Breast cancer: gentler therapies

Courage to do less - tumor therapies are becoming gentler, shorter, more individual. This requires a rethink, both among doctors and patients

Surgery, chemotherapy, radiation. For a long time this was the classic approach in the fight against breast cancer. Thanks to more detailed examination and therapy options, however, we now know that it doesn't always have to be the full program. For many patients, this means gentler, shorter treatment with fewer side effects - with the same chance of recovery.

For example, some can be spared chemo. For others, this therapy can be supplemented or even replaced by anti-hormone treatment or other targeted active ingredients. They slow down cancer growth. Still other patients have less tissue removed from their breasts after chemotherapy.

Confidence in new therapies

"In the last 30 years, breast cancer treatment has lost a lot of its radicalism," says Professor Jörg Heil. He heads the Breast Medicine Section at Heidelberg University Hospital and coordinates the Breast Center there. The therapies are still extremely strenuous, both physically and mentally. "But they are becoming more and more targeted and tailored to women and their cancer," confirms Professor Nadia Harbeck, Head of the Breast Center and the Oncological Day Clinic at the Women's Clinic of the University of Munich (LMU).

Studies show: In certain cases, gentler therapies reduce the side effects and increase the quality of life - without having a negative impact on the life expectancy of the women concerned.

"Less is more" was the motto of the Breast Cancer Congress 2017, at which international experts met in Berlin. Harbeck welcomes the beginning trend reversal, but the current development has not already arrived in everyone's mind. "We have to rethink," says the expert, "and trust newer therapies more." For example, doctors and patients sometimes still have doubts as to whether the anti-hormone therapy tablets that the patient takes at home would work as well as the chemo administered on an outpatient basis.

Deaths are on the decline

The diagnosis of breast cancer is no longer a death sentence - even if the disease can come back years after successful therapy. According to the German Cancer Society, almost 90 percent of the patients are still alive five years after treatment. Ten years later it is still over 80 percent, they are considered cured. The number of deaths is falling continuously, although more and more women - around 70,000 per year in Germany - are newly diagnosed with breast cancer.

The reason for the increasing number of people affected is, on the one hand, that the cancer simply occurs more often - for example because women are getting older. On the other hand, doctors discover more knots thanks to closer and more precise preventive examinations. For example, as a result of screening programs, they are diagnosing the preliminary stages that could develop into breast cancer more frequently than in the past.

If a doctor detects a possible growth by means of imaging procedures, a tissue sample shows whether it is a harmless cyst, a preliminary stage or breast cancer - and what properties this has: Does the tumor grow quickly or slowly, hormone-dependent or independent? Does he have certain growth factors?

Operations continued, but often to a lesser extent

The further course of action is planned depending on the tumor, age and state of health of the patient. Ideally, this happens in a certified breast cancer center. Therapy then no longer necessarily has to take place in the classic three-step process. "However, that still creates uncertainty," observes Harbeck. Read what women should know about this below.

Cancer can only be cured if all tumor cells disappear from the body. In the case of breast tumors that have not yet spread, this is relatively easy: They are surgically removed. Affected women can still expect such an intervention today. What has changed, however, is the when and how of the operations.

Get body image

"30 years ago, almost every woman had their entire breast removed - regardless of whether the tumor was large or small," says Heidelberg expert Jörg Heil. Today, however, over 70 percent of the patients are spared this.

"On the one hand, tumors are discovered earlier today; on the other hand, we have developed methods that give many women an appealing breast and thus their body image, even with larger tumors," says Heil. For certain cases, a data comparison by researchers in Rotterdam has also shown: Preserving the breast makes survival over several years even 28 percent more likely.

Interventions less radical

In addition, the interventions are less radical today. One reason for this: Many patients who absolutely need chemotherapy receive it beforehand. The operation will take place later. Procrastination has two advantages. Doctors can observe how the tumor reacts to medication and readjust it if necessary. Ideally, it will shrink. Afterwards, surgeons can operate in a narrower area, the wound is smaller.
In special cases, no tumor cells at all can be detected after chemotherapy. "We are currently investigating whether it would be possible to dispense with surgery and radiation altogether for these patients in the future," says Heil. That is not unrealistic.

Today more adjacent tissue is preserved. "We are more generous when it comes to the edges around the tumor," explains Professor Eva-Maria Grischke from the gynecological oncology department at the University of Tübingen's women's clinic. "In the past, surgeons cut out several millimeters of the margin. Today one is enough." The wound heals faster and looks more aesthetic.

More quality of life

Since breast cancer cells can migrate to neighboring lymph nodes in the armpit, doctors always examine them as well. In the past, many of the lumps were removed as a precaution, but now doctors are more cautious here too. According to Grischke, only one to a few nearest lymph nodes are removed. The prognosis does not deteriorate for women, but the quality of life increases. Because after the removal of the lymph nodes, painful edema, numbness in the arm and swelling can occur. "These subsequent problems are much less due to the changed therapy," says Heil.

If a lymph node is actually affected, the neighboring nodes are currently also removed to be on the safe side. Scientists around the world are currently investigating whether this has to be the case. Heil believes that the number of these cases will halve in the next ten years. "In more than half of the women, no other lymph nodes are involved." In order to identify these patients as precisely as possible, the diagnostic options would have to be improved.

Chemotherapy - no longer the first choice

It is still what many people immediately associate with cancer: chemotherapy. And it used to be clear: it would be administered after the operation. Because it eliminates cancer cells not only in the breast and lymph nodes, but also through the blood in the entire organism. However, since the drugs also attack the body's own cells, patients sometimes have to accept severe side effects.

Many women perceive so-called fatigue, a chronic fatigue, to be the most stressful acute problem. In addition, there are usually nausea and vomiting, inflammation of the oral mucosa, hair loss and constipation, sometimes tingling and numbness in the hands and feet.

"So it's good that today there are two approaches here too, doing less instead of more," says Harbeck. One affects women who have developed breast cancer for the first time. Your tumor must be hormone-sensitive and "HER2-negative", i.e. without certain growth factors. That means it doesn't divide quickly and responds well to other drug therapies. In addition, it must not have exceeded a certain size and not have spread. If all of these characteristics apply, a tissue sample can be examined with a so-called gene expression test.

Overview of breast cancer types

  • Luminal A is a breast cancer that grows slowly and is highly dependent on hormones. Chemotherapy is usually not necessary.
  • Luminal B is the name of the largest group. Cancer takes many forms and can respond to both hormonal and chemotherapy. The latter works in about half of the cases. In which, genetic tests can indicate.
  • Hormone receptor positive tumors are stimulated to grow by the female hormones estrogen or progesterone. These dock on the surface of cancer cells. Hormone withdrawal or antiestrogenic drugs can therefore stop growth.
  • Triple-negative tumors have neither hormone nor HER2 receptors. They are particularly difficult to treat, grow aggressively, so they scatter quickly and a lot. So far, these tumors could only be fought with chemotherapy. New antibodies are currently about to be approved.
  • BRCA1 and BRCA2 gene changes are inheritable and greatly increase the risk of breast and ovarian cancer. Affected women are monitored very closely. If necessary, preventive intervention is recommended.
  • Pre-cancerous cells are changed cells from which breast cancer can develop. Some of them are treated surgically as a precautionary measure.

Relapse risk

The gene expression test determines how active certain genes are in the tumor. With the result, the doctor can calculate the patient's individual risk of relapse. If it is low, she can be spared the stress of chemotherapy after an operation. The only restriction: no more than three lymph nodes may be involved.

"Ten or 15 years ago, around 40 percent of these patients were receiving chemotherapy here in Heidelberg," reports Mediziner Heil. Today there are only 30. Similar figures are likely to apply to the whole country.

Several of these gene expression tests are already on the market. The Institute for Quality and Efficiency in Health Care has now confirmed the additional benefit of a test for certain cancer cases. Current treatment guidelines only recommend it if the results of conventional examinations do not allow a clear choice of therapy.

A decision by the Federal Joint Committee (G-BA) was still pending at the time of going to press. The G-BA decides whether the statutory health insurances have to cover the costs for the test. So far, some have been doing this voluntarily.

A few more years

Doctors are also more gentle when it comes to chemotherapy with breast tumors that have already metastasized in the body and are stimulated to grow by female sex hormones. New drugs, so-called CDK 4/6 inhibitors, can increase the effects of anti-hormone treatment. The tumors grow more slowly. "In this way we can postpone chemotherapy by three to four years," explains Harbeck. "A great success!"

According to the expert, the approach is particularly advantageous because metastatic breast cancer is a chronic disease. She must be treated for several years. It is all the more important that this is done particularly gently for the patient.

But one thing is also certain: Without therapy, metastatic cancer would lead to death. Acute and later side effects are therefore much more likely to be accepted than with more easily curable forms of cancer, emphasizes Harbeck.

Better education, more trust

Overall, the chemotherapy drugs themselves have not become any gentler, says Jörg Heil. Rather even stronger and therefore more side effects. "At the same time, however, the medication and accompanying therapies have also improved, reducing the side effects." Targeted agents such as immunotherapeutics given in addition to chemotherapy can also improve their effects.

Although it is still one of the most feared medical treatments, patients are sometimes skeptical if they are not receiving chemotherapy. "For example, a young woman with liver metastases who is only supposed to swallow pills. She thinks: fewer side effects? That can't help," is Harbeck's experience. It is up to the doctors to explain more about the possibilities beyond chemo - and perhaps to believe in them themselves even more.

Less side effects with radiation

The operation or chemotherapy is followed by local radiation. According to the gynecologist Heil, this treatment is particularly recommended after breast-conserving surgery. It is now also reduced and individualized.

While the meetings used to take place regularly over six to seven weeks, today it can only be four weeks. "In selected cases, irradiation may only be carried out during the surgical procedure," reports Heil.

Because the times are shorter and the devices work more precisely, effects such as skin changes and pain are very limited, according to expert Grischke. Heil warns, however, not to underestimate long-term consequences: "Redness disappears quickly. But years later, up to ten percent of patients suffer from painful induration and swellings."

In some precancerous stages, experts now consider radiation to be superfluous. For patients over 50 years of age, the so-called boost can be omitted in certain cases. Doctors only irradiate the tumor with a specific additional dose after the entire breast.

Here you can get more information:

  • Cancer information service www.krebsinformationsdienst.de
  • German Cancer Society www.krebsgesellschaft.de
  • Breast Cancer Germany www.brustkrebsdeutschland.de
  • Mamazone www.mamazone.de
  • Certified cancer centers www.oncomap.de
Breast cancer