Breast cancer

The most common form of breast cancer is the so-called mammary carcinoma. This is a malignant (cancerous) tumor which starts from the glandular tissue of the breast. The mammary carcinoma can be classified into several subtypes. There are, for example, types of breast cancer that are dependent on a hormone for growth and/or survival and those that don’t.

In Germany, about 69,000 women and about 700 to 800 men get breast cancer every year. 

Ductal carcinoma in situ (DCIS) is the earliest form of the mammary carcinoma. This is where the cells already have many of the characteristics of a “real” mammary carcinoma, but they haven’t yet spread into surrounding tissue or out into more distant organs. 

The treatment of breast cancer, especially one that is sensitive to hormones, usually lasts for five or more years. But many women manage to resume their daily routine during this time, while other women still feel limited in what they can do for a long time.  

Women who have survived breast cancer do not have to limit themselves in their everyday life. On the contrary – an active lifestyle with lots of exercise can help to avoid or alleviate complications. Exercise may even reduce the risk of a relapse. 

Possible signs of breast cancer are for example 

• a palpable lump in a breast, 
• a retracted nipple (a nipple that turns inward instead of outward), 
• fluid coming out of a nipple, 
• a breast that is red and warm and stays that way for a long time and does not respond to antibiotics. 

Small tumors often have no symptoms. But they can be identified with cancer screening. 

It is important for women to see their doctor if they notice any of these changes in their breast. This way doctors can start really narrowing down what is causing the symptoms or introduce any further steps needed to establish a diagnosis. 

It is not clear what causes breast cancer in most people affected. But there are a number of things that are known to make it more likely to get it, especially increasing age. 

For some women, breast cancer runs in the family. In many cases, it is caused by a cancer-inducing mutation (change) in one of the cancer genes known as BRCA1 and BRCA2. These changes significantly increase the risk of breast cancer.  

Intensive radiotherapy of the chest during childhood and adolescence can also significantly increase the risk of getting breast cancer. An example of this is a procedure known as mantle field radiation used to treat Hodgkin’s lymphoma.  

A dense mammary gland tissue or certain benign (non-cancerous) breast conditions are also associated with a slightly increased risk of breast cancer. 

Hormone-related factors are also associated with a slightly increased risk of breast cancer. These include, for example, periods that start at an earlier age than is normal and a last period later than average, or long-term use of combined hormone therapy after the menopause.   

Treatment options for breast cancer have much improved in the last few years and decades. In general the earlier breast cancer is detected, the more favorable the outlook and the better the chances of recovery.

But some subtypes of breast cancer that depend on hormones for their growth or survival can still relapse more than 10 years after they have first been diagnosed. They then have to be treated again.

A complete cure is usually no longer possible if the breast cancer is already advanced. But the variety of different treatment options available have meant that those affected can often live long and fulfilling lives with the cancer.

Scientists believe that a healthy lifestyle can significantly reduce the risk of breast cancer. This includes for example avoiding being over- or underweight, having a varied and balanced diet, not drinking too much alcohol, not smoking and doing lots of exercise.  

Medication preventing breast cancer is not yet approved in Germany. 

If a woman has a high risk of getting cancer because of her genes then she may have the option of having surgery to prevent this, in addition to being monitored more closely so that it can be detected early on. 

All women aged 30 and above are entitled to have annual screening of the breast and surrounding lymph nodes performed by a gynecologist. While they’re there, they can also be shown how to examine their own breast.

Women aged 50 to 69 years are also invited to take part in screening using mammography every two years. This involves examining the breast with low dose x-rays. Participation is voluntary.

And what if cancer is hereditary?

Women at high risk of breast cancer because of their genes can take part in a closely monitored cancer screening program, offered by Centers for Familial Breast and Ovarian Cancer, for example.

The Cancer Information Service of the German Cancer Research Center explains on its website how a mammogram and other cancer screening tests work, how they benefit patients and whether there are disadvantages involved (in German).

More detailed information and support for decision-making in relation to mammography screening is provided in the patient brochure published by the Joint Federal Committee (G-BA).

If a doctor suspects breast cancer the first thing they do, in addition to performing a mammogram, is an ultrasound. Some people affected also undergo additional tests such as magnetic resonance imaging (MRI).  

If the possibility of breast cancer persists after this, they take a tissue sample from the area of the breast under suspicion (biopsy). A pathologist is able to examine this biopsy and definitely confirm or rule out breast cancer. 

If breast cancer is confirmed

If breast cancer is confirmed beyond doubt through the biopsy, it is examined further to find out its characteristics and how far it has spread. This is important for choosing the right treatment.  

The following are some of the factors examined: 

• Receptor status: this determines whether the tumor cells are producing binding sites for the sex hormones estrogen and progesterone and how many. Doctors also test the quantity of HER2 receptors on the breast cancer cells. 
• Similarity of the tumor tissue with normal glandular breast tissue  
• Speed at which the tumor cells divide 
• Whether the lymph nodes surrounding the tumor are involved: these days, doctors usually carry out a procedure known as a “sentinel lymph node biopsy” where they take a sample of the one to three lymph nodes into which the lymph fluid first enters from the tumor and examine them. They are usually in the armpit.  

Sometimes additional tests are used to decide whether or not to perform chemotherapy, for example a test known as a gene expression test. 

Do you want to know more about the tests used to diagnose breast cancer? You can find more information about each procedure and how it works on the website of the Cancer Information Service of the German Cancer Research Center (in German). 

There are lots of treatment options for breast cancer. Doctors often combine different treatment approaches, but this mainly depends on the type of the tumor. The extent to which the cancer has spread also plays an important role. A distinction is made between local and whole body treatments.

Local treatment: surgery and radiotherapy

The main treatment for breast cancer in its early stages is surgery. 

These days, surgery is able to preserve most of the breast in many cases. Breast-conserving treatment involves only removing the part of the breast that has the tumor. Doctors usually then treat the remaining breast to kill off any tumor cells that may still be there.

If the entire glandular breast tissue is removed, this is known as a mastectomy. Once a mastectomy has been performed, surgeons have various options for reconstructing the breast e.g. with a silicone implant or with the patient’s own tissue.

Sometimes the armpits or continuing lymphatic pathways are also treated with radiotherapy. If a lot of cancer cells are found in the lymph nodes in the armpit, surgery is performed to remove them – it is usually not enough to treat them with radiotherapy in this situation.

Effective throughout the body: systemic treatments

In addition to local treatment, almost every breast cancer patient will get other supportive treatments that have an effect on their whole body and make it even less likely that they will have a relapse. Doctors use these treatments before surgery (neoadjuvant) or after surgery (adjuvant).

If the cancer is in its early stages, these are chemotherapy, anti-hormone therapy, HER2-targeted therapies and treatments that have an effect on the bones. They can be used individually or in combination.

• Anti-hormone treatments are available to patients with early breast cancer where hormone receptors have been detected. This is called endocrine therapy. Typical medication is Tamoxifen before the menopause and aromatase inhibitors after the menopause. Doctors usually use them after surgery.
• Doctors mainly use chemotherapy when a tumor has no or hardly any hormone receptors and/or other tumor characteristics indicate rapid growth, often used before surgery. This helps doctors to see early on whether the tumor will get smaller with treatment or even completely disappear.
• Doctors use HER2-targeted therapies if the breast cancer cells have an increased number of HER2 receptors. The tumor then often grows rapidly. One method in response is to give patients antibodies, usually combined with chemotherapy.
• Doctors use medication that stabilizes the bones to prevent bone metastases, e.g. bisphosphonates.

What is “post-neoadjuvant” treatment?

If some of the tumor is still there at the time of the surgery, it can be helpful to give the patient another bout of chemotherapy or targeted therapy. Doctors call this post-neoadjuvant treatment.

What about advanced cancer?

If the cancer is advanced in the breast or if it is metastatic, that is, it has spread to other organs or tissues, doctors also use additional medication and procedures to keep the disease at bay, paying particular attention to making sure that the patient maintains a good quality of life for as long as possible.

You can find more information about each treatment for breast cancer, its effects and side effects on the website of the Cancer Information Service of the German Cancer Research Center (in German).

Breast cancer treatment can bring physical and emotional stress along with it. Typical examples of physical stress are:  

• limited mobility 
• a build-up of fluid (lymphedema) in the arm on the side operated on
• anxiety or lack of drive or motivation.  

To deal with this, breast cancer rehab includes many different options, ranging from movement and lymphedema therapy to nutrition advice and relaxation exercises. 

What examinations are included in the aftercare? 

As part of their aftercare, doctors regularly check whether there are any side effects they can and must treat after the patients have completed rehab.  

They also check at regular intervals whether the affected breast, and also the other one, are still cancer-free. This is important so that any local relapse is identified early on and can be treated. 

Doctors of various specialties work closely together in the treatment of breast cancer. Hospitals that are particularly experienced in the treatment of patients with breast cancer can have this confirmed with certification. The German Cancer Society (DKG) regularly checks their compliance with certain professional requirements.  

You can find the addresses of the certified centers on the OncoMAP website.

The German Consortium for Hereditary Breast and Ovarian Cancer has particular experience in the care and/or treatment of people with a family history of breast and ovarian cancer.

The consortium gives an overview of the Centers for Familial Breast and Ovarian Cancer in Germany on its website. Link to the website

Do you have further questions about dealing with the condition in everyday life and additional support options? You can find information about this on the website of the Cancer Information Service of the German Cancer Research Center (in German).

If you have any questions about breast cancer you can also make personal contact with the Cancer Information Service by dialing the freephone number 0800 - 420 30 40 or writing an email to krebsinformationsdienst@dkfz.de