Early-stage breast cancer: Treatment

Breast cancer is considered to be early-stage if it hasn’t yet spread to other organs, and it also hasn't spread to the lymph nodes in the armpits (or only a little).

Early-stage breast cancer can have various symptoms. The shape or size of the breast might change, or you might be able to feel a lump. Sometimes there's a sunken dip (dimple) on the breast, or fluid might leak out of the nipple.

There is a certain category of early-stage breast cancer called “ductal carcinoma in situ” (DCIS). This is where cells in the milk ducts of the breast have changed but it doesn't cause any symptoms. DCIS remains harmless in some women, while in others it develops into an invasive tumor (a tumor that spreads to surrounding tissues).

The most suitable treatment options will depend on things like

• the size of the tumor,
• where exactly it is,
• whether it has spread to lymph nodes and/or organs,
• whether the cancer cells have receptors for certain hormones, and
• how aggressive the cancer is.

Your age and general state of health will also play a role. Last but not least, your personal needs and aims will be considered in the treatment plan.

Various examinations are done to classify the tumor. This "TNM classification" helps to assess how the disease is likely to progress, and also to plan the treatment:

• T refers to the size of the tumor.
• N refers to whether the cancer has spread to nearby lymph nodes.
• M refers to whether there are any metastases (in other words, whether the tumor has spread to other parts of the body).

A tissue sample is taken to see how much the cancer cells have changed compared to normal cells ( grading).

The cancer cells are also tested to see if they respond to hormones. If they do respond, hormone therapy is an option.

It is also possible to see whether the cancer cells have a lot of certain receptors on them (HER2 receptors, short for "human epidermal growth factor" receptors). If they do, certain medications can slow down the growth of the cancer cells.

Breast cancer can be treated with surgery, radiotherapy and medication. Often, several treatment approaches are combined.

The standard treatment is to try to surgically remove as much of the tumor as possible. Nearby lymph nodes are sometimes removed too. If the tumor is small, women are often faced with a decision: Do they want to keep the breast or have it completely removed? Nowadays, it's often possible to remove the tumor but keep the breast. This breast-conserving surgery is called a "lumpectomy" or "partial mastectomy." But sometimes the whole breast has to be removed (mastectomy) to make sure all of the tumor tissue has gone. It may be possible to do this without removing the nipple. After a breast has been removed, surgeons can "rebuild" the breast (reconstruction surgery). This is done using tissue from the woman’s body and/or an implant.

After breast-conserving surgery, the surrounding tissue is exposed to radiation, if possible, to destroy any remaining tumor cells. The aim is to prevent the cancer from coming back (recurrence). Radiotherapy is sometimes needed after a mastectomy, too. It is also usually offered if the tumor can't be surgically removed. To protect the surrounding tissue as much as possible, the beams of radiation are aimed directly at the cancer.

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 may also be used after surgery if it's likely that some cancer cells weren't successfully removed (adjuvant chemotherapy). The medications used in chemotherapy are usually given through a drip, and sometimes as tablets. One course of chemotherapy lasts about 4 to 6 months in total. It involves several repeated cycles of treatment with breaks in between them.

Laboratory tests can help doctors find out whether estrogen and progesterone hormones stimulate the growth of the tumor. If they do, hormone therapy is an option after surgery: Here, medications are used to slow down the growth of the tumor. They do this by inhibiting the hormones’ effects or reducing the amount of hormones produced in the body. Hormone therapy medications include tamoxifen, aromatase inhibitors and GnRH analogs. The most suitable medication for you will depend on whether you have already been through the menopause. The medications are taken daily as tablets for at least five years.

Some medications are used specifically for the treatment of types of cancer with certain tumor cell characteristics. If the cancer cells have HER2 receptors on them, antibodies can block growth-promoting signals. This slows down the growth of the cancer cells and can also shrink metastatic tumors. Antibody therapy drugs are typically used in combination with chemotherapy. The medication is injected into a vein or under the skin, once a week or every three weeks, for about a year.

Chemotherapy can be very hard to deal with. Most women with early-stage breast cancer don’t need it – surgery and radiotherapy are usually enough. Chemotherapy is mainly considered if there is an increased risk of the cancer coming back. But nobody can say for sure whether the cancer will come back in a particular woman. So it can be a difficult decision to make. The bigger the risk of recurrence, the greater the potential benefit of chemotherapy. You can discuss the pros and cons of this treatment with your doctors.

Most women choose to have treatment because they want to get rid of the cancer and live longer. But another important goal is to be able to live with as few cancer-related problems and restrictions as possible. In other words, being as independent as possible in daily life and doing the things you need and want to do. Different people may have very different needs and wishes here.

If detected early enough, breast cancer can usually be treated successfully.

Out of 100 women diagnosed with early-stage breast cancer,

• around 80 of them are still alive five years after the diagnosis, and
• around 70 are still alive ten years after the diagnosis.

The chances of recovery depend on your individual circumstances: What type of breast cancer do you have? How fast is it growing? What are the treatment options?

The cancer returns in about 20 out of 100 women despite successful treatment.

All of the treatment options can have side effects. These can often be treated effectively, or go away on their own. But sometimes they are severe or lead to other health problems.

The side effects vary depending on the type of treatment:

• Radiotherapy can cause skin irritation (like soreness or sensitivity) and scar-like changes to the tissue.
• The possible side effects of chemotherapy include nausea, pain, hair loss, anemia and severe tiredness.
• Surgery can lead to pain, infections and wound-healing problems. If lymph nodes are removed, lymphedema may develop.
• Hormone therapy can cause menopause-like symptoms such as hot flushes and mood swings.
• Antibody therapy may lead to flu-like symptoms, infections and diarrhea.

These kinds of side effects are treated with supportive therapy. Examples of supportive therapy include medications for anemia or nausea.

There are various things you can do yourself to feel better and to relieve the side effects of cancer treatment. These include relaxation exercises to reduce sleep problems, and exercise programs to help with severe exhaustion ( fatigue). Eating a balanced diet, and eating enough, can also make a positive difference. Some people don’t have much of an appetite during the treatment. Support from a dietitian can be particularly helpful for them.

Cancer patients and their family members are often given psycho-oncological support to help them cope better with the emotional stress of the disease and the treatment. Most treatment teams have psycho-oncological experts who offer counselling and advice. Support groups can also provide valuable help. Sometimes, patients take part in special courses that can help them to cope better with having cancer.

Patients may have follow-up rehabilitation treatment after their cancer treatment. The aim is to ensure the best treatment outcome, improve your physical and mental wellbeing, and to help you cope with the disease. In Germany, a program called the "Hamburg Model” helps people to gradually return to work after being away for a long time due to illness.

Follow-up care includes regular check-ups. The aim is to relieve the effects of the disease and look out for signs that the cancer has come back. In the first few years after treatment, check-ups are usually offered about every three months, and after five years an annual check-up is normally enough. Follow-up care lasts at least ten years.

It is very rare for men to get breast cancer. Most of those who do are over the age of 60. Unfortunately, there are only a few studies on the various treatment options for men. But the treatment for breast cancer in men is similar to the treatment for breast cancer in women.

The cancer is diagnosed using x-ray and ultrasound scans of the breast. If doctors suspect that the cancer has spread to other organs, a CT scan may be done to find out for sure.

Men who have breast cancer are normally advised to have genetic counseling because the disease is often hereditary in men.

Where possible, doctors try to keep the breast intact when operating. But sometimes they may have to remove the breast tissue and the lymph nodes. Radiotherapy is also performed on the breast after surgery. Hormone therapy, chemotherapy and antibody therapy are further treatment options.