Breast Cancer

Treatment Options

Your doctor will create a treatment plan tailored specifically to you. It will be based on many factors: diagnostic test results, including imaging, bloodwork, genetic tests and biopsies; your age, general health and menopausal status; and tumor size, tumor markers and hormone receptor status (ER, PR and HER2) (see Tumor Markers).

Your treatment plan may include surgery, targeted therapy, chemotherapy, immunotherapy, radiation therapy or hormone therapy (for hormone receptor-positive disease). You may also be a candidate for a clinical trial, which may offer access to new agents (drugs) or therapies that are still in development.

As you discuss the available options with your doctor, share your expectations for your quality of life. Be aware that your doctor may adjust your treatment plan if your cancer becomes resistant to any of your drug therapies or if it recurs.

Surgical Options

Surgery is the most common treatment for most breast cancers. As you consider your surgical options, be aware of the common misperception that surgery eliminates the chance of recurrence. The survival rates for a lumpectomy and a mastectomy are essentially the same. Ongoing follow-ups after both types of breast cancer surgery are important and recommended.

A lumpectomy, which is considered breast-conserving or breast-sparing, removes only the tumor and a small margin of normal-appearing tissue around it. A lumpectomy is usually followed by radiation therapy designed to kill microscopic cancer cells hiding in other parts of the breast. If the tumor is relatively small and you wish to spare as much of your breast as possible, this surgical plan may be an option. You may not be a candidate for a lumpectomy if diffuse abnormalities are seen on your imaging tests (mammogram or breast ultrasound) or if you are unable to receive radiation therapy. It is important to discuss the likely cosmetic result of breast-conserving surgery with your doctor because radiation therapy can cause some shrinkage of the breast over time.

A mastectomy involves removing the entire breast and may be preferred for larger tumors, especially when they occur in a smaller breast. Several types of mastectomy exist, including total mastectomy and modified radical mastectomy. Total mastectomy surgically removes the entire breast without removing muscle. A modified radical mastectomy is a total mastectomy that is performed along with removing a block of underarm/axillary lymph node tissue (axillary dissection). You may need temporary drains following this surgery. If so, your medical team will give you information for drainage care.

Most mastectomy patients will be candidates for breast reconstructive surgery, which is often performed by plastic surgeons during a single operation immediately after the mastectomy. Mastectomy patients undergoing immediate reconstruction may be eligible for enhanced cosmetic approaches, such as a skin-sparing or nipple-sparing mastectomy. After the incisions have healed, outpatient radiation therapy to the breast may be necessary for cases of high-risk breast cancer.

Chronic nerve pain, known as post-mastectomy pain syndrome (PMPS), is a possible side effect from a mastectomy. The most common areas to feel this pain are in the chest, armpit and/or arm. Symptoms of PMPS include tightness, burning, tingling or itching in these areas. In addition, the surgical site may have numbness or may be extra sensitive. Tell your doctor about your pain or symptoms to ensure your PMPS is managed as effectively as possible.

Another possible side effect from a mastectomy is phantom limb pain. Your brain may treat your mastectomy site as if the breast were still present. You may feel nipple or breast pain. This can be temporary or can linger for a long time. Eventually, the brain adjusts to understanding the absence of the breast.

 

Breast cancer can spread to lymph nodes, particularly in the underarm area, which are called axillary lymph nodes. For staging and treatment purposes, your doctor will need to determine if your lymph nodes have been affected. A common procedure to determine this is called a sentinel lymph node biopsy. It involves injection of a small quantity of a blue dye and/or a radioactive substance into the breast prior to or during the operation. The surgeon uses a probe and visual inspection to identify the radioactive and/or blue-stained lymph nodes. If the sentinel nodes contain a tumor, a more extensive operation to remove additional tissue from the underarm may be necessary. This is an axillary lymph node dissection.

In some circumstances after a lumpectomy, if the patient is receiving radiation therapy and systemic therapy (drug therapy that travels throughout the body), no further axillary surgery is recommended, even when there are metastases in the sentinel node. Some patients will have cancerous axillary lymph nodes detected by a needle biopsy performed prior to their breast surgical procedure. If a needle biopsy reveals a metastatic lymph node, neoadjuvant (preoperative) chemotherapy may be recommended. The axillary lymph node dissection may be avoided if the neoadjuvant chemotherapy is successful in clearing/killing the axillary lymph node disease.

After surgery to remove breast cancer and after breast reconstruction surgery, exercise is an important part of your healing process to increase mobility, promote circulation and reduce stiffness and scar tissue. Your doctor will likely recommend specific post-surgery exercises, but you can typically begin two or three days after surgery with gentle stretches, such as shoulder rolls or arm circles. You may follow up with additional exercises to strengthen your muscles as you feel able. It is important to talk with your doctor before resuming any pre-surgery workouts.

Radiation Therapy

Radiation therapy uses high-energy X-rays to kill cancer cells or keep them from growing. It is almost always delivered after a lumpectomy to destroy any cancer cells that may be hidden in normal-appearing breast tissue. Research shows that a person who has a small tumor removed in a lumpectomy followed by radiation therapy has similar survival rates and risk of recurrence as someone who has a mastectomy.

Post-mastectomy radiation therapy is sometimes necessary, particularly for people who face a high risk of the cancer growing back on the chest wall area (mastectomy skin flaps, underarm/axillary region). Post- mastectomy radiation therapy can lower this risk.

External-beam radiation therapy (EBRT) is the most common form of radiation therapy given to people with breast cancer. It is similar to a conventional X-ray, except the radiation beams are strong enough to kill cancer cells. Another option is internal radiation, or brachytherapy. Used alone or in combination with EBRT after breast-conserving surgery, this type of therapy involves the placement of radioactive “seeds” through a catheter inserted into the breast to deliver radiation directly to the area where the tumor was removed.

Radiation therapy may also be used to manage symptoms from specific areas of cancer involvement, such as bone or brain metastases. This is typically called palliative radiation therapy.

Chemotherapy

Chemotherapy is systemic therapy that uses powerful drugs to kill rapidly multiplying cells throughout the body. Neoadjuvant (preoperative) chemotherapy may be used to shrink a large, bulky tumor so it can be removed surgically or to reduce the tumor’s size so a patient can undergo a lumpectomy rather than a mastectomy. Neoadjuvant chemotherapy also helps your doctor determine how well the chemotherapy drugs work against the tumor. Adjuvant chemotherapy is given postoperatively to destroy cancer cells that may remain, some of which may be too small to detect with laboratory testing or imaging studies. This can be lifesaving 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 (AIs), sometimes 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. The drugs used in adjuvant therapy should be discussed with your doctor.

Targeted Therapy

Targeted therapy uses drugs or other substances to identify and attack specific types of cancer cells. Unlike chemotherapy, which attacks healthy cells as well as cancer cells, targeted therapy is designed to affect only cancer cells. Many targeted therapy drugs are oral medications, and some may be given in combination with other drug therapies.

About 20 percent of breast cancer tumors make extra copies of HER2, which promotes cell division. Targeted therapy drugs made to treat HER2+ breast cancer are called anti-HER2 agents. Some patients will be candidates for extended adjuvant therapy, which is designed to further reduce the risk of tumors recurring.

Immunotherapy

Immunotherapy harnesses the potential of the body’s own immune system to fight cancer and may now be a treatment option, depending on your diagnosis. Sometimes referred to as biologic therapy or biotherapy, immunotherapy trains the immune system to respond to cancer cells and has the potential for a more lasting response that can extend beyond the end of treatment.

A significant advancement in breast cancer treatment occurred in early 2019 when an immunotherapy used in combination with a chemotherapy was approved to treat certain forms of triple negative breast cancer (see Tumor Markers).

 
Commonly Used Medications (as of 8/15/19)
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)
Hormone Therapy
PREMENOPAUSAL
  • fluoxymesterone
  • goserelin acetate (Zoladex)
  • leuprolide acetate (Eligard, Lupron, Lupron Depot)
  • megestrol acetate (Megace)
  • tamoxifen
POSTMENOPAUSAL
  • anastrozole (Arimidex)
  • ethinyl estradiol
  • exemestane (Aromasin)
  • fluoxymesterone
  • fulvestrant (Faslodex)
  • letrozole (Femara)
  • megestrol acetate (Megace)
  • tamoxifen
  • toremifene (Fareston)
Immunotherapy
atezolizumab (Tecentriq)
Targeted Therapy
  • abemaciclib (Verzenio)
  • ado-trastuzumab emtansine (Kadcyla)
  • alpelisib (Piqray)
  • everolimus (Afinitor, Afinitor Disperz)
  • lapatinib (Tykerb)
  • olaparib (Lynparza)
  • palbociclib (Ibrance)
  • pertuzumab (Perjeta)
  • ribociclib (Kisqali)
  • ribociclib and letrozole (Kisqali Femara Co-Pack)
  • talazoparib (Talzenna)
  • trastuzumab (Herceptin)
  • trastuzumab-anns (Kanjinti)
  • trastuzumab-dkst (Ogivri)
  • trastuzumab-dttb (Ontruzant)
  • trastuzumab-pkrb (Herzuma)
  • trastuzumab and hyaluronidase-oysk (Herceptin Hylecta)
Extended adjuvant therapy
  • neratinib (Nerlynx)

                                                                                                       

Clinical Trials

Clinical trials are research studies that may offer access to leading-edge treatments not yet widely available. They may be an alternative if your current treatment isn’t working as well as it once was or if you have a rare type of breast cancer that hasn’t been studied as much as others.

As you weigh treatment options, it is important to remember that participating in a clinical trial will not jeopardize your care. Talk to your medical team about available trials for your particular type, subtype and stage of breast cancer. You can also search for one yourself online. Along with achieving your treatment goals, you may have the opportunity to help advance cancer treatments for future patients.

Treating Bone Metastasis

Breast cancer that spreads to the bone creates bone metastases (also referred to as mets). Your doctor may use some of the following options to help prevent or delay bone fractures and manage the symptoms.

  • Bisphosphonates slow the loss of bone mass that can occur from cancer or from other treatments.
  • Radiation therapy, in the form of EBRT, can target and kill symptomatic bone metastases.
  • Radiopharmaceuticals are intravenous (IV) drugs that give off low levels of radiation intended to travel directly to the area in the bone containing metastases.
  • Targeted therapy inhibits a protein that is responsible for bone loss. It also helps increase bone mass and strengthen bones.

 

Reconstruction: Post-Surgical Options

Your decision regarding breast reconstruction is one only you can make. Your breasts may play a crucial role in your personal sense of femininity and sexuality. You may be eager to replace them to feel more like your pre-cancer self. If so, consider reconstructive surgery or prostheses. Or you may prefer what’s referred to as “going flat,” which means not having a breast prosthesis, enhancement or additional surgery. Before you make this highly personal choice, learn as much as you can about your options and think about what will make you most comfortable.

If you are having a mastectomy or lumpectomy, your doctor will likely discuss breast reconstruction, which involves additional surgeries to restore or reshape one or both breasts. Reconstructive surgery is often performed, or at least started, during a mastectomy or can be delayed for a few months or even years. It may be done during or after a lumpectomy if the surgery will cause the affected breast to look significantly different from the other after the tumor is removed.

Flap reconstruction involves recreating the breast using a flap of tissue, usually with skin, fat, possibly muscle and blood vessels from elsewhere in your body. Various techniques are available depending on the tumor’s size and location, size of your breasts, your body type, whether your breast has been radiated in the past and your preferences. Flap procedures should be performed by an experienced plastic surgeon who specializes in breast reconstruction.

Implant-based reconstruction, using silicone or saline implants, initially requires less extensive surgery than tissue flap procedures. The overlying chest wall muscle and skin may be stretched by inserting a tissue expander under the muscle to accommodate the implant. The expander is gradually inflated with fluid injections through the skin until the desired size is reached. In some cases, the implant is placed on top of the chest wall muscle but underneath the skin. When the tissue expander is inflated to the proper size, the plastic surgeon will arrange for a follow-up “exchange” surgical procedure that replaces the tissue expander with the final implant. Some patients will be candidates for a single-stage, direct-to-implant reconstruction performed at the time of the mastectomy.

Non-surgical options, such as a breast prosthesis, are also available. Made from artificial materials, the prosthesis is designed to provide a natural, symmetrical appearance when you’re dressed. You must wait until you’re healed from surgery to be fitted for a prosthesis. One type is worn inside the hidden pocket of a mastectomy bra. Another type attaches to your body with a special adhesive, though this approach may not be recommended after chest wall radiation therapy.

Mastectomy bras are available in many styles and colors. Many health insurance providers will cover the costs of a prosthesis and mastectomy bras if you provide a prescription from your oncologist or oncology surgeon. Call your insurer beforehand to verify which mastectomy-related products are covered, documentation required for reimbursement and how often you can purchase replacements.

As you explore your options, consider:

  • Breasts are not essential organs for life, though you may feel they are integral to your identity as a woman.
  • Your plastic surgeon will work with you to set expectations for what your new or reconstructed breast(s) will look like. Keep in mind that even with reconstruction, your breast(s) will not look or feel exactly as they did before or have the same sensation.
  • Many advocacy groups offer peer counseling, so you can ask questions of women who’ve had reconstruction procedures. Ask your nurse/patient navigator for referrals, and use the resources in the back of this guide.

Additonal Resources

 

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