Breast Cancer

A. Introduction

According to the Swiss Cancer League, breast cancer is the most common type of cancer among women in Switzerland. In 2020, approximately 6,100 new cases of breast cancer were diagnosed, accounting for about 30% of all cancer diagnoses in women. About one in eight women in Switzerland will be diagnosed with breast cancer during their lifetime.

The average age at diagnosis of breast cancer in Switzerland is 62 years. Breast cancer also affects men, but very rarely. In Switzerland, about one in 100,000 men is diagnosed with breast cancer.

B. Early Detection, Screening

Breast cancer screening is recommended in Switzerland for women between the ages of 50 and 69. Women in this age group receive an invitation for a mammography examination every two years. A quality-assured, interdisciplinary breast cancer early detection/screening program can significantly reduce breast cancer mortality.

If risk factors are present, an individual early detection strategy must be discussed and recommended. Breast self-examination should be learned early and performed by the patient, as it can promote motivation and awareness for preventive measures.

C. Risk Factors for the Development of Breast Cancer

• Normal Weight: Obesity - Increase in new cases by 150%
• No Relatives of the 1st Degree Affected: Family history (mother diagnosed before the age of 60) - Increase in new cases by 100%
• Age at First Birth > 20 Years: Age at First Birth > 30 Years and Childlessness - Increase in new cases by 90%
• Non-Smoker: Smoking (> 20 cigarettes/day) - Increase in new cases by 83%
• Last Menstrual Period at 45 – 54 Years: Last Menstrual Period at > 55 Years - Increase in new cases by 50%
• First Menstrual Period at 14 Years: First Menstrual Period at 11 Years - Increase in new cases by 30%
• No Alcohol: Alcohol Consumption (> 20 g/day ~ 0.25 l wine) - Increase in new cases by 30%
• Total Duration of Breastfeeding > 5 Years: No Breastfeeding - Increase in new cases by 20%
• Physical Activity: Physical Inactivity - Increase in new cases by 20%
• Never Hormone Therapy:
  • Hormone Therapy 1-4 Years - Increase in new cases by 8%
  • Hormone Therapy 5-9 Years - Increase in new cases by 31%
  • Hormone Therapy 10-14 Years - Increase in new cases by 24%
  • Hormone Therapy > 15 Years - Increase in new cases by 56%

D. Diagnostics in Symptomatic Patients

Basic Diagnostics

The basic diagnostics of any suspicious breast change consist of:

• Palpation of the breast and lymphatic drainage areas
• Mammography
• Ultrasound diagnostics with high-frequency probes 7.5-13
• Histological clarification-Diagnosis assurance
• MRI supplementary to local staging

Imaging Diagnostic Procedures

Every patient should receive a mammography in 2 planes. The mammosonography with high-frequency probes can provide informative value and should therefore be performed additionally. Mammosonography has its place particularly in women under 35 years with connective tissue-rich breasts. Ultrasound offers better disease detection in younger patients compared to mammography.

Histology (Breast lesion)

Every suspicious mammal lesion should be clarified through tissue examination regarding its dignity.

The fine tissue examinations for clarification are carried out as follows:

• X-ray guided vacuum biopsies-Stereotaxy (mammographic changes)
• Ultrasound-guided vacuum biopsies (sonographic changes)
• Ultrasound-guided needle core biopsies (sonographic changes)

The diagnostic measures using imaging procedures (mammographies and breast ultrasound) with subsequent necessary histological clarification of the breast change through STEREOTAXY or VACUUM BIOPSIES is a focus of treatment at GYNAEKOLOGIE ZÜRICHSEE.

E. General Therapeutic Strategy

E.1. Surgical Therapy of Breast Carcinoma

Clinical studies have shown that considering certain clinical and histological parameters, breast-conserving therapy achieves identical survival rates as mastectomy. Patients for whom breast-conserving therapy is an option must be informed about this possibility.

Breast-Conserving Therapy

Breast-conserving therapy (BCT) with subsequent radiation treatment is at least equivalent in terms of survival to a modified radical mastectomy (MRM). Therefore, all patients should be informed about the possibility of breast-conserving therapy (BCT) and modified radical mastectomy (MRM) with and without immediate reconstruction. The patient's wish must be respected.

Mastectomy

Modified radical mastectomy (breast removal) is always performed when breast-conserving treatment is not possible according to the criteria mentioned above. The entire breast tissue, skin, and nipple-areola complex, as well as the pectoral fascia, are removed. The pectoral muscle is preserved.

Plastic Reconstructive Surgery

The reconstruction of the amputated female breast can only be offered to a patient after comprehensive information about all existing possibilities. The indication for breast reconstruction is made by the patient after individual consultation with her advising and treating doctors. Plastic reconstructive surgeries can be performed as part of the primary procedure or at an interval. They serve to cover defects and replace volume, as well as fulfill the patient's desire to restore her physical integrity.

Surgical Therapy of the Axilla

The sentinel lymph node finding is a procedure for examining the sentinel lymph node in breast cancer. This procedure examines the sentinel lymph node, which is the first lymph node to which lymph fluid flows from the breast. If this lymph node is free of cancer cells, it can be assumed that the other lymph nodes and the entire lymphatic system are also not affected. This helps doctors decide whether the removal of further lymph nodes is necessary. The method can reduce the need for axillary lymph node dissection and thus reduce the side effects associated with this procedure.

E.2. Adjuvant Radiotherapy of Breast Carcinoma

Radiotherapy after surgical tumor removal may be necessary because systemic therapy alone does not have sufficient influence on local or locoregional tumor control. Preventing isolated local or locoregional recurrence has a positive impact on survival rates and quality of life for patients. In invasive breast cancer, post-operative irradiation of the remaining breast is indicated as it can improve local control.

E.3. Systemic Adjuvant Therapy (Hormone and Chemotherapy)

After the surgical removal of a breast carcinoma, chemotherapy may be recommended as adjuvant therapy (in addition to surgery) depending on tumor characteristics and stage. The goal is to kill any potentially remaining cancer cells in the body and reduce the risk of recurrence or metastasis. The decision for chemotherapy depends on various factors such as tumor size, lymph node involvement, hormone receptor status, and HER2 status.

Chemotherapy is often conducted in multiple cycles, either before or after radiation therapy. Depending on the type of chemotherapy, side effects may include hair loss, nausea, vomiting, fatigue, risk of infection, and pain. There are also neoadjuvant chemotherapies performed before surgery to shrink or stabilize the tumor, potentially allowing for breast-conserving surgery that might not otherwise be possible.

F. Aftercare

Aftercare for Breast Carcinoma

Aftercare not only serves to monitor the course of the disease but also aims to promote the physical and psychological health of affected women and support their psychosocial rehabilitation. It should be tailored to the individual needs of women and aimed at alleviating post-operative and post-therapeutic symptoms.

Further goals of aftercare include:

• Early detection of local or intramammary recurrences
• Timely diagnosis and treatment of consequences and side effects of previous breast cancer treatment
• Targeted search for distant metastases in case of complaints or justified suspicion
• Diagnosis of treatment-associated changes/diseases

Follow-up and Early Detection Examinations

Years after primary therapy:

• 1, 2, 3 Years:

  • Anamnesis, physical examination, information/education: Quarterly
  • Laboratory examinations, imaging procedures (excluding mammography) only if clinically suspected recurrence and/or metastases

• 4, 5 Years:

  • Anamnesis, physical examination, information/education: Semi-annually

• 6 and further Years:

  • Anamnesis, physical examination, information/education: Annually

Follow-up Examinations for Breast Carcinoma – Mammography

• 1 – 3 Years: Breast-conserving operation:

  • Affected breast: Every 6 months
  • Contralateral breast: Annually

• From the 4th Year:

  • Breast-conserving operation:
    • Affected breast: Annually
    • Contralateral breast: Annually
  • Mastectomy – contralateral breast: Annually

Related Links:

• AGO Online
• NCCN Breast Guidelines
• NCCN Cervical Guidelines
• NCCN Ovarian Guidelines
• BC Cancer
• DGHO
• NLM
• Cochrane
• NCBI
• ZBMED
• Medscape
• Cancer Screening NHS
• Senology