Three different therapies are essentially available in the fight to treat breast cancer:
- radiotherapy and
- treatment with medication (chemotherapy and/or hormone therapy).
Lymph nodes are endogenous filters which capture harmful substances from the lymphatic pathways, including toxins, pathogens, cell fragments, and possibly even cancer cells.
Sentinel lymph nodes, also known simply as "sentinel nodes", refer to any lymph node to which the lymph first flows from a tumour area. Only then does this reach other lymph nodes in the area of the armpit. This lymph node, so to speak, watches over the other lymph nodes. It is also highly likely to be the first lymph nodes to find tumour cells.
In the sentinel lymph nodes procedure, the first node in the lymphatic pathway is identified, surgically removed and examined for cancer cells. The sentinel lymph node is tracked by marking it with a dye or a low-level radioactive protein.
If the pathologist finds no cancer cells in the sentinel lymph node preparation, it will not be necessary to remove further lymph nodes.
Only when the sentinel lymph node contains cancer cells are the remaining, up to 15 lymph nodes in the armpit area removed as a precautionary measure.
Breast conservation surgery
During this operation, the tumour and lymph nodes in the armpit are removed. This often requires a second incision in the armpit area. A tumour-bearing quarter of the breast (quadrantectomy), the affected segment (segmental resection) or only the tumour itself (lumpectomy) are then removed. The success of this procedure may avoid the need to remove the entire breast, but certain important conditions must be borne in mind, which your physician will be happy to discuss with you on a case-by-case basis.
Radical breast surgery
When the entire breast must be removed, this is called a "radical breast surgery". The varying characteristics of a tumour or its size may mean that the breast cannot always be saved during an operation.
The surgeon normally removes the entire mammary gland together with fat and connective tissue. In the same way, the nipple, parts of the breast skin and lymph nodes in the armpit are removed (a so-called modified mastectomy). The skin must be removed at the point where the tumour lies directly underneath the skin.
The pectoral muscle itself must only be removed if this is affected by the tumour.
The reconstruction of the soft breast is intended to restore the shape and aesthetic of the breast. In recent years, breast reconstruction following the removal of a breast has become increasingly popular. Different procedures are available for reconstructing the soft breast, and these must be individually adapted to each patient.
Where a complete or partial amputation of the breast is unavoidable (a so-called mastectomy), the question arises of whether a reconstruction is desirable, and when this should be performed.
It is possible for us to reconstruct the breast in the same operation during which it is removed. This is called primary or immediate reconstruction. This avoids the feeling of "waking up without a breast". Experience has shown that removing the breast and reconstructing it in the same operation has no negative impact on the cancer or further chemotherapy.
So-called secondary or subsequent reconstruction is another possibility. If the breast has already been removed for a period of time, or if primary reconstruction is not wanted, the breast can be reconstructed at a later time. Here too, it is possible to choose from a range of techniques and procedures.
German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC for short) has certified the practice of Prof. Heitmann as a reconstructive breast centre.
Selecting a procedure
On the basis of careful preliminary investigation and individual consultancy, we offer the following procedures:
- Reconstruction using foreign body tissue (expander/implant), possibly with so-called cellular matrices (ADM)
- Reconstruction of the breast using the body’s own tissue
a. Reconstruction using tissue from the back (latissimus muscle or TDAP flap plastic)
b. Reconstruction using tissue from the belly (DIEP flap plastic, formerly TRAM flap plastic, and SIEA flap plastic)
c. Reconstruction of the breast using tissue from the buttocks (S-GAP or I-GAP or FCI flap plastic)
d. Reconstruction of the breast using tissue from the thigh and gluteal fold (TMG flap plastic)
External breast prostheses
Should you not wish to undergo or have doubts about breast reconstruction, suitable external breast prostheses are also available. These usually consist of a cushion on the operated side, which is sewn into a bra or swimsuit. Because of its perfect fit, it is not possible to see the difference from the outside. The cost of a breast prosthetic is covered by statutory health insurance.
After the operation
To prevent re-bleeding in the wound or the accumulation of tissue fluid, suction tubes are placed under the breast skin during the operation.
These threads are removed 8-10 days after the operation. The wound itself usually heals within 3-4 weeks.
Chemotherapy involves the administration of cytotoxic drugs (which are poisonous to cells). These are particularly effective on the rapidly multiplying cancer cells and kill these off.
According to current recommendations, chemotherapy is recommended for patients with affected armpit lymph nodes as well as for patients who carry an increased risk.
The criteria for increased risk are:
- Nodes exceeding 1 cm in size
- One or more affected lymph nodes
- A rapidly growing tumour
- The cancer cells have no receptors for hormones
- The patient is younger than 35 years of age
How does chemotherapy work?
Cytotoxic drugs are primarily effective on cells which divide rapidly and constantly, such as cancer cells
Cells in the cell subdivision phase are particularly susceptible. The drugs intervene in this cell division process, by deliberately preventing their multiplication.
Chemotherapy is administered based on a schedule with fixed intervals, in order to combat the cancer cells during their division phases. Multiple treatments also allow attacks on cancer cells which were in a rest phase and did not divide during a previous treatment. The drugs are administered individually or in combination, usually as an infusion or injection, but sometimes also in tablet format. A single portion of the treatment is called a “cycle”. A treatment normally comprises six cycles, with a pause of between one to three weeks between each cycle.
Potential side-effects of chemotherapy
Cytotoxic drugs act on cells which divide rapidly. These include not only cancer cells, but also cells in the blood, the digestive tract, the ovaries and the hair roots. Side-effects of cytotoxic drugs can include hair loss, nausea, fever, vomiting, diarrhoea and irritation of the skin and mucous membranes. These side-effects can be avoided and resolve on their own following the end of treatment.
What is the radiation used for?
Radiotherapy is an integral part of the treatment of breast tumours. It is used to any individual tumour cells which may still be present at the site of the original tumour after surgery.
It is used in different situations in the treatment of breast cancer:
- Following breast conservation surgery
- Often following the complete removal of the breast (mastectomy)
- In the event of the infection of the lymph nodes
- In metastases in order to remove individual foci, to relieve pain, and prevent complications
How does radiotherapy work?
The rays used in radiotherapy are almost always wave rays (photons). The radiation which passes through the irradiated tissue is only generated in the radiation unit for the short exposure period.
This damages the tumour cells. These are unable to recover from the radiation damage and die off. Healthy cells recover very rapidly.
The patient retains none of the radiation in their body, and never themselves emit radiation.
The radiotherapy process
Radiotherapy is initiated after surgery, once the internal and external scars have healed sufficiently, normally after 4-6 weeks. Where chemotherapy is used, radiotherapy only begins once the former has been completed.
Before the start of radiotherapy, the area to be irradiated is measured using a special planning computer tomography and entered into the radiation planning system.
Physicians, together with their medicine physicists, use this radiation planning system to draw up an individual radiation plan for each patient. This is how the physicians determine the daily dose and the overall dose for the treatment series. This then determines the number of sessions (fractions).
A radiation session normally lasts between 3 to 7 weeks from Monday to Friday, i.e. a total of 15-35 times. The irradiation itself only lasts a few minutes, and the entire session, with its preparations (storage and field controls) last anywhere between 10-20 minutes.
Tolerability of radiotherapy
Most patients tolerate radiotherapy and the localised side-effects well.
Towards the end of the series of the radiations, there is almost always slight, sometimes marked reddening of the skin in the irradiated area, and sometimes a slight swelling of the breast. Patients may also feel fatigued. Other side-effects such as mild nausea are very rare.
Your radiotherapist will give you instructions on how to control these symptoms.
The symptoms normally subside around 3 weeks after the completion of the radiotherapy.
Serious consequences for the lungs and heart, nerves or lymphatic pathways occur extremely rarely with the latest radiation equipment, and these no longer pose a serious threat.
How does hormone therapy work?
Hormone therapy blocks the growth of cancer triggered by female hormones. However, the therapy is only effective if the relevant tumour cells react to the hormone. This requires specific docking points, called hormone receptors, to be present on the tumour cells.
These docking points can be found in tumour preparations in approximately 40% of premenopausal women and 60% of postmenopausal women.
Whether the so-called anti-hormone treatment is administered to the female patient is strongly dependent on whether she is in the menopause or not. It has however been shown that therapy efficacy increases significantly, particularly when a new disease is involved.
Potential side-effects of hormone therapy
Hormone therapy has relatively few side-effects when compared to chemotherapy. The side-effects are mainly related to the triggered hormone deficiency and may manifest as hot flashes or dryness of the mucous membrane.