Breast cancer

Breast cancer is usually not painful in the early stages. But some things may be signs of breast cancer – or a non-cancerous lump. It is important to see your doctor very soon if you notice any of the following changes:

• One breast changes size or shape
• You can feel a lump in a breast or armpit
• There is a sunken dip (dimple) on the nipple or elsewhere on the breast
• Red or scaly skin on a breast that doesn’t go away
• A clear or bloody fluid comes out of a nipple

it is very important to see a doctor about these symptoms soon.

Abnormalities may also be discovered through breast cancer screening (a physical examination, ultrasound or mammography). If this is the case, further examinations can be done to take a closer look at the area.

Breast cancer can develop when the genetic material in cells changes (“mutates”) and causes them to start multiplying in an uncontrolled way. Lumps and nodules then form after some time. Why those changes come about, and how the cells develop, depends on many factors that can influence each other. The main factors include the woman’s age, hormones, and whether there is a higher risk of breast cancer in her family. But sometimes genetic mutations happen for no particular reason.

Breast cancer is more common in some families. If your mother or sister (a first-degree relative) develops the disease, that doubles your risk of getting it. If, on the other hand, a more distant relative has breast cancer, that hardly affects your risk.

About 5 to 10% of all breast cancer cases are known to be caused by gene mutations (changes) due to “hereditary breast cancer.” The mutations mainly affect the genes known as BRCA1 and BRCA2. The abbreviation “BRCA” stands for “breast cancer gene.” About 45 to 65% of women with these mutations develop breast cancer before the age of 69.

Some women worry that they might be partly to blame for getting cancer because of their lifestyle. But lifestyle only plays a small role overall. You may also hear theories that certain character traits can increase a person’s risk of getting cancer. These theories have never been proven, though, and are now considered to be outdated. Nobody is to blame for a serious disease like cancer. Anyone can get cancer, regardless of their lifestyle or character traits.

In Germany and many other countries, breast cancer is the most common type of cancer in women. It is usually detected in older age: More than half of all women with breast cancer are over 60 years old when it is first diagnosed. Men can get breast cancer too, although this is very rare: About 1 out of 1,000 men will get it at some point in their lives.

The odds of successfully treating breast cancer depend on many factors. These factors include

• the size of the tumor,
• whether the tumor is confined to breast tissue and where exactly it is located in the breast,
• whether the tumor growth is affected by hormones,
• whether the cancer cells have growth factor receptors (HER2 receptors) on them,
• how much the cancer cells have changed,
• the number of cancerous growths,
• whether the cancer cells have spread through the lymph vessels in the skin (inflammatory breast cancer),
• whether all of the tumor tissue can be removed,
• whether it has already spread to distant parts of the body, and
• whether the woman has already had breast cancer in the past.

Sometimes breast cancer is first diagnosed after it has already reached an advanced stage. In this case the cancer is often no longer only found in the breast and surrounding tissue. It may already have led to the growth of other tumors (metastatic tumors), for instance in bones or lymph nodes. But even if this happens the disease can still be treated.

If a tumor can be completely removed and there are no distant metastases, full recovery is possible. This is also true for breast cancer that returns after going away, known as recurrent breast cancer.

Your doctor is the first person to go to if you think you might have breast cancer. After discussing previous and/or current medical conditions (your medical history) with the doctor, he or she will perform a physical exam. This may include the following:

• Feeling (palpating) the breast and armpits
• Breast x-ray (mammography)
• Ultrasound ( sonography)
• Magnetic resonance imaging (MRI)
• Biopsy (taking a tissue sample for lab analysis)

If a breast tumor is detected, your doctor will also check whether the tumor has spread to the other breast or any other parts of the body. This can be done using an ultrasound examination or x-ray of the other breast, an x-ray of the chest (thorax), a bone scan (bone scintigraphy), an ultrasound of the liver, or a computed tomography (CT) scan. If anything abnormal is detected, that part of the body can be examined more closely.

After all the tests have been done, the breast cancer is then “classified.” A classification system is used to record the tumor size and information about whether the lymph nodes are also affected or whether there are any metastases (whether the cancer has spread). The doctors will also assess how rapidly the tumor cells are growing and whether that growth can be influenced by hormones or certain growth factors. This classification is important when it comes to choosing the most suitable treatment.

From the age of 30, all women who have statutory health insurance in Germany are eligible for an annual breast exam by touch (palpation) at no additional cost. These and other screening examinations are not able to stop breast cancer from developing, though. The aim of screening is to detect breast cancer as soon as possible in order to provide better treatment and increase the chances of recovery. Only mammography has been shown to lower the risk of dying of breast cancer.

In Germany, women between the ages of 50 and 69 can also have a mammogram every two years. In order to ensure a high level of quality, screening is only done at specialized facilities that are part of the German national mammogram screening program. Participation is voluntary, and the costs are covered by statutory health insurers. As with all screening programs, there are advantages and disadvantages to breast cancer screening: For example, it may lead to unnecessary treatment. Your doctor can help give you advice and support if you have questions about breast cancer screening.

The treatment options always depend on the type and size of the tumor, where it has spread to (if it has spread), the patient’s general health, as well as their personal preferences. Breast cancer can be treated with surgery, radiation and medication. Different treatment approaches are often combined.

The standard treatment is to try to surgically remove as much of the tumor as possible. Neighboring lymph nodes are sometimes also removed. If the tumor is small, women are often faced with a decision: Should they keep the breast or have it completely removed? Nowadays many women can have surgery that allows them to keep the breast (breast-conserving surgery). But sometimes the entire breast needs to be removed (mastectomy) to make sure that all of the tumor tissue has gone.

Chemotherapy (treatment with medication) is sometimes used to shrink larger tumors before surgery and make it easier to operate on them. This kind of treatment is called “neoadjuvant chemotherapy.”

Chemotherapy is sometimes used after surgery too. Women who have a hormone-sensitive tumor may have anti-hormonal therapy. This aims to slow down tumor growth.

After breast-conserving surgery the surrounding tissue is exposed to radiation, if possible, so that any remaining tumor cells can be destroyed. This is sometimes necessary after a mastectomy as well. Radiotherapy is also commonly used if the tumor cannot be surgically removed.

The different types of treatment can be very difficult to go through and sometimes have very severe side effects or cause other medical problems. The side effects vary depending on the kind of treatment, but they are often easy to treat. The treatment of side effects is part of what is known as supportive care.

Before deciding on whether to have a particular treatment, there is usually enough time to get information from your doctor about the possible benefits and the expected side effects, and to talk with your family or other people who are close to you. In certain cases, biomarker testing can help some women decide whether or not to have chemotherapy. You also have the right to seek a second opinion from another doctor or to decide not to have a treatment.

In Germany, people can have rehabilitation treatment directly after leaving the hospital or at a later time. Other kinds of rehabilitative care can be started at any time. Rehabilitation is offered in both inpatient and outpatient settings. These kinds of programs aim to ensure the success of the treatment, improve your physical and mental wellbeing and help you cope with the disease. Rehabilitative programs usually last three weeks in Germany. A doctor has to prescribe them, and approval from your health insurer is also required. The hospital’s support services department can help you apply for rehabilitation treatment.

In Germany there are rehabilitation service centers that provide information about the rehabilitation treatments offered by different institutions. Addresses are available from health insurers and pension funds.

A program called the "Hamburg Model” helps people gradually return to work after being off work for a long time due to illness. This model allows working hours to be adjusted in a flexible way. To do this kind of reintegration you need to get the approval of your employer and your health insurer first. You can find out more about the Hamburg Model on the website of the German Federal Ministry of Labour and Social Affairs (in German).

Any life-threatening disease that requires repeated courses of physically draining treatment will inevitably end up affecting your mental health too. Most people in this situation would feel quite down from time to time.

Many women say that it comes as a relief to admit that they are feeling scared, anxious or desperate, and to talk things over with people close to them. In addition to talking with friends and relatives, psychosocial counseling or joining a self-help group can also help.

Self-help groups offer women the opportunity to meet others who have first-hand experience with the feelings and practical problems associated with the disease. There they can discuss topics that are often difficult to speak about with people who don’t have cancer. Talking with others can take some of the weight off your shoulders. Many women say that they draw strength from the solidarity they find in the group and the willingness of others to help. Self-help groups often provide even more, like organizing sports groups or offering help with social law issues.

Nowadays, psycho-oncological counseling is usually offered as part of cancer treatment. Psycho-oncologists are specialists with a background in psychology, medicine and/or social work. They help patients and those close to them to cope with the emotional and social aspects of the disease.

It is very important for women with breast cancer to take good care of themselves. Here are some ways for women to actively support their treatment and to do themselves some good:

• Exercise regularly, if possible
• Eat what you enjoy and feel like
• Find the right balance of activity and rest
• Get as much restful sleep as you can
• Generally do things that make you feel good during this difficult time

In Germany, breast cancer treatment plans are usually put together, and treatment is usually carried out, in certified breast cancer or tumor centers, or in doctor’s practices specializing in oncology. There, specialists from different disciplines work together to treat the various effects that both the disease and the treatment have on your body and mind. Treatment may also be carried out in a non-certified hospital or in a gynecologist’s practice. Gynecologists or family doctors might carry out some of the treatment and check-ups too.

In Germany, you are entitled to a variety of support services, including sickness benefit, home help and nursing care. There are numerous places you can go to for advice and help if you need to apply for support.

Professional help is available when making personal decisions, as well as getting advice about financial and legal matters. In Germany, individual advice is available – either over the telephone or in person – from

• the Cancer Information Service (Krebsinformationsdienst),
• various cancer information centers,
• health insurers and pension funds, and
• local (psycho-)social information centers. The social services department or local health authorities can tell you who to contact.

The addresses of self-help groups in Germany are available from the Cancer Information Service (Krebsinformationsdienst) or local health authorities.