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In Germany, breast cancer is the most common form of oncology among women. Nevertheless, due to the possibilities of genetic and immunohistochemical treatment planning, 80% of patients can achieve persistent remission. Breast cancer treatment in Germany includes various modifications of minimally invasive and radical surgical procedures, radiation therapy and systemic treatment. Chemotherapy, hormonal and targeted therapy are planned individually, based on Oncotype Dx™, MammaPrint® tests, ER and PR, HER2/neu receptor testing, and Ki-67 analysis.
- Surgical treatment
- Radiation therapy
- Hormone therapy
- Targeted therapy
- Leading hospitals and cost of treatment
- Treatment in Germany with Booking Health
The surgical treatment of a breast tumor is aimed at the maximal removal of atypical tissues, including the primary tumor and potentially affected lymph nodes, as well as at the correction of a postoperative cosmetic defect. If necessary, a surgical procedure for tumor removing is immediately supplemented with plastic surgery, which avoids repeated anesthesia.
The modifications of organ-preserving operations include sectoral resection with lymphadenectomy, tumorectomy, and lumpectomy. They are performed for removing neoplasms less than 25 mm in size. As a rule, the surgeons remove the tumor along with several nearby lymph nodes. This helps prevent relapse of the malignant process. To improve the accuracy of the operation, surgeons use the FDA-approved Margin Probe device, which allows detecting the remains of atypical tissue in the surgical field and removing them.
Radical mastectomy in Germany is performed only in cases when the tumor spreads to the pectoral muscles and axillary lymph nodes. In other patients, the surgeons prefer more sparing modifications of mastectomy:
- Skin-sparing mastectomy, which facilitates the subsequent autologous breast reconstruction
- Nipple-sparing mastectomy, which additionally preserves the nipple and areola
- Simple mastectomy, which preserves axillary lymph nodes and pectoral muscles
German clinics use 5 modes of radiation therapy for breast cancer:
- Preoperative radiotherapy in the form of an intensive or delayed course. A short intensive course can destroy or damage malignant cells located on the periphery of the tumor. This prevents the dispersion of cancer cells in the wound and their spreading to distant parts of the body. A delayed course allows doctors to transform an inoperable breast cancer into an operable due to the tumor size decreasing.
- Postoperative radiotherapy is carried out in 2-4 weeks after surgery, in the conventional mode. Its goal is to affect the preserved lymph nodes (for example, supraclavicular or parasternal ones) and prevent cancer recurrence.
- Intraoperative radiotherapy (intrabeam technique) is performed during organ-preserving operations. The bed of the removed tumor and the bed of axillary lymph nodes are irradiated.
- Radiation therapy as an independent treatment method is carried out in case of inoperable neoplasia or presence of severe contraindications for the surgical treatment. This therapy option can also be used at the request of the woman, when she refuses the operation for some reason.
- Interstitial radiotherapy can complement external radiation therapy in the treatment of nodular breast carcinomas. The advantage of this technique is minimal damage to surrounding healthy tissues.
If indicated clinically, the whole breast radiation therapy can be replaced by the partial one. This allows doctors to reduce the number of procedures and the risk of side effects.
German clinics carry out chemotherapy for breast cancer in two modes, namely the neoadjuvant and adjuvant ones. Neoadjuvant chemotherapy is prescribed before surgery. It helps to reduce the tumor size, so that the surgeon can perform organ-preserving surgery, without total mammary gland excision. Adjuvant chemotherapy is prescribed after surgery. Its task is to suppress cancer cells remaining in the body.
The chemotherapeutic treatment of breast cancer in Germany mainly uses modern preparations of taxanes (paclitaxel and docetaxel) and anthracyclines (daunorubicin) that demonstrate the best antitumor activity according to the results of clinical trials. The postmenopausal women with ER-positive tumors are the most sensitive to chemotherapy.
To determine the most effective systemic treatment regimen (monotherapy, combination chemotherapy, a combination of chemotherapy with hormonal drugs), prognostic genomic testing is used widely in German clinics:
- Oncotype Dx™, which assesses the risk of relapse based on an analysis of 21 relevant genes
- MammaPrint®, which assesses the expression profile of 70 relevant genes
- PAM50 test, which examines 50 genes potentially associated with cancer recurrence
The mammary gland is sensitive to the action of hormones – it develops and performs its function under the influence of estrogen and progesterone. In 50-70% of women, breast carcinomas are also hormone-sensitive and hormone-dependent. Such tumors contain specific proteins on their surface, namely estrogen and progesterone receptors. Hormone therapy uses the effect on these receptors in order to suppress the growth of malignant neoplasms.
German oncologists use three types of hormone drugs with fundamentally different mechanisms of action:
- Antiestrogens directly block hormonal receptors and thus prevent hormones from stimulating tumor growth. The drugs of this group include Tamoxifen and its analogues.
- Aromatase inhibitors suppress the synthesis of estrogen and at the same time cause an increase in the levels of male sex hormones. This group of drugs includes Letrozole, Aromasin, Arimidex and their analogues. Aromatase inhibitors are mainly used in older women at the menopause.
- Androgens lower estrogen levels and are prescribed for the treatment of metastatic tumors that are resistant to other hormonal influences. The clinical practice mostly involves the use of a steroid with the pronounced androgenic properties – Halotestin.
Prior to hormone therapy, it is important to evaluate the expression of receptors on the membrane of tumor cells, since the effectiveness of drugs directly depends on this. The German clinics conduct an immunohistochemical study of the ER (estrogen) and PR (progesterone) receptors density.
Immunohistochemical diagnostics is also an important step in planning the targeted breast cancer treatment in Germany. When planning a targeted therapy regimen, the doctors determine the number of specific receptors and indicators of proliferative activity of cancer cells:
- HER2/neu is the second type of the receptor to the human epidermal growth factor. It is intensively produced in 20-25% of women with breast cancer. Should HER2 receptors be activated, the cancer cells will start their division, the tumor will grow into healthy tissues and metastasize. The clinical trials have revealed that HER2-positive tumors are more aggressive and resistant to hormone therapy with Tamoxifen, but at the same time they are sensitive to monoclonal antibodies – trastuzumab, pertuzumab and lapatinib. In complex diagnostic cases, HER2 status can be additionally determined using the FISH and CISH methods.
- Ki-67 is a protein that is synthesized only in actively proliferating cells. Its levels in cancer cells serve as the indicator of the tumor proliferative activity. The higher the levels of Ki-67 are, the more malignant the tumor is. The protein levels exceeding 30% are an indication for application of a comprehensive regimen of maintenance therapy, including targeted drugs.
The breast centers in Germany treat patients with metastatic breast cancer using Herceptin. It is a drug of trastuzumab, a monoclonal antibody. Herceptin has proven its effectiveness as the first-line drug, as well as the component of a combination treatment regimen with chemotherapeutic agents. Depending on the clinical situation, the drug can be administered 1 time per week or 1 time in 3 weeks. An additional advantage is its good tolerance, since only less than 5% of patients develop side effects. The doctors can also use pembrolizumab preparations. In addition, in 2019 the FDA approved the use of a new type of monoclonal antibody – atezolizumab.
Leading hospitals and cost of treatment
Leading university hospitals for breast cancer treatment are:
- University Hospital Tuebingen, Department of Adult and Pediatric Gynecology, Mammology, Obstetrics
- University Hospital Ulm, Department of Obstetrics, Adult and Pediatric Gynecology
- Charite University Hospital Berlin, Department of Adult and Pediatric Gynecology, Mammology
- University Hospital Frankfurt am Main, Department of Adult and Pediatric Gynecology, Obstetrics, Mammology
- University Hospital Halle (Saale), Department of Gynecology and Mammology
The cost of the medical program depends on the procedures included into the preliminary examination, the method of treatment, the hospital and the attending physician, the presence of concomitant diseases. The estimated cost of treatment in specialized cancer centers in Germany is as follows:
- Diagnostics of breast cancer – from €642
- Sectoral resection with flap reconstruction – from €3,696
- Radical mastectomy with removing fascia of the pectoralis major or minor – from €4,140
- Chemotherapy for stage 4 breast cancer – from €2,483
- Radiation therapy for breast cancer – from €13,800
- Proton therapy for breast cancer – from €44,526
- Breast reconstruction after mastectomy with own tissues or implant – from €5,419
- Breast reconstruction after tumor removal with an expander or alloprosthesis – from €4,020
- Plastic reconstruction of the breast with own tissues using the DIEP flap method – from €14,198
- Oncological rehabilitation – from €951 per day
Treatment in Germany with Booking Health
The high quality of medical care and the active use of innovative approaches to treatment contributes to the fact that women from Europe, Asia and Arab countries often seek medical care in the German clinics. German oncologists treat patients from all countries, but only if they have German medical insurance or a properly prepared package of documents for a foreign patient. The patients who do not have experience of treatment in international clinics can use the services of Booking Health – a certified medical tourism operator and an official partner of leading medical facilities in Germany.
The specialists of Booking Health will help you with the following important issues:
- Selection of the right clinic specializing in oncology and mammology, based on the annual qualification profile
- Direct communication with your attending physician
- Preliminary preparation of a treatment program in Germany, without repeating previous examinations
- Provision of a favorable treatment cost without overpricing and additional coefficients for foreign patients (saving up to 50%)
- Making an appointment with a doctor for the desired date
- Monitoring of the medical program at all its stages
- Assistance in buying and forwarding medicines
- Communication with the clinic after treatment completion, receiving and translating medical records
- Control of invoices and return of unspent funds
- Organization of additional and follow-up examinations
- Top-class service: booking hotels, airline tickets, transfer
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