2014)
Breast cancer in men:
http://www.krebsinformationsdienst.de/tumorarten/brustkrebs-mann
Self-help: http://www.brustkrebs-beim-mann.de
Psychosocial support:
http://www.krebsinformationsdienst.de/wegweiser/index.php
Attention: www.apotheken-umschau.de is not responsible and accepts no liability for the content of external internet sites
Breast cancer, the most common cancer in women, is produced in the mammary gland. Information on risk factors, pre-cancerous lesions, diagnosis and current therapies
Breast Cancer - turning point in life
Diagnosis: Breast Cancer. Who gradually tried after this shocking message, to bring order into his thoughts, often is faced with a tough job: mobilize our own forces to take life into their own hands, create confidence. To deal with the treatment recommendations, make important decisions. But also accept aid: All this is extremely important in order to survive the coming hardships without too many injuries.
The future? Later, please. First, it is about the here and now. The goal: to gain valuable life years. In fact, this is now often and for a long time realistic in breast cancer. Despite the stress that often makes the therapy itself, but many sufferers acknowledge that they can lift. And the cancer? Once defeated and over.
This article provides an overview of breast cancer. It provides information on risk factors such as hormones and genes on benign findings in the chest , bring an increased breast cancer risk, through non-invasive (non-destructive growing) cancer precursors such as ductal carcinoma in situ (DCIS), through early detection, diagnosis, prognosis and therapy.
With the chapter list in the box above or the bar at the bottom allows you to navigate quickly, just on the chapter links in the text.
Breast Cancer: The most common cancer in women
In Germany every year receive more than 71,000 women are diagnosed with breast cancer. Breast cancer is the most frequent cancer in women.
Around half of those affected are old at diagnosis less than 65, about one in ten sick woman even under 45 years.
By the way: Even men can get breast cancer, but very rarely. Only about one in a hundred breast cancer patient is a man.
Early shows success
However, the undoubtedly alarming numbers can be a positive development to face: breast cancer is no longer now the most threatening tumor in women. Meanwhile, he has been among women in the industrialized countries of lung cancer surpassed (in men lung cancer tops the list of cancers with the highest mortality rates - both in industrialized and development countries Ling - on). The main cause is considered smoking .
Diagnosis and treatment have steadily improved just in breast cancer. This includes current assessment also introduced in Germany in 2005 mammography screening, ie, the X-ray examination of the breast as part of the free screening program for women between 50 and 69 years of age. Furthermore informs the chapter "early detection, diagnosis, prognosis, "detail.
The relative 5-year survival rates of breast cancer patients, considered over all stages of the disease are, now more than 83 percent. The term "relative 5-year survival rate" is a statistic that is often used for cancers.
It says how many patients affected by hundred live five years after establishing the diagnosis, based on the survivors in the same period the general population of the same age and sex.
The vast majority of breast cancer sufferers is five years after the diagnosis alive, many even ten or fifteen years later. Nevertheless, the disease develops differently in each woman.
What determines the prognosis depends on?
First of all, the earlier breast cancer is detected, the better are generally the treatment prospects.
Crucial for the prognosis is next to the tumor size and lymph node involvement of a possible armpit of biological character of cancer. From this, conclusions can be drawn regarding its growth behavior. For the therapy is becoming increasingly important.
However, the type of treatment, the age of the patient, possible personal risk factors for breast cancer and comorbidities play a role in the prognosis.
Therefore, statistical figures are ultimately always be considered relative and with regard to the individual course of the disease with caution.
What are the risk factors for breast cancer, there are?
Breast cancer is very diverse - there are known only about thirty forms. Meanwhile it is even the view that any patient "their" breast cancer. The determining cause simply does not exist.
Among the important risk factors include effects of female sex hormones and lifestyle, then the age and genetic factors.
In some families, breast cancer occurs more frequently. But only some of them there is a clear genetic predisposition. Thus, for example, certain changes (mutations) of the two genes BRCA1 and BRCA2 (BRCA is derived from the English term for breast cancer: Br east Ca ncer) responsible for about five percent of all breast cancers. In another five percent there are changes in other genes, including similarly influential as the BRCA genes. Some researchers increased cancer potential in interaction with environmental factors such as alcohol have also been found.
What symptoms indicate breast cancer?
Breast cancer often develops over many years. Possible signs are nodes in the breast tissue, dimples or redness of the skin , a unilateral increase in breast size, rarely chest pain . The nipple may be retracted or liquid secrete (more on this in chapter "symptoms ")
A swelling or hardening of the breast with redness and pain may occur, for example, even with a blocked duct or mastitis developing therefrom. These changes typically occur at the beginning of lactation. When a breast infection, the pain is even more pronounced, individuals feel uncomfortable and also have a fever. For an engorgement usually help against local measures, such as regular emptying of the breast as well as local heating and cooling after breastfeeding . There is evidence of infection , the doctor will also treat the woman with antibiotics. Then the inflammation subsides generally.
Otherwise - and outside of pregnancy and lactation in principle - is an inflammation with redness and swelling or hardening of the breast always suspect and in need of clarification. Rarely, as in one to four percent of the cases, a so-called inflammatory (inflammatory) breast cancer are present. The average age of patients is 57 years, and fever is not a typical symptom. Breast cancer should always be promptly detected and treated. This is especially true for an inflammatory breast cancer because it tends to progress rapidly.
Breast cancer: early detection - diagnosis
Still, breast cancer is mainly an incidental finding. Often women discover the changes in the breast itself - by accident or conscious when scanning (self-examination).
The instructions for self-investigation is part of the breast cancer screening examination by the gynecologist.
It is recommended for every woman to use the regular basic cancer screening rates.
The assumption of costs by the national health insurance in women with no increased risk provides:
Women from 20 years receive an annual free early detection test for cervical cancer .
For women over 30 years a free early detection test for breast cancer is annually provided.
The doctor examines the breasts carefully and thereby scans the lymphatic drainage of the breast from. For specifics, he will quickly follow up on.
The most important for the diagnosis of breast cancer, in addition to the palpation mammography, ie, the X-ray examination of the breast.
There are essentially two ways: volunteers series X-ray examinations of the breast should contribute to earlier detection and better prognosis of breast cancer.
For this mammography s creening be "breast health" women between 50 and 69 years - ie until the end of the 70th year of life - invited every two years. For more information, see the chapter "Early detection, diagnosis, prognosis". Occurs between screening appointments or any time an obscure change in the breast, the doctor is a so-called Abklärungs- or curative if necessary mammography cause.
Other imaging techniques such as ultrasound (sonography Mamma), in some cases, the magnetic resonance imaging ( MRI ) of the breast can additionally be needed - both for the clarification of incurred on the curative mammography screening as well as a suspicious finding. Modern imaging is constantly evolving, what is proving to be useful in the diagnosis of breast cancer.
Ultimately, however, may a tissue sample (biopsy) confirm the diagnosis only the histological analysis. For this, the doctor takes samples as needed from a suspicious area of the breast. The tissue is then examined in detail.
It focuses first on the fundamental question of whether a destructive growing, invasive cancer or a non invasive, certain tissues limits not exceeding tissue change as ductal carcinoma in situ (DCIS; see among others the chapter "breast cancer (breast carcinoma) suspected: Even benign or even cancer? ") is present.
In both cases, the determination of specific proteins on the cell surface follows. Among them are those which docking sites for sex hormones such as estrogen or progesterone form, and the molecule HER2. Doctors refer to in the context of hormone receptors and HER2 receptors. About these receptors receive both normal cells and cancer cells signals to divide. Cancer cells can have a particularly large number of them. Then they grow faster. At the same time here are starting points for therapy (see below).
Which diagnostic procedures may come in detail, this also more in the chapter "early detection, diagnosis, prognosis".
Breast Cancer Therapy: by guidelines
Basically affects the spread of the tumor - the stage at which the cancer is at diagnosis - treatment planning. Often the first step in treatment consists of surgical removal of the tumor, and possibly also of axillary lymph nodes (more on this in chapter "therapy "). During surgery, the breast can often be retained. Does it need to be removed, the surgeon can they. Using an implant with autologous tissue or both rebuild (breast reconstruction)
In addition are the radiation, anti-hormone therapy, chemotherapy and so-called targeted therapies, such as an antibody therapy.
Which treatment sequence is selected ultimately depends on various factors. So breast cancer may be different aggressive. Certain variants as HER2-positive tumors treated doctors usually in advance with an antibody therapy and / or chemotherapy. But in other cases in which chemotherapy is indicated, this is now preceded by increasingly surgery.
And: hormone-sensitive tumor cells respond to female sex hormones, thus a hormone withdrawal. The use doctors for therapy (anti-hormone treatment). The key here is, among other things, whether the tumor in a woman before or after menopause has occurred. When a hormone-sensitive breast cancer overall has a favorable prognosis, sufficient for its complete removal followed by radiation usually a sole anti-hormonal treatment.
Important: The treatment of breast cancer today follows scientific guidelines and is also tailored to the individual patient.
Medical guidelines are recommendations for physicians on the basis of clinical trial results secured. Here the highest possible level of agreement is aimed at the broadest possible expert level.
The guidelines are intended to provide adequate health care. The aim in the medium and long term, reduced in breast cancer mortality and quality of life are improved. The recommendations are regularly adjusted to current developments.
What are breast units?
Breast (cancer) centers are recognized by the German Cancer Society and the German Society for Senology (certified) clinics to diagnose and treat breast cancer.
The name derives from the French word senology for the female breast, "le be" off.
They therefore meet the requirements of a breast cancer treatment in full. And they ensure the necessary quality of treatment because of their medical equipment and technical qualification. More information in the section "Consulting expert, specialist literature" .
The health insurance companies have developed structured treatment programs for chronic diseases such as breast cancer, based on the guidelines. Participation is voluntary.
Such programs are aimed at breast cancer from it, to ensure that standards of care and to accompany the person concerned in the follow-up after initial treatment.
They should also help to ensure that the woman is left at this critical juncture is not alone and learns the necessary psychosocial support.
Finally, the program is designed to help improve the coordination of doctors responsible for each other and the family doctor.
With the growth of knowledge is also the treatment of breast cancer varies in a relatively short time. Inform yourself. Before making important decisions in which it comes to your health, including to the relevant research and advisory facilities
Literature and more information:
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More on that below and in Chapter: "Consulting expert, specialist literature" .
This article provides only general information and may not be used for self-diagnosis or treatment. He can not replace a doctor's visit. The answer individual questions by our experts is not possible.
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Breast cancer (breast cancer): Structure of the breast - and what changes in the tissue
Millions of women feel the hormones with each monthly cycle: Before menstrual chest begins to tighten or feels nodular. After menopause settles that. Therefore, the shape of the breast after
So the breast is constructed
The female breast (latin "Mamma") consists of glandular, fat, connective tissue and skin . It also has nerve, blood - and lymph vessels . About this tracks the breast is the nerve -, immune and vascular system of the body connected.
The mammary gland itself is composed of about 15 to 20 branched, different sized glands (lobules) together. They are each surrounded by connective and supporting tissue. Each of these glands lobe consists of several lobules, the smallest units of the mammary gland.
There each small milk ducts have their origin. Towards the nipple they unite to form larger corridors (see drawing).
What do the sex hormones
In the fertile phase of life, the breast tissue is subject to the changing influence of female sex hormones, estrogen and progesterone .
After ovulation at midcycle, the milk ducts wide easily, and the lobules enlarge temporarily. The connective tissue takes up more liquid, the breast is bigger, stronger, spanning perhaps something.
Sense of it all: preparation for the production of milk and the breast-feeding , the actual tasks of the chest. Places that feel somewhat uneven, bumpy or even knotty, may increase in the second half of the cycle and be sensitive to pain.
These cyclical problems, even the somewhat nodular character of the fabric to go with the onset of menses, often back.
The glandular cells of the breast mature way, only during pregnancy completely. You zoom in and then multiply even more. Pregnancy and breast-feeding over a certain total duration may affect breast cancer risk low.
This Age also plays in the first pregnancy a role. Women who have their first child at the age of under 20 years, appear to have a lower risk of breast cancer than women without children or those who are first time with more than 30 mother.
Breast disease: Benign conversion
Sometimes the reason for the symptoms described earlier, is a cyclical mastopathy. This refers to specific remodeling of the breast tissue.
They are often linked to the imbalances of sex hormones during the menstrual cycle. Interactions with other hormones are believed to play a role.
After the menopause, the glandular and connective tissue developed back, the shape of the breast strength decreases. Often then the mastopathischen changes weaken also. Sometimes, however, also leads the regression of the breast tissue in the age to mastopathischen findings. A breast disease can therefore occur throughout the adulthood of women.
Possible symptoms, especially in the childbearing years, are pain , leakage of secretions from the nipple and breast lumps. Rarely show signs of inflammation. All in all, can be represented very differently in their course a breast disease.
Important: Neither is the remodeling of the tissue necessarily morbid, still must therefore go hand in hand complaints. But if, for example, is leaking from the nipple or notice a nodular change, the gynecologist should necessarily clarify.
If, in the context of breast disease to pathological changes, then they are assigned to the benign breast disease.
There are three degrees of severity of fibrocystic breast disease (I, II and III). In grade III breast cancer risk is slightly increased.
Certainty about the nature of a lesion can be only a fine tissue examined tissue sample. When it is recommended that you read the chapter "early detection, diagnosis, prognosis" .
Breast cancer: malignant growth
In a malignant tumor of the breast cells to change in the glandular tissue and can fundamentally uncontrolled and destructive grow into the surrounding tissue. The starting point is damage in the genetic material of these cells.
Affected are either cells in the region of a lobule (lobular), more commonly, in a milk duct (ductal). By the female sex hormones - estrogens and progestin progesterone - and other factors affect the glandular cells of the breast, they can also promote irregular growth processes.
The tumor grows and can be palpated as a node. Malignant cells can migrate through the lymphatic and blood vessel system, reach other organs and form secondary tumors (metastases).
Breast cancer (breast cancer): causes, risk factors, prevention
Hormones, lifestyle and heredity influence the development of breast cancer. The personal risk of cancer usually depends on several factors not always tangible
Cancer cells grow in an uncontrolled manner
Every now and then spontaneously degenerate cells in the body, but are separated. In the development of cancer , the genetic program and a cell line changed. There are developing new cell structures which deviate more and more from normal.
Has this trend prevailed, start the degenerated cells - now cancer cells - to be strengthened multiply. It grows a tumor. As a so-called carcinoma in situ (non-invasive cancer) and is restricted to its "natural tissue boundaries," as invasive cancer it grows destructively into the environment. Important limitations in the tissue - in breast cancer about the so-called basement membrane under the glandular cells - can command him unable to control.
Sex "blessing and a curse" at the same time
Female sex hormones - estrogens and progestins - play a tangible role in breast cancer. That the hormone levels fluctuate during each menstrual cycle and affect the structure of the mammary gland, is first of all very normal.
Yet sustainable change a pregnancy and the menopause the breast tissue (see section "Structure of the chest ..." ). Put simply, the female hormones exert a growth stimulus on the gland cells. In breast cancer, this process gets out of control. In addition to the natural, endogenous hormones and the "outside" fed hormone preparations are relevant.
The links between hormone exposure and breast cancer can be summarized as follows:
Time between the first and last menstrual period (menarche and menopause): The earlier the menstrual period and the later the menopause begin, the longer the breast is exposed to hormonal influences. This circumstance is considered as a factor that increases the risk of breast cancer.
Multiple pregnancies with subsequent lactation periods: You can reduce the risk of breast cancer - the younger the person concerned at the time of pregnancy and breastfeeding, the better. Affordable: a total standstill period of more than a half to two years.
Birth Control Pill & Co: The hormonal contraception, in the form of birth control pills or short pill that breast cancer risk increases hardly. At the same time the pill reduces the risk of other cancers, such as uterine (body) - and ovarian cancer. Other malignant diseases, including cervical cancer , take turn to light. Overall, the risk-benefit profile of the pill in healthy women with regard to the risk of cancer truncates positive.
Hormone therapy for menopause symptoms: It increases the risk of breast cancer and ovarian cancer. This applies especially to the combined treatment with estrogens and progestins. After completion of the hormone it drops back and does not differ more within a few years from the risk of women who have never done a hormone therapy.
In healthy women who have pronounced symptoms such as severe hot flashes, keep gynecologist a temporary, low-dose hormone replacement therapy for justifiable.
Vegetable materials against menopausal symptoms: Dietary supplement with so-called soy isoflavones can act as estrogen-like. Hence the name phytoestrogens. Findings as to whether they affect the risk of breast cancer favorable or unfavorable, are contradictory.
Let yourself before taking the safe side of your gynecologist advise you, particularly in hormone-dependent breast cancer. People who eat a balanced and occasionally also consumed natural soy foods, his health certainly does not hurt.
Preparations that black cohosh extract contains, do not increase the risk of breast cancer. However, they may be able to interact with administered drugs. Talk Again definitely with your gynecologist before you apply these and other herbal remedies, especially during a breast cancer therapy.
Pregnancy after breast cancer treatment is complete: There are no known adverse effects on the development of the disease.
Is a preventive anti-hormone treatment possible?
There are indications that most women at increased risk of breast cancer can reduce their risk of illness by means of preventive anti-hormone therapy. In Germany, however, has so far not a drug for breast cancer prevention admitted. It is currently being explored yet intense, in which women of the expected benefits of such preventive therapy outweighs the potential damages associated with the (early) hormone withdrawal
Lifestyle, environment, X-rays
Certain risk factors can be influenced very well as lack of exercise and obesity . That they can increase the risk of breast cancer, is made in particular during and watch after menopause. Apparently, here plays an unbalanced metabolic state, which is also generally harmful to health, a role.
An example: the so-called metabolic syndrome , which work closely with the diabetes (diabetes mellitus) and heart disease -cycle is connected. From lifestyle related metabolic disorders such as type 2 diabetes can be very well avoid or detect in time and have to get to grips with. A key role to play in weight control. Both - the increased risk of breast cancer as well as breast cancer disease in its course - are thus favorable influenced.
Also risky: frequent consumption of alcohol. The risk increases to bring it to a common denominator, with the amount. As low as 18 grams of alcohol daily (equivalent for example a glass with about 150 milliliters of wine, Alcohol 13 Vol .-%) takes it to clear.
Also smoking promotes studies by the World Health Organization (WHO), the development of breast cancer. Stress , however, has no discernible effect. However, night and shift work in the modifiable risk factors for breast cancer is sometimes mentioned.
Finally, numerous chemicals are discussed as possible risk factors for breast cancer, such as mold toxins, then harmful substances produced during grilling and roasting meat and fish (as polycyclic aromatic hydrocarbons, PAHs), benzene and other substances in car exhaust or cigarette smoke. The list (see section "Consulting expert, specialist literature ") long.
An earlier radiation treatment in the area of the thorax may increase the risk of breast cancer. Of course, doctors perform radiotherapy only when it is medically necessary. This also applies to the treatment of breast cancer. In addition, modern radiation techniques are helping to keep the radiation dose as low as possible.
Conclusion: Direct causes of breast cancer are not known. And: A healthy lifestyle can help reduce breast cancer risk.
The role of genes in breast cancer
Sometimes the predisposition to breast cancer is the change of a single gene underlying (breast cancer genes or high-risk genes). Much more common, however, affect a number of factors, including genetic, together. In sum, they then contribute to the fact that fundamental changes in the genetic material of a cell and sneak it comes to degeneration.
If appropriate genetic modifications in someone present, various factors (environmental, lifestyle) can easily cause the cancer develops. In other words: The sufferers are more sensitive than people with "normal" Genausstattung.
These factors include in particular the female sex hormones and an unhealthy lifestyle with lack of exercise, obesity and increased alcohol consumption (see sections above).
More and more well-known breast cancer genes
Scientists have mid-nineties, two breast cancer genes, namely discovered BRCA1 and BRCA2, which are often changed in hereditary predisposition to breast cancer families.
BRCA stands for "Breast Cancer", ie breast cancer. The mutations responsible are inherited via the egg or sperm cell and are found in all body cells. What does it mean when a woman has a Hochrisikogen for breast cancer? It states that their risk of developing breast cancer during her lifetime, is high. Also the risk that the other breast is ill, then increased, as the risk for ovarian cancer.
There is also evidence that in families with familial breast cancer risk is increased for other cancers.
A change in the BRCA genes is but only about five percent of all breast cancer sufferers. In another five percent other genes play a role.
In fact, now been further genes, including the high risk gene RAD51C, also referred to as BRCA3 discovered. Mutations of this gene may also hereditary breast and ovarian cancer trigger. Are known today no less than 49 different genes whose changes affect the risk of breast cancer, and probably in the future come to some.
What to do in case of suspected familial breast cancer?
Women, in their families breast cancer occurs more frequently are, rightly concerned and want to know what they can do to prevent it.
If there is suspicion of an inherited burden on a woman, it can to a specialized human genetics center or at one of 16 university centers "Hereditary Breast and Ovarian Cancer" call (for more information see the links at the bottom and in the chapter "Consulting expert, literature " ). You can also obtain advice from her gynecologist, which point is suitable.
Concrete examples: If the mother or sister has had breast cancer before age 36. or if two first-degree relatives have ovarian cancer, this may indicate a genetic predisposition. There are in breast and ovarian cancer, of course, other family disease patterns that may suggest a heritability.
If certain family constellations present, recommends the consortium "Hereditary Breast and Ovarian Cancer" at the time a test for BRCA mutations. The list of criteria can also be found in the section "Consulting expert, specialist literature".
What does the BRCA gene test?
The test can establish whether the disease accumulation underlies a change in the BRCA genes and, where appropriate, whether the person tested this genetic alteration also possesses or not at heaped incidence of breast cancer in a family clarity. However, the theme "Hereditary breast cancer" is very complicated. To take advantage of the advisory services and expertise of specialists before deciding for or against a genetic test is all the more important. One has to also of the consequences - for themselves as well as possibly affected family members - be aware.
If applicable, do not question a genetic test. That would be the case if the calculated risk was not high enough to accept a certain probability of a BRCA mutation. If at a correspondingly high risk of the test is performed, it may still happen that no BRCA mutation is found. Then one would assume that the risk is very likely caused by changes in the family in other genes.
Because breast cancer can occur more frequently in some families, without being charged with any of the previously known hereditary gene mutations for breast cancer. It may also be that they have a (BRCA -) - have gene variant that is still unclear in its meaning. This affects about five to 30 percent of the BRCA mutations.
In addition, for example, not a negative result when tested a healthy person from a hereditary risk of breast cancer. By contrast, the announcement that the test is positive, not only for the sufferers consequences (see below), but for all relatives in the family or on the affected family page. They would have but henceforth in the stressful living consciousness, part of a "cancer family" to be and possibly even have the gene mutation and thus a high risk of disease. It applies, however, important to note that not everyone who has inherited the predisposition actually suffering from breast cancer or ovarian cancer.
More meaningful is the test if it is possible an already diseased family member, a so-called "index patient" test: If the test that if this person is present a high-risk gene mutation, other related family members can be examined at the request of the gene back.
If the test would demonstrate that when a family member, this change does not occur, the person in question would have no increased risk of breast cancer - he or she would be "relieved" by the test.
Before the test is carried out at the center always only a pedigree analysis as well as medical and psychological counseling. Then there is enough time to deal with the issue and to make well-founded his own decision. Until the test result is available, by the way can take a long time - if it is in a hurry, then it goes even faster.
Important: The test is voluntary. Who can be tested, has a right not to know. He or she may also choose not to know the result after the analysis.
What are the other consequences of a positive test result?
For a more early: For women with a BRCA1 - / - 2 mutation there is a project financed by various health insurance companies and private health insurance companies, to the specialized centers "Hereditary Breast and Ovarian Cancer" bound program for intensified screening for breast cancer. This should of course then actually take place in such a center.
The program can, incidentally, be taken even without genetic testing to complete if the pedigree analysis indicates a high-risk situation. This program is then but a little less intense than that in women with proven BRCA mutation.
That the program envisages the intensified breast cancer screening:
From the age of 25 or five years before the youngest age of onset in the family every six months medical Tastuntersuchungen and Sonografien and annual contrast-enhanced magnetic resonance imaging of the chest.
From the age of 40 every one to two years to come mammograms added. Once a month, the person concerned should perform a breast self-examination. The mammograms should be continued at least until the age of 50 and no longer than until the age of 70 or as long as the recordings are easily evaluated.
Women without proven BRCA mutation (see above), have the virtue of other genetic constellations an increased lifetime risk of breast cancer (about 30 percent), offered a little less intensive screening measures. Annual MRIs are for example only provided here from the age of 30 years. From 50 years the victims the usual screening measures (the "screening") will be accessible.
Engagingly, but more security: preventive operations
On the other hand come with a positive BRCA test preventive operations into consideration. This allows reduce cancer risk sustainably.
Removal of the ovaries and fallopian tubes: healthy BRCA mutation carriers it is recommended to the age of 40 or after completion of family planning - in addition to intensified screening. The measure has a double benefit to be: The risk of ovarian cancer, also increased significantly in BRCA mutation carriers, decreases by about 85 percent, and the risk of breast cancer is halved. Against early onset menopause symptoms as a result of the procedure, a low-dose hormone therapy be used.
Complete removal of the breasts: To reduce the increased risk of breast cancer up to a very low residual risk, there are only one, but radical solution, namely, the complete removal of the breast on both sides, so the mastectomy. The chest can be rebuilt (see section "Therapy" , the "breast reconstruction"). The minimum age for this preventive operation is 25 years. There are different methods with different advantages and disadvantages. Meanwhile, techniques have been developed to obtain in the amputation the breast skin and in some cases the nipples and areolas. What does this mean for the balance of risks, is not yet clear.
That in particular the mastectomy - despite the breast reconstruction option - is perceived as disfiguring and therefore often meets with rejection, not surprised. But there are women who want to put in a breast cancer high-risk situation to the greatest possible safety and take the burden upon himself.
The decision on the own way is easy for any person concerned. You can also here recourse to competent medical and psychological counseling where you already famous center for "Familial Breast and Ovarian Cancer".
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Breast cancer (breast cancer): Symptoms
Hardening or lumps in the breast are common. Who scans a node or unusual symptoms observed, this should always be to clarify by a doctor
At the initial stage causes breast cancer usually no discomfort. Possible warning signs are tissue induration, nodules and secretions from the nipple.
The majority of the nodes in the breast are benign. Nevertheless, a newly established change you should always get to the bottom.
The following symptoms may be a sign of breast cancer:
The breasts are in their size or shape recently differently.
When scanning the breast or armpit fall on unusual knots or lumps.
The nipple is retracted.
The nipple secretes clear or bloody secretions.
At a certain point the skin of the breast appears grübchenartig drawn (so-called orange peel).
There you will find redness or flaking of the skin that does not regress again, sometimes associated with pulling in the chest, pain or swelling.
Possibly the physician in the regular early detection (see also Chapter "Early detection, diagnosis, prognosis" ), in which it scans not only both breasts, but also the associated lymphatic carefully and systematically, a little swelling in the armpit area determined. It has probably points to an enlarged lymph node. This may in turn be related to a previously hidden change in the chest, so that the findings should be further investigated in a timely manner.
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Breast cancer (breast cancer): screening, diagnosis, prognosis
Screening tests to the gynecologist, imaging, especially mammography and ultrasound, tissue samples - in this context moves the diagnosis of breast cancer
Inspect the breasts regularly yourself
Every woman should have one at the same time their monthly breast self-sampling, pre-menopausal best in the first ten days of the cycle, so on the days after the menstrual period.
The self-examination has the particular advantage of a feel for the nature of the breast to develop and perceive abnormalities conscious. How it works best, you can ask to see the doctor in the early detection and then reconstruct at home alone.
Breast cancer screening at the doctor
The statutory cancer screening breast examination is aimed at women over 30. The doctor considered in this study both breasts and examined it with his preferred tactile technology. The woman takes various postures one: standing, sitting, arms on hips, lifted over his head.
He also inspected the lymphatic drainage and scans them off: the underarms and the ranges above and below the clavicle. With eye-catching Tastbefunden in the second half of the cycle should be a check in the first half of the next cycle.
The gynecologist also noted the important points of the individual and family medical history and information about occupied drugs .
The gold standard: Mammography
For 50- to 69-year-old women is currently available in addition every two years voluntary X-ray screening of breast available mammography screening.
When mammography in its current form, the breast is held by two plates and compressed, so that it is as flat as possible, and then illuminated by X-rays - a bit unpleasant and sometimes painful, but brief moment. Each breast is imaged in two directions.
Mammography screening: organization, procedure
Because the breast tissue is more sensitive to radiation in younger women, the screening mammography begin until the age of 50 years.
Women of that age group will receive every two years an invitation to mammography in a qualified mammography unit. One or more such units form a so-called qualified screening unit along with units for diagnostic evaluation. In Germany there are currently more than 90 of them with a total of 400 locations.
The images of the breast are evaluated by at least two doctors independently (double reading). The doctors involved found among other mammograms per year of at least 5000 women. The result follows in writing after about seven working days.
When a suspicious or unclear findings, the party has been given an invitation again. The situation will be discussed in detail with the woman and, for example by means of a ultrasound scan (see below) clarified. Sometimes even includes a specific magnification mammography. Perhaps the recommendation, a tissue sample from the resulting chest to take (more on that later too).
The person may be, to vote on the proposed follow-up examinations at any time with the doctor of their choice, which will be informed on request. The studies for the clarification of suspicious mammography findings can be carried out with the screening unit in the screening unit or to other qualified, in consultation.
Advantages and disadvantages of mammography screening
Advantages: The screening is naturally not foolproof. It should identify as early as possible any existing tumors already. Because then is breast cancer treated very well and the chances of getting a permanent cure are high. Screening protects but of course not before that breast cancer arises at all. The latest data for the evaluation of screening refer to the year 2010: At about seven to eight in 1000 women with breast cancer detected by a Früherkennungsmammografie before he was conspicuous by symptoms.
Prior to the introduction of the program there were two or three. Around 80 percent of tumors are now recognized at an early stage. Before the screening, there were 49 per cent. In other words: In the meantime, to halve the proportion of larger tumors in the participants was recorded. Discussed, however, that the main reason is that small, little aggressive tumors were found, which would anyway never been noticed (see below: cons).
The also increasingly discovered breast cancer precursors, such as the ductal carcinoma in situ (DCIS), are sometimes those which may later develop into an invasive, so destructive growing into the surrounding tissue breast cancer.
That the breast cancer screening can save lives, is proven. It is estimated that about three to four of 1000 women participating more than 20 years on regular screening, can be cured by early detection of her breast cancer.
Worse quantify, but certainly also to be observed is the benefit of the women concerned arises that can obtain a less burdensome treatment by the early discovery of their tumor.
Disadvantages: It is possible that a breast cancer is detected and treated in the screening that would never have made the women's problems (overdiagnosis). The frequency of diagnosis is highly controversial from experts. According to the Euro Screen Working Group estimated that about three percent of all breast cancer diagnoses in screening overdiagnosis. In addition, in some women up examinations are necessary, which can burden the affected physically and mentally.
As with any imaging examination may become a smaller part of false negative (incorrectly inconspicuous) findings arise that outweigh the woman in question falsely in safety.
In the course of screening the woman an increased radiation exposure is exposed. However, this is thanks to modern digital technology as a relatively small and is compared to the renunciation of the investigation by the majority of experts are currently considered to be less risky. One approach: The single dose of mammography corresponds roughly to the natural radiation that in a week's stay in the mountains over 2000 meters altitude hits the body (source: University Women's Hospital, 2014).
Currently: Check trials currently considering whether further improvements of the current screening or additional new screening techniques, such as by means of ultrasound, bring benefits to uncover some hitherto undetectable changes early in the screening and the rates of unnecessary diagnostic measures to biopsies can reduce. Accurate long-term data for the reduction of breast cancer mortality of nationwide screenings are expected in 2018.
Conclusion: Every woman should consider whether they want to participate in mammography screening. You should obtain advice from a doctor exactly, in detail inform themselves and then make your choice. Your decision may reconsider again. More information on the subject is the attending gynecologist or the Cancer Information Service (see link at the bottom and in the chapter "Consulting expert, specialist literature" ).
Small reading aid in the imaging findings: The Bi-RADS system
Developed in the US Breast Imaging Reporting and Data System (BI-RADS) is used mainly in the Abklärungs mammography to classify mammography findings to detail. Here's a little reading aid.
BI-RADS system
BI-RADS 0: The diagnosis is incomplete; an additional imaging is necessary to complete the evaluation
BI-RADS I: No pathological findings
BI-RADS II: Benign changes, no suspicion of cancer
BI-RADS III: Unclear change, rather benign, re-evaluation after six months
BI-RADS IV: Unclear, suspicious changes, further investigation by histological examination ( biopsy )
BI-RADS V: Great probability of breast cancer, the diagnosis must be clarified through a tissue sample
BI-RADS VI: Histologically assured breast cancer
Imaging methods without radiation exposure: ultrasound and magnetic resonance imaging
Women who are younger than 40 years, often have a very dense breast tissue. Similarly, if after menopause hormones are taken is.
In order to clarify a suspicious palpable mass in the breast, lends itself in these cases initially an ultrasound (high-frequency ultrasound ) to.
This is true even if the radiation exposure should be avoided by mammography as possible, especially in young women, even during pregnancy . In lactation focused ultrasound is also the first investigative measure.
Harmless changes such as fluid-filled blisters ( cysts ) recognizes the physician using sonography particularly well.
Even with eye-catching signs in mammography or if this is poorly assessed because very dense glandular tissue, the ultrasound is connected. Lymph nodes in the armpit can be represented very well mitttels ultrasound also.
As early detection is the ultrasound examination also - in addition to the scanning of the chest and investigation of abdominal organs by the doctor - used in semi-annual basis in women aged 25 or over who have a significantly increased hereditary risk of breast cancer (see chapter "Causes, Risk Factors" ).
To help diagnose the ultrasound but not enough. It is an additional method of investigation and complements mammography in the clarification of suspicious or unclear, especially non-palpable findings. In other words: If in doubt, a mammogram should be performed.
Meanwhile sometimes come even newer techniques such as ultrasound acoustic wave elastography - sort of a sampling of the breast with ultrasound - and 3D procedure in specialized centers in addition to the application.
As the ultrasound brings the magnetic resonance imaging ( MRI ) no radiation exposure with it. Here magnetic fields and radio waves come to fruition. However, it is usually necessary a contrast medium through the bloodstream. This does not contain iodine in breast examinations.
The doctor will examine in advance whether there are risks in terms of the contrast agent. In young women at increased hereditary risk of breast cancer, especially at a BRCA1 or BRCA2 mutation, the program provides early from the age of 25 years, among other things, an annual MRI before.
While mammography for example has its strengths in the preparation of so-called microcalcifications, the MRT very dense breast tissue forms better.
The MRI can clearly show some changes, including scars after surgery. But it is expensive and often results in a false positive result. That is, they are not specific enough: The changes shown may be ambiguous and give unnecessary additional examinations occasion. Therefore, the MRT for the routine is not suitable. For specific questions in the clarification striking mammography findings or follow-up MRI, however, can be very useful. She belongs in young women with a significantly increased hereditary risk of cancer to the statutory early, because at this age because of the dense glandular tissue, the X-ray mammography is often not descriptive enough.
It is also important that at a Abklärungs MRI - as with a diagnostic mammogram or ultrasound examination of the breast well - technically it is possible, a biopsy to connect.
Important: The MRI is not paid in all cases by health insurance. The physician must justify the need.
Nevertheless, the woman should first check with their health insurance company if the costs are covered - otherwise it can happen that you have to pay the examination itself (about 400 to 600 euros). Some funds are now offering to the reimbursement in the course of certain programs.
In addition to the aforementioned cases, the health insurance companies cover the cost mainly in the following situations:
To the local recurrence (local recurrence) of breast cancer after breast conserving therapy (surgery and radiotherapy) exclude when mammography and sonography are not enough to clarify.
Tumor looking at cellular level backed lymph node metastasis of breast cancer in the armpit when the primary tumor (primary tumor in the breast) neither clinically nor can be shown with the imaging standard methods mammography and sonography. Otherwise, a single application must be made at the expense of acquisition.
Even when ultrasound and magnetic resonance imaging, the above-described BI-RADS system is applied. For the ultrasound then the abbreviations mean US BI-RADS, for magnetic resonance imaging MRI BI-RADS.
In BI-RADS IV and -V findings, including those with no palpable mass, the removal of a tissue sample (biopsy) and a histologic examination is necessary.
Suspicious findings chest: How is going on the doctor?
In a striking change in the chest - if the mammography screening (see above) stated spontaneously or as a palpable mass - led the doctor a Abklärungs mammography.
In addition, most other studies, all follow ahead an ultrasound (sonography). The final diagnosis usually provides only the control of a tissue sample (biopsy) under the microscope.
In a malignant development, the cells are studied extensively. More on this in the text sections below.
The biopsy of the breast
In cases of suspected breast cancer doctors take a tissue sample from the node or suspicious area. Various methods are possible:
High-speed punch biopsy
Under local anesthesia be a about two millimeters thick hollow needle several tissue samples, so-called punching cylinder, taken from the breast. The withdrawal itself is done using a special punching machine.
Previously, the doctor placed a guide cannula in the suspected area. He is guided primarily by ultrasound or palpation. As a "guidance method" but is also the mammography possible when it comes to microcalcifications.
However, when the vacuum-assisted biopsy microcalcifications (see below) is increasingly recommended as the only abnormality.
In any case, there is only a single puncture from the outside. The small procedure is performed on an outpatient basis. Sometimes then forms a small bruise, but hardly a scar.
Vacuum biopsy
This also for ambulatory method is especially suitable when in the breast microcalcifications was found without visible or palpable tumor. After the doctor has to finding located by a mammogram or an MRI, the correct positioning of about three millimeters thick hollow needle automatically controls a computer.
Also it is inserted only once after local anesthesia. Tissue - significantly more than in the punch biopsy - is sucked by the vacuum and taken around by a cutting-turning operation. Following the biopsy, the doctor may use a small clip at the donor site. You can thus recognize in later steps.
Initially, the doctor puts local anesthetic to a small incision, the later leaves only a tiny scar. After the procedure a pressure dressing is applied. A sometimes occurring bruising usually goes back soon.
Was the suspect tissue area actually noticed by microcalcifications, x-rays, the doctor's chest and the removed tissue to control after the biopsy yet.
Both the core biopsy and the biopsy vacuum are referred to in the jargon as an imaging-controlled, interventional or minimally invasive diagnosis of breast.
Open biopsy
In exceptional cases, such as when one of the processes outlined above has not helped to clarify the findings or not feasible, the possibility of open biopsy (excisional biopsy). It is a small outpatient procedure, performed under local anesthesia, depending on the scope or a short-term anesthesia.
About a skin incision, the surgeon removes the previously marked by suspicious imaging area completely out of my chest. Possibly the removal area is also still marked with a small steel clip in order to understand the place later. The imaging is performed previously by a mammogram or MRI and thereby placed marking wire. This procedure does not apply to palpable findings that stand only as microcalcifications.
The primary, open diagnostic excisional biopsy should warden carried out only in exceptional cases where an image-guided intervention is impossible or risky.
If more tissue - virtually the entire "nodes" or tumor or suspicious area, such as one already established in a minimally invasive biopsy DCIS (ductal carcinoma in situ, see below) - is removed, has become a therapeutic intervention from the biopsy.
In tissues formed after a biopsy a small scar, of course, outside of the skin . In an excisional biopsy, it is slightly larger.
More rarely performed: the fine needle aspiration
A fine needle aspiration, so the puncture of the tissue with a very thin needle under ultrasound guidance, provides much less information about the tissue under examination and is not normally used to clarify a suspicious findings in the chest. It occurs only in certain situations, to apply, for example when in a cyst liquid contained has to be sucked.
If a lymph node at the keys or at the ultrasound examination in the armpit pathologically altered appear, doctors put too fine needle aspiration, but also ultrasound-guided high-speed punch biopsies.
Possible Biopsy Results
A specialized on diseases of the breast tissue pathologist examines the samples from the breast tissue. Apart from a commonly occurring fortunately benign findings the following results are sometimes possible:
Tissue changes with uncertain biological growth behavior (preinvasive lesions) and ductal carcinoma in situ (DCIS)
There are tissue changes that bring an increased risk of breast cancer with and partially applicable as breast cancer precursor, known as preinvasive lesions. Präinvasiv means: you remain a certain extent within their "natural limits". Sometimes they are also called neoplasms. The term neoplasia is a neoplasm tissue, caused by a dysregulated cell growth. About goodness or evilness that says nothing. May be mentioned here include forms such as lobular neoplasia (as LN or LIN abbreviated) and atypical ductal hyperplasia (ADH).
In particular, as the growths called ductal carcinoma in situ (DCIS) are classified as a precursor of invasive breast cancer. The addition of "in situ" takes off that the cells contained, although cancer cells are quite similar, have stayed at source. In contrast to an invasive carcinoma, it has not come to an aggressive growth in the surrounding area. More on this in chapter "breast cancer (breast carcinoma) suspected: Even benign or even cancer?".
Invasive cancer (breast cancer, breast cancer)
If cancer cells outgrow destructive over predetermined tissue boundaries, is an invasive carcinoma. In breast cancer cells of the lobules or either milk ducts transform into cancer cells.
Accordingly, a distinction is made between the invasive Läppchenkarzinom (lobular) and invasive ductal carcinoma (ductal).
Staging of breast cancer
If the diagnosis of breast cancer histological secured and detects the location of the tumor exactly Further studies are needed to determine the stage of cancer. Doctors talking about the so-called staging (staging). Usually this is done in advance clinically based on touch and ultrasound findings.
First, the doctor asks the patient to their medical history and any complaints (outside the breast). The findings on palpation it rises mostly as part of a physical examination . Here, the state of the lymph nodes in the armpit area and in other lymph drainage in the collarbone area and the sternum is particularly checked. For smaller tumors (T1, T2, see below) the doctors dispense mostly on further investigations.
When chemotherapy is planned before the breast surgery (neoadjuvant or primary chemotherapy), can check-ups after a few weeks tell if the tumor responds to the therapy. Even before the chemotherapy, so-called sentinel lymph nodes are often removed in the armpit and examined (Sentinellymphknotenexzision, see chapter "therapy").
Sometimes it is, however, a matter to exclude distant metastases (secondary tumors). The risk that such metastases have formed is, for example, increases with larger tumors. In order to clarify whether the main target organs for secondary tumors - lung, liver and skeleton - are healthy, an x-ray of the chest, an ultrasound of the liver and a bone scan are performed in these cases.
After completion of the staging measures the breast cancer disease is based on the so-called (c) TNM system - and then after the operation on the basis of p TNM system - associated with a particular stage.
The upstream letter p indicates that the results on investigation of the removed tissue during surgery are based by the pathologist. Sometimes y precedes. This means that the operation was preceded by a drug (systemic) therapy. The addition c is clinically.
The individual letters stand for the tumor size (in millimeters or centimeters, T), the lymph node status (N, derived from English. Node) and the presence or absence of metastases (secondary tumors, M). Here is an abridged, limited to the tumor size version.
The TNM system
Tis: Carcinoma in situ (see above)
T1mic: Slightly (0.1 cm) into the environment ingrown tumor (called microinvasion)
T1: The tumor size of less than two centimeters
T2: The tumor size is between two and five centimeters
T3: The tumor is larger than five centimeters
T4: The tumor has grown into the chest wall or skin
With regard to the lymph nodes, there is the gradation N1 to N3, which divides the number of neighboring miterkrankten (regionären) lymph nodes in three groups N0 means. No infection. If the doctor has determined, for example, on the basis of touch and ultrasound examination of the armpit no abnormalities, this corresponds to the clinical evaluation cN0. Confirms the pathologist that removed lymph nodes are fine tissue healthy, that's a pN0 -Befund. The addition sn assigns the findings to the Wächerlymphknoten, so for example: pN0 (sn).
If no metastases found in other organs, the doctor documented this with M0, M1 otherwise. Another division leads the TNM stages together new groups. The result is then stages from 0 to IV.
This so-called UICC classification of the International Association against cancer is as follows:
Stage 0: In situ carcinoma, N0, M0
Stage IA: T1, N0, M0
Stage IB: T2, N0, M0
Stage IIA: T3, N0, M0
Stage IIb: T4 N0, M0
Stage IIIa: Any T N1, M0
Stage IIIb: Each T with N2, M0
Which prognostic factors are there?
The tumor stage influences the therapy and prognosis. The forecast, however, play other aspects involved, namely the so-called grading and the content of specific tissue receptors.
Grading: Ausreifungsgrad and speed of growth
The pathologist also examined how much cancer cells differ in appearance and growth behavior of normal mammary gland cells. This is described with the degree of differentiation (Ausreifungsgrad, grading).
Going to the Grading three factors: the speed with which share the tumor cells, and the deviation of the tumor cells and the milk ducts in the tumor from the normal glandular tissue. The higher the grading, the more aggressive the tumor is growing. There are three degrees: In G1, the tumor cells resemble largely the healthy cells; they are "well differentiated" and divide more slowly. In G3 soak most of its original form from and divide rapidly. G2 in between.
Information about the growth activity is also the Ki-67 antigen, which can be represented by dyeing the fabric with the pathologist Ki-67 also finds its way in the classification of luminal breast cancer. (See section below "Breast cancer is not the same as breast cancer") ,
Pathologists perform today a tumor grading also in breast cancer precursors such as ductal carcinoma in situ (DCIS) by.
Risk Forecast: Important for therapy decisions
On fresh breast tissue can be - taken by punch biopsy or surgery - that determine the proteins uPA and PAI-1. Affected women should consult their doctor and be informed as to whether the analysis is useful in their case and will be offered in the competent office or clinic.
Furthermore, should the eventual assumption of costs previously clear (clinic? Health insurance?). In addition, the procedure must be agreed before the tissue sampling / operation, even with the pathologist.
In addition, the new predictive genetic testing Multi help the doctor in the risk assessment and support the jointly taken by doctor and patient decision for or against chemotherapy. This especially when the standard criteria do not allow treatment decision. More also section below "Breast cancer is not the same as breast cancer."
Receptors determination
Finally, it is important to determine whether the tumor cells - that goes for invasive breast cancer as well as for a DCIS - are hormone sensitive or increased wear a protein (a receptor) called HER2 on their surface.
In general, the fabric is already possible from the biopsy from the pathologist for the presence of binding sites (receptors) for hormones investigated and on the HER2 receptor.
The hormone receptors it comes to those of estrogens (Abbreviation:. ER) and progesterone (PgR or PR; Progesterone is the corpus luteum hormone, a naturally occurring progesterone, as the estrogen include progestins to the female sex hormones).
The growth of many breast cancers is promoted by estrogens. If at least one percent of the tumor cell nuclei hormone receptors wear on the surface, the tumor is considered to be hormone-sensitive. Consequence: It provides an anti-hormone therapy to, in a sense a hormone withdrawal treatment.
HER2 receptor is human epidermal growth factor receptor 2. The more receptors of this type are on the breast cancer cells, the stronger these tend to divide and multiply.
Whether the cells are HER2-positive or not, is also relevant for subsequent treatment: In the positive case is an antibody therapy in question.
A tumor is HER2-positive,
if the immunohistochemistry (IHC) test is triple positive (3+).
Is he just a double positive (2+), further investigations are necessary.
If the IHC test only a single positive (1+), the tumor is considered HER2-negative and an anti-HER2 therapy is not an option.
Breast cancer is not the same as breast cancer
There is now growing evidence that breast cancer is a diverse disease. Ideally, orient the treatment as individual as possible, and they deliberately use where it is really needed and promising would.Thus overtreatment could be avoided. In fact, breast cancer can now classify more precisely into the tumor cells by analysis of gene activity. Doctors refer to this as the "molecular signature" and derive increasing decision support for therapy. But is this concept still in its possibilities.
Currently, at least four breast cancer subtypes (subtypes) are defined, which differ in their gene pattern, their biological and clinical characteristics and therefore also in the therapy:
Luminal A type: ER and / or PgR highly positive, HER2-negative, growth activity low (low risk of relapse): General Therapy Recommendation *: in addition to surgery (breast-conserving plus radiotherapy) usually only anti-hormonal therapy.
Luminal B type: ER and / or PgR positive growth activity high (medium to high risk of relapse): General Therapy Recommendation *: in addition to surgery (breast-conserving plus radiation therapy) is currently chemotherapy and anti-hormone therapy
HER2-positive ER / PgR positive or negative; Growth activity high (high risk of relapse): General Therapy Recommendation * : in addition to surgery (breast-conserving plus radiotherapy) chemotherapy (neoadjuvant often, so before the operation), antibody therapy and anti-hormone therapy if ER / PgR positive.
Basalzellartiger type: cells immature (if, in addition ER / PgR and HER2 negative, even triple-negative = triple-negative called; high in this combination relapse risk): General Therapy Recommendation *: in addition to surgery (breast-conserving plus radiotherapy) Chemotherapy (often neoadjuvant); More optionally after the recommendations of the high-risk group (see section "Therapy" section: "In particular, women should be treated in the following situations with chemotherapy"). Non-basalzellartige, triple-negative tumors may also have favorable biological properties. In rare cases, there may also be receptor-positive tumors with basalzellartigen properties.
* Note: The therapy is always designed the doctor at each woman individually based on the conditions present in person with her. The general requirements and guidelines serve him as a framework for action. For more detailed information about treatment in the relevant chapter "therapy".
About two-thirds of all breast cancer patients are diagnosed with Luminal A-like breast cancer. Luminal refers to cancer cells that are derived from glandular cells and in sufficient quantity have hormone receptors. While for patients from the luminal low-risk group (Luminal A) often satisfies an anti-hormone therapy, women need with high risk of relapse (Luminal B) usually chemotherapy. A first approximation allows the receptor and Ki-67 determination (see above: Grading) in the tumor tissue. However, lacking a fixed threshold in order to distinguish accurately between Luminal-A-like and luminal-B-like breast cancer can. New molecular tests, known as multi-gene tests , can help to better delineation and shed light on this, if a woman concerned without can survive chemotherapy. The Working Group Gynecologic Oncology eV Mamma (AGO) currently recommends two tests for women after menopause, who are suffering from luminal breast cancer and have tumor-free lymph nodes. Further tests are in clinical evaluation (evaluation). Dealing with such predictive testing (predictive testing) requires a thorough knowledge and great care. The assumption of costs should be clarified. Outside of clinical trials, the tests are used only in m justified individual cases, which also applies to the reimbursement by the national health insurance (only on medically justified request in individual cases). In some breast cancer centers, the tests are used in studies. If the validity is finally resolved, they will come primarily in front of adjuvant therapy for use. Also decisive for the prognosis: The operation result after the operation is, among other things, an indication as PR0 important stating that the malignant tissue completely in healthy area was removed. If PR1 result can be found under the microscope, even tumor cells at the cut edge. The doctor will then often suggest a reoperation.
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Breast cancer (breast carcinoma) suspected: Even benign or even cancer?
Some benign changes in the breast are associated with an increased risk of breast cancer. There are also precursors of invasive breast cancer such as ductal carcinoma in situ (DCIS)
A breast biopsy is for many women a disturbing measure, because it is necessary to go to one of unclear findings on the ground. The majority of the results are benign, as well as so-called microcalcifications often corresponds to a benign finding.
However, some changes must be monitored and / or removed tighter, because the risk for breast cancer may increase or be a precancerous condition.
Absolutely benign
Among the clearly benign changes that do not affect the risk of breast cancer a woman, for example, include simple fibroadenomas and remodeling of the connective tissue of the breast.
Special case papilloma?
Papillomas are actually benign: small, finger-like or wart-like, also highly vascular growths of cells that line the milk duct system. The problem: Sometimes atypical cells are included (atypical papilloma). Or the papilloma occurs along with other tissue changes as a atypical ductal hyperplasia (ADH) or ductal carcinoma in situ (DCIS; see each below), possibly even with an invasive breast cancer. This is shown at times until the tissue was completely removed. Against this background, arrange doctors papillomas today described below "tissue changes with uncertain biological behavior" to.
Papillomas can occur individually (solitary papilloma), approximately in the center of the chest , in a large duct, brustwarzennah. There they can be felt as a node, possibly with pain and bloody discharge from the nipple. If they are more peripherally in the chest - while they sometimes spread among several small milk ducts and their end sections (multiple papillomas) -, they can be generally not keys and are otherwise asymptomatic.
Therapy: In order to examine a tissue zone with a papilloma to the extent necessary, the area is now mostly removed minimally invasively.
Papillomas, which already in the biopsy can be regarded as completely eliminated - mostly they are then very small - and do not contain atypical cells, increase the risk of breast cancer most likely not. Then usually satisfy the usual screening mammograms to check. In other cases, may be about two to three fold increased risk of breast cancer. The further procedure the physician is clear from the findings and in consultation with the patient.
Tissue changes with uncertain biological behavior
Some tissue changes in the mammary gland be classified at this stage, similar to the papillomas previously described as benign. But you can continue to develop under certain conditions to invasive breast cancer. Generally one can say that a higher cell division activity (proliferation) and a deviation (atypia) of proliferating cells of its "normal" appearance in the relevant tissue changes usually associated with an increased risk of breast cancer. The deviations or atypia may vary greatly. In a ductal carcinoma in situ (DCIS), for example, the cells contained already very similar to cancer cells (more on that below).
Another technical term that is more common in this context, is preinvasive lesion. He says that the change or growth (lesion) is not destructive waxing at present in other tissues, including it has the potential, but to a certain extent even within their "natural limits" remains. Preinvasive lesions may be direct precursors of invasive breast cancer. You can also show a generally increased risk of breast cancer.
Often such findings are asymptomatic, thus not palpable. However, when mammography screening dunk increasingly common (more on this in chapter "Early detection, diagnosis, prognosis , "the" mammography screening "). Sometimes they show up just by chance in a tissue biopsy.
Depending feingeweblichem results and other individual risk factors of the woman concerned, the consequences can be very different. Sometimes there is the Council to examine the breast in greater detail with reference to a excisional biopsy (diagnostic excision, excision of a larger tissue part in a outpatient procedure). Either takes place in the local anesthesia or in a short-term anesthesia.
Sometimes, such as when there is a DCIS, for safety's sake surgery like breast cancer may be necessary. But often it is only at the usual regular mammography every two years -screening studies. Partial surveillance mammograms (so-called curative mammography) recommended at shorter intervals.
Preinvasive lesions: Two groups
The pre-invasive lesions can be divided into two groups: those that emanate from the milk ducts of the mammary gland (ductal) and those that arise in the lobules (lobular). The ductal lesions include atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS). The atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LN / LCIS) are lobular preinvasive lesions.
Originate in the milk ducts
- Atypical ductal hyperplasia (ADH): The cell proliferation increases the risk of breast cancer depending on the extent about three to five times for both breasts after ten years. Beyond a certain size, a ADH is assessed as low-gradiges DCIS (see below). An ADH is also seen as a possible precursor of breast cancer.
- Flat epithelial atypia (FEA): One of the ADH related change is the so-called flat epithelial atypia (FEA). Epithelial refers to the epithelium - the lining here, the cells, the milk ducts and lobules. Are formed new, very flat cell layers. A FEA is considered earliest possible neoplastic change with very little risk of malignancy (neoplastic: Declaration under neoplasia in the next section).
Therapy: The changes must be removed only in special cases (for more information see section "aftercare" at the end of this chapter). Frequently satisfy the normal screening checks every two years.
Originate in the lobules
These changes are summarized as lobular neoplasia. A neoplasm is a formation of new tissue, caused by dysregulated cell growth. Lobular neoplasia (often the abbreviations LN or LIN are used here) are formed in the lobules or in the transition zone between lobules and milk duct. They include all variants of atypical epithelial proliferation of the atypical lobular hyperplasia (ALH) to their expanded form, the lobular carcinoma in situ (LCIS or CLIS).
In particular, simple, classic forms of LN are benign. In about half the cases they occur, however, in several places (multifocal) in the breast on, in one-third in both breasts simultaneously. The risk of developing invasive cancer is increased about 7-fold in ten years at this, also known as "risk lesions" for a later breast changes (applies to both breasts). It is currently not clear whether it is in the LN to direct breast cancer precursors. Many affected women are not breast cancer.
Therapy: Sometimes lobular neoplasia can contain very distinct cellular changes. Sometimes they occur together with a DCIS or invasive breast cancer with. Therefore, the affected breast is carefully checked for abnormalities and other suspicious areas are optionally removed. In a pure, classical LN, however it is usually not necessary to remove more tissue from the breast, especially not when the imaging findings after the biopsy is no longer recognizable.
Important: Sometimes can not safely distinguished from a ductal carcinoma in situ (DCIS) a LN, ADH or FEA. In cases of doubt, the change is regarded as a DCIS. To prevent breast cancer later, is then recommended as the DCIS individually matched with the patient, adequate intensive therapy (more on that below).
Ductal carcinoma in situ (DCIS)
A DCIS arises in milk ducts and has seen many changes typical for breast cancer on. Sometimes it is even classified under "breast cancer". The present, often described as malignant or malignant cells have not yet developed the ability to "spread" over their natural tissue boundaries in other tissues.
Often a DCIS forms although only in a breast area (quadrant), but there may have several foci. The doctors call multifocal. On the other hand, it may occur (multicentric) in more than one quadrant of the breast. And it may, but need not be palpable. The exact delimitation if not yet already there is an invasive cancer is sometimes based on the biopsy difficult because they only reflects a very small part of the breast or of the tissue change.
Pathologists distinguish the DCIS essentially three forms: growths with low, medium or highly modified cells. In addition, can be - as with invasive breast cancer - recognize different biological properties. These are also taken into account in treatment planning because DCIS is now being treated like an invasive breast cancer.
The risk of invasive (certain tissue boundaries aggressive border) breast cancer is even higher than for the aforementioned changes in DCIS. It is clear as a precursor of invasive breast cancer. If left untreated, about going up to half of the cases in an invasive cancer in the affected breast DCIS in one third. But this possible development may take different lengths. And: After a DCIS therapy relapses (relapses) possible - as DCIS or invasive breast cancer as well. Nevertheless, the prognosis of affected patients is very good overall.
Therapy: Because DCIS is not yet grown beyond the natural borders into the surrounding tissue, is usually only a less burdensome treatment of here. In many cases, the doctor can operate the overgrowth breast conserving and only the affected part of the breast. Usually followed by a radiation. It reduces the risk significantly, a local relapse (relapse) suffer.
If the tissue is hormone sensitive, an adjuvant anti-hormonal treatment with the therapy as additional drug tamoxifen are eligible. This also weigh the doctors at every question from individually. The risk that the DCIS occurs again, can be explained by the combined hormone and radiation therapy reduce further. Tamoxifen is a so-called selective estrogen receptor modulator (abbreviated SERM): It works by blocking estrogen receptors without then to the breast (cancer) cells as an estrogen to act; in other tissues, it may on the other hand have an estrogen-like effect.
Come for an Affected tamoxifen not eligible for medical reasons, it may be optionally treated with an aromatase inhibitor, if you already the menopause has been reached (more about these therapies in chapter "therapy ", the" anti-hormone therapy - After menopause ").
Sometimes when DCIS the entire breast must be removed for safety's sake but. Then there is the possibility surgically reconstruct the breast (see again Chapter "therapy", the "breast reconstruction"). If necessary, the surgeon removes the sentinel lymph node and the histological examination (so-called Sentinel Lymph Node; more on that also in the section "Early detection, diagnosis, prognosis," "What is a sentinel lymph node?").
It is always important that the changed or diseased area has been completely removed. Otherwise, the breast has to be reoperated.
Aftercare after removal of a pre-invasive lesion
It has already been said: Both after removal of a pre-invasive lesion and after treatment of DCIS may recur change or create a new, up to a breast cancer. Therefore, (50 to 69 years age group) are provided in the first five years after treatment follow-up actions at certain intervals, and from the sixth year screening examinations for the women concerned.
In a FEA satisfy the usual yearly medical Tastuntersuchungen in connection with the doctor's advice and the usual screening mammograms every two years. After treatment of ADH against Kontrollmammografien are recommended every twelve months.
After breast-conserving surgery and radiation for DCIS medical palpation of both breasts and the consultation with the patient is provided for five years every six to twelve months, at yearly intervals thereafter. The same applies to a correspondingly treated LN (LCIS). Kontrollmammografien and Sonografien both breasts offered patients with DCIS / LN (LCIS) at yearly intervals.
For example, if the breast had to be removed with a DCIS, the doctor samples the chest wall on the operated side and the chest on the opposite side in the first five years after surgery every six to twelve months from, every twelve months thereafter. The remaining breast, he also controls every twelve months by means of mammography and sonography . Only when there are new symptoms or changes in the breast area, further studies are indicated.
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Breast cancer (breast cancer) therapy
For the treatment of breast cancer, there are various therapies: surgery, radiation, anti-hormone therapy, chemotherapy, antibody therapy and new targeted therapies for advanced disease
Treatment of breast cancer: What we need is a team of specialists
In the treatment of breast cancer , different specialists are involved, for example, gynecologists, oncologists, surgeons, pathologists, radiotherapists. They shall consult each other on (interdisciplinary conference, tumor board the certified breast center) and discuss the steps with the patient.
The choice of treatment depends inter alia on the type of tumor, the stage of the disease, the age of the patient (before or after menopause) and on whether the cancer is hormone-sensitive, ie hormones react. Even biological characteristics of the tumor, the growth characteristics, play an important role.
There are several pillars of therapy
Operation
Radiotherapy
Anti-hormonal therapy
Chemotherapy
Targeted therapies, including treatment with antibodies
Operation: Custom made and Security
In the majority of cases of breast cancer surgery is necessary. But that does not necessarily mean that the entire breast must be removed (mastectomy). Nowadays can be in many women with breast cancer who received breast (breast-conserving surgery, BET). In the subsequent microscopic inspection the pathologist the removed tissue should have tumor-free cut edges.
The doctor also speaks then of a PR0 resection. This means that the tumor was visually and fine tissue removed "in healthy individuals". If differences are found in the tissue sample under a microscope tumor cells in the peripheral region, the surgeon removes the tumor remains usually at a subsequent surgery (resection).
It marks both the removal edges and the former tumor area, so that in case of reoperation and is taken care of during irradiation for orientation.
If the tumor is located in several places or if it could not be removed in healthy tissue area, even during a reoperation, the doctor removes the breast. The chest wall muscles that form the chest wall remain, in particular the large chest muscle obtained.
If a patient wishes can remove the breast because of cancer, although it is possible to get them during surgery, so doctors respect the desire of course.
In focus: the lymph nodes and the sentinel lymph node
The breast tissue is rich in lymphatics. They carry tissue fluid, fat, protein, pathogens, cellular material (lymph). On their way the lymph passes several lymph nodes: control stations of the immune system. Suspect components lymph defused here of the immune defense. Especially in the armpit, there are many lymph nodes as we just hurt us to hands and arms often and so can penetrate all possible germs and impurities. Therefore, at this point a high hurdle defense is necessary.
Above all, a lymph node category have doctors in breast cancer in their sights: the so-called sentinel lymph node or the (technical term: sentinel lymph node). These are the ones who reached the lymphatic drainage of the breast first. If a tumor in the lymph spreads, the sentinel lymph node is the one who is attacked in the first rule.
Important: It has been found that most likely the local (regionären) lymph nodes that follow the sentinel lymph node, are tumor-free when it is itself also free of tumor. This fact speaks for being able to keep the tumor throughout the treatment even without any further intervention on the armpit well under control.
And to know the status of / the sentinel lymph node (s), as relevant for the more accurate staging of cancer after surgery and for further therapy planning. If there are no lymph nodes, usually a less invasive therapy is sufficient.
Prior to surgery or before neoadjuvant chemotherapy (see below, section "chemotherapy") are checked, the lymph nodes in the armpit by palpation and an ultrasound. Were anticipated no abnormalities, the doctor usually during breast surgery after or seek the sentinel lymph node is. He can track it by using a low-level radioactive and / or a colored substance which he injected into the vicinity of the tumor.
Advanced armpit surgery: Yes or no?
Then the doctor removes the / the entire sentinel lymph nodes for histological examination (Sentinel Lymph Node, SNE). In the workup of the tissue by the pathologist is proven whether the sentinel lymph node is tumor-free. If it contains tumor cells, it may be necessary, a sufficient number of lymph nodes, at least ten, in the armpit to remove (or axillary lymph node dissection).
But doctors are thus now more cautious than before. Because the procedure is potentially stressful. For example, after such an armpit surgery, a swelling of the arm, lymphedema develop and affect the woman permanently. In an SNE the corresponding risk is lower.
Important: If a breast-conserving surgery planned and are loud histologic analysis only one or two sentinel lymph nodes infected, the doctor may consider in early breast cancer, together with the patient, to dispense with the removal of additional lymph nodes from the armpit.
Whilst it might be only microscopically detect small metastases in sentinel lymph nodes, it is possible to dispense with the larger armpits intervention, provided a drug treatment in addition to surgery takes place. In this case, it is particularly important that patients then carry out the planned follow-up.
An operation of the axilla must, for example, but in the rare cases occur, in which previously could not find the sentinel lymph node. Even from a T3 tumor size (see chapter "Early detection, diagnosis, prognosis ") or if the physician already has clinical evidence that lymph nodes of the axilla are miterkrankt, it is not useful to determine sentinel lymph node. Instead, then mostly multiple lymph nodes, at least ten, drawn from the armpit. This applies also when the chest and / or shoulder was operated on the affected side for other reasons.
Breast reconstruction
Is much breast tissue or the whole breast removed, can already be started during the same surgery to rebuild the breast (immediate reconstruction). But Dr reconstruction is also possible at a later date - as the second engagement after the drug treatment and / or radiation therapy (interval reconstruction).
Building a Implant
If he chooses the woman for an implant, there are several ways. Frequently first an expander is used. This is a silicone shell that is filled gradually over a valve from the outside with salt. If after a few months, the skin stretched sufficiently, the expander is in a second procedure under general anesthesia through the final implant ("Silikongelkissen") exchanged. Can be a sufficiently large skin layers get to take the implant, it can be used immediately (skin-sparing mastectomy, skin-sparing technique). Sometimes you can even the nipple and the surrounding areola they receive, at least in part (nipple-sparing technique): for example when the tissue just under the nipple is free of tumor and the tumor was far enough away.
Reconstruction with autologous tissue
There is also the option to reconstruct the breast from its own tissue. For example, from skin and fat - a so-called "tissue flap" along with blood vessels -. With and without muscle percentage for a reconstruction with autologous tissue that can be removed from the abdomen, buttocks, back or thigh instead of a tissue flap, the physician may in some cases. aspirate and fat cells from the abdomen, legs or buttocks and transplant (lipofilling). But this is a longer procedure in which, after a pre-strain of the breast skin envelope in many meetings over several months small portions fat be added, which then finds connection to vessels and can heal.
Even putting doctors, currently mainly in studies, proportionally tissue replacement material as so-called acellular dermis.
The surgical techniques, there are several variants that differ consuming and productive. For the reconstruction of small breasts, other methods are eligible as for the construction of large breasts . In addition, combined methods are possible, ie prosthesis plus own tissue.
Adapting the healthy breast
The reconstructed breast implant means is fixed and does not fall as the healthy breast. However, the skin is still a little stretch. A chest built with own tissue sometimes descends still. That is, until the final result is achieved, it always takes a few months. A significant side difference has arisen, may be a plastic-surgery on the healthy breast to improve symmetry. Either a lift (mastopexy) or downsizing comes (reduction surgery) or an enlargement (augmentation) into consideration. As expected, increased an aesthetically satisfactory operation result, the quality of life of those affected.
Construction of nipple and areola
The nipple can be rebuilt. This is done but only if the breast rebuilt completely healed and a matching operation of the healthy breast is complete.
The new nipple can be shaped from a skin portion of the restored chest or abdominal skin. Also there is the possibility of "Nipple Sharing": Here, the surgeon removes a small portion of healthy nipple and put him on the reconstructed breast. In order to replicate the areola, also there are several options available: For example, a graft from the slightly darker pigmented skin of the groin may be used. Or there is a medical tattoo.
Possible problems with breast reconstruction
- Structure with an implant: Although the quality of the implants is steadily improving, keep not permanently. An implant rupture, for example by the action of external forces or fatigue, may well happen. The latter happens sometimes unnoticed. Suspicious symptoms may deformation of the chest or pain be.
That forms with time around the prosthesis a thin capsule of connective tissue, is a normal response of the body. In some women, the capsule can thicken, possibly even contract (capsular contracture). Depending on the severity that is visible and palpable, often painful. The breast may be harder and deform the implant shifting. Saline or silicone implants are but as a health hazard.
The doctor controls the prosthesis in regular intervals. If it has come in the meantime to changes and breast symptoms, the woman should go to the doctor in advance to determine the cause. If necessary, a surgical correction is necessary, possibly also a replacement of the prosthesis. Information on the safety of breast implants, please visit: www.bfarm.de, Keyword: breast implants. (Www.apotheken-umschau.de assumes no liability and is not responsible for the content of external websites).
- Reconstruction with autologous tissue: Every operation has its risks, as well as the breast reconstruction of body tissue. It takes longer than the reconstruction with a prosthesis and is already burdensome hence. Add to this the additional wound and the tissue defect at the donor site. An important, though not the only factor in the success of an intervention is the experience of the surgeon. Against this background, it will talk to the patient in detail about the advantages and disadvantages as well as the appropriate time as part of breast cancer treatment and recommend you the optimum method for them.
Possible problems include bleeding, collections of wound fluid (seroma), infection and wound healing problems. Own tissue flap - as so-called free grafts without vascular supporting tissue stem - must be microsurgically, vessel for vessel reconnected. They are more prone to circulatory disorders and tissue damage as stalked grafts, hanging on a vascular bundle and let therefore anchor itself more easily to the new location.
Smokers have a higher risk of circulatory problems. Those affected - as well as severely obese women and diabetics - should therefore be quite in depth advice from the doctor about the best procedure for breast reconstruction. Doctors recommend women smokers necessarily the smoking set at least six weeks prior to surgery.
About the various options for breast reconstruction informs the article " Breast Reconstruction "accurate.
Radiotherapy in breast cancer: as much as necessary, as little as possible
The irradiation (radiation therapy or radiotherapy) in breast cancer aims by means of high-energy rays to destroy cancer cells. The beams are used as specifically as possible, sparing surrounding tissue and adjacent organs as far as possible.
There is a local therapy, which is usually carried out by a breast-conserving surgery (adjuvant radiotherapy). Possibly in the tumor bed remaining cancer cells to be destroyed. Has been proven that this will lower the risk for local recurrence of the tumor and so the chances of survival can be improved. Here also the stage of cancer at diagnosis plays a role.
Breast irradiation
Is irradiated usually the entire breast. The standard dose is 50 Gray (Gy). In addition, the "tumor bed" often still specially irradiated (Engl. Boost, boost). All in all, this enables the local risk of relapse significantly reduce.
Meanwhile recommend some rays physicians called hypofractionated radiation for patients in early stage breast cancer after complete removal of the tumor. The total dose of radiation is generally lower. The women concerned have rarely go for irradiation, since the duration of treatment is shortened. However, this means the gift of a slightly higher single dose per day. They may affect the healthy tissue a little more. But she is also true presumably remaining cancer cells accordingly. Again, an additional boost irradiation of the tumor bed is often provided.
The hypofractionated radiation seemed to comparative studies as well as to act the conventional irradiation. However, has been shown only for women over 50. Long-term results for possible late side effects are still pending.
Possible irradiation but also during operation: Immediately after the tumor has been removed, a radiation source is placed in the wound cavity. They are over about 30 minutes from radiation (50 kV). Various new forms of radiation, including the so-called accelerated partial breast irradiation of advanced tumor bed are not yet assessed in clinical trials (see also section "Consulting expert, specialist literature ")
Irradiation of the breast is also particularly important when the tumor tissue completely not in the operation - not even by a reoperation - could be removed or if surgery is not possible.
Irradiation of the chest wall after removal of the breast
When the tumor was rather high, about T3 or T4, and the chest was removed (mastectomy), often followed by a irradiation of the chest wall. In addition, there are other situations in which doctors recommend to irradiate the chest wall after a mastectomy, as if more than three lymph nodes were miterkrankt. The aim is always to reduce the risk of relapse and improve survival.
Irradiation of the axilla
In miterkrankten, but not completely removable lymph nodes in the armpit or in a remaining there residual tumor and it is irradiated. This applies also if no armpit surgery was performed, although urgent suspicion that corresponding lymph nodes are mitbefallen.
In addition, the lymphatic drainage can be irradiated in the collarbone area.
Chronology of therapy
Radiation therapy usually starts a few weeks after surgery, when the surgical wound has healed, or after adjuvant chemotherapy.
About the optimal operation, the doctor will advise the affected exactly. He will start the irradiation only as early as is feasible without risk of local complications at the breast.
An anti-hormone therapy such as the treatment with the HER2 antibody trastuzumab (see further below) can take place simultaneously with the radiotherapy. If chemotherapy is planned, the irradiation usually takes place afterwards.
Drugs against breast cancer
As already mentioned, there are several drugs for the treatment of breast cancer:
Anti-hormonal therapy (Anti-hormonal treatment). Technical term: endocrine therapy
Chemotherapy
Targeted therapies, such as antibody therapy
The drugs can come before or after breast cancer surgery are used: one at a time, sometimes in combination. Unlike locally-faceted therapy as surgery and radiation, they act throughout the body.
Therefore, the drug treatment is also known as systemic therapy. The throughout the body acting therapy reduces relapse and been shown to improve survival rates.
Anti-hormonal therapy
Many breast cancers are hormone sensitive. This means that these tumors are stimulated by the female sex hormones to growth. This is what makes you look and therapeutic advantage: Assign the breast cancer cells receiving agencies for the hormones to (hormone receptors: ER = estrogen receptor and / or PgR- = progesterone receptor-positive), the tumor is called hormone receptor-positive (again, see Chapter "Early detection, diagnosis, prognosis "). Here is recommended in most cases, an anti-hormone therapy.
The antihormonal therapy is also used to treat women who are weakened by other diseases or old age. For this, the breast cancer must naturally have hormone receptors.
Sometimes an anti-hormone therapy is also before the operation, ie neoadjuvant, into consideration. This will be the doctors turn to weigh very carefully because with this procedure have any further questions.
Before menopause
Women are usually treated before menopause than five years of tamoxifen. Tamoxifen is a so called selective estrogen receptor modulator (SERM). It works by blocking estrogen receptors without then to the breast (cancer) cells to act like an estrogen. On other fabrics, it acts against estrogenic. When the anti-hormonal therapy is continued more than ten years, which may be an additional advantage.
There is also in pre-menopausal women the opportunity to the ovaries - and thus also the body's own estrogen production - by administering so-called GnRH agonists artificially eliminating. GnRH agonists, which are also called GnRH analogues are the body's neurohormone GnRH (gonadotropin releasing hormone) similarly formed in the brain. In the short term applied (as in fertility treatment, see below, section "supportive therapy") rise to the hormone levels. For the treatment of breast cancer a longer handover is necessary. Because then comes the hormone production in the ovaries to a standstill, and account for the hormonal growth impetus to the cancer cells.
GnRH agonists are used as a monthly injections under the skin or as an implant once every three months. After completion of therapy, which usually takes at least two years, the ovaries can theoretically return to work.
The anti-hormone therapy takes place usually after surgery, therefore adjuvant. At high risk of relapse of endocrine therapy is also preceded by a chemotherapy, for example, if the tumor was larger than two centimeters, axillary lymph nodes were mitbefallen or the cancer cells have a significantly increased growth rate or corresponding other features. Then the anti-hormone therapy follows in the next step.
After menopause
Another group of drugs with anti-hormonal effect are known as aromatase inhibitors. They block the enzyme aromatase, which is necessary for the production of estrogen in the body. To use come anastrozole, exemestane or letrozole - which is the so-called third-generation aromatase inhibitors.
The aromatase inhibitor is taken for five years. Or he followed two to three years of tamoxifen, which is then replaced for another two to three years by the aromatase inhibitors (so-called "switch"). The total duration of successive or sequential therapy is five years.
After an exclusive five-year tamoxifen treatment, however, can still be achieved an increased therapeutic effect by an aromatase inhibitor which is occupied for another three to five years. That is, the total duration of the anti-hormone therapy is then up to ten years.
In women with high risk of relapse and the less common lobular breast cancer, which arises in the lobules, an aromatase inhibitor should be used first as antihormonal therapy after menopause. He is taken for a maximum of five years.
If an aromatase inhibitor is not an option, it stays with tamoxifen (total: five to ten years).
Again back to treat pre-menopausal: aromatase here offer themselves rare. If another disease militates against taking tamoxifen, for example, certain disorders of the bone marrow, an aromatase inhibitor may however questioned. Are aromatase inhibitors used before menopause, normally the ovarian function must be switched off in addition.
Chemotherapy
In breast cancer, in addition to an operation chemotherapy be necessary to fight the tumor cells intensely. The chemotherapy may, for example, after the operation, so adjuvant, take place.
Due to this subsequent treatment, the risk of relapse and metastasis can be significantly reduced. The benefit of chemotherapy is the greater, the higher the individual risk of relapse of a woman.
In particular, if the risk is very high that the cancer recurs, women should receive chemotherapy. The risk of relapse may be increased, for example in the following situations:
If a woman is ill at the age under 35 years
If a HER2-positive tumor is present
In negative breast cancer (see "Early detection, diagnosis, prognosis," sections "receptors-determination" and "Breast cancer is not the same as breast cancer")
When a tumor grade 3 (G3 grading; on the grading also refer to "early detection, diagnosis, prognosis"), probably from grade 2 (G2 Grading)
In miterkrankten axillary lymph nodes
If chemotherapy surgery is preceded by it is called neoadjuvant chemotherapy.
Important: The neoadjuvant chemotherapy is now considered equivalent to adjuvant chemotherapy. If possible, it is recommended by some experts to use them preferred. Other technical terms here: preoperative or primary systemic chemotherapy.
Advantages: The tumor can be significantly reduced and made inoperable, the safety margin of healthy tissue often to the point that the person concerned will be spared the removal of the breast. In addition, it can be checked in this way the tumor response to chemotherapy.
Even at a neoadjuvant treatment - preferably before, sometimes only after that - axillary lymph nodes examined (Sentinel Lymph Node or removal of multiple axillary lymph nodes = axillary dissection, see above).
What medications are eligible?
In the chemotherapy come substances are used which inhibit cell division and destroy the cancer cells: cytotoxic drugs, also called chemotherapeutics. This type of systemic therapy is also aimed at cancer cells that may have spread outside the breast within the body.
There are several drug classes and agents
In breast cancer, preferably so-called anthracyclines such as doxorubicin or epirubicin (also known as Adriamycin), and taxanes (paclitaxel, docetaxel) applied in different combinations, as well as cyclophosphamide and 5-fluorouracil. Other substances in chemotherapy such as gemcitabine, capecitabine, or platinum salts may be useful in specific situations.
Even in older women (over 65 years) chemotherapy is possible in principle. If certain comorbidities before, about a heart disease, which can mean that the therapy would have to be lower doses in order to avoid serious side effects. Doctors who specialize in the treatment of cancer patients, but most are of the opinion that chemotherapy is only useful in high enough doses. If this is not ensured, should rather be waived.
As the chemotherapy work?
Cytostatics are often as an infusion into the vein administered less frequently than tablet. Chemotherapy is carried out in cycles with breaks in between, for example, every three weeks (= q3w), a total of 4 to 6, sometimes even to 8 times. Neoadjuvant therapy should necessarily include 6 cycles. The treatment usually takes then a total of about 12 to 24 weeks.
For each cycle, the fixed combination of drugs is given. After a few cycles, it can be replaced by a new combination.
The doctors grab here back to specific sequences that have been subjected to extensive testing in trials or will be. In special cases, such as in the neoadjuvant therapy of receptor negative breast cancer, putting doctors, so-called dose-dense therapies in shorter rhythm and dose-intensified therapy, a higher dose of medication.
How many cycles are necessary in breast cancer, and whether the chemotherapy is outpatient or inpatient, aimed primarily to the health of the patient, the severity of the disease and then the selected regimen. Today, however, can run most outpatient therapies and the intermediate controls.
Targeted Antibody Therapy
A further possibility of treatment of breast cancer is the so-called therapy with anti-HER2 antibodies. Approximately every fifth patient with breast cancer have tumors with many HER2 receptors on their surface (see "Early detection, diagnosis, prognosis"): The tumor is HER2-positive.
Then can be selectively intervene: in addition to chemotherapy, the antibody trastuzumab is used. This is already the longest applied in breast cancer drug from relatively new group "targeted" drugs. A Trastuzumab Treatment is aimed generally at all HER2-positive breast cancers.
The antibody may parallel to chemotherapy in different stages of early treatment be given either before the first breast surgery, so neoadjuvant or after surgery, therefore adjuvant. Sometimes the chemotherapy and antibody therapy is also used in succession.
The begun before surgery antibody therapy should then be continued to a treatment period of one year. They can be administered every three weeks as an injection under the skin.
It has been found that in HER2-positive patients neoadjuvant treatment with trastuzumab and chemotherapy the tumor in the first-line treatment can even make completely disappear. This can be seen then the surgical specimen (technical term: pathological complete response, pCR short).
Trastuzumab can also be combined with another antibody called pertuzumab zielgericheten - to neoadjuvant treatment in Germany is not yet approved, but by the Working Group Gynecological Oncology (AGO) is recommended as part of studies.
The therapy with two active principles - chemotherapy and anti-HER2 therapy - improves the clinical course and the prognosis. Under the current therapy the doctor regularly checked heart and lungs to detect in time any adverse effects of trastuzumab on these organs.
The OP is carried out in any case within the original dimension after the tumor has been previously labeled by biopsy for the surgeon.
In patients with HER2-positive breast cancer who also has hormone receptors (HER2-positive Luminal B-type; again, see Chapter "Early detection, diagnosis, prognosis"), is a combination of trastuzumab with an anti-hormonal therapy possible.
Even with advanced HER2-positive breast cancers may trastuzumab slow tumor growth and extend survival. Here doctors combine trastuzumab partly again with other targeted agents (see section: "Targeted therapies with different drugs" under "Advanced breast cancer - distant metastasis" in the text below).
Side effects of the therapy
To the cancer fight as completely as possible, intensive treatment is often necessary. The therapy can have side effects. But the extent of side effects is very different from woman to woman and from therapy to therapy. Whether and what side effects occur in advance can not be estimated. In some cases, treatment may be changed if a patient feels the current therapy as too onerous. However, since the chances of recovery from breast cancer are low to non-existent without treatment outweighs usually of benefit risks. Some of the best-known side effects of chemotherapy, such as nausea , can nowadays be well controlled or avoided the same (see below, section "Supportive therapies"). Complications of surgery Possible complications can occur during an operation to bleeding, inflammation or wound healing. Depending on how extensive tissue had to be removed, the result can be very visually disturbing or unacceptable to the woman. An initially not planned breast reconstruction (more on that in the earlier section "breast reconstruction") can also be made up, but should always be integrated into the overall treatment at the Breast Center. Problem lymphedema Sometimes sooner or later after surgery developed lymphedema at Arm ("thick arm"). Because today operates increasingly gently or if possible to the removal of axillary lymph nodes (axillary dissection) is omitted, the corresponding hazard is no longer so great. Lymphedema is caused by a backlog of lymphatic fluid. This can happen, if restricted or overloaded after the removal of lymph nodes in the armpit of the lymphatic drainage. Already in the clinic is cautiously with an exercise treatment for arms started and shoulders to improve blood circulation and lymph flow and relieve tension. Such exercises are actually getting a good companion in everyday life, such as when the neck, shoulders and arms by working independently are braced on the computer. After breast surgery, it is strongly recommended to continue the exercises at home: you will help to prevent lymphedema. Some women check at certain intervals the circumference of the upper and lower arm (always measure at the same places!) To detect a swelling time. Symptoms that may indicate an incipient lymphedema, heaviness or tingling in the arm, pain can in the armpit and his swelling of the arm and the fingers in loads. At the first sign that person should go to the doctor. He will review the cause and begin treatment as soon possible. In the certified breast center, patients receive a lot of tips and information for the prevention of lymphedema. Important: On the operated side, no pressure on the arm should be exercised - either through massage or by medical procedures such as blood pressure measurement and blood samples. Moderate physical activity, as well as tennis is allowed after some time certainly. A moderate exercise the arm muscles affects swelling favorable than conservation. side effects of radiation in the radiation field lying healthy tissue, such as lung and heart are so well protected during irradiation it is to avoid damage such as hardened tissue (fibrosis). On the skin can cause irritation and discoloration. Irradiation of the axilla can there hair loss occur. Some patients also suffer from constant fatigue. More information in the section "Fatigue in cancer ..." below. Side Effects of Chemotherapy Chemotherapy is known, can often cause unpleasant symptoms, such as hair loss, mucositis, anorexia , nausea and vomiting, diarrhea , anemia, malaise and fatigue (Fatigue, see below). Possibly also occur nervous disorders such as tingling and numbness on or skin and nail changes. . Sometimes heart damage and allergic reactions are possible Some of the side effects, in addition to nausea, for example, an excessive drop of blood cells, however, can be very well absorbed by other medicines (see below: section "Supportive therapies"). And: The majority of complaints goes back after treatment, many sufferers feel better soon. Some women wear but still more to the side effects, such as damage to nerves (neuropathy) or other organs, premature onset of menopause, infertility (more on that below, "What opportunities can help to maintain the fertility?").
What does frequency of side effects?
* Very common side effects: affect more than one in ten patients treated (ten percent)
** Common side effects: occurrence in a treated to ten of 100 patients (less than ten percent)
Side effects of anti-hormone therapy
Typical adverse reactions in pre-menopausal women in hormone deficiencies, as they can in the "natural" menopause and occur thereafter. Very often patients complain * as hot flashes. Many of those affected face a cycle changes, possibly menstruation remains from all over. Important: Irregular bleeding (after menopause: emerging bleeding) you should be checked by the gynecologist to rule out changes in the tissue of the uterine lining. Other symptoms that may occur with an anti-hormonal therapy (for example):
- Tamoxifen: headaches and leg cramps, clot formation in the veins ( venous thrombosis ), pulmonary embolism and stroke. If, for example, a visual disturbance , which have eyes to be examined immediately. - GnRH agonists: The bone system can lose beyond the ordinary to substance. After the end of therapy it brings the loss usually go on, at least partially. - Aromatase inhibitors: headache , joint and muscle pain, depression. Also and especially here, osteoporosis is a problem (see section "What's up with bisphosphonates to?" Below). Side effects of the HER2 antibody trastuzumab
The antibody trastuzumab often leads among others ** headache, diarrhea and heart problems.
Fatigue in cancer: constantly tired, depressed, powerless
Sometimes it is as if the tumor, even if it is overcome as such, individuals downright paralyzing. So do not suffer a few patients - in Germany, there are well over one-third - in the course of their disease on a type leaden tiredness and exhaustion. Sometimes these Fatigue begins already during therapy, sometimes afterwards. The disease is tumor-related fatigue syndrome. The causes effects of breast cancer treatment themselves are not to be underestimated: In particular, chemotherapy and radiation contribute greatly to fatigue at. In addition, inflammatory processes, genetic factors, a tendency to depression and other comorbid conditions play a role. The person concerned does not recover even while resting. You sleep poorly, have no appetite, are kraftos and no longer function properly. This amplifies the discomfort, leading to inactivity and social withdrawal. The diagnosis includes a detailed and at the same time targeted survey for the complaints, physical examination, various laboratory tests and, if necessary further investigations. It is important to have a (co-) inducing depression and possible organic causes such as an infection to identify and treat or anemia. Depression is one in breast cancer the most common comorbidities: Approximately 20-30 percent of patients suffer during their breast cancer disease also a depressive episode. Specific questionnaires for self-assessment of the patient can help to identify a psychological background. The diagnosis of depression is a medical specialist. He also makes a treatment proposal.
Often already relieve lifestyle changes like exercise, lots of exercise in the fresh air or relaxing exercises like yoga fatigue and upset. This is not sufficient, even certain medications can be used. These are aimed at once possible organic causes, such as pain. Even an herbal remedy such as ginseng may be considered against fatigue in hormone receptor negative breast cancer. Questions Always, always tell your doctor if you pull a "self-therapy" into consideration (see also the last paragraph: "Alternative Therapies").
Supportive therapies
So-called supportive or supportive measures are intended to prevent side effects of cancer therapy or alleviate them. Chemotherapeutics behave very differently in the body (see above), as many antidotes. When collecting side effects of cancer therapy such persons can even help a little. It is, for example, extremely important to stick to the prescription and to follow dosage instructions. Find out the safe side always in the package insert and read the information from the pharmacy. - nausea, vomiting: Here prevention does become quite good. Against vomiting give doctors as medications such as so-called 5-HT3 receptor antagonist, corticosteroid, and neurokinin-1 receptor antagonist prior to the start of chemotherapy or and / after radiotherapy. Other drugs are dopamine receptor antagonists, such as metoclopramide, or antihistamines.
- Stomatitis: Recommended once a good oral care before chemotherapy. The teeth, for example, you should remediate quickly and seek treatment gingivitis. Eat during chemotherapy as little sour, avoid strong spices and alcohol. Regular mouthwashes with sage and Pinselungen with myrrh tincture or with others recommended by the physician preparations from the pharmacy have a disinfecting and anti-inflammatory. Local anesthetic agents, such as mouthwash can Benzocainlösung, pain relieve. A fungal infection insulate a locally applied anti-fungal agent. Frequently also be herpesviruses active again. You can fight with locally effective antiviral agents. Sucking ice cubes and mouthwashes with dexpanthenol during and after chemotherapy can protect something the mucosa. Depending on the used cytostatics prescribe doctors also special mouth therapeutics. - Infections: Often, the white blood cells fall significantly from because some chemotherapeutics meet the formation of blood cells in bone marrow. As a result, it can lead to infections and fever come. Based on certain decision criteria, administration of so-called G-CSF (is preventive granulocytes -Kolonie-stimulating factors) possible. These special growth factors accelerate the formation of white blood cells in the bone marrow. Even doctors start if necessary a pathogen diagnostics and treatment with antibiotics. - anemia: You often causes fatigue and weakness. The causes of anemia (anemia) in cancers and their treatments are varied and should be evaluated carefully. If possible, the treatment takes account of the trigger. Thus comes about in cases of proven iron deficiency taking iron questioned. Sometimes that is iron injected. If a lack of vitamin B12 or folic acid before, the corresponding transfer makes sense. Whether in a particular case a blood transfusion (red blood cell concentrate) is necessary, the attending physicians of the findings and complaints of the patient are addictive. Possibly the doctor administered turn special growth factors: Erythropoietin stimulates the bone marrow to produce red blood cells. The doctor will control the therapy so that the hemoglobin ( hemoglobin is the red blood pigment) does not exceed 11 to 12 g / L. Note: Under erythropoietin as well as vitamin B-12 administration (each spraying, for example under the skin ) increases the thrombosis risk. The doctor will inform the patient about this and possible warning signs such as swelling and pain in the leg.
What opportunities can help to maintain the fertility?
For many couples, who are confronted with breast cancer at a young age, this question is quite an important issue. In particular, chemotherapy in young women can cause your menstrual periods temporarily suspend or entirely or premature in the menopause occur.
Meanwhile, some methods are available to these women after completion of therapy the chance of a pregnancy to allow. All those involved - the competent oncologist, reproductive medicine and the woman concerned or the couple - will be matched carefully about whether a particular measure for fertility preservation should be carried out.
Relatively new and not yet widely used method to remove ovarian tissue as a fertility Reserve is to freeze (cryopreserve to) and the woman later replant. This is done each by means of a laparoscopy . The chances of success are not yet sure assessable.
Another approach is hormonally stimulating the ovaries as a fertility treatment (assisted fertility or fertility treatment) and trigger ovulation. Thereafter, the eggs - are removed and frozen - unfertilized or fertilized. Assisted fertility treatment in hormone-sensitive breast cancer, however, is often regarded as not safe, because the hormone signals cancer cells may provide an incentive to multiply (see above, section "hormone therapy before menopause"). The process expensive and are usually not covered by health insurance.
What's up with bisphosphonates to be?
Bisphosphonates are drugs that primarily used to treat osteoporosis are (brittle bones), in addition to vitamin D and calcium in accordance with doctor's orders. To play in the treatment of bone loss in breast cancer patients an important role: Osteoporosis can develop, for example as an adverse effect of the anti-hormonal breast cancer therapy. Bisphosphonates support the prevention and treatment of osteoporosis.
Another field of application of bisphosphonates in cancer are diseases with increased bone loss or elevated calcium levels in the blood (hypercalcaemia) as part of a skeletal metastasis. In the treatment of pain caused by tumor foci in bone caused, they also show a good efficacy.
In addition, studies have shown that bisphosphonates can probably improve the prognosis also in breast cancer: You may be able to contribute to the prevention of bone metastases and so and improve our survival rates overall. Therefore, experts recommend bisphosphonates now in adjuvant therapy in women after menopause. For this application, however, bisphosphonates are not (yet) approved. What does this mean in individual cases for reimbursement by the health insurance, the doctor, the patient will explain exactly.
In metastatic breast cancer, however bisphosphonates are approved. The dentist should check the teeth carefully before starting treatment, because the drug can attack the jawbone (osteonecrosis of the jaw).
And if the cancer recurs?
After breast-conserving surgery and adjuvant therapy of tumor may again in the chest, after removal occur on the chest wall or skin. The armpit may be affected. . This means that there has been a local recurrence or loco-regionären recurrence, as doctors say to check if the cancer has spread to other organs, the patient is first again in more detail with imaging - mammography, x-ray of the lungs, Ultrasound of the upper abdominal organs, scintigraphy of the skeleton - examined. In a relapse in the chest this often needs to be removed. But there are sometimes small tumors that can be removed safely and still cosmetically acceptable without sacrificing the breast. However, this approach usually see doctors but as uncertain and therefore less advisable to. When lymph nodes in the armpit it is operated. The aim is always to remove the tumor tissue completely (PR0-resection). This is also true for a tumor that has returned after removal of the breast - either on the chest wall, either in the armpit or in the wider community, including in the area of scar: it should be completely removed also, if possible. The pathologist takes each turn a grading (see "Early detection, diagnosis, prognosis," section: "prognostic factors") before and receptors determination (hormone and HER2 receptors) of the tumor cells. In hormone sensitivity of the tissue may again be proposed or hormone therapy but the doctor is an ongoing hormonal therapy. Based on the individual situation of the patient, he also checks for the recurrence-operation and chemotherapy should be done. This is, for example, for patients in an elevated risk situation in question, as at a young age or when certain tumor characteristics are present. Here, however, prior therapies should be considered. If the tumor is HER2-positive, the antibody trastuzumab can also be used, especially if the person concerned has not previously been treated with it. A second time operated breast after removal of the breast, the chest wall or a diseased lymphatic drainage of the breast are - if possible - again irradiated. Even with localized recurrences a cure is possible. This largely depends on the same factors as in the forecast Ersttumor. A role playing, was how large the disease-free time windows: The larger, about more than two to three years, the better chances.
Locally advanced, inoperable breast cancer - distant metastases
Can a localized tumor can not be completely removed or distant metastases can be identified, there is an advanced cancer. This also applies when distant metastases are already present at the time of diagnosis. Fernmetatasen are metastases of the tumor that occur far away from the chest. They develop from cancer cells that have migrated through the blood and lymph vessels and elsewhere to settle in the body. Although the therapy from the outset aimed at meeting also detached tumor cells, some sometimes escape the clutches. In breast cancer affecting metastasis most frequently the skeleton, but also the liver, lungs, brain and skin, in very rare cases, other organs. In the skeleton are in descending order of frequency vertebrae, femur, pelvis, ribs, sternum, skull (the bony skullcap) and humerus affected. Depending on the type and location of a metastasis symptoms such as painful bone fractures, can back pain , pain in the upper abdomen, pain when breathing, shortness of breath , blurred vision, headache, or dizziness may occur. Weight loss can weaken the body as a whole. A cure is not very likely in this situation. However, under certain conditions, the disease may be some time well be influenced in this phase through special therapies. That is, for example, a total of more favorable characteristics of the tumor tissue of the case. Or if metastases occur in isolation or exclusively present bone metastases. Speaking of medical palliative treatment, so making it a treatment meant that is aimed at alleviating or eliminating symptoms, prolong the life, increase the quality of life and prevent complications. It is important to weigh the burden of side effects of the therapy to the advantage for the further prognosis, adequate quality of life and the patient's wishes. Some therapies found in studies instead (more on studies in "Therapy Studies" section below).
Treatment Planning: Contain metastatic growth
First, the localization of metastases by imaging methods is necessary for the treatment of metastases (see above, section: "And if the cancer recurs?"). It is also important to determine the tissue type of metastasis, since compared to the Ersttumor changes may have occurred, especially in the hormone and HER2 receptors. This can affect the therapy. With bone metastases the determination, however, is technically more difficult. As a medication, the physician may, depending on medical constellation and the wishes of the person concerned is either a (new) anti-hormonal or chemotherapy or targeted therapy initiated. They all act again on the whole body, so systemic. Anti-hormone therapy
The anti-hormone therapy is effective normally requires proof of hormone receptors. Which drug is used in each case will depend among other things on whether the person concerned is before or after menopause, also of the previous treatment. Which therapy individually comes to a patient in question, their doctors will discuss with her. In principle, in women after menopause as in the adjuvant tamoxifen and aromatase into account. The aromatase inhibitors can be optionally combined with the targeted substance everolimus, to improve the response. Also, the estrogen antagonist fulvestrant is in this phase of treatment a possibility.
Women before menopause is often recommended therapy with tamoxifen and the ligation of the hormone production in the ovaries. This can, for example, by means of drugs such as the so-called GnRH agonists (see section "drugs / anti-hormone therapy" above) done.
Later or if tamoxifen is not tolerated, the treatment can also be converted to an aromatase inhibitor together with a suppression of ovarian function (GnRH agonist). Possibly is also used fulvestrant, optionally together with a GnRH agonist. come then questioned high-dose progestins Again ,
About the side effects of the substances used in the anti-hormone therapy most commonly see "side effects of therapy / drugs / anti-hormone therapy," earlier information. Chemotherapy as chemotherapy consult doctors in this treatment situation usually single substances to (monochemotherapy) to the to limit side effects. Very frequently, for example, anthracyclines or taxanes employed individual, but especially when the victims are thus not treated. There are also alternatives. A role always played by the general condition of the patient, as well as the question of where the metastases are located, whether they have receptors and which, moreover, the course of the disease. If the tumor too fast, a combined chemotherapy (chemotherapy) with various can offering substances. Which selects the doctor here also depends on the pre-treatment.
Targeted therapies with various medications
also for the advanced stage of breast cancer, there are now drugs that slow the growth of tumors in a targeted and so can prolong survival. The term "targeted therapies" derives from the English word "target" from (the target). Treatment comes in at specific structures in the cell (target). Metastases can be, for example HER2 receptor-positive. If we find this feature on the cancer cells, they tend to be faster divide and multiply. Then can be selectively intervene: In addition to the chemotherapy used in the treatment of the antibody trastuzumab. He was mentioned several times in this article, for example, in the initial treatment of early breast cancer. Depending on the pre-treatment and other individual requirements suitable for the purposes of targeted therapy various substances, including combinations of antibodies and chemotherapeutic agents . If the metastases have hormone receptors simultaneously, an aromatase inhibitor or fulvestrant can happen. The targeted drugs are constantly evolving. Currently approved and launched for the treatment of advanced or metastatic breast cancer in Germany: - Trastuzumab: use in HER2-positive metastatic breast cancer including hormone receptor-positive forms; Infusion into the bloodstream through a catheter port or port (= venous access with longer retention periods), together with an anti-Allergikum. The administration under the skin (subcutaneously) is possible. Among the very common side effects * (explanation * see above): allergic reactions, flu-like symptoms, palpitations, chest pain, dyspnea, headache, diarrhea, facial swelling, nail damage. - pertuzumab: In combination with trastuzumab and a taxane (particularly docetaxel ), currently in HER2-positive breast cancer in locally advanced (tumor relapse, inoperable) or metastatic disease; Infusion into the bloodstream. Also recommended as part of neoadjuvant breast cancer treatment in studies. As a very common side effects * occur, for example, respiratory infections, blood disorders with anemia and decrease in white blood cells, as well as fever, further oral mucosal inflammation, nail disorder, disturbances of cardiac function, fatigue (see section "Fatigue in cancer" above). - T-DM1 (trastuzumab emtansine): So-called antibody-drug conjugate for women with locally advanced or metastatic HER2-positive breast cancer. The preparation contains the aforementioned antibody trastuzumab (T), the stable through a connecting another active agent has been attached (DM1 or emtansine). DM1 is a cytostatic agent that inhibits cell division. The antibody trastuzumab causes a targeted enrichment of cytostatic directly in HER2-positive tumor. Again, side effects can occur: about drop in platelet count (thrombocytopenia), increase in liver enzymes, fever, headache, cough, epistaxis. - Lapatinib: For advanced or metastatic HER2-positive breast cancer, and hormone receptor positive; Application as tablets. Very common side effects * include diarrhea, nausea, vomiting, rash, blistering and redness on the palms and soles (hand-foot syndrome), disorders of cardiac function. - Bevacizumab: Metastatic stage in HER2 negative breast cancer; Infusion into the bloodstream (Port). Common side effects **: hypertension, joint pain, fever, headache, eye disorders, altered taste. - Everolimus: Sogenannter mTOR kinase inhibitor, which inhibits the mTOR protein; Approved for HER2 negative , thereby also hormone receptor-positive advanced breast cancers; Application as tablets, currently approved in combination with the aromatase inhibitor exemestane. Frequently ** it comes to side effects such as respiratory infections, anemia, oral mucositis, diarrhea, weight loss, venous thrombosis, heart failure, kidney disorders. Other substances are approved in Europe or are currently being examined in the context of studies.
Metastases: tackle specifically Depending on location
Individual secondary tumors, for example in the liver or lung, for example, be surgically removed. Not operationally let liver metastases turned off by a so-called radio frequency ablation (RFA). This electrodes are inserted under ultrasound guidance in the metastasis and those placed under high-frequency current. The evolving heat destroys the tissue. couches spread to the bones before, it can be prevented by the use of bisphosphonates or a so-called Rankligand inhibitor as denosumab bone fractures. Bone pain go back. For stabilization and pain relief was diagnosed with metastatic skeletal regions are also irradiated or treated surgically. This is especially true when a vertebral fracture or if the risk of spinal cord contusion is by an unstable spine.
Single or few brain metastases can ("radiosurgery") are surgically or through a targeted radiotherapy treated.
In addition, the entire brain can be irradiated. The latter is a way even in the presence of many brain metastases. If the underlying disease HER2-positivity, treated with trastuzumab breast cancer, so can a treatment with the small molecule lapatinib (see above, section "Targeted therapies"), possibly in combination with capecitabine are eligible. suppress pain lasting
If pain occurs as a result of tumor growth, can help a very specifically designed pain management today. Pain into the background, without having to take strong side effects by the drugs in purchasing. Permanent pain, however, are grueling and can lead to chronic insomnia, to the development of depression and social withdrawal. Therefore, a pain management is very important to increase the quality of life of affected women.
When pain medications come or analgesic interventions into consideration. A supplementary adjuvant, for example, antidepressants (agents for depression) can support the effects of painkillers. These can then be lower dosage, so that fewer side effects occur. The pain therapy is more effective, the better it is tailored to the needs and wishes of those affected and their daily routines. The schedule of intake should be strictly adhered to. The doctor can check at any time and adjust the medication to a changed situation but him. In severe cases, the attending physician will consult a pain management physician. With good management of therapy and pain management can improve your grip.
Therapy trials
Without studies no therapeutic progress - this is true for breast cancer as well as for any other disease. Only when new, potentially better therapy with existing could be compared with a sufficient number of patients, doctors know if your assumption is correct and the alleged progress worthy of the name. In cancers , especially breast cancer, more and more sufferers are now ready to be treated as part of studies. This is accompanied by a tighter supply and control. In addition, the participants, if appropriate, have the opportunity to benefit in a clinical trial of a new, innovative therapy. Participation is voluntary and can be canceled anytime. The treatment is then continued in the manner customary for the corresponding disease situation manner. In breast cancer, there are various studies -. For adjuvant therapy after surgery, neoadjuvant before, for the treatment of hereditary breast cancer and for the treatment of metastatic breast cancer or locally advanced stage but one should before making a decision whether or not to participate fully with inform conditions. In general, the doctors who care available at the competent certified Breast Center as a contact person.
Alternative Therapies in Breast Cancer
In general, from a scientific perspective none of the alternative therapies can replace the traditional medical standard procedure for breast cancer and should. For homeopathy or mistletoe therapy in breast cancer, for example, are so far insufficient scientific evidence before. Green tea is a lot of sympathy; adverse effects are unknown, favorable not backed up. If you want to use homeopathic, herbal or other alternative therapies, discuss this in any case with your treating physician. This also applies to the use of so-called dietary supplements. There are substances that can, in combination with the drugs used in breast cancer therapy for interactions. If alternative means and medicaments of the cancer therapy, for example, over the same path in the liver are metabolized, the effect can increase or decrease of the drugs. In addition, herbal medicines are not without side effects.
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Breast cancer (breast cancer): Special situations
This is about breast cancer in pregnancy in older women and in men
Breast - Pregnancy - Birth Control
Breast cancer is a dangerous and extremely stressful diagnosis for any woman. Even more so if the frightening message falls in the period of pregnancy.
But even here, the disease can be fought - and without harming the child. The treatment can be scheduled at rest, when the diagnosis has been made. She turns out similar to non-pregnant women.
Surgery and chemotherapy are in the pregnancy possible, the chemotherapy can be carried out in the second and third trimesters.
• In need radiation or hormone - and antibody therapy is a time from two to three weeks after childbirth relocated. This should be done when the fetus has attained sufficient maturity. Between chemotherapy and childbirth should be at least three weeks. Four weeks after completion of cancer treatment can make your child a woman breast-feeding .
Hormonal contraception after first-line treatment of breast cancer is considered risky. There are alternative methods, for example, inserting a copper IUD in the uterus .
However, may be impaired fertility after chemotherapy.
Pregnancy after completion of first-line treatment of breast cancer does not increase the risk of a recurrence of the tumor. We recommend a minimum two-year distance.
Breast Cancer in old age
When planning the treatment of health of the patient as a whole is decisive, not so much the age. With sprightly women no compromises in the treatment must be made.
If a patient but older and frail, the doctor will schedule the treatment in a reasonable manner shall individually.
Breast cancer in men: possible but rare
The male mammary gland are compared to those of mature woman underdeveloped, but otherwise created very similar. Therefore, they also respond to estrogens .
When enlarged, the male chest and a feeling of tension occurs, it must not have to be breast cancer - it may be behind a so-called gynecomastia. It is a benign enlargement of the mammary gland, which is probably caused by hormonal changes. Breast augmentation by the formation of fatty tissue called "pseudogynecomastia".
Only every hundredth breast cancer affects a man. This breast cancer in men is indeed a rare disease, but it is not excluded.
Those affected are at the time of diagnosis, on average, slightly older than women, such as between 60 and 70 years.
Important: Any change in the chest - if the juvenile or adult male - should be studied for safety's sake. This applies especially to any unilateral magnification. First contact is, for example, the general practitioner.
Risk factors come in men, among other things questioned diseases associated with an excess of estrogen or a lack of testosterone , accompanied, the male sex hormone.
In addition to the already mentioned obesity (adiposity) are the example of the testes, the adrenal glands, diseases thyroid and liver.
In a genetic disease such as Klinefelter's syndrome sufferers have one or more additional X chromosomes in the genes. It comes to testosterone deficiency and various aberrations. Also, the risk of breast cancer is increased.
Hereditary changes (mutations) in particular the risk of breast cancer gene BRCA2 and other, as yet unknown breast cancer genes (more about these genes in the chapter "Causes, Risk Factors" , which may carry and pass on in men also play a potential role.
In women, only a minority of breast cancers with hereditary predisposition is related. In male patients, the true in one of five or six cases.
The breast cancer risk for men with a BRCA2 mutation is life-long ten percent (with a significant increase from the age of 50).
Thus, it reaches at least about the level of normal breast cancer risk of women. Hereditary burdened men are at the time of the disease usually younger than 60 years.
Increased radiation exposure, for example, after an earlier radiation treatment in the area of the thorax, the breast cancer risk also increases. This is also true for women.
Symptoms generally occur in one breast and are the same as in women (see section "symptoms" ). The breast forms are also the same.
The prognosis for treated breast cancer are similar to those in women, going from comparable conditions from.
As the doctor goes on before?
The family doctor will consider whether a urologist or andrologist should continue to pursue the issue. Andrologist deal with disorders of male fertility. But it may also be that he has the same affected to a certified breast center.
Diagnosis, treatment and aftercare run in men with breast cancer in the Broad as in women, with the removal of the diseased breast is in the foreground and the breast reconstruction naturally does not matter.
The conditions and the use of chemotherapy and radiation therapy are the same.
In course of the (anti-) hormone therapy eliminates the differentiation in terms of age, so the distinction "before or after menopause."
As a medicine primarily Tamoxifen is used to treat hormone-sensitive breast cancer in men. Aromatase inhibitors currently in metastatic breast cancer are more likely to use (only in adjuvant studies), as well as other anti-hormonal therapies.
Also, trastuzumab can be used with HER2-positive tumors (information about this therapy in women in the chapter "therapy" ).
Important: In addition to the actual breast cancer aftercare individuals should always use the cancer screening tests currently offered for men with the urologist and dermatologist. Let specific advice, which offers free care available to you. If a / s continued / s direct / r Related / r also be suffering from breast cancer, genetic counseling is recommended. More information in the section "Consulting expert, specialist literature"
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Breast cancer (breast cancer): aftercare
After the treatment of breast cancer sufferers are regularly re-examined to identify a recurring or new cancer as early as possible
Breast Cancer: follow-up according to schedule
The follow-up is focused primarily on a possible relapse in time to discover. For example, the tumor when it occurs again in the original position, be very effectively treated (see section "Therapy "section: And if the cancer recurs?").
In addition, possible side effects of cancer therapy are to be found and treated.
This involves, for example, problems such as menopausal symptoms, osteoporosis or lymphedema of the arm. Signs of fatigue ssyndroms (tumor Fatigue, see chapter each "therapy"), you should not try to put away, but to address to the doctor.
In addition, rehabilitation and psycho-social assistance can be promoted and coordinated at the time of initial treatment concluded in the context of follow-up.
Info Mieren your doctor therefore also independent of the designated check points with unusual symptoms or if you abnormalities of the breast or notice on the chest.
The check-ups take place in the first three years after completion of breast cancer treatment at intervals of three months.
Until the fifth year, the checks take place every six months, annually thereafter.
The focus of the events is the conversation with the doctor - usually that's the attending gynecologist - who asks the woman at length to her physical and mental condition, and the physical examination. This means that the physician also checks the abdominal organs.
Technical follow-up examinations in women
After breast-conserving therapy is the treated breast in the first three years also mammografiert least once a year and sonografiert, from the fourth year annually.
If the operated breast with this method is difficult to assess, there is a magnetic resonance imaging . The healthy breast is mammografiert once a year, possibly also sonografiert.
Even after removal of the breast is a once a year mammography provided the other breast. The operated side examined the doctor also at least annually with ultrasound .
Additional diagnostic measures are usually reserved special issues, such as in cases of suspected relapse, metastasis or of course a different disease.
If the physician determines that certain investigations necessary to the costs, apart from few specific exceptions, also be covered by health insurance.
Once a month, individuals should think about the breast self-examination.
Breast Cancer aftercare in men
Even men are after initial treatment of breast cancer (for more information in the chapter "Special situations ", the" breast cancer in men, "and in the section "Consulting expert, specialist literature "; see also below, KID) regular follow-ups provided. Also possible are rehabilitation - stationary as an outpatient. Self-help organizations provide further assistance.
Live well and healthy
The main recommendations for this purpose can be summed up in a few words: eat healthy, exercise as much as possible, maintain normal weight - that's the best way to keep fit and to feel comfortable. Normal weight and movement, possibly even a healthy diet can likely reduce the breast cancer risk of relapse.
Concretely, this means, for example, in the diet a sufficient proportion of fresh fruits, vegetables to use, salads and whole grains. Except vitamins and minerals, they also provide other valuable components such as dietary fiber.
Sweets and high fat foods from animal sources, such as meat and cold cuts, as well as alcohol and nicotine are against unfavorable and should disregard stand.
If you are physically active at least three hours per week, so this increases according to experience well-being and is conducive to health. You can approach your performance limit calmly to achieve a training effect
Mental coping with the breast cancer
Many sufferers put their lives after breast cancer treatment in order to live more consciously, pay more attention to your body and let your own needs space. The physical fitness is often even better than before.
More difficult to grasp, let alone in a few words is abzuhandeln the mental side of the disease.
The confrontation with the diagnosis " cancer ", the" overthrow of normality ", days of fear and despair, the feeling that they can no longer rely on their own bodies, nerve-wracking waiting for medical findings, strains and suffering of therapy - the everything leaves deep scars.
Many sufferers feel even for a long time subliminally "alarmed". It is also not always easy to find the right balance between too little and too much attentiveness to one's own body.
Gelingende coping takes time and understanding accompaniment in private and professional environment. A person may be looking for advice and help and externally.
Competent contacts in breast centers are psycho-oncologists, the mainly cancer patients manage psychological.
Psychosocial Cancer counseling centers and psycho-oncologists outpatient active offer professional psychological help.
Addresses and links can be found at the Cancer Information Service (KID) of the German Cancer Research Centre (contact details see chapter "Consulting expert" , "psychosocial support", for example, "KID-sign". You will also find information on self-help groups).
A positive attitude towards life, fulfilling tasks and interests, the conversation in the family, with the partner and with friends, the exchange with other stakeholders, possibly in a support group locally, experiencing solidarity and assistance, including the experience of the recovered body strength - everything This also strengthens the mind and helps to accept the disease and to deal with.
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Breast Cancer: Advisory expert literature
This text was written with generous support from the Cancer Information Service of the German Cancer Research Center
Sources and further Internet addresses:
Comprehensive information about breast cancer:
German Cancer Information Centre, Cancer Information Service KID:
Free Hotline: 0800 - 420 30 40, daily 8-20 clock
Internet: www.krebsinformationsdienst.de
and www.facebook.com/krebsinformationsdienst
Email: krebsinformationsdienst@dkfz.de
Centre for Cancer Registry Data at the Robert Koch Institute, Berlin: http: //www.krebsdaten.de/Krebs/DE/Home/homepage_node.html
Guidelines of the Working Group Gynecological Oncology (AGO) eV:
- Diagnosis and Threapie of patients with primary and metastatic breast cancer: http://www.ago-online.de/fileadmin/downloads/leitlinien/mamma/maerz2014
/de/2014D_Alle_aktuellen_Empfehlungen.pdf (recall: 28/05/2014)
- Information for patients: http://www.ago-online.de/de/fuer-patienten/allgemeines/
German Cancer Society (DKG) German Society of Gynaecology and Obstetrics (DGGG) eV: German Cancer Aid, AWMF:
Interdisciplinary S3 guideline for the diagnosis, treatment and aftercare of breast cancer
Long Version 3.0, update 2012 AWMF register number 032-045OL:
http://leitlinienprogramm-onkologie.de/uploads/tx_sbdownloader/S3-Brustkrebs-v2012-OL-Langversion.pdf
German Cancer Society (DKG) and the German Society for Gynaecology and Obstetrics (DGGG) eV: Interdisciplinary Level 3 (S3) guideline (AWMF 015/062) hormone therapy in the peri- and postmenopause (HT), 2009 (valid until 1.9 .2014)
Radiotherapy (DEGRO):
http://www.ncbi.nlm.nih.gov/pubmed/24306068
Other:
St. Gallen Consensus Conference early breast cancer 2013:
http://www.medinfo-verlag.ch/upload/File/onko_2_2013/06_onko_2-13_WA_Kongress_Breast%20Cancer.pdf
Janni W, Kuhn T, Schwentner L et al .: Sentinel node biopsy and axillary dissection in breast cancer - evidence and its limitations. Dtsch Ärztebl 2014; 111 (14): 244-9. DOI 10.3238 / arztebl.2014.0244
Harbeck N: Breast Cancer: Tumor Biology-based concepts for surgical and drug therapy. Dtsch Med Wochenschr 2013; 138: 180-182, Georg Thieme Stuttgart. DOI 10.1055 / s-0032-1327410
Rudel RA: Environmental Exposures and Mammary Gland Development: State of the Science, Public Health Implications, Research and Recommendations; Environ Health Perspect 119: 1070-1076 (2011). http://dx.doi.org/10.1289/ehp.1002741 (online April 18, 2011; demand: 05/16/2014)
Aluminum in deodorants:
http://www.bfr.bund.de/cm/343/aluminiumhaltige-antitranspirantien-tragen-zur-aufnahme-von-aluminium-bei.pdf (Polling: 19/07/2014)
Familial breast cancer:
Information sheet with key facts and responses of the KID (see above):
http://www.krebsinformation.de/wegweiser/iblatt/iblatt-familiaerer-brustkrebs.pdf.
http://www.krebshilfe.de/fileadmin/Inhalte/Downloads/PDFs/Praeventionsfaltblaetter/444_familienangelegenheit.pdf
http://www.brca-netzwerk.de/risikofaktoren-brustkrebs.html (polling 06/04/2014)
www.mammamia-online.de (polling 04/06/2014)
Breast cancer in men:
http://www.krebsinformationsdienst.de/tumorarten/brustkrebs-mann
Self-help: http://www.brustkrebs-beim-mann.de
Psychosocial support:
http://www.krebsinformationsdienst.de/wegweiser/index.php
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