Treatment

The tumor in the breast
Usually, when a patient is diagnosed with breast cancer, surgery is at the top of the list of treatment options. The goal here is the complete removal of the tumor. For decades, complete removal of the breast (mastectomy) was the usual procedure. However, this has changed fundamentally in the past 25 years. Today, the breast only needs to be completely removed in a minority of cases; in about two-thirds of cases, breast-conserving surgery can be performed. It is clear that breast-conserving surgery, especially when performed with modern oncoplastic techniques, yields much more appealing cosmetic results than mastectomy. We also know today that the concept of breast-conserving therapy (which then involves radiation after surgery) does not impose any restrictions on the patient in terms of oncological safety.
However, in some cases, mastectomy must still be recommended today. Among other things, the tumor size and localization, breast size and, of course, the patient’s personal preferences are taken into account.
If the patient undergoing a mastectomy desires breast reconstruction (either primary, meaning directly with the mastectomy, or secondary, meaning at a later date), the plastic reconstructive surgeons at the Breast Center can provide all internationally established options for reconstruction. These range from silicone prostheses to breast reconstruction with autologous tissue.

Lymph nodes in the axilla
A clear tendency towards less radicality and aggressiveness in breast surgery has prevailed over the past two decades, this is even more true for surgery of the lymph nodes in the axilla. 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 removed completely in each case of breast cancer, today this is necessary in only about 20–25 percent of cases. With the aid of new techniques, individual representative lymph nodes, the so-called sentinel lymph nodes, can now be located intraoperatively and specifically removed. The significantly lower number of removed lymph nodes with the sentinel technique, usually only 1–2 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 as well as limited sensitivity and mobility of the arm are practically no longer observed under this technique.

The tailor-made therapy concept: Surgery before or after systemic therapy?
We place chemotherapy at the beginning of therapy in selected cases with aggressive forms of breast cancer that require it anyway. In this so-called neoadjuvant approach, surgery then follows systemic pretreatment. In most cases, chemotherapy succeeds in reducing the tumor extent in the breast and axilla so that less extensive surgery can be performed. This usually means more favorable cosmetic results and fewer functional limitations for the patient.
The coordinated integration of the main forms of therapy for breast cancer (surgery, chemotherapy, radiotherapy) to create a customized therapy concept for each patient requires close cooperation between the various disciplines. Every case of a patient with breast cancer is therefore discussed in an interdisciplinary tumor board at our Breast Center. Surgeons, radiologists, pathologists, medical oncologists and radiation oncologists then formulate the treatment recommendation that offers the best chance of cure based on current medical knowledge.

Operations for benign foci in the breast.
In earlier times, benign changes or lesions of unclear nature concerning malignancy were also operated on using an open approach. This usually involves general anesthesia, hospitalization, and a scar several inches long on and inside the breast. With the diagnostic possibilities available today, especially using targeted biopsies, lesions of unclear nature can usually be reliably diagnosed. Benign tumors, such as fibroadenomas, can be removed up to a certain size with little effort using a vacuum biopsy: Little effort in this case is synonymous with an outpatient procedure under local anesthesia and a few millimeters of scar on the skin. Major surgery for benign or unclear focal findings can usually be avoided.

Breast Reconstruction

Chemotherapy
“Chemotherapy” is usually the term used to describe the drug therapy for the treatment of malignant tumors, while the administered drugs are called cytostatics (Greek:kytos=cell, statikos = bring to a standstill). Chemotherapy can be provided via blood vessels or also in tablet form. In some patients with early or advanced breast cancer, the cancer cells are inhibited in their growth or destroyed by the administration of these cytostatic drugs. Cytostatics damage the cell nucleus and other components of tumor cells, thus inhibiting their uncontrolled proliferation. Chemotherapy may involve a single cytostatic drug or a combination of different cytostatics. The therapy impacts the whole body, so healthy cells (such as hair follicles, intestinal mucosa) can also be affected. Thanks to careful planning and implementation of chemotherapy, relevant side effects can usually be well controlled. In addition, healthy cells recover quickly after the end of therapy.

Personalized targeted therapies
The collective term “targeted therapies” covers a whole range of different modes of action that are directed against specific molecular or genetic properties of cancer cells. This type of therapy includes monoclonal antibodies, kinase inhibitors (enzyme/protein inhibitors), angiogenesis inhibitors, and conjugates. They thus differ fundamentally from the mode of action of chemotherapy, since they do not destroy the tumor cells but, for example, block existing receptors or functional proteins, thus “starving” the tumor. However, the patient can only benefit from this treatment if the tumor cell has these specific characteristics. Although the drugs primarily attack only cancer cells and not healthy cells, side effects are still possible. The drugs may be given in combination with chemotherapy or separately. They can be administered as infusions via blood vessels, injected under the skin, or taken as tablets.

Anti-hormone therapy
About 80 percent of all malignant breast tumors have receptors that respond to the female hormones estrogen and progesterone. This means that the growth of cancer cells is enhanced by these hormones. Endocrine therapy takes advantage of this hormone dependence by either blocking hormone receptors or lowering hormone production. This way, not only can the development of distant metastases be prevented, but the healthy breast can also be prophylactically protected from tumor formation.
Endocrine therapy is usually given as a tablet taken once a day. In younger pre-menopausal women, additional suppression of the ovaries is often achieved with an injection applied at 1- or 3-month intervals. Since endocrine therapy also involves side effects, one goal of our follow-up visits is to alleviate these with appropriate measures.

Despite complete removal of a malignant breast tumor, follow-up radiation is often also recommended. The reason for this is that microscopic tumor cells may still be present, which remain hidden from the surgeon’s view and can lead to disease recurrence – locally or in the rest of the body. Certain precancerous breast lesions (for example, ductal carcinoma in situ – DCIS) can lead to recurrence in the breast, which is why radiotherapy is also often performed for DCIS. Even after removal of the breast, follow-up radiotherapy is still sometimes recommended, depending on the risk constellation.

Nowadays, radiotherapy is performed almost exclusively with a linear accelerator. Ionizing rays are emitted (photons or electrons) that interact with the tissue being irradiated, which can lead to the death of cells. One advantage of the linear accelerator is that the dose rate is high, and the irradiation times are correspondingly short. The so-called INRABEAM® is available for possible intraoperative irradiation.

With careful planning and implementation, relevant side effects can usually be kept low. A distinction should be made between acute side effects (e.g., redness of the skin, superficial skin lesions, breast swelling, fatigue) during therapy, which usually resolve completely, and late side effects, which appear weeks or months after the end of treatment and may be permanent (e.g., skin changes, breast induration). Side effects involving the 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 provide deep inspiration breath hold irradiation, i.e., irradiation takes place only when the patient breathes in. If the lymph node regions also have to be irradiated, the risk of a swollen arm (arm lymphedema) increases slightly.

The diagnosis of breast cancer can trigger massive crises in affected women. Phases of fear, rejection, resignation and doubt can alternate. Some of those affected need a special level of qualified care during this time – and an open ear for their questions and concerns. The Breast Care Nurses, like the entire team of the Breast Center, stand as partners by the patients and their relatives in all phases of the disease.

At the Zurich Breast Center, we employ qualified nurses with additional training as breast care nurses, who specialize in providing guidance, information and advice to women with breast diseases. As part of our interdisciplinary team, they care for our breast cancer patients with a focus on the following:

• individual consultation after various breast surgeries – inpatient in the clinic or outpatient in the breast center
• continuous care and counseling in all phases of the diagnostic and therapeutic treatment process, taking into account physical, psychological and social factors
• coordination of internal and external treatments for the best possible treatment success
• care not only around the disease and the healing process, but also around issues such as anxiety, body image changes, beauty, sexuality, family, social problems, and much more
• referral and scheduling to expert collaborative partners for any further care or treatment.

The professional nursing care provided by certified nurses in oncology has the mission to treat, counsel and care for persons with cancer and their families in all phases of the disease in an autonomous and targeted manner. Approximately 85 percent of all tumor therapies are performed on an outpatient basis.

At the Zurich Breast Center, the nurses work very closely with the medical oncologists and the breast care nurses. All nurses have advanced oncology training and many years of oncology experience. This allows them to address the needs of patients and their families holistically and help reduce symptoms of the disease and/or adverse effects of various tumor therapies.

What does this mean for you?

• Targeted information during the nursing consultation before therapy with regard to the prevention and treatment of side effects during oncological therapy, such as fatigue, inflammation of the oral mucosa, nausea and vomiting, skin changes, altered appearance, and much more.
• Safe and careful execution of complex drug therapies according to international standards.
• Possibility to minimize hair loss under chemotherapy with the DigniCap® scalp cooling system. Three DigniCap® units with a total of six cooling stations are available for our patients.
• Instruction regarding the nursing tasks that our patients perform themselves during therapy, for example, administering injections themselves or applying wound dressings.
• Support and guidance for our patients and their relatives in dealing with a wide variety of stresses and strains during therapy and arranging the appropriate contacts, such as nutritional counseling or psycho-oncological care.
• Offer of palliative (alleviative) care. The focus is on quality of life.

A cancer illness can massively destabilize the life of the person affected as well as that of those around them, especially their partner. Often, this upheaval also manifests itself in sexuality, usually due to the physical changes and side effects brought on by the required, stressful therapies.

In breast cancer, the main symptoms are a decrease in sexual interest and pain during sexual intercourse. Acceptance of the new body image often causes difficulties, and shame prevents the desired and needed closeness to the partner.

The need for attention, tenderness and sexuality remains important for many women of all ages, even with and despite breast cancer.

Although sexuality and intimacy are an important part of almost everyone’s life, regardless of age, talking about it is often not easy. For example, problems in sexual life resulting from breast cancer are rarely discussed in the partnership and hardly ever with the treatment team.

Hardly anyone talks about it or asks about it, but it preoccupies many …
Clarifying information in a calm atmosphere with special emphasis on treatment options can bring lasting improvement. Any fears and shame can be reduced. It is also helpful to include the partner in this adjustment process, so that misunderstandings can be avoided and a shared approach to jointly cope with the disease and its consequences can become possible again.