Current Diagnostic and Treatment Algorithms for Breast Cancer
Breast cancer, the most frequently occurring cancer in women, is a major public health problem, with 69,000 estimated new cases in Germany (1). An estimated 650 men in Germany are diagnosed with breast cancer every year. The death rate from breast cancer has declined in Germany in recent years. This is due to greater awareness and screening, along with the advanced treatments that are available. The prognosis of breast cancer is generally good in Germany with an estimated relative 5 years survival rate of 73 % for men and 88% for women (1).
One of the key elements of this success in the treatment of cancer is the comprehensive and precise approach taken with each cancer patient. The health system in Germany has made such an approach possible for all cancer patients, inclusive of those with breast cancer.
The personalized care plan is the cornerstone of the successful treatment of cancers in Germany. Each patient receives an individualized treatment plan depending on their tumour type and its stage of progression. In this procedure, the identification of tumour histology and staging of the tumour is of fundamental importance for the successful planning of treatment options. This is a key factor in the German Health Advisors’ daily work.
For each patient with a tumour, we attempt to initially fulfill these two aspects in collaboration with our patients and local colleagues. We then discuss the case with the specialists, or, at the multidisciplinary tumour boards at our partner clinics in Germany. If any problems arise, we communicate this to our patients and try to find solutions. This usually happens when we get incorrect or incomplete pathology or radiology reports (discussed in details below).
Initial Staging and Risk Assessment
The staging for overseas patients is usually not complete when they contact us for a second opinion and/or any subsequent treatment recommendations. The system employed by German Health Advisors, however, allows for the completion of this stage while the patients are in their homeland. It is not necessary to come to Germany for cancer staging. You will be informed if there are any obstacles in the staging process. For the staging of breast cancer, please bear in mind the following:
- Family history, physical examination, blood count and differential, tumor markers, liver and renal function tests (see the request form for German Health Advisors). This will usually be carried out by our local colleagues and documented in the form of a doctor’s letter.
- Core needle biopsy and tumour histology. Please provide us with your pathology report if available. In some cases, when our specialists are not satisfied by the quality of a pathology report, we will contact you with recommendations for further steps. You may have to send us the frozen/paraffin embedded tissue samples for further histology analyses at one of German Health Advisors’ partner laboratories in Germany.
- Breast cancer staging takes into account the cancer's grade; the presence of tumor markers, such as receptors for estrogen, progesterone and HER2; and proliferation factors (Ki67). If any of these tests are not attainable in your country, we will help you to access them in Germany through our partner laboratories.
- Mammogram, including the other breast, to look for signs of cancer and MRI. Breast ultrasonography can give additional information. You can send the DICOM files of CT scans using German Health Advisors’ secure data transfer system. Our experience shows that the quality of radiology images might not be good enough to correctly stage the cancer. In such cases, we will contact you to find a solution. It is of a great importance for us to have high quality radiology images from our local colleagues. This greatly assists in defining the diagnostic and treatment plan in timely fashion and helps to avoid unnecessary expenses.
- Contrast-enhanced computerized tomography (CT) scan of Abdomen and Thorax to rule out metastasis in lungs and abdomen.
- Bone scan to rule out metastasis. Bone scintiscan findings are sensitive but nonspecific.
- Whole-body MRI and FDG-PET scanning are accurate techniques that are currently limited by their high cost and will not be covered by insurance (3). However, in some countries, such radiology tests are less expensive. You can obtain MRI or/and FDG-PET scanning and send the results using German Health Advisors’ secure data transfer system. Such results would be greatly advantageous in assisting the staging
Please take into account that not all women will need all of these tests and procedures. Your doctor in Germany will select the appropriate tests based on your specific circumstances, taking into account the quality of the reports and assessment results from our local colleagues.
Treatment of Breast Cancer
Based on the type of breast cancer, its stage and grade, size, and whether the cancer cells are sensitive to hormones, your doctor in Germany can determine the breast cancer treatment options available for you. Your doctor will also consider your overall health and your own preferences (see the request form for German Health Advisors). German Health Advisors can organize a videoconference with your doctor to discuss the therapy plan.
Most patients undergo surgery for breast cancer and receive additional treatment before or after surgery, such as chemotherapy, hormone therapy and/or radiation (2). Below, we list the main current treatment options:
- Surgical treatment, such as removing the breast cancer (lumpectomy), removing the entire breast (mastectomy), removing a limited number of lymph nodes (sentinel node biopsy), removing several lymph nodes (axillary lymph node dissection), removing both breasts or limiting lymph node removal to avoid surgery-related lymphedema.
- Surgical treatments are performed with frozen section analysisprocedures, where pathologists analyzes tissue samples during surgery to guide the surgeon on further steps during the surgical procedure.
- Chemotherapy. If patient´s cancer has a high risk of relapsing or spreading to another part of your body, your doctor may recommend chemotherapy before or/and after surgery to decrease the chance of cancer recurrence.
- Hormone therapy. This therapy can be used before or after surgery (or other treatments) to decrease the chance of your cancer relapsing. If the cancer has already spread, hormone therapy may shrink and control it.
- Radiation therapy. Breast cancer radiation therapy may be used to destroy any remaining mutated cells that remain in the breast or armpit area after surgery.
- Targeted drug treatment. These kinds of treatments target the specific abnormalities within cancer cells. For about 25% women with breast cancer, the cancer cells have too much of a growth-promoting protein known as HER2/neu (or just HER2) on their surface. These cancers, known as HER2-positive breast cancers, tend to grow and spread more aggressively. A number of drugs have been developed that target this protein- Trastuzumab (or Pertuzumab) combined with chemotherapy in patients with HER2 overexpression/amplification approximately halves the recurrence risk, compared with chemotherapy alone (2).
Follow-Up After Treatment of Breast Cancer
Follow-up should be tailored to the individual patient and the stage of the disease. The German Health Advisors’ partner clinics will normally schedule follow-ups in this manner:
- Every 3 months in the first 2 yearsafter the initial treatment: physical examination, blood count and differential, liver and renal function tests, ultrasonography.
- Annual ipsilateral (after breast conserving surgery) and/or a contralateral mammography with ultrasound is recommended.
- If you are taking one of the hormone drugs, you should have pelvic exams annually, as these drugs can increase your risk of uterine cancer.
- Every 6 months from years 3–5: physical examination, blood count and differential, liver and renal function tests, ultrasonography.
- After 5 years, annual controls will be performed.
The patients, who got their treatments in Germany, usually do not need to come for the follow-up controls to Germany. German Health Advisors will provide you with follow-up care through its Telemedicine platform.
Keywords: Breast Cancer, Targeted Therapy, Breast Conserving Surgery
1. Brustkrebs (Mammakarzinom), https://www.krebsdaten.de
2. Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology, Volume 26, Issue suppl_5, 1 September 2015, Pages v8–v30
3. Imaging in Bone Metastases. Wilfred CG et al., https://emedicine.medscape.com/