Your doctor determines your breast cancer treatment options based on your type of breast cancer, its stage and grade, whether the cancer cells are sensitive to hormones, your overall health and your own preferences. Most women undergo surgery for breast cancer and also receive additional treatment, such as chemotherapy, hormone therapy or radiation.
There are many options for breast cancer treatment, and you may feel overwhelmed as you make complex decisions about your treatment. Consider seeking a second opinion from a breast specialist in a breast center or clinic. Talk to other women who have faced the same decision.
Breast cancer surgery
Operations used to treat breast cancer include:
- Removing the breast cancer (lumpectomy). During lumpectomy, which may be referred to as breast-sparing surgery or wide local excision, the surgeon removes the tumor and a small margin of surrounding healthy tissue. Lumpectomy is typically reserved for smaller tumors.
- Removing the entire breast (mastectomy). Mastectomy is surgery to remove all of your breast tissue. Most mastectomy procedures remove all of the breast tissue — the lobules, ducts, fatty tissue and some skin, including the nipple and areola (simple mastectomy). In a skin-sparing mastectomy, the skin over the breast is left intact to improve reconstruction and appearance.
- Removing a limited number of lymph nodes (sentinel node biopsy). To determine whether cancer has spread to your lymph nodes, your surgeon will discuss with you the role of removing the lymph nodes that receive the lymph drainage from your tumor. If no cancer is found in those lymph nodes, the chance of finding cancer in any of the remaining lymph nodes is small and no other nodes need to be removed.
- Removing several lymph nodes (axillary lymph node dissection). If cancer is found in the sentinel node, your surgeon will discuss with you the role of removing additional lymph nodes in your armpit.
- Removing both breasts. Some women with cancer in one breast may choose to have their other (healthy) breast removed (contralateral prophylactic mastectomy) if they have a very increased risk of cancer in the other breast. Discuss your breast cancer risk with your doctor, along with the benefits and risks of this procedure.
Complications of breast cancer surgery depend on the procedures you choose. Surgery carries a risk of bleeding and infection.
Some women choose to have breast reconstruction after surgery. Discuss your options and preferences with your surgeon. Consider a referral to a plastic surgeon before your breast cancer surgery. Your options may include reconstruction with a synthetic breast implant or reconstruction using your own tissue. These operations can be performed at the time of your mastectomy or at a later date.
Radiation therapy uses high-powered beams of energy, such as X-rays, to kill cancer cells. Radiation therapy is typically done using a large machine that aims the energy beams at your body (external beam radiation). But radiation can also be done by placing radioactive material inside your body (brachytherapy).
External beam radiation is commonly used after lumpectomy for early-stage breast cancer. Doctors may also recommend radiation therapy after mastectomy for larger breast cancers or cancers that have spread to the lymph nodes.
Side effects of radiation therapy include fatigue and a red, sunburn-like rash where the radiation is aimed. Breast tissue may also appear swollen or more firm. Rarely, more-serious problems may occur, such as damage to the heart or lungs or, very rarely, second cancers in the treated area.
Chemotherapy uses drugs to destroy cancer cells. If your cancer has a high risk of returning or spreading to another part of your body, your doctor may recommend chemotherapy to decrease the chance that the cancer will recur. This is known as adjuvant systemic chemotherapy.
Chemotherapy is sometimes given before surgery in women with larger breast tumors. The goal is to shrink a tumor to a size that makes it easier to remove with surgery.
Chemotherapy is also used in women whose cancer has already spread to other parts of the body. Chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer is causing.
Chemotherapy side effects depend on the drugs you receive. Common side effects include hair loss, nausea, vomiting, fatigue and an increased risk of developing infection. Rare side effects can include premature menopause, damage to the heart and kidneys, nerve damage, and, very rarely, blood cell cancer.
Hormone therapy — perhaps more properly termed hormone-blocking therapy — is often used to treat breast cancers that are sensitive to hormones. Doctors sometimes refer to these cancers as estrogen receptor positive (ER positive) and progesterone receptor positive (PR positive) cancers.
Hormone therapy can be used after surgery or other treatments to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control it.
Treatments that can be used in hormone therapy include:
Medications that block hormones from attaching to cancer cells. Selective estrogen receptor modulator (SERM) medications act by blocking estrogen from attaching to the estrogen receptor on the cancer cells, slowing the growth of tumors and killing tumor cells. SERMs, which can be used in both pre- and postmenopausal women, include tamoxifen, raloxifene (Evista) and toremifene (Fareston).
Possible side effects include hot flashes, night sweats and vaginal dryness. More significant risks include blood clots, stroke, uterine cancer and cataracts.
- Medications that stop the body from making estrogen after menopause. Called aromatase inhibitors, these drugs block the action of an enzyme that converts androgens in the body into estrogen. These drugs are effective only in postmenopausal women. Aromatase inhibitors include anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin). Side effects include hot flashes, night sweats, vaginal dryness, joint and muscle pain, as well as an increased risk of bone thinning (osteoporosis).
- A drug that targets estrogen receptors for destruction. The drug fulvestrant (Faslodex) blocks estrogen receptors on cancer cells and signals to the cell to destroy the receptors. Fulvestrant is used in postmenopausal women. Side effects that may occur include nausea, hot flashes and joint pain.
- Surgery or medications to stop hormone production in the ovaries. In premenopausal women, surgery to remove the ovaries or medications to stop the ovaries from making estrogen can be an effective hormonal treatment.
Targeted drug treatments attack specific abnormalities within cancer cells. Targeted drugs approved to treat breast cancer include:
May. 22, 2013
- Trastuzumab (Herceptin). Some breast cancers make excessive amounts of a protein called human growth factor receptor 2 (HER2), which helps breast cancer cells grow and survive. If your breast cancer cells make too much HER2, trastuzumab may help block that protein and cause the cancer cells to die. Side effects may include headaches, diarrhea and heart problems.
- Pertuzumab (Perjeta). Pertuzumab targets HER2 and is approved for use in metastatic breast cancer in combination with trastuzumab and chemotherapy. This combination of treatments is reserved for women who haven't yet received other drug treatments for their cancer. Side effects of pertuzumab may include diarrhea, hair loss and heart problems.
- Ado-trastuzumab emtansine (Kadcyla). This drug combines trastuzumab with a cell-killing drug. When the combination drug enters the body, the trastuzumab helps it find the cancer cells because it is attracted to HER2. The cell-killing drug is then released into the cancer cells. Ado-trastuzumab emtansine may be an option for women with metastatic breast cancer who've already tried trastuzumab and chemotherapy.
- Lapatinib (Tykerb). Lapatinib targets HER2 and is approved for use in advanced or metastatic breast cancer. Lapatinib can be used in combination with chemotherapy or hormone therapy. Potential side effects include diarrhea, painful hands and feet, nausea, and heart problems.
- Bevacizumab (Avastin). Bevacizumab is no longer approved for the treatment of breast cancer in the United States. Research suggests that although this medication may help slow the growth of breast cancer, it doesn't appear to increase survival times.
- Breast cancer. Fort Washington, Pa.: National Comprehensive Cancer Network. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp. Accessed March 13, 2013.
- Townsend CM Jr., et al. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 19th ed. Philadelphia, Pa.: Saunders Elsevier; 2012. http://www.mdconsult.com/das/book/body/208746819-6/0/1565/0.html. Accessed March 13, 2013.
- Breast cancer treatment (PDQ). National Cancer Institute. http://cancer.gov/cancertopics/pdq/treatment/breast/Patient. Accessed March 18, 2013.
- Leading new cancer cases and deaths — 2013 estimates. American Cancer Society. http://www.cancer.org/research/cancerfactsfigures/cancerfactsfigures/cancer-facts-figures-2013-most-requested-tables-figures. Accessed March 18, 2013.
- SEER stat fact sheet: Breast. National Cancer Institute. http://seer.cancer.gov/statfacts/html/breast.html. Accessed March 18, 2013.
- Breast cancer prevention (PDQ). National Cancer Institute. http://cancer.gov/cancertopics/pdq/prevention/breast/Patient. Accessed March 13, 2013.
- What you need to know about breast cancer. National Cancer Institute. http://cancer.gov/cancertopics/wyntk/breast. Accessed March 13, 2013.
- Hormone therapy for breast cancer. National Cancer Institute. http://cancer.gov/cancertopics/factsheet/Therapy/hormone-therapy-breast. Accessed March 18, 2013.
- Cancer-related fatigue. Fort Washington, Pa.: National Comprehensive Cancer Network. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp. Accessed March 18, 2013.
- AskMayoExpert. Mammogram screening guidelines. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2012.
- Faslodex (prescribing information). Wilmington, Del.: AstraZeneca; 2012. http://www.faslodex.com. Accessed March 18, 2013.
- Herceptin (prescribing information). South San Francisco, Calif.: Genentech, Inc.; 2010. http://www.herceptin.com. Accessed March 18, 2013.
- Perjeta (prescribing information). South San Francisco, Calif.: Genentech, Inc.; 2012. http://www.perjeta.com. Accessed March 18, 2013.
- Kadcyla (prescribing information). South San Francisco, Calif.: Genentech, Inc.; 2013. http://www.kadcyla.com. Accessed March 18, 2013.
- Tykerb (prescribing information). Research Triangle Park, N.C.: GlaxoSmithKline; 2012. http://www.tykerb.com. Accessed March 18, 2013.
- Breast SPOREs. National Cancer Institute. http://trp.cancer.gov/spores/breast.htm. Accessed March 19, 2013.
- Moynihan TJ (expert opinion). Mayo Clinic, Rochester, Minn. March 19, 2013.
- Pruthi S (expert opinion). Mayo Clinic, Rochester, Minn. March 21, 2013.