The tumour in the breast.
In most cases, surgery is the first possible therapy for the diagnosis of “breast cancer”. The objective is the complete removal of the tumour. For many decades, the complete removal of the breast (mastectomy) was the typical operation. However, this has changed fundamentally in the last 25 years. Today, the breast only has to be removed completely in a few cases; in about two thirds of the cases, breast-preserving surgery is possible. It is clear that a breast-preserving operation, especially when performed with modern oncoplastic techniques, produces significantly more attractive cosmetic results than a mastectomy. Today, we also know that the concept of breast-preserving therapy (which includes radiotherapy after the surgery) does not impose any restriction on the patient’s oncological safety.
However, in some cases, a mastectomy still needs to be recommended even nowadays. Among other factors, the size and location of the tumour, the size of the breast and of course the personal preferences of the patient are taken into account.
If the patient who has to undergo a mastectomy wants a reconstruction of the breast (either primary, i.e. directly with the mastectomy, or secondary, i.e. at a later date), the plastic-reconstructive-surgical surgeons at the Breast Centre can offer all internationally established reconstructive methods. These range from silicone prostheses to the reconstruction of the breast with autologous tissue.
Axillary lymph nodes
There has been a clear tendency towards less radical and aggressive breast surgeries in the last two decades and it even applies almost even more to surgery on axillary lymph nodes (lymph nodes in the armpit). These lymph nodes are important because in the dreaded spread of breast cancer the cells first metastasize there. For further therapy it is important to know whether axillary lymph nodes have metastases. Whereas in earlier years the lymphatic fatty tissue was completely removed in all cases of breast cancer, this is now only necessary in about 20 to 25 percent of cases. With the help of new techniques, individual representative lymph nodes, the so-called sentinel lymph nodes, can now be found intraoperatively and specifically removed. The significantly lower number of removed lymph nodes with the sentinel technique, usually only 1 to 2 lymph nodes are removed, leads to significantly fewer sequelae than the “classic” operation with about 10-20 removed lymph nodes; in particular, the previously feared lymphedema and limited sensitivity and mobility of the arm are practically no longer observed.
The customised treatment concept: Surgery before or after systemic therapy?
In selected cases with aggressive forms of breast cancer that will require chemotherapy in any case, the systemic therapy is started at the beginning of the treatment. In this so-called neoadjuvant concept, the surgery then follows the systemic pre-treatment. In most cases, chemotherapy succeeds in reducing the tumour spread in the breast and axilla so that a less extensive surgery can be done. For the patient, this usually means more favourable cosmetic results and fewer functional restrictions.
The coordinated interaction of the main forms of therapy for breast cancer (surgery, chemotherapy, radiation) into a therapy concept tailored to the individual patient requires close cooperation between the various medical disciplines. This is why at our Breast Centre, each case of a patient with breast cancer is discussed by an interdisciplinary tumour board. Surgeons, radiologists, pathologists, medical oncologists and radio-oncologists then formulate the therapy recommendation which, according to the current state of medical knowledge, offers the highest chance of recovery.
Surgery for benign lesions in the breast
In earlier times, benign changes or lesions of unclear malignant potential were dealt with through open surgery. Open surgery usually involves general anaesthesia, hospitalisation and a scar on and in the breast, several centimetres long. These days, with the diagnostic methods that are now available – especially targeted biopsies –lesions of unclear dignity can usually be reliably clarified. Benign tumours, such as fibroadenomas, can be removed up to a certain size with little effort using a vacuum-assisted biopsy. In this case, little effort is equivalent to an outpatient procedure under local anaesthesia and a few millimetres of scar on the skin. Larger surgeries for benign or unclear focal findings can thus usually be avoided.
Despite complete removal of a malignant breast tumour, follow-up radiation is often recommended. The reason for this is that microscopically small tumour cells may still be present, which remain hidden from the surgeon’s view and can lead to a disease relapse – either locally or somewhere else in the body. Certain preliminary stages of breast cancer (e.g. ductal carcinoma in situ – DCIS) can lead to a relapse in the breast, which is why radiotherapy is also frequently performed for DCIS. Even after removal of the breast, follow-up radiation is recommended, depending on the risk constellation.
Nowadays, radiotherapy is almost exclusively performed with a linear accelerator. Ionising rays (photons or electrons) are emitted, which interacts with the irradiated tissues, which can lead the death of cells. An advantage of the linear accelerator is that the dose rate is high and the irradiation times are correspondingly short. The so-called INTRABEAM® is available for possible intraoperative irradiation.
With careful planning and implementation, relevant side effects can usually be kept to a minimum. Acute side effects (e.g. reddening of the skin, surface skin lesions, swelling of the breast or fatigue) that occur during treatment and usually disappear completely, and late side effects that appear weeks or months after treatment has ended and may be permanent (e.g. skin changes or hardening of the breast). Side effects on ribs, lungs and heart are rare. In order to protect the lungs and especially the heart as much as possible, new technologies can be used to perform respiration-dependent radiation, i.e. radiation is only given, for example, when the patient breathes in. If the lymph node regions also need to be irradiated, there is a slightly increased risk of developing a swollen arm (arm lymphedema).
Chemotherapy is a widespread medication-based treatment for cancer. In some patients with early-stage or advanced breast cancer, medications called cytostatics are used to inhibit the growth of the cancer cells or destroy them. Cytostatics damage the nucleus and other components of tumour cells and thus inhibit their uncontrolled proliferation. Chemotherapy may involve the use of a sinlge cytostatic or a combination of different cytostatics. Chemotherapy affects the entire body (systemically), which means that healthy cells (such as hair follicles or the intestinal mucosa) may also be affected. With careful planning and execution of the Chemotherapy, relevant side effects can usually well controlled. Furthermore, the vast majority of healthy cells will recover quickly after treatment ends. Chemotherapy can be administered by infusion into the blood vessels or in tablet form.
Immunotherapy (antibody therapy)
Immunotherapy (antibody therapy)
Antibody therapy works mainly through the power of the body’s own immune system. It is therefore fundamentally different from chemotherapy in terms of how it works. The principle of antibody therapy is based on the targeted detection of specific cancer cells. With this treatment, monoclonal antibodies interrupt the signalling pathways of the tumour cells and can eliminate them with the help of the immune system. Antibody therapy – in the case of breast cancer often involves the anti-HER2 medications trastuzumab and pertuzumab, is administered as an infusion to the blood vessels. Trastuzumab can now also be administered via subcutaneous injection.
Antihormonal (endocrine) therapy
Antihormonal (endocrine) therapy
About 80 per cent of all malignant breast tumours have receptors relating to the female hormones (oestrogen and progesterone), which means that the growth of cancer cells is controlled and enhanced by these hormones. Endocrine therapy exploits the hormone-dependent nature of these cancer cells by either blocking the hormone receptors (tamoxifen) or the production of the hormones that stimulate the cancer cells (using aromatase inhibitors). In this way, not only can the development of distant metastases be prevented, but the contralateral breast (non-cancerous) can also be prophylactically protected from tumour formation.
Endocrine therapy is usually done in the form of a tablet that is taken once a day. In younger pre-menopausal, an additional blocking of the ovaries is often performed with an injection at three-month intervals. As endocrine therapy also involves side effects such as hot flushes, bone, muscle and joint pain, one of the aims of our follow-up examinations is to alleviate concomitant symptoms of endocrine therapy with suitable measures and thus guide our patients throughout the treatment over several years.
Clinical Study Department
Clinical Study Department of Breast Centre Zurich
The care of patients within the framework of clinical studies is an important aspect of quality at the breast centre.
Over the past decades, there has been significant progress in the early detection, diagnosis and treatment of breast cancer. Most of the new insights come from studies that compare the best established therapies at the time with new ones that may be even better. The focus is always on women with breast cancer.
Cultural conditions and personal circumstances are always respected. A holistic treatment is always completely comprehensive, even in the event that participation in a study is disconnected.
The results of such studies usually only available after several years, so that the benefit for breast cancer patients is not immediately apparent. The patient’s personal study data is always encrypted for data protection.
The physicians at Breast Centre Zurich are always glad to provide information on which studies are suitable for which patients.
Clinical studies help to:
- avoid unnecessary treatments;
- obtain more precise information about doses and effects;
- improve quality of life and measure the side effects of the treatment;
- to examine additional studies for their value;
- disseminate new knowledge across a global network of collaborating study groups;
- extend lives while maintaining the quality of life.
Between 2007 and 2018, about 600 patients were involved in clinical studies at the Breast Centre Zurich.