Breast cancer: Treatments

Treatment of breast cancer depends on the stage of your cancer and factors such as your age, menopause status and overall health.

Local treatments, which include surgery and radiation therapy, treat the breast and surrounding lymph nodes. Systemic treatments, including chemotherapy and hormone therapy, treat the whole body and reduce the risk of the cancer appearing elsewhere.

Breast cancer is often treated with surgery followed by another treatment, called adjuvant therapy. Adjuvant therapy treats any remaining cancer cells and includes radiation, chemotherapy and hormone therapy. Adjuvant therapies increase the chance of curing the cancer.


Surgery
Surgery can be done to remove the cancer or remove the breast. Those that remove the cancer instead of the entire breast are known as breast-sparing or breast-conserving surgeries. They include lumpectomy and partial (segmental) mastectomy. Surgeries that remove the entire breast include total, modified radical and radical mastectomies.
Lumpectomy and partial mastectomy: With a lumpectomy, the lump and a small amount of surrounding tissue is removed. It's used for single, small lumps. With a partial mastectomy (also called segmental mastectomy), the lump and more surrounding tissue is removed. Up to one-fourth of the breast may be removed. Both surgeries are followed by radiation therapy to treat the remaining breast tissue.

Benefits: Only a small amount of breast tissue is removed, leaving the breast looking as normal as possible. The rates of cancer recurrence and survival after breast-sparing surgery followed by radiation therapy are comparable to those of total or radical mastectomies.

Risks: Complications after surgery may include a wound infection or a collection of blood or clear fluid at the wound. For a few women, the breast may look different than it did before surgery or the nipples may be at different heights. For about one in 10 women, the tissue removed from around the tumor contains cancer cells and a second surgery may be needed.
Total mastectomy: With a total (simple) mastectomy, the entire breast and nipple are removed. The lymph nodes are usually left in place. This type of mastectomy may be used for noninvasive cancer.

Benefits: This is an effective treatment for women with noninvasive cancer who can't have a breast-sparing surgery. Compared to a modified radical mastectomy, removal of fewer or no lymph nodes decreases the risk of lymphedema.

Risks: Complications after surgery may include a wound infection or a collection of blood or clear fluid at the wound. For a few women, the cancer can recur in the scar, despite removal of the breast.
Modified radical mastectomy: With a modified radical mastectomy, the entire breast along with most of the underarm lymph nodes are removed. The lining over the chest muscles may also be removed. This surgery may be used if there are multiple lumps in the breast, the lump is large or radiation isn't possible. If sentinel node biopsy is used, unnecessary lymph node removal may be avoided.

Benefits: A modified radical mastectomy can often be as effective as the more extensive radical mastectomy. Leaving the chest muscle makes breast reconstruction easier.

Risks: Complications after surgery may include a wound infection or a collection of blood or clear fluid at the wound. Removing the lymph nodes can lead to complications in the arm, such as swelling, numbness or infection. For a few women, the cancer can recur in the scar, despite removal of the breast.
Radical mastectomy: With a radical mastectomy, the entire breast is removed, as well as the skin covering the tumor, the chest muscles, the underarm lymph nodes, and the deeper layers of fat and surrounding tissues in the chest. This procedure is only used for very advanced cancer that has spread through the breast and underlying muscle.

Benefits: This surgery may be helpful in removing cancer that's spread far into the breast and surrounding tissues. It may eliminate the need for radiation therapy or decrease the area that needs to be treated.

Risks: Complications after surgery may include a wound infection or a collection of blood or clear fluid at the wound. The removal of the lymph nodes can lead to complications in the arm, such as swelling, numbness or infection. For a few women, the cancer can recur in the scar, despite removal of the breast.
Reconstructive surgery: Reconstructive surgery uses a breast implant or tissue from elsewhere on the body to rebuild a breast that has been removed. It may be done at the same time as a mastectomy or at a later date. Reconstructive surgery helps preserve the cosmetic appearance of the breast.


Radiation therapy
High-energy radiation destroys cancer cells. It's used to treat or help control breast cancer. The radiation is directed toward the breast from a machine that's located outside the body. The treatments are given five days a week for about six weeks.
Benefits: It can kill cancer cells that remain in the breast, lymph nodes or chest wall after surgery and reduce the risk of the cancer returning in the same area.

Risks: The radiation may damage nearby normal tissue. During the treatment you may feel very tired, the skin in the treatment area may become irritated, and your breast may feel swollen and heavy. These symptoms usually disappear within a year. After the treatment, you may notice that your breast is firmer and smaller. Other possible side effects include inflammation of a lung or the sac around the heart (a condition known as pericarditis) and arm weakness, numbness or swelling.

Chemotherapy
Chemotherapy is the use of medications to kill the cancer cells. It may be used before surgery to shrink the tumor or as an adjuvant therapy after surgery to prevent the cancer from recurring or spreading.
Anticancer medications are usually given for four to six months by mouth or by injection into a vein (intravenous injection). Common chemotherapy medications include 5-fluorouracil, methotrexate, cyclophosphamide and doxorubicin. These medications are often given in combinations that are more effective than any one medication by itself. Medication combinations that include anthracyclines, such as doxorubicin, can increase life expectancy.

Benefits: Chemotherapy treats cancer cells that may have spread throughout the body, rather than just those in the area of the tumor. With early stage breast cancer, it can reduce the risk of a recurrence.

Risks: Along with the cancer cells, chemotherapy also affects normal cells, which can lead to side effects. The particular side effects will depend on the type of medication, the amount taken and the length of the treatment. Common side effects include nausea, vomiting, diarrhea, fatigue, appetite loss, hair loss, mouth sores and menstrual cycle changes.
Some medications can affect the production of blood cells. This can make you more susceptible to infection, more prone to bruising or bleeding, and more tired. Chemotherapy can also permanently affect your ability to have children or may cause early menopause. Some drugs can cause permanent heart damage, peripheral nerve damage or leukemia (an uncontrolled, malignant growth of white blood cells in bone marrow).


Hormone therapy
The hormone estrogen, which is produced in the ovaries and adrenal glands, stimulates breast cancer cells to grow in some women. Hormone therapy blocks the action of estrogen and stops breast cancer cell growth. In the past, surgery to remove the ovaries or the adrenal glands was used to stop estrogen production. Now, however, several antiestrogen medications are being used. Tamoxifen (Nolvadex, for example) is the most common.
Tamoxifen blocks the effect of estrogen by attaching itself to the cells' estrogen receptor sites (areas where estrogen normally attaches), leaving no place for the estrogen. Unlike estrogen, tamoxifen doesn't stimulate cell growth. This treatment is effective for women whose cancer cells test positive for estrogen receptor sites, which is known as an estrogen-receptor positive tumor. For early stage cancer, it's prescribed for five years. For advanced cancer, the length of treatment will depend how well you respond to the medication and other factors. For women whose cancer cells are estrogen-receptor negative, tamoxifen may not be helpful.

Benefits: When tamoxifen is used as an adjuvant treatment, women with ductal carcinoma in situ who are estrogen-receptor positive are less likely to develop invasive cancer or cancer in the other breast. Women with invasive cancer are less likely to have their cancer spread or recur.

Risks: Side effects of tamoxifen may include hot flashes, vaginal discharge or dryness, irregular periods, headaches and nausea. It increases the risk of uterine cancer and appears to increase the risk of developing cataracts (a cloudy area in the lens of the eye). Rarely, it may cause potentially life-threatening blood clots in the legs or lungs, as well as increase the risk of stroke.

The most effective treatment options by stage
Stage 0, carcinoma in situ

Lobular carcinoma in situ: LCIS doesn't require treatment since it's not considered cancer. However, women with LCIS have a 25 percent risk of developing breast cancer in either breast within 25 years. Therefore, close follow-up, including yearly mammograms, is necessary. Consult your doctor about how often you need evaluations and ask if you're a candidate for preventive treatment, such as tamoxifen therapy or surgical removal of both breasts.

Ductal carcinoma in situ: DCIS may be treated with breast-conserving surgery such as lumpectomy or partial mastectomy, followed by radiation therapy. Total mastectomy may be used for women who don't choose breast-conserving surgery or who have extensive DCIS throughout the tissue. Tamoxifen is added if the tumor is estrogen-receptor positive.
Stages I and II, early stage breast cancer
Treatment options will depend on factors such as location and size of the lesion, breast size and the desire to save the breast.

Treatments may include breast-conserving surgery such as lumpectomy or partial mastectomy, followed by radiation therapy or modified radical mastectomy. These treatments may be followed by radiation therapy if the risk of recurrence is high. Adjuvant chemotherapy may be used as well. Tamoxifen is added if the tumor is estrogen-receptor positive. If the tumor is large, chemotherapy may be given before surgery to shrink the tumor and make it possible to do a breast-sparing surgery.

Stage III, locally advanced breast cancer
This type of cancer may be first treated with chemotherapy. If the response to chemotherapy is good, then surgery or radiation may be done. Hormone therapy may also be recommended.

Stage IV, metastatic or advanced breast cancer
Treatment may include radiation, mastectomy, chemotherapy or hormone therapy.


Treatment research
New treatments are continually being studied. Some of these include:
High-dose chemotherapy with bone marrow transplant: If your breast cancer becomes resistant to radiation or chemotherapy treatment, very high doses of chemotherapy may be tried. To help fight possible harm to your bone marrow, some of your bone marrow may be removed before you're given the high doses of chemotherapy. Once chemotherapy is complete, the marrow is returned (or transplanted) to help fight infection and produce healthy blood cells. This procedure is still considered experimental and carries a high risk.

Biological therapy: This treatment boosts the body's defense against the cancer cells. Vaccines that help strengthen the immune system to fight the cancer are being studied. Another type is monoclonal antibody therapy (MOAB), which is being studied for use in women who have metastatic cancer with cancer cells that test positive for excessive amounts of the HER-2/neu protein. The HER-2/nue promotes rapid cancer growth. The MOAB trastuzumab (Herceptin, for example) is given to block HER-2/neu and slow cancer growth. One possible side effect is heart damage since HER-2/neu is also found in the heart muscle.