Breast Cancer

Treatment Options

After your cancer is diagnosed, your doctor will develop a treatment plan that is tailored to you. Along with the stage of your disease, your doctor will consider the tumor’s subtype, genetic markers, gene mutations, hormone receptors, menopausal status, your age and overall health. These are important because some breast cancers respond differently to treatment depending on these factors. Your medical team will discuss all of your options, including possible clinical trials, which may be right for you.

To help you make more informed and confident decisions, you should learn as much as possible about your specific cancer along with the risks and benefits associated with each type of treatment. Options for breast cancer include surgery, radiation therapy, chemotherapy, hormone therapy and targeted therapy.

Surgery of some type will almost always be included in the treatment plan for patients diagnosed with non-Stage IV breast cancer. For those patients diagnosed with advanced breast cancer/Stage IV disease, the treatment plan may be limited to non-surgical options such as chemotherapy, hormone therapy and/or targeted therapy. Although these options are not curative, they can cause tumor shrinkage or prevent growth for some period of time, thereby improving quality of life and, in some cases, prolonging survival. Radiation therapy is sometimes necessary to control bone metastases.

Surgical Options

Different types of breast cancer surgery are available but can generally be categorized as either breast-conserving (also called breast-sparing or breast-saving) or breast-removing (mastectomy). Ongoing surveillance after all surgeries, and particularly after breast-conserving surgery, is important.

Lumpectomy

Lumpectomy is used for early-stage breast cancers detected as small tumors (see Figure 1). This includes Stages 0, I and II. This procedure may be an option if your tumor is relatively small and you wish to spare as much of your breast as possible. Lumpectomy is a breast-conserving or breast-sparing treatment because only the tumor is removed along with a small margin of healthy tissue around the tumor. Radiation therapy is usually delivered after lumpectomy surgery to kill the microscopic cancer cells hiding in normal-appearing breast tissue. It is important for you to discuss the likely cosmetic outcome with breast-conservation surgery because radiation can cause some shrinkage of the breast. Patients that have a relatively larger tumor compared to their overall breast size may end up with a less satisfactory cosmetic result following a margin-negative lumpectomy and breast radiation. Other features that can influence breast conservation options include tumor location (cancers located immediately beneath the nipple may require sacrifice of the nipple-areolar skin with the lumpectomy); baseline mammogram (patients with multiple cancers located far apart in the breast may require mastectomy); and other medical conditions (patients that have received prior radiation to the breast).

Mastectomy

Total mastectomy is the surgical removal of the whole breast (see Figure 2). A radical mastectomy involves removal of the entire breast along with the chest wall muscles and an extensive amount of the underarm/axillary lymph node tissue. A modified radical mastectomy means that the total mastectomy is being performed (but with the chest wall muscles left in place) along with removal of a block of underarm/axillary lymph node tissue. Most mastectomy patients will be candidates for breast reconstruction surgery performed by plastic surgeons, which can be performed at the same time as the mastectomy or in a delayed fashion. Mastectomy patients undergoing immediate reconstruction may be eligible for enhanced cosmetic approaches, such as skin-sparing or nipple-sparing mastectomy.

 

 

Figure 1
Figure 2 Figure 3

 

Lymph node removal

Cancer can spread to lymph nodes, and your doctor will need to determine if your lymph nodes have been affected for staging and treatment purposes. The lymph nodes most commonly affected are located in the underarm area and are called the axillary lymph nodes. When cancer cells are identified in the lymph nodes, this indicates a greater likelihood that you may have cancer cells hiding in other organs and it is likely that chemotherapy will be an important component of your treatment.

Many breast cancer patients will undergo a surgical procedure called a sentinel lymph node biopsy. This involves injection of a small quantity of a blue dye and/or a radioactive substance into the breast prior to the operation. The surgeon then uses a probe and visual inspection to identify the radioactive and/or blue-stained lymph nodes. If the sentinel nodes are cancerous, an axillary lymph node dissection may be necessary. Some patients will have cancerous axillary lymph nodes detected by needle biopsy. If a needle biopsy reveals a metastatic lymph node, then neoadjuvant (preoperative) chemotherapy may be recommended.

Post-mastectomy pain syndrome

One of the possible side effects from a mastectomy is chronic nerve pain, which is known as post-mastectomy pain syndrome (PMPS). The chest, armpit and/or arm are the most common places to experience this pain. PMPS may feel like tightness, burning, tingling or itching in these areas. These sensations are in addition to the numbness or extra sensitivity around the surgical site. Tell your doctor about your pain or disability so you can begin to receive treatment. It will not go away without treatment.

Your doctor may do the following to manage your PMPS:

  • Recommend physical therapy to preserve range of motion and reduce stiffness, followed by additional exercises to build up your strength and increase flexibility. Physical therapy is an essential part of treatment as PMPS can cause you to not use your arm the way you typically would. This can eventually lead to a decrease in strength and the limited ability to use your arm normally.
  • Encourage communication because it is important to keep your doctor informed about your pain level to ensure your PMPS is being managed as effectively as possible.
  • Prescribe pain medications to help manage the pain. Common medicines used to treat pain, such as opioids (narcotics), do not always work for treating PMPS, so your doctor may prescribe a neuropathic pain medication.
  • Suggest a nerve block to stop the affected nerve from sending pain signals to the brain if physical therapy and pain medicines fail.

Options after mastectomy

Several options are available to you after surgery. Choosing one of these options is a personal decision and requires much consideration, so talk to your treatment team and learn about other women’s experiences.

Breast reconstruction is an option for most types of breast cancer. Performed by an experienced plastic surgeon, it can either be done immediately (at the same time as your mastectomy) or later (within months or years after your mastectomy). Immediate reconstruction can be done for early-stage breast cancer, but it’s usually best to wait if you have more advanced breast cancer. Reconstruction requires a long healing period, which could delay the start of chemotherapy or interfere with potential radiation therapy. If you’re considering reconstructive surgery (even if it will be done later), discuss this with your cancer surgeon and a plastic surgeon before the mastectomy so they can properly plan your treatment.

Breast reconstruction may involve the use of a breast implant or a flap of tissue (usually containing skin, fat, muscle and blood vessels) from elsewhere in your body, or a combination of the two (see Breast Reconstruction Options below). The use of a tissue flap depends on the size of your breasts, your body type and preferences regarding appearance.

Some women prefer implants (saline or silicone), which involve less surgery than a tissue flap. When an implant is used, the overlying chest wall muscle and skin must be stretched to accommodate the implant. This is usually accomplished by inserting a temporary placeholder under the muscle called a tissue expander. The tissue expander is gradually inflated with fluid injections through the skin until the patient reaches the desired size.

A breast prosthesis is another option. Made of artificial materials that make your breast look and feel natural and balanced, a breast prosthesis is either worn inside a bra or attached to the body. When worn inside a bra, the prosthesis fits into a pocket sewn into the cup. You can have a pocket sewn into your regular bra or buy a mastectomy bra with an existing pocket. You can also use a breast prosthesis that attaches to the chest wall with a special adhesive. You must wait until you have healed after surgery before you can be fitted for a permanent breast prosthesis.

Breast Reconstruction Options

Breast Reconstruction Techniques
There are two surgical methods for flap surgery. A pedicled flap is one in which the muscle is the carrier of the blood supply. A free flap contains one or two blood vessels that are attached to blood vessels in the breast area. Types of flap surgeries are listed below.
 
DIEP: deep inferior epigastric perforator flap
SIEA: superficial inferior epigastric artery flap
TRAM: transverse rectus abdominis muscle flap
LSGAP: lateral septocutaneous perforating branches of the superior gluteal artery perforator flap
SGAP: superior gluteal artery perforator flap
TUG: transverse upper gracilis flap

 

DIEP Flap Breast Reconstruction

 

Expander Implant
Implants may be used for breast reconstruction. With this option, a tissue expander is inserted at the time of the breast cancer surgery. The expander slowly expands breast tissue, and a permanent implant is inserted in a second operation.

Radiation Therapy

Radiation therapy is the use of high-energy X-rays to kill cancer cells or keep them from growing. External-beam radiation therapy (EBRT) is given with the use of a radiation machine and is similar to a conventional X-ray, except the radiation beams are strong enough to kill cancer cells. EBRT is the most common form of radiation therapy given to people with breast cancer. However, internal radiation, or brachytherapy, is another option that may be used either alone or in combination with EBRT after breast-conserving surgery (see Figure 3). This type of therapy involves the placement of radioactive “seeds” through a catheter in the breast to deliver radiation directly to the area where the tumor was removed. If your doctor includes radiation therapy in your treatment plan, a radiation oncologist will carefully plan and oversee your treatment.

As noted in the section on lumpectomy surgery, radiation therapy is usually recommended with a breast-conserving strategy for reducing the chances of the cancer growing back in the breast (local recurrence) by killing the microscopic cancer cells hiding in the remaining breast tissue. Some patients have a very low risk of having a local recurrence and can avoid radiation after a lumpectomy. Post-mastectomy radiation therapy is recommended for women at high risk for cancer recurrence on the chest wall following mastectomy surgery, such as patients with several metastatic lymph nodes or inflammatory breast cancer.

Radiation therapy may also be used after specific surgeries to help shrink tumors that may have developed in other parts of the body from metastatic breast cancer or to relieve symptoms caused by metastatic tumors (known as palliative radiation).

Medical Therapies

One or a combination of the following therapies may be used to treat breast cancer.

Chemotherapy

Chemotherapy is the use of drugs to stop the growth of cancer cells either by killing them or preventing them from dividing and growing. Chemotherapy, a systemic therapy that travels throughout the body, is sometimes referred to as conventional chemotherapy to distinguish it from targeted therapy, which also involves the use of drugs that travel throughout the body. Breast cancer can be treated with multiple types of chemotherapy drugs. Chemotherapy drugs are usually given over a specific time period called a regimen. For early-stage breast cancer, chemotherapy may be given as a combination of two or three drugs together or one after the other.

Chemotherapy may be given before surgery (neoadjuvant chemotherapy) or after surgery (adjuvant chemotherapy). When given prior to surgery, it is used to shrink the tumor, which may be inoperable, or to reduce the tumor’s size in order to do a lumpectomy rather than a mastectomy. Adjuvant chemotherapy is given to destroy cancer cells that may remain after surgery, some of which may be too small to be detected with laboratory testing or imaging studies. This can be life-saving and decrease the risk of recurrence in higher-risk patients.

Hormone therapy

Hormone therapy, also called endocrine therapy, works by reducing or blocking estrogen, which is known to drive the growth of breast tumors. This therapy is used to treat tumors that are estrogen- and/or progesterone-receptor positive (noted as ER+/PR+).

Several types of hormone therapies may be used depending on the stage of the cancer and your menopausal status. A class of drugs known as selective estrogen-receptor modulators (SERMs) lowers or blocks estrogen receptors that are present on the cancer cells, as well as other organs in the body, and can help prevent the cancer from returning. Aromatase inhibitors (AI), typically recommended for postmenopausal women, reduce the estrogenic substances that are manufactured by the body. Estrogens and synthetic androgens (similar to male hormones) may be used to manage symptoms related to advanced breast cancer, but they are used less often than SERMs and AIs.

Removal or suppression of the ovaries (by surgery, medication or radiation therapy) is another option because it substantially reduces the production of estrogens in premenopausal women. Luteinizing hormone-releasing hormone (LHRH) analogs are drugs that provide an equivalent alternative to surgical removal of the ovaries in premenopausal women. Hormone therapy drugs differ in how they work, who can use them and what side effects can result. As with chemotherapy, the schedule of treatment is fixed (typically 5-10 years) when used as adjuvant therapy for breast cancer that has not spread.

Targeted therapy

Drugs that block the cell pathways that can lead to many types of cancers are known as targeted therapies. These drugs block the signals that proteins and other molecules send along signaling pathways, which are systems in the body that direct basic functions like the growth, division and death of cells. Effective targeted therapy depends on identifying targets that play an important role in the growth and survival of cancer cells, and in developing agents that can attack those targets.

About 20 percent of breast cancer tumors make extra copies of the HER2 gene, which promotes cell division. Targeted therapy drugs made for HER2+ breast cancer are known as anti-HER2 agents. Newer anti-HER2 agents are continually being developed, in addition to new combination targeted therapy treatments.

Table 1. Targeted Therapy Options

Targeted Therapy
ado-trastuzumab emtansine (Kadcyla)
everolimus (Afinitor)
lapatinib (Tykerb)
neratinib (Nerlynx)
palbociclib (Ibrance)
pertuzumab (Perjeta)
ribociclib (Kisqali)
trastuzumab (Herceptin)

Table 2. Chemotherapy Options

Chemotherapy
capecitabine (Xeloda)
carboplatin (Paraplatin)
cisplatin
cyclophosphamide
docetaxel (Taxotere)
doxorubicin (Adriamycin)
epirubicin (Ellence)
eribulin (Halaven)
fluorouracil (also known as 5-FU)
gemcitabine (Gemzar)
ixabepilone (Ixempra)
liposomal doxorubicin (Doxil)
paclitaxel (Taxol)
protein-bound paclitaxel (Abraxane)
vinorelbine (Navelbine)

Table 3. Hormone Therapy Options

Premenopausal
fluoxymesterone
goserelin (Zoladex)
leuprolide (Lupron)
megestrol acetate (Megace)
tamoxifen
Postmenopausal
anastrozole (Arimidex)
ethinyl estradiol
exemestane (Aromasin)
fluoxymesterone
fulvestrant (Faslodex)
letrozole (Femara)
megestrol acetate (Megace)
tamoxifen, toremifene (Fareston)

 

Aromatase inhibitors (AIs) are a type of hormone therapy recommended for treating breast cancer in postmenopausal women. Estrogens and synthetic androgens (similar to male hormones) may be used to manage symptoms related to advanced breast cancer, but they are used less often than SERMs and AIs.

Removal or suppression of the ovaries (by surgery or radiation therapy) is another option because it substantially reduces the production of estrogen in premenopausal women. Luteinizing hormone-releasing hormone (LHRH) analogs are drugs that provide an equivalent alternative to surgical removal of the ovaries in premenopausal women. For advanced breast cancer, newer biologic therapies are sometimes combined with hormone therapy.

Hormone therapy drugs differ in how they work, who can use them and what side effects can result, so talk to your doctor about options available for your type of cancer. The schedule of treatment is fixed (typically five years but possibly longer) when used as adjuvant therapy for breast cancer that has not spread. In metastatic breast cancer, treatment is continued for as long as the cancer is not growing. If the cancer begins growing, treatment may be changed to another hormone therapy drug or possibly to chemotherapy.

Treating Bone Metastasis

When breast cancer metastasizes (spreads) to the bones, it may be treated with bone-modifying agents to help prevent or delay bone fractures.

  • Bisphosphonates slow the loss of bone mass that can occur from the cancer or from other treatments.
     
  • Radiopharmaceuticals are intravenous drugs that give off low levels of radiation intended to travel directly to the area in the bone to which cancer cells have metastasized.
     
  • Targeted therapy inhibits a protein that is responsible for bone loss and helps increase bone mass and to strengthen bones.

Clinical Trials

The advances in cancer treatment that are helping save lives today are all products of clinical trials. Depending on your diagnosis and other factors, research studies known as clinical trials may be a treatment option to consider. It’s important to understand what they are, in general, and what they may mean for you.

You may consider taking part in a clinical trial for many reasons. You may have a rare type of cancer that hasn’t been studied much, or you may want to contribute to research that will help other people with your type of cancer.

Clinical trials are conducted all over the United States, in large cities and small towns. Some take place in cancer centers and hospitals, others in doctor’s offices. To participate in a clinical trial, you must meet certain qualifications, such as the type and stage of cancer you have, your age, overall health condition and response to past treatments. Ask your doctor if a clinical trial may be right for you, and use the resources on here to research more about clinical trials on your own.

Additonal Resources

 

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