The Screening, Diagnosis, Treatment, and Follow-Up of Breast Cancer

Abstract

Background: Breast cancer is the most common cancer in women. The German S3 guideline of 2012 has now been updated to take account of advances in the early detection, diagnostic evaluation, treatment, and follow-up care of this disease.

Methods: The updating process was based on the adaptation of identified source guidelines and on reviews of the scientific evidence. A systematic search in multiple literature databases was carried out, and the full texts of the selected articles were evaluated. Suggested recommendations were then proposed by interdisciplinary working groups and modified and graded in a nominal consensus procedure.

Results: The value of mammographic screening is confirmed in the updated guideline. As for the diagnostic evaluation of breast cancer, computed tomography is recommended for staging in patients with a high risk of recurrence, in addition to conventional methods. As for surgical treatment, the evidence supporting locoregional surgery for primary breast cancer now affords an opportunity for de-escalation: complete resection yields the best outcome, but a safety margin of several millimeters is not necessary. Axillary dissection is no longer recommended except in certain defined situations. Radiotherapeutic approaches consist of hypofractionated applications. Adjuvant systemic therapy is indicated for patients in certain high-risk situations defined by a constellation of factors including tumor grade, patient age, node status, Ki-67 antigen expression, hormone receptor status, and human epidermal growth factor receptor 2 (HER2) status. All patients with hormone receptor-positive breast cancer should receive endocrine therapy. The indication for chemotherapy and/or anti-HER2 therapy should be determined in consideration of the expected benefit and side effects.

Conclusion: Consistent implementation of the recommendations in the newly updated guideline can help lessen morbidity and mortality from breast cancer. The actual extent to which breast cancer guidelines are implemented should be a topic of future research.

Figure 1

Relative 5-year survival in breast cancer patients according to tumor stage and malignancy grade. This representation does not form part of the guidelines, but serves to illustrate the prognosis of breast cancer patients (RKI Report on Cancer in Germany 2016). UICC I: T1 N0 M0; UICC IIA: T0/T1 N1 M0, T2 N0 M0; UICC IIB: T2 N1 M0, T3 N0 M0; UICC IIIA: T0–T2 N2 M0, T3 N1 M0; UICC IIIB: T4 N0–2 M0; UICC IIIC: T1–T4 N3 M0; UICC IV: T1–T4 N0–N2 M1 UICC, Union Internationale Contre le Cancer RKI, Robert Koch Institute

Figure 2

The guideline takes into account the complexity of modern surgical procedures (from Hoffmann and Wallwiener 2009 [39]) DIEP, deep inferior epigastric perforator; LDF, latissimus dorsi flap; BCS, breast cancer surgery; SGAP, superior gluteal artery perforator; SIEA, superficial inferior epigastric artery flap; TRAM, transverse rectus abdominis myocutaneous