treatment of breast cancer
Treatment
Women with breast cancer have many treatment options. The treatment that's best for one woman may not be best for another.
The options are surgery, radiation therapy, hormone therapy, chemotherapy, and targeted therapy. You may receive more than one type of treatment. The treatment options are described below.
Surgery and radiation therapy are types of local therapy. They remove or destroy cancer in the breast.
Hormone therapy, chemotherapy, and targeted therapy are types of systemic therapy. The drug enters the bloodstream and destroys or controls cancer throughout the body.
The treatment that's right for you depends mainly on the stage of the cancer, the results of the hormone receptor tests, the result of the HER2/neu test, and your general health.
You may want to talk with your doctor about taking part in a clinical trial, a research study of new treatment methods. Clinical trials are an important option for women at any stage of breast cancer.
Your doctor can describe your treatment choices, the expected results, and the possible side effects. Because cancer therapy often damages healthy cells and tissues, side effects are common. Before treatment starts, ask your health care team about possible side effects, how to prevent or reduce these effects, and how treatment may change your normal activities.
You may want to know how you will look during and after treatment. You and your health care team can work together to develop a treatment plan that meets your medical and personal needs.
Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat breast cancer include surgeons, medical oncologists, and radiation oncologists. You also may be referred to a plastic surgeon or reconstructive surgeon. Your health care team may also include an oncology nurse and a registered dietitian.
At any stage of disease, supportive care is available to control pain and other symptoms, to relieve the side effects of treatment, and to ease emotional concerns. Information about such care is available on the NCI Web site at http://www.cancer.gov/cancertopics/coping and from the NCI Cancer Information Service at 1-800-4-CANCER (1-800-422-6237) or at LiveHelp (http://www.cancer.gov/help).
You may want to ask your doctor these questions before you begin treatment:
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Surgery
Surgery is the most common treatment for breast cancer. Your doctor can explain each type, discuss and compare the benefits and risks, and describe how each will change the way you look:
- Breast-sparing surgery: This is an operation to remove the cancer but not the breast. It's also called breast-conserving surgery. It can be a lumpectomy or a segmental mastectomy (also called a partial mastectomy). Sometimes an excisional biopsy is the only surgery a woman needs because the surgeon removed the whole lump.
- Mastectomy: This is an operation to remove the entire breast (or as much of the breast tissue as possible). In some cases, a skin-sparing mastectomy may be an option. For this approach, the surgeon removes as little skin as possible.
The surgeon usually removes one or more lymph nodes from under the arm to check for cancer cells. If cancer cells are found in the lymph nodes, other cancer treatments will be needed.
You may choose to have breast reconstruction. This is plastic surgery to rebuild the shape of the breast. It may be done at the same time as the cancer surgery or later. If you're considering breast reconstruction, you may wish to talk with a plastic surgeon before having cancer surgery.
In breast-sparing surgery, the surgeon removes the cancer in the breast and some normal tissue around it. The surgeon may also remove lymph nodes under the arm. The surgeon sometimes removes some of the lining over the chest muscles below the tumor.
In total (simple) mastectomy, the surgeon removes the whole breast. Some lymph nodes under the arm may also be removed.
In modified radical mastectomy, the surgeon removes the whole breast and most or all of the lymph nodes under the arm. Often, the lining over the chest muscles is removed. A small chest muscle also may be taken out to make it easier to remove the lymph nodes.
The time it takes to heal after surgery is different for each woman. Surgery causes pain and tenderness. Medicine can help control the pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more relief.
Any kind of surgery also carries a risk of infection, bleeding, or other problems. You should tell your health care team right away if you develop any problems.
You may feel off balance if you've had one or both breasts removed. You may feel more off balance if you have large breasts. This imbalance can cause discomfort in your neck and back.
Also, the skin where your breast was removed may feel tight. Your arm and shoulder muscles may feel stiff and weak. These problems usually go away. The doctor, nurse, or physical therapist can suggest exercises to help you regain movement and strength in your arm and shoulder. Exercise can also reduce stiffness and pain. You may be able to begin gentle exercise within days of surgery.
Because nerves may be injured or cut during surgery, you may have numbness and tingling in your chest, underarm, shoulder, and upper arm. These feelings usually go away within a few weeks or months. But for some women, numbness does not go away.
Removing the lymph nodes under the arm slows the flow of lymph fluid. The fluid may build up in your arm and hand and cause swelling. This swelling is called lymphedema. It can develop soon after surgery or months or even years later. You'll always need to protect the arm and hand on the treated side of your body from cuts, burns, or other injuries. Information about preventing and treating lymphedema is available on the NCI Web site at http://www.cancer.gov/cancertopics/coping and from Information Specialists at 1-800-4-CANCER (1-800-422-6237) or LiveHelp (http://www.cancer.gov/help).
You may want to ask your doctor these questions before having surgery:
- What kinds of surgery can I consider? Is breast-sparing surgery an option for me? Is a skin-sparing mastectomy an option? Which operation do you recommend for me? Why?
- Will any lymph nodes be removed? How many? Why?
- How will I feel after the operation? Will I have to stay in the hospital?
- Will I need to learn how to take care of myself or my incision when I get home? Where will the scars be? What will they look like?
- If I decide to have plastic surgery to rebuild my breast, how and when can that be done? Can you suggest a plastic surgeon for me to contact?
- Will I have to do special exercises to help regain motion and strength in my arm and shoulder? Will a physical therapist or nurse show me how to do the exercises?
- Is there someone I can talk with who has had the same surgery I'll be having?
- How often will I need checkups?
Radiation therapy
Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. It affects cells only in the part of the body that is treated. Radiation therapy may be used after surgery to destroy breast cancer cells that remain in the area.
Doctors use two types of radiation therapy to treat breast cancer. Some women receive both types:
- External radiation therapy: The radiation comes from a large machine outside the body. You will go to a hospital or clinic for treatment. Treatments are usually 5 days a week for 4 to 6 weeks. External radiation is the most common type used for breast cancer.
- Internal radiation therapy (implant radiation therapy or brachytherapy): The doctor places one or more thin tubes inside the breast through a tiny incision. A radioactive substance is loaded into the tube. The treatment session may last for a few minutes, and the substance is removed. When it's removed, no radioactivity remains in your body. Internal radiation therapy may be repeated every day for a week.
Side effects depend mainly on the dose and type of radiation. It's common for the skin in the treated area to become red, dry, tender, and itchy. Your breast may feel heavy and tight. Internal radiation therapy may make your breast look red or bruised. These problems usually go away over time.
Bras and tight clothes may rub your skin and cause soreness. You may want to wear loose-fitting cotton clothes during this time.
Gentle skin care also is important. You should check with your doctor before using any deodorants, lotions, or creams on the treated area. Toward the end of treatment, your skin may become moist and "weepy." Exposing this area to air as much as possible can help the skin heal. After treatment is over, the skin will slowly heal. However, there may be a lasting change in the color of your skin.
You're likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay active, unless it leads to pain or other problems.
You may wish to discuss with your doctor the possible long-term effects of radiation therapy. For example, radiation therapy to the chest may harm the lung or heart. Also, it can change the size of your breast and the way it looks. If any of these problems occur, your health care team can tell you how to manage them.
You may want to ask your doctor these questions before having radiation therapy:
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Hormone therapy
Hormone therapy may also be called anti-hormone treatment. If lab tests show that the tumor in your breast has hormone receptors, then hormone therapy may be an option. Hormone therapy keeps cancer cells from getting or using the natural hormones (estrogen and progesterone) they need to grow.
Options before menopause
If you have not gone through menopause, the options include:
- Tamoxifen: This drug can prevent the original breast cancer from returning and also helps prevent the development of new cancers in the other breast. As treatment for metastatic breast cancer, tamoxifen slows or stops the growth of cancer cells that are in the body. It's a pill that you take every day for 5 years. In general, the side effects of tamoxifen are similar to some of the symptoms of menopause. The most common are hot flashes and vaginal discharge. Others are irregular menstrual periods, thinning bones, headaches, fatigue, nausea, vomiting, vaginal dryness or itching, irritation of the skin around the vagina, and skin rash. Serious side effects are rare, but they include blood clots, strokes, uterine cancer, and cataracts.
- LH-RH agonist: This type of drug can prevent the ovaries from making estrogen. The estrogen level falls slowly. Examples are leuprolide and goserelin. This type of drug may be given by injection under the skin in the stomach area. Side effects include hot flashes, headaches, weight gain, thinning bones, and bone pain.
- Surgery to remove your ovaries: Until you go through menopause, your ovaries are your body's main source of estrogen. When the surgeon removes your ovaries, this source of estrogen is also removed. (A woman who has gone through menopause wouldn't benefit from this kind of surgery because her ovaries produce much less estrogen.) When the ovaries are removed, menopause occurs right away. The side effects are often more severe than those caused by natural menopause. Your health care team can suggest ways to cope with these side effects.
Options after menopause
If you have gone through menopause, the options include:
- Aromatase inhibitor: This type of drug prevents the body from making a form of estrogen (estradiol). Examples are anastrazole, exemestane, and letrozole. Common side effects include hot flashes, nausea, vomiting, and painful bones or joints. Serious side effects include thinning bones and an increase in cholesterol.
- Tamoxifen: Hormone therapy is given for at least 5 years। Women who have gone through menopause receive tamoxifen for 2 to 5 years. If tamoxifen is given for less than 5 years, then an aromatase inhibitor often is given to complete the 5 years. Some women have hormone therapy for more than 5 years. See above for more information about tamoxifen and its possible side effects.
Chemotherapy
Chemotherapy uses drugs to kill cancer cells. The drugs that treat breast cancer are usually given through a vein (intravenous) or as a pill. You'll probably receive a combination of drugs.
You may receive chemotherapy in an outpatient part of the hospital, at the doctor's office, or at home. Some women need to stay in the hospital during treatment.
The side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly:
- Blood cells: When drugs lower the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of the drug. There are also medicines that can help your body make new blood cells.
- Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back after treatment, but the color and texture may be changed.
- Cells that line the digestive tract: Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Your health care team can give you medicines and suggest other ways to help with these problems.
Some drugs used for breast cancer can cause tingling or numbness in the hands or feet. This problem often goes away after treatment is over.
Other problems may not go away. For example, some of the drugs used for breast cancer may weaken the heart. Your doctor may check your heart before, during, and after treatment. A rare side effect of chemotherapy is that years after treatment, a few women have developed leukemia (cancer of the blood cells).
Some anticancer drugs can damage the ovaries. If you have not gone through menopause yet, you may have hot flashes and vaginal dryness. Your menstrual periods may no longer be regular or may stop. You may become infertile (unable to become pregnant). For women over the age of 35, this damage to the ovaries is likely to be permanent.
On the other hand, you may remain able to become pregnant during chemotherapy. Before treatment begins, you should talk with your doctor about birth control because many drugs given during the first trimester are known to cause birth defects.
Targeted therapy
Some women with breast cancer may receive drugs called targeted therapy. Targeted therapy uses drugs that block the growth of breast cancer cells. For example, targeted therapy may block the action of an abnormal protein (such as HER2) that stimulates the growth of breast cancer cells.
Trastuzumab (Herceptin®) or lapatinib (TYKERB®) may be given to a woman whose lab tests show that her breast tumor has too much HER2:
- Trastuzumab: This drug is given through a vein. It may be given alone or with chemotherapy. Side effects that most commonly occur during the first treatment include fever and chills. Other possible side effects include weakness, nausea, vomiting, diarrhea, headaches, difficulty breathing, and rashes. These side effects generally become less severe after the first treatment. Trastuzumab also may cause heart damage, heart failure, and serious breathing problems. Before and during treatment, your doctor will check your heart and lungs.
- Lapatinib: The tablet is taken by mouth. Lapatinib is given with chemotherapy. Side effects include nausea, vomiting, diarrhea, tiredness, mouth sores, and rashes. It can also cause red, painful hands and feet. Before treatment, your doctor will check your heart and liver. During treatment, your doctor will watch for signs of heart, lung, or liver problems.
You may want to ask your doctor these questions before having hormone therapy, chemotherapy, or targeted therapy:
- What drugs will I be taking? What will they do?
- When will treatment start? When will it end? How often will I have treatments?
- Where will I have treatment?
- What can I do to take care of myself during treatment?
- How will we know the treatment is working?
- Which side effects should I tell you about?
- Will there be long-term effects?
- How often will I need checkups?
Treatment choices by stage
Your treatment options depend on the stage of your disease and these factors:
- The size of the tumor in relation to the size of your breast
- The results of lab tests (such as whether the breast cancer cells need hormones to grow)
- Whether you have gone through menopause
- Your general health
Below are brief descriptions of common treatments for each stage. Other treatments may be appropriate for some women. Research studies (clinical trials) can be an option at all stages of breast cancer.
Stage 0 (DCIS)
Most women with DCIS have breast-sparing surgery followed by radiation therapy. Some women instead choose to have a total mastectomy. Women with DCIS may receive tamoxifen to reduce the risk of developing invasive breast cancer.
Stages I, II, IIIA, and some IIIC
Women with Stage I, II, IIIA, or operable IIIC breast cancer may have a combination of treatments. (Operable means the cancer can be treated with surgery.)
Some may have breast-sparing surgery followed by radiation therapy to the breast. This choice is common for women with Stage I or II breast cancer. Others decide to have a mastectomy.
With either approach, women (especially those with Stage II or IIIA breast cancer) often have lymph nodes under the arm removed.
Whether or not radiation therapy is used after mastectomy depends on the extent of the cancer. If cancer cells are found in 1 to 3 lymph nodes under the arm or if the tumor in the breast is large, the doctor sometimes suggests radiation therapy after mastectomy. If cancer cells are found in more than 3 lymph nodes under the arm, the doctor usually will suggest radiation therapy after mastectomy.
The choice between breast-sparing surgery (followed by radiation therapy) and mastectomy depends on many factors:
- The size, location, and stage of the tumor
- The size of the woman's breast
- Certain features of the cancer
- How the woman feels about how surgery will change her breast
- How the woman feels about radiation therapy
- The woman's ability to travel to a radiation treatment center
Some women have chemotherapy before surgery. This is called neoadjuvant therapy (treatment before the main treatment). Chemotherapy before surgery may shrink a large tumor so that breast-sparing surgery is possible. Women with large Stage II or IIIA breast tumors often choose this treatment.
After surgery, many women receive adjuvant therapy. Adjuvant therapy is treatment given after the main treatment to lower the chance of breast cancer returning. Radiation treatment is local therapy that can kill any remaining cancer cells in and near the breast. Women may also have hormone therapy, chemotherapy, targeted therapy, or a combination. These systemic therapies can destroy cancer cells that remain anywhere in the body. They can prevent or delay the cancer from coming back in the breast or elsewhere.
Stage IIIB and some Stage IIIC
Women with Stage IIIB (including inflammatory breast cancer) or inoperable Stage IIIC breast cancer have chemotherapy first, and then may be offered other treatments. (Inoperable means the cancer can't be treated with surgery without first shrinking the tumor.) They may also have targeted therapy.
If the chemotherapy or targeted therapy shrinks the tumor, then surgery may be possible:
- Mastectomy: The surgeon removes the breast. In most cases, the lymph nodes under the arm are removed. After surgery, a woman may receive radiation therapy to the chest and underarm area.
- Breast-sparing surgery: In rare cases, the surgeon removes the cancer but not the breast. The lymph nodes under the arm are usually removed. After surgery, a woman may receive radiation therapy to the breast and underarm area.
After surgery, the doctor will likely recommend chemotherapy, targeted therapy, hormone therapy, or a combination. This therapy may help prevent the disease from coming back in the breast or elsewhere.
Stage IV and Recurrent
Women with recurrent breast cancer will be treated based on where the cancer returned. If the cancer returned in the chest area, the doctor may suggest surgery, radiation therapy, chemotherapy, hormone therapy, or a combination.
Women with Stage IV breast cancer or recurrent cancer that has spread to the bones, liver, or other areas usually have hormone therapy, chemotherapy, targeted therapy, or a combination. Radiation therapy may be used to control tumors in certain parts of the body. These treatments are not likely to cure the disease, but they may help a woman live longer.
Many women have supportive care along with anticancer treatments। Anticancer treatments are given to slow the progress of the disease. Supportive care helps manage pain, other symptoms of cancer, or the side effects of treatment (such as nausea). This care can help a woman feel better physically and emotionally. Supportive care does not aim to extend life. Some women with advanced cancer decide to have only supportive care.
Second opinion
Before starting treatment, you might want a second opinion from another doctor about your diagnosis and treatment plan. Some women worry that their doctor will be offended if they ask for a second opinion. Usually the opposite is true. Most doctors welcome a second opinion. And many health insurance companies will pay for a second opinion if you or your doctor requests it. Some companies require a second opinion.
If you get a second opinion, the doctor may agree with your first doctor's diagnosis and treatment plan. Or the second doctor may suggest another approach. Either way, you'll have more information and perhaps a greater sense of control. You may also feel more confident about the decisions you make, knowing that you've looked carefully at your options.
It may take some time and effort to gather your medical records and see another doctor. Usually it's not a problem if it takes you several weeks to get a second opinion. In most cases, the delay in starting treatment will not make treatment less effective. To make sure, you should discuss this possible delay with your doctor. Some women with breast cancer need treatment right away.
There are many ways to find a doctor for a second opinion. You can ask your doctor, a local or state medical society, a nearby hospital, or a medical school for names of specialists.
The NCI Cancer Information Service at 1-800-4-CANCER (1-800-422-6237) or at LiveHelp (http://www.cancer.gov/help) can tell you about nearby treatment centers.
Breast reconstruction
Some women who plan to have a mastectomy decide to have breast reconstruction. Other women prefer to wear a breast form (prosthesis) inside their bra. Others decide to do nothing after surgery. All of these options have pros and cons. What is right for one woman may not be right for another. What is important is that nearly every woman treated for breast cancer has choices.
Breast reconstruction may be done at the same time as the mastectomy, or later on. If radiation therapy is part of the treatment plan, some doctors suggest waiting until after radiation therapy is complete.
If you are thinking about breast reconstruction, you should talk to a plastic surgeon before the mastectomy, even if you plan to have your reconstruction later on.
There are many ways for a surgeon to reconstruct the breast. Some women choose to have breast implants, which are filled with saline or silicone gel. You can read about breast implants on the Food and Drug Administration Web site at http://www.fda.gov.
You also may have breast reconstruction with tissue that the plastic surgeon removes from another part of your body. Skin, muscle, and fat can come from your lower abdomen, back, or buttocks. The surgeon uses this tissue to create a breast shape.
The type of reconstruction that is best for you depends on your age, body type, and the type of cancer surgery that you had. The plastic surgeon can explain the risks and benefits of each type of reconstruction.
You may want to ask your doctor these questions about breast reconstruction:
- Which type of surgery would give me the best results? How will I look afterward?
- When can my reconstruction begin?
- How many surgeries will I need?
- What are the risks at the time of surgery? Later?
- Will I have scars? Where? What will they look like?
- If tissue from another part of my body is used, will there be any permanent changes where the tissue was removed?
- What activities should I avoid? When can I return to my normal activities?
- Will I need follow-up care?
- How much will reconstruction cost? Will my health insurance pay for it?
Nutrition and physical activity
It's important for you to take very good care of yourself before, during, and after cancer treatment. Taking care of yourself includes eating well and staying as active as you can.
You need the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy.
Sometimes, especially during or soon after treatment, you may not feel like eating. You may be uncomfortable or tired. You may find that foods don't taste as good as they used to. In addition, the side effects of treatment (such as poor appetite, nausea, vomiting, or mouth blisters) can make it hard to eat well. On the other hand, some women treated for breast cancer may have a problem with weight gain.
Your doctor, a registered dietitian, or another health care provider can suggest ways to help you meet your nutrition needs.
Many women find that they feel better when they stay active. Walking, yoga, swimming, and other activities can keep you strong and increase your energy. Exercise may reduce nausea and pain and make treatment easier to handle. It also can help relieve stress. Whatever physical activity you choose, be sure to talk to your doctor before you start. Also, if your activity causes you pain or other problems, be sure to let your doctor or nurse know.
Follow-up care
You'll need regular checkups after treatment for breast cancer. Checkups help ensure that any changes in your health are noted and treated if needed. If you have any health problems between checkups, you should contact your doctor.
Your doctor will check for return of the cancer. Also, checkups help detect health problems that can result from cancer treatment.
You should report any changes in the treated area or in your other breast to the doctor right away. Tell your doctor about any health problems, such as pain, loss of appetite or weight, changes in menstrual cycles, unusual vaginal bleeding, or blurred vision. Also talk to your doctor about headaches, dizziness, shortness of breath, coughing or hoarseness, backaches, or digestive problems that seem unusual or that don't go away. Such problems may arise months or years after treatment. They may suggest that the cancer has returned, but they can also be symptoms of other health problems. It's important to share your concerns with your doctor so that problems can be diagnosed and treated as soon as possible.
Checkups usually include an exam of the neck, underarm, chest, and breast areas. Since a new breast cancer may develop, you should have regular mammograms. You probably won't need a mammogram of a reconstructed breast or if you had a mastectomy without reconstruction. Your doctor may order other imaging procedures or lab tests.
