The first suspicion might come in the shower: What is that knob, that hard spot I feel in my breast? Is it breast cancer? Or the mammographic screening shows up changes in the breast tissue. Women between 50 and 69 years of age can attend such an early-detection X-ray examination every two years. A monthly palpation at home is also recommended by gynaecologists.

One in eight women

Not for nothing: Breast cancer is one of the most common cancerous diseases for women. About one in eight of all women will suffer the disease at some stage of her life, according to the Cancer Information Service. But the medical profession has the disease under better control – and can offer a curative treatment in most cases. One factor is the quality of the diagnoses – they have become far more exact and sophisticated in recent years.

There are a number of different breast cancer types. Today, we can quite easily identify the type – and if, for example, hormones are behind the growth of a tumour. That makes the therapeutic options more pinpoint. ‘We can say quite early if a tumour is malignant thanks to a mammographic screening and ultrasound examination of the breast’, Dr Kathrin Stewen explains. She is a gynaecologist and senior physician at the breast unit of the University Medical Centre Mainz.

‘To develop the right strategy for therapy, however, we have to characterise the cancer exactly and get to know its specific properties.’ To do that, doctors need a tissue sample. It is taken in a small procedure under local anaesthesia called biopsy. With a cannula just 1.5 millimetres wide, the samples are taken directly from the tumour or the modified tissue. A biopsy takes just a few minutes and is monitored with an ultrasound scan. ‘The trephine biopsy is essential for the exact diagnosis and is done with all breast cancer patients’, says Stewen. The tumour tissue is then analysed thoroughly under the microscope. The therapy is so targeted nowadays because the doctors know exactly how to differentiate between various malignant tumour types.

In most cases, the tumours grow because of hormones, namely the female sexual hormones oestrogen and progesterone. These hormones do not only regulate the growth of breast tissue, but also of cancer cells. To do so, the cancer cells need receptors. If the doctors identify these hormone receptors in the tissue, the tumour is qualified as ‘sensitive to hormones’: For about two thirds of the patients, that is the case. They get treated with antihormone or hormone depravation therapy. The active agents either block the receptors or inhibit hormone production. The receptors are closed down.

Closely adjusted treatment

Some types of cancer cells, however, have receptors on their surface, called ‘human epidermal growth factor receptor 2’, or ‘HER2’. If the doctors identify receptors for such growth factors, they can be targeted with an antibody therapy to fight the cancer cells. ‘In addition, we can determine how rapidly the cancer cells grow, and thus tell the patient quite specifically the direction the therapy will take’, Professor Nadia Harbeck says. She is in charge of the breast centre at Munich University Hospital (LMU Klinikum).

Kathrin Stewen adds: ‘Breast cancer therapy has improved significantly in the last 20 to 30 years, especially in terms of prognosis and survival, because nowadays we can identify the type of tumour so specifically.’ There is now even hope for new therapies against a type of tumour that has caused the experts quite a headache for a long time: In ten to 15 per cent of the cases, the cancer cells feature none of the three receptors – neither oestrogen, nor progesterone, nor growth factor receptors. These ‘triple-negative’ types of cancer cells mostly affect women with genetic breast cancer. They carry a genetic anomaly most likely causing breast cancer. The patients often get afflicted relatively young: under 50 years of age. Quite often, there are a number of breast cancer cases in the family. ‘Lately, we combine chemotherapy with immunotherapy and go for surgery afterwards’, Harbeck explains.

Nowadays, a drug therapy is often the first step, the expert adds. And not surgery. ‘That way, we can find out how the tumour reacts to treatment. That, too, is an important building block in the decision-making process on how to progress with the therapy.’ Whether, for instance, a hormone-dependent tumour still needs to be fought with chemotherapy. Or if an antihormone treatment should be sufficient. Harbeck emphasises: Breast cancer is no disease of the breast, but of the whole body: ‘We need to prevent the cancer cells from dispersing, we need to prevent metastases – and we can only do that with medication.’ In the following section, we will outline the drugs available and the effect they have.

Attacking the Tumour Where It Works

Target-oriented therapies against breast cancer increase the chances of recovery and lengthen the survival time. This is how they work.

Hardly any other medical field has made as much progress in recent years as the field of cancer therapy. Especially in the fight against breast cancer, a lot has changed. ‘The chances of recovery have doubled for a daughter afflicted by breast cancer in comparison to her mother’, says Professor Nadia Harbeck, who is in charge of the breast centre at Munich University Hospital’s gynaecological clinic. In the past, the path to potential recovery was clear-cut: a combination of surgery, radio- and chemotherapy for almost any woman with a malignant tumour in her breast.

‘But that was quite often not matched to the specific patient and contributed to an “overtherapy”’, Harbeck recalls. Too much therapy, sometimes more detrimental than helpful to body and soul. But plenty of research has advanced cancer therapy again and again. ‘Today, we can treat all patients far more individually’, says Harbeck. If the cancer is discovered early on and has not yet dispersed, the chances of recovery are close to 90 per cent, according to data published in 2018 by the cancer registry of the Robert Koch Institute.

For some years now, target-oriented therapies are used in cancer treatment: drugs targeting a specific type of tumour. These can increase the chances of recovery and lengthen the survival time significantly – sometimes in connection with other types of therapy. ‘For that, we need to know the weak spots of every tumour. And they vary depending on the type of breast cancer’, Harbeck explains.

More and more research

Once the biological properties of the respective tumour are known, the physician responsible enlightens the patient about treatment options and then sets out a therapy plan together with the patient. This plan is based on the latest scientific knowledge and the up-to-date guidelines on treating breast cancer. There is also the option to partake in research studies testing active agents not yet approved. In case you are interested, contact a certified breast centre. Harbeck opines: ‘In doing so, the patient can only win, actually. Nowhere else is she as securely under care as in a study. You always get an effective drug. If it is better than the standard, we don’t yet know.’

The following therapy options show how varied the focus of cancer therapies is today. The growth receptor HER2 enables a cancer cell to grow. If the receptor is inhibited, the growth signals will cease and the cancer cell die. Some cancer cells hide from the immune system. Special drugs can obliterate the disguise. These drugs are effective – in combination with chemotherapy against triple-negative breast cancer. A target-oriented chemotherapy against trop2 receptors was newly approved in 2022. It is an option especially for patients with metastases.

In case of hormone-dependant breast cancer, female sex hormones support the growth of the tumour. An antihormone therapy inhibits either the production of oestrogens or their effect on the cells. Although this therapy has been approved for decades, it is still important today: ‘It works in a target-oriented way for all patients with hormone-dependant breast cancer and causes less side-effects’, says Professor Pia Wülfing, who was in charge of the oncology unit at the Mamma Centre Hamburg until 2020.

Help for open questions

Even if the progress in cancer treatment is very encouraging and the side-effects get rarer and better treatable: They do worry many patients. Understandably. Do I have to life with diarrhoea now? Is the sudden pain in my knee a sign of metastases? Wülfing often heard such worries when talking to her patients. Many women were asking for an internet site with easily understandable information on diagnosis, therapies, but also organisational matters.

For example: How do I apply for a disabled person’s pass. How do I go about domestic aid or childcare? ‘These are questions women are concerned with, and we often don’t have the time for them in our consultation’, Wülfing explains. In response, the website and app ‘PINK! Active Against Breast Cancer’ was created in 2020. By now, it has been approved as a Digital Health Application (DiGA) and is financed by the German health insurers.

However, the app cannot tell you if a certain therapy is the right one for you. Sometimes, it is indeed still the tried-and-tested chemotherapy. Sometimes a new, target-oriented therapy is the right choice. Surgery is done – if at all necessary – at a later stage nowadays, and not at the beginning of the therapy anymore. ‘In the past, the motto was: Let’s remove the tumour first, and then we’ll see. Today, we know that that can be detrimental to the patient’s chances of recovery’, says Nadia Harbeck.

Even with patients in whom the cancer has already dispersed benefit from the rapid progresses in breast cancer therapy. ‘Quite often, we can treat a metastasising variant like a chronic disease, with a permanent therapy. Patients should most definitely not lose hope in such cases’, Harbeck emphasises. And while a ‘HER2-positive tumour’ was a bad sign only a few years back, it can be treated successfully today. Nadia Harbeck is sure: ‘In ten years, we will cure more patients and treat them even more individually.’

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