Breast Cancer

Breast cancer is the most common cancer disease among women. Annually, over 5,000 new breast cancer cases are diagnosed in Finland. Almost every eighth Finnish woman is diagnosed with breast cancer at some point in her life. Breast cancer among men is rare.

The prognosis of breast cancer has improved continuously. At the moment, nearly 90% of breast cancer patients are alive five years after their diagnosis. The majority make a full recovery.

The high-quality treatment path of breast cancer patients at Tays covers the whole treatment chain of breast cancer, i.e. diagnostics, possible surgery and breast cancer pharmacotherapy and radiation therapy implemented as adjuvant therapies as well as monitoring following the treatments.

Breast cancer symptoms

The most common symptom of breast cancer is a lump. Other possible symptoms that may be an indication of breast cancer include retraction of the breast skin or nipple, changes in the breast size or shape, pain not linked to the hormonal cycle, bloody secretion from the nipple or breast inflammation that does not respond to antibiotic treatment.

Approximately one-third of breast cancer patients are diagnosed symptom-free due to breast cancer screenings. The manifestation of breast cancer becomes more common with age. Sometimes, the disease is diagnosed in young patients, so it is important to examine each breast lump in order to exclude breast cancer.

Breast cancer diagnosis and referral to Tays

If you notice a lump or other symptoms that are possible indications of breast cancer, schedule a doctor’s appointment at the health centre, occupational health care centre or a private practitioner. In the case of suspected breast cancer, the first examinations include imaging examinations, i.e. mammography, an ultrasound examination of the breasts and armpits, and the taking of large-core needle biopsies of the findings indicating cancer.

If the needle biopsy result confirms the suspected breast cancer, the health centre doctor, occupational health doctor or private practitioner refers the patient to Tays. If a dysplastic finding is discovered in mammography or an ultrasound examination, but the performed examinations do not reveal cancer, the patient is referred to Tays for the confirmation of the diagnosis.

We process all new referrals in a multi-professional team of experts, i.e. at the so-called breast cancer meeting attended by a cancer disease specialist, surgeon, plastic surgeon, pathologist and radiologist. In this multi-professional treatment meeting, an individual treatment recommendation is prepared for each patient.

Pre-operative doctor’s appointment

Before the breast cancer surgery, you meet with the surgeon and a breast cancer nurse during an outpatient clinic visit. The surgeon examines your breasts and prepares a surgical plan together with you, taking into consideration your wishes and the treatment recommendation prepared in the breast cancer meeting.

The breast cancer nurse provides you with the instructions for coming in for the surgery both verbally and in writing and goes over the essential matters regarding general anaesthesia. If you have severe underlying diseases or there is something else that may impact anaesthesia, the nurse discusses your treatment with an anaesthetist and, if needed, programmes the examinations he/she sees necessary.

Breast cancer surgery

Usually, you will not arrive at the surgical ward until the day of your surgery. Your breast undergoes either a lumpectomy or mastectomy.

An armpit lymph node examination is always conducted during the surgery. The sentinel lymph node of the armpit can be examined as a frozen section, i.e. a rapid analysis. If the breast cancer has spread, the most common spreading location is the armpit and more specifically the sentinel lymph node. The sentinel lymph node is located by means of radionuclide imaging on the morning of surgery.

If the sentinel lymph node is clean, it is not necessary to remove the other armpit lymph nodes. If the tumour is very large or it is known in advance that the disease has spread to the armpit or cancer cells are discovered in the sentinel lymph node, all lymph nodes of the armpit are evacuated.

If you undergo a lumpectomy and only an examination of the armpit sentinel lymph node, you may be discharged on the evening of the surgery day. In other cases, discharging or transfer to further treatment takes place on the first post-operative day. Upon discharging, you are provided with telephone numbers that you can call in case of complications.

In Pirkanmaa, the surgical treatment of benign and malignant tumours of the mammary gland has been centralised at Hatanpää Hospital.

Plastic surgery of the breasts, i.e. immediate and delayed repairs, and surgeries of patients with a high anaesthesia risk are performed at Tays Central Hospital.

Adjuvant therapies of breast cancer

A breast cancer surgery may be followed by cytostatic therapy, radiation therapy and/or hormonal therapy to prevent breast cancer recurrence. There preventative therapies are caller adjuvant therapies.

After the breast cancer surgery, the multi-professional treatment team meet to prepare an adjuvant therapy recommendation for each patient. The treatment meeting is attended by a surgeon, plastic surgeon, radiologist, pathologist and cancer disease specialist. This recommendation is individual and based on the most recent research data as well as on the national and international treatment recommendations.

An oncologist’s appointment will be scheduled for you at the cancer outpatient clinic of Tays to take place approximately one month after the surgery. By that time, the pathologist’s statement on the operated breast cancer is complete and the adjuvant therapy recommendation is prepared by the multi-professional treatment meeting. In addition, examinations to ensure that the cancer tissue has not spread elsewhere in the body can be performed as necessary.

The need for such examinations is determined by the characteristics of the removed breast cancer, its spread to the armpit lymph nodes and symptoms. The most common examinations of the spread of breast cancer include a lung X-ray and abdominal ultrasound examination or a full-body CT scan and bone scan. These are notified separately in a letter.

At the cancer outpatient clinic, the doctor discusses your breast cancer disease and the related recurrence risk, adjuvant therapy recommendation and possible side effects of the therapies with you. The oncologist decides with you which breast cancer adjuvant therapies will be applied. After the doctor’s appointment, a nurse goes over the therapies and their possible side effects in detail with you.

Scientific research is ongoing at the Department of Oncology, for example, studies on the impact of new medications. If you are a candidate for a clinical trial, you will be offered the possibility to take part in the research. Agreeing to become a clinical trial patient is always voluntary.

The adjuvant therapies of breast cancer are implemented at the cancer treatment units of Tays Central Hospital.

Cytostatics

Cytostatics are drugs developed for destroying cancer cells that are dosed intravenously or taken orally. They are carried by circulation to the whole body regardless of their administration method. Cytostatics prevent the division of cells and so cause the death of cancer cells.

Cytostatic therapy may be implemented with one cytostatic or a combination of several cytostatics. Patients suffering from the Her2+ sub type of breast cancer receive a combination of cytostatic therapy and antibody therapy, such as trastuzumab (brand name Herceptin).

The cytostatic therapy of breast cancer is implemented as day visits to the cancer outpatient clinic. The cytostatic therapy usually comprises six intravenous pharmacotherapy sessions every three weeks.

Unfortunately, the impact of cytostatics is not limited to cancer cell tissue alone, but often also damages the normal tissue of the body causing side effects. The most common side effects include fatigue, decline in the number of white blood cells, tender oral mucosa, nausea, hair loss and changes in bowel movement. The side effects vary individually and according to the provided therapy.

Adjuvant radiation therapy of breast cancer

Extensive studies have shown that radiation therapy after a breast cancer surgery, i.e. adjuvant radiation therapy, halves the local recurrence risk of breast cancer. Adjuvant radiation therapy is recommended for all patients who have had a lumpectomy. After a mastectomy, radiation therapy is recommended if metastases are discovered during the surgery in the armpit lymph nodes or the tumour is large.

If both cytostatic and radiation therapy are recommended after the surgery, the cytostatic therapy is provided first. The aim is to start radiation therapy within 3–4 weeks of the last cytostatic therapy session. Hormonal adjuvant pharmacotherapy (tamoxifen, aromatase inhibitors) is only started after the radiation therapy has been completed.

Radiation therapy is provided at Tays on weekdays from Monday to Friday at 7:30 am–8:30 pm. The radiation therapy ward has six radiation therapy devices, i.e. linear accelerators, which can all be used in providing breast cancer adjuvant radiation therapy. The radiation therapy session of a breast cancer patient usually takes 15–20 minutes. The implementation of the therapy itself only takes a few minutes. The linear accelerators produce therapeutic photon radiation, which the body does not sense in any way during the therapy session, so the treatment is completely unnoticeable and painless. Also, the patient him/herself does not radiate after the radiation therapy session.

The planning of radiation therapy begins with planning imaging, i.e. a CT scan. The radiation therapy doctor determine the treatment target and scope in the CT scans. After a lumpectomy, the treatment target is the remaining part of the breast. The lymph node areas in the armpit and supraclavicular fossa are covered by radiation therapy, if metastases have been discovered in the sentinel lymph node or the other armpit lymph nodes during the surgery. In some cases, a radiation therapy boost is provided for the area of the surgical cavity. After a mastectomy, the target area covers the thoracic wall and lymph node areas. The number of radiation therapy sessions in the area of the whole breast or chest is 16 or 25 sessions, an additional boost is provided 5–8 times as needed.

Due to radiation therapy, the skin of the treatment area typically becomes slightly irritated and red. For this reason, lotion should be applied to the skin once a day. The therapy may also cause slight fatigue. Regardless of radiation therapy, a normal and active life is recommended. Physical exercise and outdoor recreation lift your spirits, invigorate the body and help in recovery. You should quit smoking in order to ensure the effectiveness of the therapy and to reduce the cancer risk.

The aim is to target the radiation therapy at the planned treatment target to an accuracy of millimetres. This is enabled by X-rays taken before the implementation of the therapy, i.e. imaging guidance. Images ensuring the position are taken with an imaging system integrated into the treatment device while the patient is in the treatment position. At Tays, much has been done to ensure excellent precision in targeting radiation therapy of the breast. It has been ensured that the quality of the treatment position standardisation devices and interpretation instructions of the positioning images are of a good internationally comparable level.

Respiratory-gated radiation therapy of breast cancer

The respiratory-gated radiation therapy procedure of the left breast (deep inspiration breath hold, DIBH) has been a particular target of development at Tays. Tays has been the pioneer in the development of this method in Finland. The respiratory-gated procedure enables the best possible protection of the heart during radiation therapy, so reduces the formation of delayed side effects of radiation therapy targeting the heart. In addition, the procedure enables the reduction of the radiation therapy dose of the lungs.

The method development of the breast radiation therapy has also been proven to have international innovation value, and has resulted in four international, peer-assessed, scientific original publications. The publication activities have enabled the international assessment of the implemented practical renovations. In addition, by its continuous operations a work group specialising in the development of therapies ensures that the breast radiation therapies implemented at Tays are of high quality and that the therapies are implemented in an internationally proven and modern manner.

Hormonal therapy of breast cancer

Approximately three-quarters of breast cancer cases are hormone receptor-positive. This means that, in these cases of cancer, the cancer cells utilise the own hormones of the body. The impact of hormonal cancer therapy is based on preventing this. The hormonal therapy of cancer aims to prevent the production of the hormone vital to the cancer in question and its impacts on the body.

According to studies, the hormonal therapy of breast cancer yields the greatest benefit in five years of use. However, recent studies have shown that some patients may benefit from longer hormonal therapy of up to 10 years.

The hormonal therapy of young women is usually implemented with tamoxifen. If necessary, tamoxifen can be combined with medication to temporarily stop the ovarian function in the case of young patients. The hormonal therapy of patients beyond menopause may also be implemented with tamoxifen or aromatase inhibitors alone or in turn with tamoxifen. The aromatase inhibitors (letrozole, anastrozole and exemestane) prevent the formation of post-menopausal oestrogen in the body.

Common side effects of the hormonal therapies include menopausal symptoms, such as sweating, hot flashes and drying of the mucous membranes. Tamoxifen to some extent increases the risk of venous thrombosis and slightly the risk of uterine cancer. On the other hand, the aromatase inhibitors cause more joint pains than tamoxifen and predispose to osteoporosis and fractures. The menopausal symptoms may be alleviated as the therapy progresses and with the help of an active life style involving physical exercise and weight management and by avoiding excessive alcohol use. In the case of difficult side effects, the patients are recommended to call the breast cancer patients’ counselling number 03 311 63379.

After the treatments

Breast cancer patients are monitored in special health care, depending on the prognosis of the disease, usually for five years. If the disease has such a good prognosis that no adjuvant therapies are provided, the patient sees an oncologist only once who explains the situation and programmes the monitoring of breast cancer to be implemented in primary health care or occupational health care.

The patients who have received adjuvant pharmacotherapy are invited to the cancer outpatient clinic of Tays approximately three months, one year, three years and five years from the end of radiation and cytostatic therapies or from the beginning of hormonal therapy.

Patients, who have only received radiation therapy after their breast cancer surgery, are scheduled with a monitoring visit to take place three months after the end of radiation therapy. Then, monitoring is transferred to primary health care or occupational health care.

During the first monitoring visits, the possible side effects are discussed and the first post-operative mammography and ultrasound examination of the breasts are programmed. Then, mammography and an ultrasound examination are performed regularly every 1–2 years during the five years of monitoring. The interval of the examinations depends on the age of the patient and the applied surgery method. During the latter monitoring visits (after 3 years and 5 years), the possible delayed side effects are discussed and, if necessary, decisions are made on the nature and duration of the patient’s hormonal suppression therapy.

There is a counselling number for the breast cancer patients of Tays that the patients can call if they experience symptoms during the monitoring intervals. The counselling telephone number is 03 311 63379. Based on the symptoms, the aim is to arrange for the patient the necessary examinations, contact or appointment with a doctor and treatment as necessary.

New contact method testing

Online outpatient clinic is a new e-service to support your well-being. At first, we are testing the Noona mobile application that enables electronic contact between the patient and personnel while ensuring information security. The new service is an option for the traditional telephone contact. You may still choose to call the telephone number provided by your treatment unit.

The mobile application can be used to contact the treatment personnel at any phase of the breast cancer treatment path. You can ask questions about your symptoms or any other matters from a breast cancer nurse via the service. Your contact request is answered during office hours.

You need an email address and a telephone, tablet or computer with Internet access to use the mobile application. The user name and instructions for logging in are provided to you by email. More detailed use instructions are provided at the website of the service.

Persons in charge

Chief Physician of the Unit Minna Tanner (Tays Central Hospital)

Chief Physician of the Unit Ulla Karhunen-Enckell (Hatanpää Hospital)