Breast cancer treatment in Germany: diagnosis, therapy and surgery

Every year, thousands of medical tourists from all over the world seek innovative diagnostic services and breast cancer treatment in Germany.

One out of eight women will develop breast cancer at some point of her life.

Terrible number.

Breast malignancies are rarely diagnosed in young women, but the incidence increases dramatically after 45-50 years.

The median age of onset is 64 years.

This is several years below the age of onset for other cancers. Nevertheless, every fourth patient is younger than 55 years.

How often does breast cancer occur?

This is the most common malignancy among the women in developed countries.

It accounts for about 30.5% of all malignant diseases.

Since the 1980s, the incidence in Germany has doubled to 69,000 times a year.

This cancer type is well-studied, and standard treatment is usually working well. Despite all the achievements, the disease kills 18 thousand women annually.

Breast cancer can develop even in men, but because of a small amount of glandular tissue, this happens very rare. In 2014, only 70 cases were registered. Despite the growing number of cases, breast cancer mortality in Germany is steadily declining. Today, the 5-year survival rate (regardless of the stage) is 82%.

The statistics of university clinics and large certified centers is even better.

Over the past 15 years, unique methods have been introduced to remove breast tumors and prevent metastasis. There were new chemotherapy and targeted drugs.

Best breast cancer clinics in Germany

Since 2003, local clinics undergo voluntary certification.

Certification is carried out by such respected organizations as the German Cancer Society (Deutschen Krebsgesellschaft) and the European Association of Breast Cancer Specialists (EUSOMA).

There are three European Cancer Centers (ECC) in Germany:

• Klinikum Bremen-Mitte (Bremen, St.-Jürgen-Str. 1)
• DRK Krankenhaus Chemnitz-Rabenstein (Chemnitz, Unritzstraße 23)
• Westplatz-Klinikum Kaiserslautern (Kaiserslautern, Hellmut Hartert-Straße 1)

ECC certified center must provide a certain range of medical services. The goal of certification is to maximize the effectiveness and safety of treatment through the interdisciplinary collaboration and strict adherence to standards.

Other famous breast cancer clinics in Germany:

• Städtisches Klinikum Solingen
• Universitätsklinikum Düsseldorf
• Klinikum Bremen-Nord
• Asklepios Klinik Barmbek
• Helios Klinikum Berlin-Buch
• Krankenhaus Nordwest Frankfurt am Main
• Universitätsklinikum Hamburg-Eppendorf (UKE)
• Charité - Universitätsmedizin Berlin
• Universitätsklinikum Essen
• Alfried Krupp Krankenhaus in Essen
• Universitätsklinikum Würzburg
• Universitätsklinikum Erlangen
• Universitätsklinikum Aachen
• Universitätsklinik Freiburg
• Universitätsklinikum Stuttgart
• Universitätsklinikum München

Screening and early diagnosis of breast cancer in Germany

The best prevention is a healthy lifestyle and avoiding risk factors. But early diagnosis significantly increases the chances of a full recovery.

German screening guidelines:

1. Women aged 30 to 49 years and over 70: axillary lymph nodes, the shape and size of the breast (nipples) are checked annually. During the examination, the presence of discharge from the nipple is checked.
2. Women aged 50-69 years (high risk group): In addition to annual screening, mammography screening is recommended every two years.

Some women carry genetic mutations BRCA1 or BRCA2, which increase the risk of gynecological malignancies at a relatively early age. Women with a breast or ovarian cancer run in their families, annual examinations are recommended starting at 25 years. Every year – MRI, every six months – ultrasound. In addition, from the age of 40, mammography is done every 2 years.

Breast cancer or benign calcification?

Spot on a mammogram is a real shock for any woman. But experts say: there is no reason for panic. In most cases, additional examinations will give encouraging results, because these suspicious changes in the mammary gland are usually benign.

Benign tumors

Remember: "You have a tumor" do not necessarily mean "You have cancer." Tumor means any neoplasm, regardless of whether its cells are benign or malignant. Many women notice harmless lumps that disappear after menses. But even the nodules that do not depend on the menstrual cycle are often benign. These are neoplasms originating in fat, glandular or connective tissues: lipomas, fibroadenomas, fibrocystic breast disease, and even papillomas.

Precancerous conditions

Modern visualization methods allow detecting the smallest changes. Precancerous conditions are cellular changes that can turn into real invasive breast cancer.

1. Atypical ductal hyperplasia
2. Lobular intraepithelial neoplasia
3. Squamous metaplasia, etc.

German oncologists call these conditions "premalignant" (Vorstufen von Brustkrebs) when cells do not invade normal tissues and do not pose a threat to the patient's life. Even carcinoma in situ is not a reason for panic. CIS literally means localized tumor. Carcinoma in situ can be located in the ducts (ductal, DCIS) or in lobules (lobular, LCIS).

A simple surgery will completely cure such a tumor.

Breast malignancies

Invasive cancers are divided into ductal carcinomas (up to 80% of cases), lobular carcinomas (up to 15% of cases) and other, relatively rare types. The prognosis and treatment tactics for each type is completely different.

The stage of the disease is determined by the size of the neoplasm (T), lymph node involvement (N) and the presence of distant metastases (M).

Breast cancer diagnostic tests & procedures in Germany

A number of diagnostic procedures are used to detect cancer, determine the stage of the disease and select optimal treatment strategy. Ultrasound, MRI, mammography and biopsy are supplemented with tumor markers lab tests.

Consultations of leading oncologists cost about 500-1000 euros.

Digital mammography

This X-ray examination of the breast is the current gold standard of diagnosis. This technology is used to inspect suspicious nodules. Mammography is widely used for diagnostic and screening purposes. But mammography does not always detect cancer. About 5% of tumors remain undetected and untreated. After all, the accuracy depends on different factors, including the density of glandular tissue, medications, etc.

Breast ultrasound (diagnostic sonography)

The term “sonography” means something like "sound drawing." Organs and tissues reflect sound waves differently. Therefore, ultrasound is helpful to detect dense formations, fluid-filled cysts and other abnormalities in the gland. Together with palpation and mammography, ultrasound provides the doctor with valuable information. These methods are highly reliable in combination.

The cost of breast ultrasound in Germany is about 300-500 euros.

Breast MRI

With magnetic resonance imaging, the organ is divided into visual layers. This method is based on the use of a magnetic field, which acts on the hydrogen atoms contained in the body. This is clinically useful and safe procedure.

Advantages of MRI: high sensitivity and no harmful radiation.
Disadvantages: insufficient specificity, high cost, and technical complexity.

Insufficient specificity of MR imaging means that the detected neoplasms are not necessarily malignant. This leads to additional unnecessary biopsies. MRI is usually recommended to detect small tumors that are invisible in mammography. It is widely used for monitoring and examining women with breast implants.

Breast MRI in Germany costs 1000 to 1800 euros or more.

Biopsy and pathology

Detecting a tumor on MRI is not enough for correct diagnosis and treatment. Histological examination of tissues is used to determine the cancer type and reveal cellular features, which are necessary for further planning and prognosis. Breast biopsy is performed in operating room, usually under local anesthesia. Special tools are inserted in the breast under the ultrasound, X-ray or MRI control. Fine needle aspiration, punch biopsy and excisional biopsy among the most widely used techniques.

Fine needle aspiration allows the doctor to receive a small number of cells for histological examination. Punch biopsy (PB) is used to examine larger fragments.

An open (excisional) biopsy means surgical removal of the neoplasm followed by examination in the laboratory. Unlike FNA and PB, open biopsy is a “real” surgery, which is usually performed under short-term general anesthesia.

The cost of punch biopsy in Germany is about 1500-3000 euros.

Galactography (ductography)

X-ray examination of the milk ducts is prescribed in suspicious cases when digital mammography and ultrasound have not detected any tumors. With galactography, even the smallest ducts can be assessed with special contrast medium.

Galactoscopy

This endoscopic technique is also called ductoscopy. During the procedure, the doctor inserts a thin flexible endoscope with a video camera (fiber optic ductoscope) into the milk ducts. This camera broadcasts a live video to the operating room. Nowadays, ductoscopy is extremely rare technique.

Breast thermography

Thermography is a diagnostic procedure based on the use of infrared sensors.

Cancer is intensively supplied with blood and therefore emits a lot of thermal radiation. However, benign breast tumors affect the thermal image. The technique is cheap, but it is considered unreliable and clearly inferior to modern diagnostic options.

Diagnosis of breast cancer metastases

When the cancer is diagnosed at stage IV, an additional examination is usually required to search for metastases in distant organs and tissues.

Bone scintigraphy

Before the procedure, the patient is given a radioactive tracer, which is quickly absorbed by the bone. Accumulating in malignant cells with intensive metabolism, radioactive agent "highlights" the suspicious areas for further biopsy.

Scintigraphy in Germany costs 900 to 1600 euros or more.

Abdominal ultrasound exam

In stage IV breast cancer, ultrasound is used to monitor the formation of secondary tumors in the liver and other internal organs. This is a safe and affordable technique.

Chest X-ray

In addition to liver and bone tissue, breast carcinoma often spreads into the lungs. Chest X-ray is a simple procedure to detect relatively large secondary tumors.

CT scan

CT can replace radiography and ultrasound. This high-tech method allows us to examine literally each area of the body, even inaccessible to sonography. Clinical effectiveness and safety of computed tomography depends on the technical level of the cancer clinic and the experience of radiologists. Diagnosis of breast cancer metastases becomes safer every year.



For example, the SOMATOM Force CT designed by the German engineers from SIEMENS requires only 0.1 mSv to scan patient’s lungs. This dose of radiation is comparable to that received by the passenger during a flight across the Atlantic!

The cost of CT in Germany is about 900-1200 euros for one area.

PET / CT scan

PET / CT combines the best of the two worlds – computed tomography and positron emission tomography. PET uses radioactive sugar, which is quickly absorbed by cells with fast metabolism. This agent highlights malignancies and inflamed tissues.

PET / CT is an expensive procedure that cost about 2000-3600 euros.

Breast cancer surgery in Germany

Surgery is still the most important cancer treatment option.

Just 30-35 years ago, surgery usually meant radical mastectomy (complete removal of the breast) leaving terrible scars for the rest of life. Today, German surgeons perform organ-preserving surgeries, which save the breast in most cases. Plastic surgeons make everything possible to correct horrifying cosmetic defects and improve patient’s quality of life.

The cost of breast cancer surgery in Germany is about 10,000-15,000 euros.

Breast cancer resection

• Organ-preserving surgery (lumpectomy, partial mastectomy, quadrantectomy): resection of the tumor and surrounding healthy tissue with the maximum possible preservation of the gland. Suitable in the early stages.
• Total mastectomy: complete removal of the affected breast and surrounding tissue (lymph nodes). Surgery can be one- or two-sided. After the course of treatment, silicone implants are recommended to correct defect.

Removal of lymph nodes

• Sentinel lymph node biopsy: removal of the axillary lymph nodes is often recommended, because the cancer uses them to spread to distant organs.
• Axillary dissection: removal of multiple lymph nodes if a lymphatic invasion is suspected. This surgery is much more complicated and risky.

Plastic surgery

Plastic surgery offers every woman to restore an attractive breast. Reconstruction is performed immediately after mastectomy or after treatment (delayed reconstruction).

Surgery for metastatic cancer

The chance of complete cure for breast cancer stage IV is minimal. But some surgical options may slow down the spread of disease or alleviate symptoms.

Surgery for metastatic cancer is indicated when:

• Metastases appear in the brain
• Tumors compress the nerves
• Bile ducts are blocked
• In open wounds, etc.

Radiotherapy for breast cancer in Germany

Radiation therapy destroys malignant cells and makes them susceptible to chemo. Doses and ways of irradiation depend on the stage of the disease, the involvement of lymph nodes, the presence of metastases, the age and general patient’s condition.

Radiation therapy can be used:

1. For metastatic breast cancer
2. After an organ-preserving surgery to minimize the risk of spreading
3. After total mastectomy, especially if lymph nodes are involved

There is external beam radiotherapy (when the source of radiation is outside the body) and internal radiotherapy (when the radioactive seeds are placed into the tumor).

The cost of radiotherapy for breast cancer in Germany is 8,000-15,000 euros.

Common types of external beam radiotherapy (EBRT):

• Hypofractionated radiotherapy: therapy requires fewer sessions with large single doses (3 weeks). Because of shorter course, side effects are usually mild, and the patient’s quality of life of is higher.
• Intraoperative radiotherapy (IORT): single exposure to a high dose during the surgery in the operating room. It is performed right after the resection, just before the sutures are applied.
• 3D-conformal radiation therapy: this is a high-precision technique that allows treating the “tumor bed” without unnecessary side effects. 3D-CRT is prescribed by an intensive course lasting about 5-6 days.



Among the most common side effects of external beam radiation therapy: skin burns, breast swelling, and general symptoms (weakness, fatigue).

Breast cancer brachytherapy

German clinics widely use intracavitary brachytherapy (ICBT). ICBT is the most often option. It’s quite painful and technically complex. The surgeon puts a tube with radioactive material in the resection cavity. The inner end is fixed in the cavity, and the outer end is led out the body to load the radioactive seeds. Possible side effects of brachytherapy include skin redness, bruises, high risk of infections, pain and swelling of the mammary gland, low rib bone density.

Hormonal therapy for breast cancer in Germany

About 65-70% of all breast malignancies depend on estrogen. When the doctors first learned this, many women removed the ovaries (oophorectomy) or irradiated them. But the resulting infertility became very problematic for young cancer survivors. Since the 1970s, “anti-hormonal” drugs have appeared (also called endocrine therapy). These agents stop or slow down the tumors growth, allowing preserving fertility and restoring reproductive function after the treatment course is over.

Like standard chemo, hormonal therapy works throughout the body, destroying even invisible microscopic neoplasms (micrometastases). Unlike highly toxic chemotherapy, “anti-hormonal” drugs do not attack healthy cells directly.

These drugs are usually well tolerated, and treatment can last 5-10 years.

Selective estrogen receptor modulators

This group (also called SERMs) does not affect the production of estrogen in the body. SERMs interact with specific receptors, blocking the stimulating effect of the hormone on the malignant cell.

Examples: tamoxifen and more potent fulvestrant.

Fulvestrant completely "cuts off" the estrogen receptors and causes them to degrade. The drug is prescribed for aggressive and metastatic breast cancer.

Side effects resemble the classical symptoms of menopause: hot flashes, night sweats, nausea, sleep disorders, depression, vaginal itching, thrombosis. Tamoxifen may cause endometrial hyperplasia and even endometrial cancer (rarely).

Aromatase inhibitors (AIs)

After menopause, the ovaries stop producing estrogen, but the hormone is still produced in small amounts by other tissues, such as muscles, fat and breast.

Aromatase inhibitors act on the key enzyme involved in the production of the female sex hormone. They are prescribed in the early stage of the disease. AIs reduce the risk of recurrence after surgery (adjuvant therapy), stop or slow down the growth of secondary tumors in metastatic breast cancer. When lymph nodes are involves, German oncologists recommend the following: aromatase inhibitors => tamoxifen (fulvestrant) if AIs are not working.

The side effects of aromatase inhibitors are similar to the tamoxifen. There are typical symptoms of menopause. Serious side effects, such as thrombosis, strokes and uterine cancers, are less common than with tamoxifen.

Examples of AIs: anastrozole, letrozole and exemestane.

GnRH analogues

GnRH analogues are very similar to the endogenous hormone of the hypothalamus gonadoliberin. This hormone is synthesized in the brain. Gonadoliberin controls the endocrine processes associated with the female reproduction. Analogues of gonadoliberin bind the receptors of GnRH in the pituitary gland, interfering with the real hormone. This stops the synthesis of estrogen.Suitable for patients before menopause. Used as adjuvant and palliative therapy, usually in combination with tamoxifen or aromatase inhibitors.

Side effects are typical for artificial menopause: hot flushes, sweating, vaginal dryness, headaches, depression, bone loss and fractures. Unlike ovarian removal, this “chemical” menopause is reversible. The menstrual cycle and fertility can be restored.

Examples of GnRH analogues: leuprorelin and goserelin.

How long does hormonal therapy last?

Adjuvant hormonal therapy usually takes five years. But recently German scientists have shown that 10-year prolonged therapy with tamoxifen significantly reduces the risk of cancer recurrence. Metastatic breast cancer is treated until the disease start to progress. If necessary, endocrine therapy is combined with targeted drugs and other therapeutic options.

Chemotherapy for breast cancer in Germany

People often associate chemotherapy with an incurable disease. This is a misconception. Chemo is prescribed not only for stages III and IV, but also for the early stage with appropriate indications. Chemotherapy drugs reduce the tumor before surgery and minimize the risk of recurrence after mastectomy. The surgeon's scalpel works only in a limited surgical field, but chemotherapy is distributed throughout the body. Toxic molecules destroy cancer cells, wherever they hide. Chemotherapy is the most powerful weapon against micrometastases that can’t be seen on MRI or CT.

Who is a candidate for chemo?

It is indicated to almost every patient. German oncologists do not prescribe chemotherapy only to women with the earliest stage of cancer (low risk).

Chemo is used in advanced breast cancer:

• if the rapid growth of a tumor becomes life threating
• if there are serious symptoms associated with metastases
• if previous hormonal therapy is no longer effective
• if the tumor is hormone-receptor-negative

What medications are used?

There are several classes of medications that interfere with the different phases of the cell cycle. Cytotoxic drugs suppress the proliferation of malignant cells. The faster the cell divides, the more successful chemo acts. Since malignant cells have a high rate of division, they are very susceptible to chemotherapy. But these drugs also affect healthy tissues, which are responsible for the typical side effects of chemotherapy: nausea, vomiting and hair loss.

Main types of chemotherapy drugs approved in Germany:

1. Alkylating agents, such as cyclophosphamide
2. Anthracycline derivatives: epirubicin, doxorubicin
3. Antimetabolites: 5-FU, capecitabine, methotrexate, gemcitabine
4. Platinum compounds, such as carboplatin and cisplatin
5. Taxanes: paclitaxel, docetaxel, (nab)-paclitaxel
6. Analogues of vinca alkaloids, including vinorelbine
7. Analogues of Halichondrin B: Eribulin (Halaven), etc.

Active scientific research adds to the clinical practice of new drugs and regimens of therapy every year. They are effective. Comfortable. Safe.

The cost of chemotherapy for breast cancer in Germany 1500 euros or more per course.

What are the side effects of chemotherapy?

Chemo attacks cells that quickly divide. These include hematopoietic cells of the bone marrow, mucous membrane of the gastrointestinal tract and hair follicles.

Common side effects of chemotherapy:

• Vomiting and nausea
• Weakness and fatigue
• Diarrhea, stomatitis, painful swallowing
• Hematopoietic suppression, severe anemia
• Immunodeficiency due to neutropenia
• Bleeding associated with thrombocytopenia
• Numbness in the arms and legs
• Temporary mental disorder
• Heart failure
• Hair loss
• Skin rash

After chemotherapy, the long-term risk of secondary cancer increases. There is also significant risk of ovarian failure and ovarian insufficiency (infertility, miscarriage). The effectiveness and safety of treatment depends on the professional level of medical personnel, the technical equipment of the clinic and the quality of monitoring.

Breast cancer targeted therapy in Germany

This is a relatively new molecular approach. Standard chemo attacks all cells in the body, while targeted drugs target specific tumor receptors. This option is much safer.

Since 2015, German clinics have been using:

• Monoclonal antibodies against HER2 receptors (trastuzumab, pertuzumab) or combinations of anti-HER2 antibodies with chemotherapeutic drugs.
• Tyrosine kinase inhibitors (lapatinib) that disrupt the transmission of key intracellular signals controlling growth and reproduction of malignant cells.
• Inhibitors of the intracellular signaling pathway mTOR (everolimus).
• CDK4 / 6 kinase inhibitors (palbociclib).
• Angiogenesis inhibitors (bevacizumab).

Numerous targeted drugs and regimens are currently being developed and will be introduced into clinical practice in the next few years.

Treatment of metastatic breast cancer

When malignant cells migrate through the lymphatic system and blood vessels to distant organs, they form metastases (secondary tumors). They colonize almost any organs and tissues, but most often bones, lungs, liver and brain.

Metastatic breast cancer is considered incurable.

The basis of treatment is chemotherapy, endocrine therapy and targeted drugs, acting on micrometastases throughout the body. Bisphosphonates (zoledronic acid) and RANK ligand inhibitors (denosumab) are used in palliative therapy of bone metastases.

Some metastases are treated with local therapy:

• Skin metastases: local chemotherapy, electrochemotherapy
• Peritoneal metastases: hyperthermic intraoperative intraperitoneal chemo is a modern technique that is used to treat peritoneal carcinomatosis (PC).

In some cases, skin, bone, liver, lung and brain metastases are treated with surgery. Radiotherapy is prescribed for bone and skin metastases, as well as secondary tumors in the brain or soft tissues (for example, in muscles). Palliative surgery and chemotherapy are also used.

Cost of diagnosis and breast cancer treatment in Germany

Efficacy and overall cost depend on the cancer stage. At stage I the five-year survival rate reaches 99-100%, and treatment is limited to organ-preserving surgery. But stage III-IV cancer requires huge expenses every month.

Approximate prices for diagnostic tests:

• Oncologist consultation: 500 euros
• Breast ultrasound: 300 euros or more
• Laboratory blood tests: 300 euros or more
• Computed tomography: 900 euros or more
• Magnetic resonance imaging: 1000 euros or more
• Positron emission tomography: 2000 euros or more
• Skeletal scintigraphy (bone metastases): 900 euros or more
• Punch biopsy and pathology: 1500 euros or more

Total cost of breast cancer diagnosis in Germany is about 3000-5000 euros, including oncologist consultations, diagnostic imaging and a minimally required lab tests.

Approximate prices for treatment:

• Radiotherapy: 8000 to 15000 euros or more
• Surgical resection (mastectomy): 10,000 to 20,000 euros or more
• Chemotherapy: 1500 to 5000 euros or more per course
• Immunotherapy: 2000 euros or more

Total cost of breast cancer treatment in Germany start from 10-15 thousand euros for the early stages to tens of thousands of euros per year for metastatic disease.

© Analytical reviews and oncology news by K. Mokanov: clinical pharmacist and professional medical translator