Breast Cancer specialist Salzburg: Dr. Armando Farmini

Index

Diagnosis breast cancer

One in eight women will get breast cancer at some point in her life. This is the result of a statistical calculation based on the number of breast cancer cases up to the age of 83 years (life expectancy). This statistical statement would be correct if all women lived to the age of 83 years; however, this is not the case.

These days, breast cancer is unfortunately a common disease, that is mostly pain-free and affecting one breast. With approx. 1.7 million newly diagnosed cases in 2012, breast cancer is the most common form of cancer in women worldwide.

It represents approx. 12 percent of new cancer cases and 25 percent of all female cancers. And the numbers keep rising. The survival rate for breast cancer varies, but the rate has generally improved, because breast cancer is identified early in countries with a good health service and also because treatments strategies are continually further improved. Most breast cancer subtypes are hormone-mediated.

The tumour infiltrates the surrounding tissue and is associated with a risk of spreading and forming metastases. With the aid of sonography (ultrasound) and mammography, the diagnosis can be made with a high level of certainty. In selected cases, magnetic resonance imaging (MRI) may be used.

The first spreading of the cancer (metastasisation) can affect the lymph nodes in the arm pit, later other organs such as liver, lungs and bones. Based on tissue type, a distinction is made between ductal carcinoma (65-80% of cases) and lobular carcinoma (6-15% of cases). There are other variants, but they are extremely rare. A special variant is inflammatory breast cancer, in which the tumour is accompanied by an inflammation of the skin.

As someone affected by cancer, you will feel helpless at first, but you will not be left to your own devices to cope. In a confidential consultation, Dr Farmini will explain the various treatment paths, thus converting the enormous emotional burden from the diagnosis into a positive cooperation between doctor and patient. The choice of therapeutic approach results from the type of breast cancer and the individual decision by the patient.

Breast cancer (invasive mamma carcinoma)

Age group Probability of getting breast cancer within one year
25–29 years 0,002 % 2 in 100,000 women
30–34 years 0,2 % 2 in 10,000 women
35–39 years 0,1 % 1 in 1,000 women
40–44 years 0,1 % 1 in 1,000 women
45–49 years 0,2 % 2 in 1,000 women
50–54 years 0,2 % 2 in 1,000 women
55–59 years 0,2 % 2 in 1,000 women
60–64 years 0,3 % 3 in 1,000 women
65–69 years 0,3 % 3 in 1,000 women
70–74 years 0,3 % 3 in 1,000 women
75–79 years 0,3 % 3 in 1,000 women

Source: Kürzl 2004

 

Operation

Breast cancer surgery – operation

This is the removal of just the tumour while leaving the remaining breast gland in place. This is only possible if it concerns only one tumour or several tumours alongside each other with a favourable ratio of breast size to tumour size. If the ratio of breast size to tumour size is unfavourable, because the tumour or tumours are larger than a quarter of the breast volume, the removal of the entire breast is recommended, known as mastectomy, possible while retaining the skin and nipple which can result in an aesthetic to outstanding cosmetic result.

Risks:

  • Wound fluid accumulation
  • Damaged blood vessels
  • Thrombosis
  • Inadequate cosmetic result
  • Severe scarring
  • Infections
  • Abnormal sensations (paraesthesia)
  • Post-operative haemorrhages
  • Damaged nerves
  • Wound healing disorders

 

Breast-conserving surgery (BCS)/ lumpectomy

“Small incision, short surgery time, no after-bleeding and a clean cosmetic result are the aims of any breast surgery,” Dr Armando Farmini, breast cancer specialist, maintains.

Dr Farmini, as an experienced specialist for breast cancer surgery, you have developed your own signature procedure. What does it involve?

“My endeavour together with the patient is to remove the malignant lump or the affected tissue with a safety margin. To this end, I make use of surgical techniques that I have developed myself that result in an optimum outcome in terms of cosmetics as well as oncology (e.g. scarless technique according to Dr Farmini). My motto for selecting the incision is ‘as inconspicuous as possible’. Ideal sites are in the lower breast fold (submammary fold), laterally at the transition to the armpit (axilla) or the areola for tumours inconveniently located in the cleavage (periareolar incision according to Benelli). My aim is to use the time in theatre as efficiently as possible in order to minimize the duration of anaesthesia. I do not fit drains and bandage both breast in a tight dressing in order to minimize the risk of post-operative haemorrhages, thus avoiding revision surgery as far as possible. If all goes well, patients can be discharged between the second and fourth day after surgery. With each operation, my aim for the patient is that if at all possible there will be no need for her to undergo plastic surgery.”

Sentinel lymph nodes

The removal of the entire lymphatic tissue is no longer considered necessary these days.

The first lymph node to be linked to the breast tissue is located in the axilla; it is known as the sentinel lymph node. According to the current state of knowledge, the removal of the sentinel lymph node is part of the tumour excision. This method is not therapeutic but diagnostic, because it serves to assess the spread of the tumour. The previous practice had been to remove the entire lymphatic tissue from the armpit. But surgery undergoes constant development; there are a number of studies ongoing at the moment with the aim of answering the question whether the removal of the sentinel lymph node is necessary from an oncological perspective if the armpit is otherwise clinically and sonographically normal.

Breast removal (mastectomy)

“Breast reconstruction is possible even years after breast removal.

Breast conserving surgery is sometimes not possible because of the unfavourable ration between the size of the tumour and the size of the breast. This happens when a single tumour has a diameter that is larger than a quarter of the breast volume or when there are several tumours spread over a quarter of the breast volume. In these cases, the entire breast gland is removed. My aim is to conserve the cleavage, thus enabling the patients to wear lower-cut garments. Breast removal has a major impact on femininity. However, there is the option of performing reconstruction with implants or own tissue either immediately after the removal of the breast or months or even years later,” Dr Farmini points out.

 

Hospital Affiliation with the Wehrle-Diakonissen Private Hospital in Salzburg

A pleasant atmosphere, excellent care and state-of-the-art medical equipment provide safety at the highest level.

The renowned Wehrle-Diakonissen private hospital in Salzburg-Aigen invests regularly in the latest medical devices and appliances to ensure outstanding medical care of patients at all times. The operating theatres as well as the intensive care and recovery facilities were modernized in 2016 and thus meet the highest standards. The latest specialist equipment makes it possible to employ less invasive surgical techniques. The private hospital is the only one in Salzburg to have its own intensive care unit that guarantees patients the safety of intensive medical supervision and treatment after surgery.

More information available from:

http://www.privatklinik-wehrle-diakonissen.at/en/

 

 

Radiation

Radiation is usually recommended after surgery to reduce long-term the probability of the cancer recurring in the same breast.

  • Radiation without chemotherapy: Treatment is recommended to start approx. 4-6 weeks after surgery.
  • Radiation with chemotherapy: The treatment should follow on from chemotherapy, but start no later than 7 months after surgery.

Risks:

  • Redness
  • Chronic pain
  • Abnormal sensations (paraesthesia)
  • Cardiac complications
  • Pain
  • Cancer
  • Induration (hardness)
  • Swelling
  • Impaired motion
  • Pneumonia 1–1.5 %
  • Skin changes

 

Chemotherapy

To reduce the risk of recurrence, it is standard practice for more aggressive tumours to administer chemotherapy after surgery. Alternatively, in some cases chemotherapy may be given prior to surgery, with the aim of shrinking the tumour and thus making surgery easier.

Risks:

  • Hair loss
  • Cardiac damage
  • Vomiting
  • Cancer
  • Mucositis (inflammation of the mucous membranes)
  • Bone marrow damage
  • Kidney damage

 

Hyperthermia (thermotherapy)

Hyperthermia is not part of the standard treatment and is as yet only offered by a few centres.

This treatment involves a raise in body temperature. The effect on the cancer cells is thus two-fold: The tumour cells are destroyed by the higher temperature and at the same time the immune system stimulated and alerted to the malignant cells. Hyperthermia can be administered concurrently with chemotherapy. In consequence of the thus improved blood flow to the tumour, the effect of the chemotherapy can be intensified.

Anti-hormone therapy (endocrine therapy)

Anti-hormone therapy uses medicines with a range of different effects in order to minimize the oestrogen-mediated growth of the tumour cells. There is scientific evidence of a lower risk of relapses.

Tamoxifen

Tamoxifen is a drug that acts like a weak oestrogen by binding to the receptors in the breast cells. Thanks to its oestrogen effect, it also has a positive effect on bone density.

Risks:

  • Taste disorders
  • High blood lipid levels
  • Numbness/ tingling of skin
  • Thrombosis
  • Cataracts
  • Stroke
  • Changes to the retina
  • Hot flushes
  • Pneumonia
  • Fatigue
  • Vomiting
  • High liver enzyme levels
  • Diarrhoea
  • Itching in genital area
  • Constipation
  • Myoma
  • Hair loss
  • Uterine cancer
  • Muscle pain
  • Ovarian cysts
  • Water retention

Aromatase inhibitors

Aromatase inhibitors refers to a group made up of three drugs:

  • Arimidex (anastrozole)
  • Letrozole
  • Exemestane

They reduce the effect of oestrogens by reducing their production from testosterone. A reduced relapse risk has been scientifically proven.

Risks:

  • Headache
  • High cholesterol
  • Hot flushes
  • Taste disorders
  • Nausea
  • Diarrhoea
  • Skin rash
  • Vomiting
  • Joint pain
  • Hair loss
  • Osteoporosis
  • Vaginal dryness
  • Muscle pain
  • Bone pain
  • Concentration disorders

GnRH analogue (Zoladex/ goserelin)

The GnRH analogue is administered by injection. It blocks the hormone production in the brain that normally stimulates the release of hormones in the ovaries.

Risks:

  • Vaginal dryness
  • Headache
  • Sweating
  • Depression
  • Lack of libido

 

Antibody treatment (Herceptin/trastuzumab)

This antibody treatment is recommended for “HER2 positive” breast cancer cases. This applies to approx. 20% of all cases. On their surface, these tumour cells have HER2 antibodies (Human Epidermal growth factor Receptor 2) that send growth-promoting signals to the cell. The drug Herceptin can block these receptors and thus slow the growth. It is administered intravenously one to three times a week for at least twelve months.

Risks:

  • Fever
  • Headache
  • Nausea
  • Cardiac weakness
  • Vomiting
  • Shivering fits

 

Bioidentical hormone therapy

Bioidentical hormone therapy is not a standard treatment. According to the current state of science, a bioidentical hormone therapy can be prescribed to alleviate complaints, if a patient after breast cancer surgery makes a deliberate decision against guideline-compliant treatments because of their serious side effects. Numerous scientific studies confirm that the administration of bioidentical hormones does not increase the relapse risk[1]. Bioidentical hormone therapy is not recommended as an adjuvant treatment with the respective standard treatments.

Some interesting data are already available regarding the prescription of bioidentical hormones prior to cancer surgery [2]: Studies confirm that the hormone progesterone has a strong growth-inhibiting effect on breast cancer cells, because it promotes their cell death. The intravenous administration of progesterone prior to breast cancer surgery also reduces the relapse risk and increases the survival rate. However, this treatment cannot replace surgery because of the absence of relevant scientific data.

[1] Anticancer Res. 1998 May-Jun;18(3C):2253-5. Int J Fertil Womens Med. 1999 Jun-Aug;44(4):186-92. Oncology. 2001;60(3):199-206. Ann Surg Oncol. 2001 Dec;8(10):828-32. Menopause. 2003 Jul-Aug;10(4):277-85. J Reprod Med. 2004 Jul;49(7):510-26. Maturitas. 2006 Jan 20;53(2):123-32. Ann N Y Acad Sci. 2006 Dec;1092:349-60. Oncology (Williston Park). 2009 Nov 15;23(12):1099-100. Eur J Cancer. 2013 Jan;49(1):52-9.

[2] J Clin Oncol. 2011; 29: 2845–2851. Ann Clin Lab Sci. 1998 Nov-Dec; 28(6): 360-9. J Biol Chem. 2011 Dec 16; 286(50): 43091-102.

 

Is breast cancer hereditary? – Genetic consultation

A particular case is the genetic mutation that increases the risk of breast cancer as well as ovarian cancer.

BRCA1 and BRCA2

BRCA stands for breast cancer. BRCA1 and BRCA2 are two genes that can prevent the development of cancer by activating repairs to gene damage. If these genes are mutated, repairs are impaired.

Diagnostics

Identifying the gene mutation only requires taking a blood sample and examining the genetic makeup of the red blood corpuscles. However, as this method is very expensive, this special test is only recommended in selected cases.

Criteria for the BRCA1 and BRCA2 genetic test

In one side of the family (paternal or maternal) their are at least:

  • 2 cases of breast cancer before the age of 50 years
  • 3 cases of breast cancer before the age of 60 years
  • 1 cases of breast cancer before the age of 35 years
  • 1 cases of breast cancer before the age of 50 years and 1 case of ovarian cancer at any age
  • 2 cases of ovarian cancer at any age
  • Male and female breast cancer at any age

Assumption of costs

If the above criteria are met, statutory health insurers assume the costs for this test.

If you are a carrier of this condition (applies to men and women), you can pass it to your children. Conversely, if you are not a carrier, your children cannot have this mutation.

Test result

Because of the complexity of the test and the high demand, months can pass before the test result is back. However, there is the option of a fast test for patients diagnosed with cancer and facing surgery or chemotherapy; in those cases, the result comes back in approx. 3 weeks.

A negative result means that the children of the tested person are at no risk of having this mutation, unless their other parent has a conspicuous family history. A positive result means that the tested person carries a higher risk of developing breast and/or at some point in her life.

Conservative approach in case of mutation

This variant envisages that affected woman undergoes annual breast screening, ultrasound of the breast, breast MRI, gynaecological examination and a blood test to determine tumour markers.

Surgical approach in case of mutation

  • Breast surgery – mastectomy

In this variant, both breasts are surgically removed while retaining skin and nipples and prosthetics fitted.

  • Surgical removal of ovaries and tubes – adnexectomy

The ovaries are removed by laparoscopy (key hole surgery)

 

Aftercare

Early recognition of relapses

Breast cancer aftercare is indispensable. Regular check-ups permit the early detection of relapses (recurrent breast cancer).

“In a consultation, I create an aftercare plan with the patient compliant with current guidelines,” Dr explains.

The current recommendation is for the following schedule of check-ups:

Years after primary treatment In the first 3 years In Year 4 and 5 From Year 5 to Year 10
Consultation, physical examination Every 3 months Every 6 months Annually
Self-checks Monthly Monthly Monthly
Imaging diagnostics, laboratory tests Only for suspected metastatic spread Only for suspected metastatic spread Only for suspected metastatic spread
Mammography and

ultrasound

 Annually Annually Annually

Source: Working group for Gynaecological Oncology.