Breast Cancer Treatment

Many women with breast cancer want to take an active part in making decisions about their medical care. It is natural to want to learn all you can about your disease and treatment choices. Knowing more about breast cancer helps many women cope.

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.

Treatment options include surgery, radiation therapy, chemotherapy, hormone therapy, and biological therapy. These options are described below. Many women receive more than one type of treatment.

The choice of treatment depends mainly on the stage of the disease. Treatment options by stage are described below. You and your doctor can work together to develop a treatment plan that reflects your medical needs and personal values.

Cancer treatment is either local or systemic.

Local therapy

Surgery and radiation therapy are local treatments. They remove or destroy cancer in the breast. When breast cancer has spread to other parts of the body, local therapy may be used to control the disease in those specific areas.

Systemic therapy

Chemotherapy, hormone therapy, and biological therapy are systemic treatments. They enter the bloodstream and destroy or control cancer throughout the body. Some women with breast cancer have systemic therapy to shrink the tumor before surgery or radiation. Others have systemic therapy after surgery and/or radiation to prevent the cancer from coming back. Systemic treatments also are used for cancer that has spread.

New treatment options

"We've come to realize that breast cancer isn't just one disease," says Clifford Hudis, M.D., chief of the breast-cancer medicine service at Memorial Sloan-Kettering Cancer Center. "We're separating tumors into subsets based on their genetic and molecular traits, and as a result, we're offering women more targeted, effective treatments."

That's been made easier thanks to two new diagnostic tests, the Oncotype DX and MammaPrint. These allow doctors to look at the status of genes in the tumor tissue to determine who will need chemotherapy in addition to surgery and radiation--and to predict a tumor's likelihood of recurrence. For example, only 15 to 20 percent of women with early stage estrogen-fueled tumors actually need chemo, but until now it hasn't been easy to tell who does and who doesn't.

Side effects

Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each woman, and they may change from one treatment session to the next.

Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them.

Supportive care

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 NCI's Web site at http://www.cancer.gov/cancertopics/coping and from Information Specialists at 1-800-4-CANCER or LiveHelp.

Surgery

Surgery is the most common treatment for breast cancer. There are several types of surgery:

1. Breast-sparing surgery

An operation to remove the cancer but not the breast is breast-sparing surgery. It is also called breast-conserving surgery, lumpectomy, segmental mastectomy, and partial mastectomy. Sometimes an excisional biopsy serves as a lumpectomy because the surgeon removes the whole lump. The surgeon often removes the underarm lymph nodes as well. This procedure, which involves a separate incision, is called an axillary lymph node dissection. It shows whether cancer cells have entered the lymphatic system. After breast-sparing surgery, most women receive radiation therapy to the breast in order to destroy any remaining cancer cells.

2. Mastectomy

An operation to remove the breast (or as much of the breast tissue as possible) is a mastectomy. In most cases, the surgeon also removes lymph nodes under the arm. Some women have radiation therapy after surgery.

Studies have found equal survival rates for breast-sparing surgery (with radiation therapy) and mastectomy for Stage I and Stage II breast cancer.

3. Sentinel lymph node biopsy

This is a new method of checking for cancer cells in the lymph nodes. A surgeon removes fewer lymph nodes, which causes fewer side effects. (If the doctor finds cancer cells in the axillary lymph nodes, an axillary lymph node dissection usually is done.)

4. Breast reconstruction

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 a mastectomy or later. If you are considering reconstruction, you may wish to talk with a plastic surgeon before having a mastectomy.

Post-op

The time it takes to heal after surgery is different for each woman. Before surgery, discuss the plan for pain relief with your doctor or nurse. Any kind of surgery also carries a risk of infection, bleeding, or other problems. Tell your health care provider right away if you develop any problems.

You may feel off balance if you've had one or both breasts removed, especially if you are large breasted. 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 with time. Your 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 exercises 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, the numbness persists.

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 lymphedema. Lymphedema can develop right after surgery or months to years later.

You will need to continue to protect your arm and hand on the treated side:

• Avoid wearing tight clothing or jewelry on your affected arm
• Carry your purse or luggage with the other arm
• Use an electric razor to avoid cuts when shaving under your arm
• Have shots, blood tests, and blood pressure measurements on the other arm
• Wear gloves to protect your hands when gardening and when using strong detergents
• Have careful manicures and avoid cutting your cuticles
• Avoid burns or sunburns to your affected arm and hand

Ask your doctor how to handle any cuts, insect bites, sunburn, or other injuries to your arm or hand. Also, contact your physician if your arm or hand is injured, swells, or becomes red and warm.

If lymphedema occurs, the doctor may suggest raising your arm above your heart whenever you can. Some women with lymphedema wear an elastic sleeve to improve lymph circulation. Medication, manual lymph drainage (massage), or use of a machine that gently compresses the arm may also help. And your doctor may refer you to a physical therapist or other specialist.

Radiation therapy

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. Most women receive radiation therapy after breast-sparing surgery. Some women receive radiation therapy after a mastectomy. Treatment depends on the size of the tumor and other factors. The radiation destroys breast cancer cells that may remain in the area.

Some women have radiation therapy before surgery to destroy cancer cells and shrink the tumor. Doctors use this approach when the tumor is large or may be difficult to remove. Some women also have chemotherapy or hormone therapy before surgery.

Doctors use two types of radiation therapy to treat breast cancer. Some women receive both types:

• External radiation The radiation comes from a large machine outside the body. Most women go to a hospital or clinic for treatment. Treatments are usually 5 days a week for several weeks.
• Internal radiation (implant radiation) Thin plastic tubes (implants) that hold a radioactive substance are put directly in the breast. The implants stay in place for several days, during which time a woman remains in the hospital. Doctors remove the implants before discharge.

Potential side effects depend mainly on the dose and type of radiation and the part of your body that is treated.

It is common for the skin in the treated area to become red, dry, tender, and itchy. Your breast may feel heavy and tight. These problems will go away over time. 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.

Bras and some other types of clothing 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. These effects of radiation therapy on the skin will go away. The area gradually heals once treatment is completed. However, there may be a lasting change in the color of your skin.

You are 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 as active as they can.

Although the side effects of radiation therapy can be distressing, they're usually treatable.

Chemotherapy

Chemotherapy uses anticancer drugs to kill cancer cells. Chemotherapy for breast cancer usually involves a combination of drugs. The drugs may be given as a pill or by injection into a vein (IV). Either way, the drugs enter the bloodstream and travel throughout the body. Some women need to stay in the hospital during treatment.

Side effects depend mainly on the specific drugs and the dose. The drugs affect cancer cells and other cells that divide rapidly:

• Blood cells These cells fight infection, help your blood to clot, and carry oxygen to all parts of the body. When drugs affect your blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired. Years after chemotherapy, some women develop leukemia (cancer of the blood cells).
• Cells in hair roots Chemotherapy can cause hair loss. Your hair will grow back, but it may be somewhat different in color and texture.
• Cells that line the digestive tract Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores.

Your doctor can suggest ways to control many of these side effects.

Some drugs used for breast cancer can cause tingling or numbness in the hands or feet. This problem usually goes away after treatment is over. Other problems may be more permanent. In some women, the drugs used for breast cancer may weaken the heart.

Some anticancer drugs can damage the ovaries, causing them to stop producing hormones. You may have symptoms of menopause. The symptoms include hot flashes and vaginal dryness. Your menstrual periods may no longer be regular or may stop. Some women become infertile and for women over the age of 35, the infertility is likely to be permanent.

On the other hand, you may remain fertile during chemotherapy and be able to become pregnant. The effects of chemotherapy on an unborn child are not known. You should talk to your doctor about birth control before treatment begins.

Hormone therapy

Some breast tumors need hormones to grow. Hormone therapy keeps cancer cells from getting or using the natural hormones they need--estrogen and progesterone. Lab tests can show if a breast tumor has hormone receptors. If you have this kind of tumor, you may require hormone therapy.

This treatment uses drugs or surgery:

• Drugs Tamoxifen blocks estrogen. Another type of drug prevents the body from making the female hormone estradiol. Estradiol is a form of estrogen. This type of drug is an aromatase inhibitor. If you have not gone through menopause, your doctor may give you a drug that stops the ovaries from producing estrogen.
• Surgery If you have not gone through menopause, you may require surgery to remove your ovaries. The ovaries are the main source of the body's estrogen.

The side effects of hormone therapy depend largely on the specific drug or type of treatment. Tamoxifen is the most common hormone treatment. 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. Other side effects are irregular menstrual periods, headaches, fatigue, nausea, vomiting, vaginal dryness or itching, irritation of the skin around the vagina, and skin rash. Not all women who take tamoxifen have side effects.

It is possible to become pregnant when taking tamoxifen. Tamoxifen may harm the unborn baby. If you are still menstruating, you should discuss birth control methods with your doctor.

Serious side effects of tamoxifen are rare. However, it can cause blood clots in the veins. Blood clots form most often in the legs and in the lungs. Women have a slight increase in their risk of stroke.

Tamoxifen can also cause cancer of the uterus. Your doctor should perform regular pelvic exams and you should tell your doctor about any unusual vaginal bleeding between exams.

When the ovaries are removed, menopause occurs at once. The side effects are often more severe than those caused by natural menopause. Your health care provider can suggest ways to cope with these side effects.

Biological therapy

The immune system is the body's natural defense against disease and biological therapy helps the immune system fight cancer..

Herceptin (trastuzumab), a monoclonal antibody that binds to cancer cells,

is given to women whose lab tests show that a breast tumor has too much of a specific protein known as HER2. By blocking HER2, it can slow or stop the growth of the cancer cells.

Herceptin is given intravenously either alone or with chemotherapy.

The most common side effects are fever and chills. Some women also have pain, weakness, nausea, vomiting, diarrhea, headaches, difficulty breathing, or rashes. Side effects usually become milder after the first treatment.

Herceptin also may cause heart damage. This may lead to heart failure. Herceptin can also affect the lungs, causing breathing problems that require immediate medical attention, which is why you will be carefully checked out before and monitored closely during treatment.

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. Clinical trials can be an option at all stages of breast cancer so ask your doctor if any of these might be right for you.

Stage 0

Stage 0 breast cancer refers to lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS). Most women with LCIS do not have treatment. Instead, the doctor may suggest regular checkups to watch for signs of breast cancer. Some women take tamoxifen to reduce the risk of developing breast cancer. Others may take part in studies of promising new preventive treatments.

Having LCIS in one breast increases the risk of cancer for both breasts. A very small number of women with LCIS try to prevent cancer with surgery to remove both breasts. This is a bilateral prophylactic mastectomy. The surgeon usually does not remove the underarm lymph nodes.

Most women with DCIS have breast-sparing surgery followed by radiation therapy although some choose to have a total mastectomy. Underarm lymph nodes are not usually removed. Women with DCIS may receive tamoxifen to reduce the risk of developing invasive breast cancer.

Stages I, II, IIIA, and Operable IIIC

Women with Stage I, II, IIIA, and operable (can treat with surgery) IIIC breast cancer may have a combination of treatments. 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. The doctor may suggest radiation therapy after mastectomy if cancer cells are found in 1 to 3 lymph nodes under the arm, or if the tumor in the breast is large. 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 saving 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 increase the chances of a cure. Radiation treatment can kill cancer cells in and near the breast. Women also may have systemic treatment such as chemotherapy, hormone therapy, or both. This treatment can destroy cancer cells that remain anywhere in the body. It can prevent the cancer from coming back in the breast or elsewhere.

Stages IIIB and Inoperable IIIC

Women with Stage IIIB (including inflammatory breast cancer) or inoperable Stage IIIC breast cancer usually have chemotherapy. If the chemotherapy shrinks the tumor, the doctor then may suggest further treatment:

• Mastectomy possibly followed by radiation therapy to the chest and underarm area.
• Breast-sparing surgery possibly followed by radiation therapy to the chest and underarm area.
• Radiation therapy. The doctor also may recommend more chemotherapy, hormone therapy, or both, to help prevent the disease from coming back in the breast or elsewhere.

Stage IV

In most cases, women with Stage IV breast cancer have hormone therapy, chemotherapy, or both. Some also may have biological therapy. Radiation 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 extend life.

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, or side effects (such as nausea). It's goal is increasing quality of life rather than life extension. Some women with advanced cancer decide to have only supportive care.

When breast cancer recurs

Treatment for the recurrent disease depends mainly on the location and extent of the cancer. Another main factor is the type of treatment the woman had before.

If breast cancer comes back only in the breast after breast-sparing surgery, a mastectomy may be recommended. Chances are good that the disease will not come back again.

If breast cancer recurs in other parts of the body, treatment may involve chemotherapy, hormone therapy, or biological therapy. Radiation therapy may help control cancer that recurs in the chest muscles or in certain other areas of the body. Although it's important to know that treatment can seldom cure cancer that recurs outside the breast. Supportive care is often an important part of the treatment plan at this point.

Complementary and alternative medicine (CAM)

An approach is generally called complementary medicine when it is used along with standard treatment and alternative when it is used instead of standard treatment. Before deciding to use CAM, it's important to understand possible side effects and risks.

Types of CAM include acupuncture, massage therapy, herbal products, vitamins or special diets, visualization, meditation, and spiritual healing. Although CAM helps many women feel better, some methods may change the way standard treatment works. So it's always important to weight the benefits against the risks before embarking on any treatment. Also to bear in mind: Health insurance may not cover the cost of various forms of CAM.

Nutrition and physical activity

It is important for women with breast cancer to take care of themselves. 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 do not taste as good as they used to. In addition, the side effects of treatment (such as poor appetite, nausea, vomiting, or mouth sores) can make it difficult to eat well. Your doctor, dietitian, or other health care provider can suggest ways to deal with these problems.

Many women find 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

Follow-up care after treatment for breast cancer is important. Recovery is different for each woman. Your recovery depends on your treatment, whether the disease has spread, and other factors.

Even when the cancer seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment. That's why it's important for your doctor to monitor your recovery and check for recurrence.

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.

Follow-up exams usually include the breasts, chest, neck, and underarm areas. Since you are at risk of getting cancer again, you should have mammograms of your preserved breast and your other breast. You probably will not 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.