Treat breast cancer: a lot doesn't always help a lot

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Four out of five breast cancer patients are cured today. A great success – but often bought with serious side effects. A less aggressive therapy is often just as effective as Prof. Dr. Sara Brucker explained in an interview.

Does breast cancer therapy sometimes do more harm than good?

Prof. Dr. Sara Brucker: There are actually such cases of over-therapy. For example, a woman has a very small tumor and her chances of healing after surgery and radiation are excellent. If this woman were treated with "chemotherapy" just to be on the safe side, her chances of survival would even decrease due to the possible side effects of the therapy. And their quality of life would also be worse.

But in such a case, a doctor wouldn't recommend chemo at all.

Of course not if the case were very clear. However, we always have borderline cases where we know that some of the patients would benefit from additional, so-called adjuvant therapy, be it chemotherapy or hormone therapy. The only problem is: We often do not know exactly which patients will really benefit from it and which will not.

So everyone is treated according to the watering can principle.

We want to get away from that. We are developing more and more individual therapies. There are now a whole series of so-called gene signature tests that can be used to estimate how aggressively it could grow based on the genetic properties of the tumor. In borderline cases, this can help to make the decision for or against chemotherapy. But there are still a number of pressing questions.

Which ones are particularly topical at the moment?

For example, the question of whether and how many lymph nodes have to be removed from the armpit. After all, many women have major problems with lymphedema in their arms after such an intervention. At the moment this is mainly handled in such a way that the so-called sentinel lymph node in the armpit is definitely removed. If no tumor cells are found there, no further lymph nodes are removed. If it is already infected, the other axillary lymph nodes are also removed.

And what could you do differently?

There are currently considerations that the guardian lymph node can be completely removed if the ultrasound and tactile findings under the armpit are normal. And if the sentinel lymph node actually contains tumor cells: do you really have to remove the other lymph nodes? After all, it is now known that the further spread of the tumor cannot be prevented at all. Metastases could have developed elsewhere long ago, for example via the blood. Then you can also spare a woman the stressful clearing of the armpit, because then she has to be treated systemically anyway, for example with chemotherapy.

And the operation of the breast tumor itself?

In the meantime, so-called neoadjuvant therapy is being carried out more and more, that is, chemotherapy before the operation. With the aim of reducing the size of the tumor in advance so that it can be operated more gently afterwards. At the moment it is still the case that tissue is operated on where the tumor was located – even if the tumor has shrunk so much as a result of prior therapy that it can no longer be found. It is now being discussed whether the operation could not be saved entirely in such cases.

However, many people are convinced that the more that is cut away, the better the chances of survival.

In most cases it is just as safe to cut out only the tumor with an appropriate safety margin – which today should be checked with ultrasound during the operation; however only if it is subsequently irradiated. The total removal of the breast also bears a certain residual risk that the tumor will come back, because the glandular tissue directly under the skin cannot be removed completely. And since the entire breast amputation is often not followed by radiation, such gland remains can cause tumor growth.

Are there any options for radiation therapy to treat less intensively?

The radiation has been targeted for a long time, so that neighboring organs such as the heart and lungs are spared. Recently there have also been more and more studies suggesting that shorter and lower-dose irradiation could achieve results as good as using more aggressive radiation methods. But overall we need more insights here.

And how can a patient best get through this treatment jungle?

Ultimately, she must always have a say in how she weighs the possible benefits and potential risks of therapy for herself. For this, she needs very good advice, which you can get at certified breast cancer centers. And the KID * advisory phone is also of great help.

* Cancer information service of the German Cancer Research Center. Free advice on 0800-420 30 40

Prof. Dr. Sara Brucker is the director of the Center for Gynecological Oncology and Medical Director of the Research Institute for Women's Health at the University of Tübingen.

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BRIGITTE 16/2020