Breast Cancer Treatment

Today, most women with breast cancer are diagnosed at an early stage and they benefit from newer, more effective treatments. There are treatments available for patients at all stages of breast cancer. Often, more than one type of treatment is needed.

Questions and Expectations

Ask Questions

After looking at your test results, the doctor will tell you the stage of your cancer. Be sure to ask your doctor to explain your stage in a way you understand. This will help you both decide on the best treatment for you.

Each type of treatment has benefits and drawbacks. There may be side effects. Your age, your overall health, and the stage of your cancer are all factors to consider. If you would like to talk to another woman who has had breast cancer, the American Cancer Society can connect you with a volunteer in the Reach to Recovery program. Visits may be face to face, or via phone. Visitors are trained to provide current information, both before and after treatment.

About Local and Systemic Therapies

The purpose of local therapy is to treat the main (primary) breast tumor. Surgery and radiation therapy are examples of local therapies. Systemic therapy is given through the bloodstream to reach cancer cells that may have spread beyond the breast. Chemotherapy, hormonal therapy, and immunotherapy are systemic therapies.

Post-Treatment Expectations

Treatments have changes over time. Today, many women who are diagnosed with breast cancer do not have to lose a breast. Because there are improved ways to treat breast cancer, it is more important than ever for you to learn all you can. Working with your team of medical specialists, you can play a key role in choosing the treatment that is best for you.

Once your doctor has determined your specific type and stage of breast cancer, you can begin to plan for your treatment and recovery. Your chance of recovery will depend on many factors, including:

The type and stage of your cancer (what kind of cancer; the size of the tumor; and whether it is only in your breast, or has spread to any lymph nodes or to other parts of your body).
How fast the cancer is growing. Special lab tests on the tissue can measure how fast the cancer cells are dividing and how different they are compared to normal breast cells.
How much the breast cancer cells depend on female hormones (estrogen and progesterone) for growth, which can be measured by hormone receptor tests. Patients whose tumors are found to be dependent on hormones (described as estrogen-positive or progesterone-positive) can be treated by hormonal therapy to prevent further growth or recurrence of breast cancer.
Your age and menopausal status (whether or not you still have monthly menstrual periods.)
Your general state of health.

Local Treatments

Surgery

Most women with breast cancer will have some type of surgery. The purpose of surgery is to remove as much of the cancer as possible. Most women can choose between breast-conserving surgery (lumpectomy with radiation therapy) or removal of the breast (mastectomy). Surgery may also be combined with other treatments like chemotherapy, hormone therapy, or radiation therapy.

Surgery may also be done to find out whether breast cancer has spread to the lymph nodes under the arm (axillary dissection), to restore a more normal appearance (reconstructive surgery), or to relieve symptoms of advanced cancer.

Surgical Procedures

Breast Conserving Surgery
Lumpectomy: The surgeon removes the breast cancer and some normal tissue around it (in order to get clear margins). This procedure usually results in removing all the cancer, while leaving you with a breast that looks much the same as it did before surgery. Usually, the surgeon also takes out some of the lymph nodes under the arm to find out if the cancer has spread. Women who have lumpectomies almost always have radiation therapy as well. Radiation therapy is used to destroy any cancer cells that may now have been removed by surgery.

Partial or segmental mastectomy: Depending on the size and location of the cancer, this surgery can conserve much of the breast. The surgeon removes the cancer, some of the breast tissue, the lining of the chest muscles below the tumor, and usually some of the lymph nodes under the arm. In most cases, radiation therapy follows.

Mastectomy
Total (or simple) mastectomy: The surgeon removes the entire breast. Some lymph nodes under the arm may be removed, also.

Modified radical mastectomy: The surgeon removes the breast, some of the lymph nodes under the arm, and the lining over chest muscles, and sometimes part of the chest wall muscles.

Radical mastectomy: The surgeon removes the breast, chest muscles, and all the lymph nodes under the arm. This was the standard operation for many years, but it is used now only when a tumor has spread to the chest muscles.

A mastectomy may be recommended when:

Cancer is found in more than one part of the breast.
The breast is small or shaped so that the lumpectomy would leave little breast tissue or a very deformed breast.
A woman chooses not to have radiation therapy.
A woman prefers a mastectomy.

Removal of Lymph Nodes
Whether you have a lumpectomy or mastectomy, your surgeon will probably remove some of the lymph nodes under our arm. This procedure is usually done at the same time as the breast surgery to check if the cancer has spread outside the breast. Clear lymph nodes are reported as negative nodes. If cancer is found, you have positive nodes. Your doctor will talk with you about any additional treatments needed to destroy and control cancer cells.

Sentinel Lymph Node Biopsy
Surgeons are investigating a new procedure in cancer patients used to detect lymph node involvement. In this procedure, either a blue dye or a small amount of radioactive material is injected around the tumor site. The surgeon performs a small incision in the axillarly underarm area looking for a lymph node containing the blue dye or uses a scanner to locate the radioactive material. The lymph node(s) where the dye first accumulates after leaving the tumor region is called the "sentinel node(s)." This node(s) is then surgically removed and examined by a pathologist. If it is positive for cancer cells, then the rest of the nodes are usually removed; if it is negative, the remaining lymph nodes may not have to be removed.

Results/Side Effects
As in any kind of surgery, there is a risk of infection, poor wound healing, bleeding, or a reaction to the anesthesia used in surgery. There may be a collection of fluid under the skin; or tingling, numbness, stiffness, weakness, or swelling of the arm. Physical therapy and exercise can help to restore arm movement and strength.

After a mastectomy, a woman may choose to:

Wear a breast form, called a prosthesis, which fits in her bra. To find stores that have breast forms and fitters, talk with your doctor, nurse, or a volunteer from the American Cancer Society Reach for Recovery program or other breast cancer organization, or other women who have had breast cancer.
Have her breast reconstructed by a plastic surgeon.
Do neither.

Some health insurance plans pay for all or part of the costs of a prosthesis or for breast reconstruction. However, there may be health insurance rules about where a woman can have breast reconstruction surgery or where to buy a prosthesis. For details about your health plan coverage, contact your insurance company.

After underarm lymph nodes are removed, your arm will have to be protected for the rest of your life.

Lymphedema
The lymph nodes under your arm drain lymph fluid from your chest and arm. Both surgery and radiation therapy can change the normal drainage pattern. This can result in a swelling of the arm called lymphedema. The problem can develop right after surgery or months to years later.

Treatment of lymphedema depends on how serious the problem becomes. Options include an elastic sleeve, an arm pump, arm massage, and bandaging the arm. Exercise and diet also are important. If you have this problem, talk with your doctor and see a physical therapist as soon as possible. Many hospitals and breast clinics offer help with lymphedema. There is no cure for this condition, so you should do what you can do to prevent it.

To help prevent or control lymphedema and to protect your arm after treatment:

Carry packages or handbags on the other arm or shoulder.
Avoid sunburns and burns to your affected arm and hand.
Have shots (including chemotherapy), blood draws, and blood pressure tests done on the other arm.
Avoid cuts when shaving underarms; use an electric shaver.
Wash cuts promptly, apply antibacterial medication, and cover with a bandage. Call your doctor if you think that you have an infection.
Wear gloves to protect your hands when gardening and when using strong detergents.
Avoid wearing tight jewelry on your affected arm; avoid elastic cuffs on blouses and nightgowns.
Have careful manicures; avoid cutting your cuticles.

Prognosis
Surgery does not guarantee that cancer will not recur. Whichever choice you make, you will need close medical follow-up for the rest of your life.

Local Treatments (continued)

Radiation Therapy

During radiation therapy, high-energy x-rays are used to destroy cancer cells that still may be present in the affected breast or in nearby lymph nodes.

Radiation therapy is sometimes used to shrink tumors before surgery. Doctors sometimes use radiation therapy along with chemotherapy, before or instead of surgery, to destroy cancer cells and shrink tumors.

Radiation Therapy Procedures:

Radiation Therapy After Lumpectomy
In radiation therapy after a lumpectomy, a machine delivers radiation to the affected breast and, in some cases, to the lymph nodes under the arm or at the collarbone (clavicle). The usual schedule for radiation therapy is 5 days a week for 5 to 6 weeks. The actual treatment, given by a radiation therapist, takes only a few minutes each day. Sometimes an additional "boost" or higher dose of radiation is given to the area where the cancer was found.

During your first visit for radiation treatment planning, your chest area will be marked with ink or with a few long-lasting tattoos. These marks must stay on your skin during the entire treatment period because they show exactly where the radiation will be given. Your radiation oncologist will plan your specific treatment based on a physical exam, mammograms, pathology and lab reports, and your medical history. Doctors carefully limit both the intensity of each treatment and the area being treated so that the least amount of normal tissue will be affected. Throughout your therapy, your radiation oncologist will check on the effects of your treatment, and you will have regular physical exams and blood tests to check your general health. To get the full benefit from radiation therapy, you need to complete all your treatments as scheduled.

Radiation Therapy After Mastectomy
There are times when radiation therapy is used after a mastectomy. It may be used if:

The tumor is larger than 2 inches.
Cancer is found in many lymph nodes under the arm.

The tumor is close to the rib cage or chest wall muscles.

Results/Side Effects
Feeling more tired than usually; skin problems such as itchiness, redness, soreness, peeling, darkening, or shininess of the skin; or decreased sensation in the breast. Radiation to the breast does not cause hair loss, vomiting, or diarrhea.

Long-term changes may include changes in the shape and color of the treated breast or a feeling of heaviness in the breast. Once a breast has been irradiated, it cannot be irradiated again. Any local recurrence or new tumor would have to be treated by mastectomy.

Treatment of axillary lymph nodes can also cause swelling of the arm caused by fluid retention. This condition, known as lymphedema, can occur right after the surgery or months or even years later. If you notice a feeling of tightness around the arm or hand on the same side as the breast cancer, talk to your doctor or nurse promptly.

Systemic Treatments

Chemotherapy

Chemotherapy refers to the use of anticancer drugs to kill cancer cells. The drugs are given in the form of shots or pills. They enter the bloodstream and reach all areas of the body.

Research suggests that, even if a lump is small, cancer cells may have spread outside the breast. Doctors can use chemotherapy drugs to destroy cancer cells. Some chemotherapy drugs work better when combined with other chemotherapy drugs than when used alone.

Chemotherapy is used to:

Decrease the chances that cancer will come back after breast cancer surgery.
Shrink breast cancer before surgery, when the tumor is large or it is inflammatory cancer.
Control the disease when breast cancer is found in the lungs, bones, liver, brain, or other parts of the body.

Chemotherapy Procedures
The oncologist will recommend a treatment plan according to your individual case. The treatment will depend on your age, whether or not you are still having periods, the risk for spread or recurrence, and your general health. The drugs you take will depend on the type and stage of cancer, where it is located, how much or how fast it has grown, and how it is affecting you.

When chemotherapy is given after surgery (adjuvant therapy) it can reduce the chance of breast cancer coming back. Chemotherapy can also be used as the main treatment for women whose cancer is widespread when it is found or spreads widely after initial treatment.

Neoadjuvant chemotherapy means that it is given before surgery, often to shrink the tumor and make it easier to remove. Another advantage of neoadjuvant chemotherapy is that the doctors can watch how the tumor responds to the drugs. If the tumor does not shrink, different drugs can be used.

Chemotherapy drugs travel throughout the body to slow the growth of cancer cells or kill them. Often, the drugs are injected into the bloodstream through an intravenous (IV) needle that is inserted into a vein. Some drugs are given as pills. Treatment can be as short as a few months or as long as 2 years.

Chemotherapy is usually given in cycles during which you have treatment for a period of time, and then you have a few weeks to recover before your next treatment. Depending on the drugs you take, you may have your chemotherapy at home, in your doctor?s office, in a clinic, in a hospital?s outpatient department, or in a hospital. How often and how long you have chemotherapy will depend on the type and stage of breast cancer, the drugs that are used and how your body responds to them, and the goals of the treatment. You should follow the schedule prescribed by your doctor.

Throughout chemotherapy, your oncologist and nurse will watch how you respond to the therapy. You will have frequent physical exams and blood tests. You should check with your doctor before taking any other medications during your treatment.

Chemotherapy affects all fast-growing cells throughout the body. Therefore, in addition to killing cancer cells, it also kills fast-growing normal cells. This is what may cause side effects such as hair loss, mouth sores, and fatigue. Today, because of that has been learned in research studies, doctors are able to control, lessen, or avoid many side effects of chemotherapy.

Results/Side Effects
Chemotherapy can cause short-term and long-term side effects that are different for each patient, depending on the drugs used.

The most common short-term side effects that may appear during chemotherapy include: loss of appetite, nausea, vomiting, diarrhea, constipation, fatigue, infections, bleeding, weight change, mouth sores, and throat soreness. Some of these problems may continue for some time after chemotherapy ends.

Some drugs cause short-term hair loss. Hair will grow back either during treatment or after treatment is completed. Before you start chemotherapy, you may want to have your hair cut short, or buy a wig, hat, or scarves that you can wear while you are going through treatment.

Serious long-term side effects may include weakening of your heart, damage to your ovaries, infertility, early menopause, or second cancers such as leukemia (cancer of the blood). These side effects may not appear until later, some time after chemotherapy is completed.

Fighting Infections
You are more likely to get infections during chemotherapy, and your body is less able to fight infections during this time. You can help yourself stay healthy by following these steps:

Finish dental work before starting chemotherapy. You cannot have dental work during chemotherapy.
Eat a healthy diet and get plenty of rest.
Stay away from large crowds and from anyone with a cold, infection, or contagious disease.
Bathe daily, wash your hands often, and follow good mouth care.
Wear work gloves to protect your hands against cuts and burns.
If you cut yourself, keep the wound clean and covered. Talk with your doctor or nurse about applying antibiotics or medication.

Pregnancy
During chemotherapy you may stop having monthly menstrual periods. You still can get pregnant, however, so talk with your doctor about birth control. The effect of chemotherapy on an unborn baby is unknown. After your treatment is over, your ability to get pregnant will depend on your age and the types of drugs you received. If you hope to become pregnant after treatment, talk with your doctor before starting chemotherapy.

Managing Nausea
Feeling nauseous, or as if you have to vomit, is a common side effect of chemotherapy. Your doctor can prescribe medication to help with this problem. Good nutrition is especially important during cancer treatment. The following suggestions may help:

Eat small meals often; do not eat 3 to 4 hours before your treatment.
Eat whatever you can tolerate; for example, popsicles, gelatin, desserts, cream of wheat, oatmeal, baked potatoes, and fruit juices mixed with water.
Chew your food thoroughly and try to relax during meals.
Learn stress reduction exercises such as relaxation, meditation, and deep breathing.

Systemic Treatments (continued)

Hormonal Therapy

Hormonal therapy is used to prevent the growth, spread, or recurrence of breast cancer.

The female hormone estrogen can increase the growth of breast cancer cells in some women. If lab test show that your tumor depended on your natural hormones to grow, it will be described as estrogen-positive or progesterone-positive in the lab report. This means that any remaining cancer cells may continue to grow then these hormones are present in your body. Hormonal therapy can block your body?s natural hormones from reaching any remaining cancer cells may continue to grow when these hormones are present in your body. Hormonal therapy can block your body?s natural hormones from reaching any remaining cancer cells.

Hormonal Therapy Procedures
A drug such as tamoxifen, which blocks the effect of estrogen, is given to counter this growth. Tamoxifen is taken in pill form, usually for five years. Recent studies have clearly shown that women with early breast cancer are helped by this drug regardless of their age.

Another drug, raloxifene, also blocks the effect of estrogen on breast tissue and breast cancer. It is now being tested to see if it can reduce women's risk of developing breast cancer. At this time it is not recommend as hormonal therapy for women who already have breast cancer.

You may have surgery to remove both ovaries that produce natural hormones.

Results/Side Effects
Side effects could include hot flashes, nausea, vaginal spotting (small amounts of blood) or increased fertility in younger women. Less common side effects include depression; vaginal itching, bleeding, or discharge; loss of appetite; eye problems; headache; and weight gain.

Like chemotherapy, hormonal therapy affects cells throughout your body. Studies have shown that there is some increased risk for cancer of the uterus. Blood clots have been reported in the veins of a small percentage of patients who take tamoxifen along with chemotherapy. These risks, however, are much lower than the benefits received from tamoxifen.

Of course, you will have frequent blood test and physical exams while you are on hormonal therapy. Be sure your gynecologist and primary care doctor know you are taking this drug. You should have yearly pelvic exams while taking tamoxifen, and you should notify your doctor about any unusually bleeding or pain.

Prognosis
Research has proven that hormonal therapy can extend the life span of a breast cancer patient who has cancer cells that depend on hormones to grow. Tamoxifin has been used for nearly 20 years to treat patients with advanced stage breast cancer. Now it is being used also as additional treatment for early stage disease after breast cancer is removed by surgery. Clinical trials show that taking Tamoxifin as part of the treatment for breast cancer helps to reduce the chances of recurrence in the treated breast and of new cancer developing in the other breast.

Systemic Treatments (continued)

Immunotherapies

Medical researchers are looking at many types of biological therapies that use and boost the substances produced naturally by the body?s own cells. They are also creating new substances that can imitate or help the body?s naturally immune system to work against infection and disease. These are being used in clinical trials with chemotherapy and radiation therapy.

Your own immune system is your body?s naturally defense against diseases, including cancer. Your immune system also defends your body against infections and other side effects of cancer treatment. A strong immune system detects the difference between healthy cells and cancer cells, and it can get rid of those that become cancer. The immune system can be strengthened and improved by new biological therapies. These treatments are designed to repair, stimulate, or increase your body?s natural ability to fight infections and cancer.

Procedures
Trastuzumab (Herceptin) is a drug that attaches to a growth-promoting protein known as HER2/nue, which is present in small amounts on the surface of normal breast cells and most breast cancers. This protein can cause the cancer to grow and spread faster. Herceptin can stop the HER2/nue protein from causing breast cancer cell growth. It may also help the immune system to better attack the cancer.

Herceptin is generally started after standard hormonal or chemotherapy is no longer working, but studies are going on now to see if it should be added to the first course of chemotherapy.

Results/Side Effects
Biological therapies may produce side effects such as rashes or swellings at the site where shots are given; flu-like symptoms, including fever, chills and fatigue; digestive tract problems; or allergic reactions.

The side effects of Herceptin are fairly mild; they may include fever and chills, weakness, nausea, vomiting, cough, diarrhea, and headache.

Advanced Treatments

High Dose Chemotherapy

In breast cancer treatment clinical trials, researchers at NCI and other health institutions are testing high-dose chemotherapy to find out if it is better than standard chemotherapy. They are trying to learn if higher doses of drugs can prevent or delay the spread or return of breast cancer better than standard doses of drugs, and which type of treatment helps patients live longer.

Results/Side Effects
Patients who receive high-dose chemotherapy are at great risk of suffering life-threatening side effects because the treatment damages their bone marrow and they no longer are able to produce needed blood cells. To help repair the damage done by high doses of drugs, the treatment includes peripheral blood stem cell transplantation and/or bone marrow transplantation.

Advanced Treatments (Continued)

Peripheral (Autologous) Blood Stem Cell Transplant

Peripheral blood stem cell transplantation involves the removal of a certain type of blood cell (stem cell) from a patient?s blood. Stem cells are immature cells from which all blood cells develop as they are needed. Stem cells are able to divide and form more stem cells (copies of themselves) or they can become fully mature red blood cells (erythrocytes), platelets, and white blood cells (leukocytes).

Procedure
The removed stem cells are frozen and stored while the patient is treated with high-dose chemotherapy. After chemotherapy ends and the drugs are gone from the body, the stem cells are returned to the patient through a vein. The healthy stem cells can then begin to grow and produce all types of blood cells the patient need to survive.

Results/Side Effects
It hasn?t been proven yet whether high-dose chemotherapy is better than standard chemotherapy, or which breast cancer patients need this treatment. It is best to have high-dose chemotherapy at an established transplant center or medical institution conducting a clinical trial. Some health insurance plans pay for some of the costs of peripheral blood stem cell or bone marrow transplantation.

Advanced Treatments (Continued)

Bone Marrow Transplant

Bone marrow is the sponge-like material found inside bones that produces blood cells. Autologous bone marrow transplantation is used in breast cancer treatment.

Procedure
Some of a patient?s own healthy bone marrow is removed with a needle before treatment begins. The bone marrow is then frozen and stored while the patient is treated with high-dose chemotherapy. Several days after the treatment ends and the drugs are gone from the body, the healthy bone marrow is given back to the patient through a vein. The healthy bone marrow can then begin to produce blood cells that the patient needs to survive. Peripheral blood stem cells and bone marrow transplantation may be used together as part of high-dose chemotherapy.

There are major risks involved with high-dose chemotherapy. Talk with your doctor about possible complications and severe side effects, and whether this would be an appropriate treatment for your type and stage of breast cancer.

Advanced Treatments (Continued)

Reconstructive Surgery

Breast reconstruction (surgery to rebuild a breast?s shape) is often an option after mastectomy. Some health insurance plans pay for all or part of the cost of breast reconstruction and, also, for surgery to the other breast so that both breasts are about the same shape and size.

Reconstruction will not give you back your breast. Although the reconstructed breast will not have natural sensation, the surgery can give you result that looks like a breast. If you are thinking about reconstruction, you should talk with a plastic surgeon before your mastectomy. Ask your surgeon for a referral to an experienced plastic surgeon. Some women begin reconstruction at the same time as the mastectomy is done; others wait several months or even years.

Procedures
A plastic surgeon is able to form a breast mound by using an implant or by using tissues from another part of your body. Breast implants are silicone sacs filled with saline (salt water) or silicone gel. The sacs are placed under your skin behind your chest muscle. Your body type, age, and cancer treatment will determine which type of reconstruction will give you the best result.

Saline-filled breast implants are available for anyone who wants them. Some scientists are concerned about possible short-term and long-term health problems associated with silicone gel-filled breast implants. The Food and Drug Administration (FDA) has decided that breast implants fill with silicone gel may be used only in an FDA-approved clinical trial. Your surgeon can determine if you are eligible and can make arrangements for you to join the study.

A flap (section) of skin, muscle, and fat can be moved from another part of the body to the chest area where it is formed to create a breast shape. This tissue can be taken from the lower abdomen, back, or buttocks. Choose a plastic surgeon who has been trained in this procedure and has performed it successfully on many women. Of course, you will need to have regularly scheduled follow-up care and mammograms.

Most women who have breast reconstruction are happy with their decisions. A woman starting this process, however, should know that breast reconstruction requires nothing more than one surgery. Extra steps may include:

Adding a nipple.
Changing the shape or size of the reconstructed breast.
Surgery on the opposite breast to create a good match.

With most of these extra surgeries, you can go home the same day as the operation.

Results/Side Effects
As with any surgery, you may have some pain, swelling, bruising, and tenderness. These problems should disappear as you recover. Scars will fade over time. You should let your doctor know immediately about any fever, infection, or bleeding.

Side effects that could appear later with implants include rupture, leakage, deflation or shifting of the implant, or interference with mammography readings. Breast implants age over time and may need to be replaced.

Tissue flap reconstruction is a major operation, resulting in large surgical wounds. If there is a poor blood supply to the flap tissue, part or all of the tissue in the breast area may not survive the transplant. Infection and poor wound healing are possible problems.

Complimentary Therapies

In addition to medical treatment, some cancer patients want to try complementary therapies. Complementary therapies include acupuncture, herbs, biofeedback, visualization, meditation, yoga, nutritional supplements, and vitamins. Some breast cancer patients feel that they benefit from some of these therapies.

Before you try any of these therapies, you should discuss their possible value and side effects with your medical doctors. You should let them know if you are using any such therapies. These therapies should never be used instead of medical treatment. Be aware that these therapies may be expensive and some are not paid for by health insurance. You should consider asking the therapist for evidence of how the therapy has helped others, possibly by giving you references.