There are several treatment options for women with breast cancer. The type of treatment the doctor recommends will depend on the type and stage of your disease at the time of diagnosis. Whatever the stage, you will always have options for treatment: no one can make you undergo a treatment that you don’t think is right for you. Work with your doctor to discuss all the possible treatment options and the benefits and drawbacks of each. Some clinics have different treatment strategies than others so you may want to seek out a second opinion regarding your diagnosis and treatment.

Once you have decided on a course of treatment, your doctor can answer all of your questions about how the treatment may change your normal activities and how you will look and feel during and after treatment. Before you start treatment, your health care team should explain the possible side effects and suggest ways to help you manage them.

Surgery

Surgery is the most common treatment for breast cancer. There are several types of surgery, ranging from simply removing a tumor to complete removal of both breasts. Typically, the more advanced your cancer is (the higher the stage number) the more tissue may need to be removed.

Breast-sparing surgery

Any operation that removes cancer but not the whole breast is called breast-sparing or breast-conserving surgery. Specific breast-sparing surgeries include a lumpectomy, in which only the lump is removed and a segmental mastectomy (also called a partial mastectomy) in which the tumor, a portion of breast tissue around the tumor, and the lining over the chest muscles below the tumor is removed. The surgeon may also perform an axillary lymph node dissection to remove the lymph nodes in the armpit region. The lymph nodes can be examined to determine if the cancer has spread. After breast-sparing surgery, many doctors suggest radiation therapy targeted at the breast to destroy any cancer cells that may remain.

Some people should not have breast-sparing surgery even if they have early stage cancer. These include women who have two or more tumors in different “quadrants’ of the breast and women with a prior history of breast irradiation. Pregnant women are also not the best candidates for breast sparing surgery due to the fact that radiation (which can be very dangerous to a developing fetus) is usually used after this type of surgery. Also, there are some medical conditions such as lupus or scleroderma that make a person less tolerant to radiation therapy, so if you have one of these diseases your doctor may suggest a mastectomy.

Mastectomy

A mastectomy involves removing the entire breast or as much of the breast as possible. In most cases, the surgeon will also remove the axillary (underarm) lymph nodes. Some doctors may recommend radiation therapy after the surgery. There are three basic types of mastectomy, based on how much tissue is removed:

• Simple (total) mastectomy removes the entire breast and may remove a small number of axillary lymph nodes as well.
• Modified radical mastectomy removes the entire breast and most or all of the axillary lymph nodes. The lining over the chest muscles is often removed and sometimes a small chest muscle as well. This is the most common type of mastectomy performed today.
• Radical mastectomy removes the entire breast, all of axillary lymph nodes and the chest wall muscles of the pectoral region under the breast. This procedure is rarely used anymore because the modified procedure is usually just as effective and allows a woman to retain more of her tissue.

According to the National Cancer Institute, evidence indicates that women with Stage I and Stage II cancer who are treated with breast-sparing surgery (along with radiation therapy) have the same survival rate as if they had mastectomies.

Reconstructive options

After a mastectomy, a woman may choose to have plastic surgery to rebuild the shape of the breast. There are several types of surgery to reconstruct a missing breast so talk to your doctor to find out more about this option. Another option is to wear a breast prosthesis (also called a breast form) which is made of silicone, foam or fiberfill and is worn in a specially designed post-mastectomy bra with a pocket to hold it in place. This is the option that a majority of women choose.

Axillary lymph node dissection

Removing the axillary lymph nodes slows the return of lymph fluid from the arm. The fluid may build up in your arm and hand and cause swelling called lymphedema. This is a dangerous condition because the fluid in the arm stagnates and cannot be monitored for invaders by the lymphatic system, and so infections occur much more frequently. If you have had axillary lymph nodes removed you will probably need to take special precautions to protect your arm and hand on the treated side of your body from cuts, scrapes, burns and other injuries.

Sentinel lymph node biopsy

Sentinel lymph node biopsy is a newer and less invasive approach to staging breast cancer that is being performed by more and more surgeons. A radioactive or blue “marker” dye is injected into the area near the tumor during surgery (breast-sparing or mastectomy) and this marker then travels along the lymph vessels that drain lymph from the tumor. Then, only those axillary lymph nodes which were marked are removed - these would be the first lymph nodes to contain cancer cells if the cancer is spreading.

While the patient is still in surgery, these lymph nodes are sent to a pathologist for evaluation. The surgeon waits for the pathologist’s diagnosis (usually about 15 minutes). If these “sentinel” lymph nodes are negative (meaning they don’t have any cancer in them), then no further lymph nodes need to be removed. If, however, they are positive, then the surgeon can proceed with complete axillary lymph node dissection. This procedure has proven to be 98% to 100% as effective as “typical” complete axillary lymph node dissection and has the added benefit of sparing the patient from a drastic lymph node dissection (and subsequent potential complications) if none is really needed. You can ask your doctor if he or she can recommend a surgeon who performs this procedure.

Radiation

Radiation therapy uses high-energy radiation to kill cancer cells. Radiation works because it kills cells that are dividing rapidly and cancer cells divide faster than any other cell type. Radiation is usually used after breast-sparing surgery to kill the remaining cancer cells in the breast, although it is sometimes used after a mastectomy as well. Radiation therapy can also be used before surgery to destroy cancer cells and shrink the tumor if it is large or hard to remove.

There are two main types of radiation therapy used to treat breast cancer. Your doctor may recommend one or both types. External radiation is radiation from a large machine outside the body. Treatment is usually five days a week for several weeks and must take place in a medical center. Internal radiation therapy involves implanting thin plastic tubes full of a radioactive substance directly in the breast, where they stay in place for several days. While the implants are in, the patient must stay in the hospital.

Radiation side effects depend on the dose and type of radiation and the part of your body that is treated. Regardless of those factors, one common side effect of radiation is fatigue, especially in the later weeks of treatment.

Systemic treatments

While surgery and radiation are localized treatments that remove or destroy cancer in the breast, they do nothing to treat cancer that has spread to other parts of the body. In that case, localized therapy can be used in the areas the cancer has spread to, or systemic therapies can be used. Chemotherapy, hormone therapy, and biological therapy are systemic treatments that travel in the blood and help destroy cancer throughout the body. In many cases, women with breast cancer will have systemic therapy along with surgery and/or radiation. This works to shrink a tumor before surgery or radiation, to prevent cancer from recurring, or to treat cancer that has spread.

Most systemic cancer treatments have unfortunate side effects. These are due to the fact that cancer cells are your own body cells whose growth has gone out of control rather than a foreign invader, such as a virus. The treatments designed to kill the cancerous cells have the unfortunate side effect of killing several of your healthy cells as well. The side effects may vary from person to person and from one treatment session to the next.

Chemotherapy

Chemotherapy uses drugs (“chemo-” means chemical) to kill cancer cells. The drugs are given in a pill form or by intravenous injection (I.V.) and travel throughout the body in the blood. Depending on the drug, the chemotherapy may be given at a hospital or taken at home. There are many possible side effects of chemotherapy, which depend on the specific drugs and the dose administered. Chemotherapy drugs kill cancer cells but also healthy cells that normally divide rapidly, including:

• Blood cells, which carry oxygen, fight infection, and help blood to clot. When these cells die, it can cause anemia, fatigue, infections, bleeding, and bruising.
• Hair roots cells which cause hair to grow. This causes some people to lose their hair during treatment. It will grow back, but it may have a different color and texture.
• Digestive tract lining cells which aid in digestion and absorption of nutrients. When these cells die, it may cause poor appetite, nausea, diarrhea, or vomiting.

Some anticancer drugs can damage the ovaries and cause women to experience premature menopause or become infertile. The likelihood of this increases the older you are at the time of treatment. Another side effect is “chemobrain,” which include memory and concentration problems that happen to some people during and after chemotherapy. Chemobrain may cause difficulties performing simple mental activities such as finding the right word, remembering names, and multitasking.

Some of the main chemotherapy drugs used to treat breast cancer are listed below. They may be used alone or in combination. Each one is linked to information about the drug on Medline Plus, a website of the National Institutes of Health.

• Cyclophosphamide
• Epirubicin
• 5-Fluorouracil (5 FU)
• Methotrexate
• Mitomycin
• Doxorubicin (Adriamycin)
• Docetaxel (Taxotere)

A cancer specialist called an oncologist will determine what is the best type (or combination) of chemotherapy and other treatments for your specific condition.

Hormone Therapy

The development of breast tissue is a secondary sexual characteristic that does not appear until puberty. The reason for this is that breast tissue depends on hormones for its development and maintenance. This need for hormone signals remains in some breast cancers, so one method of breast cancer treatment involves blocking the cancer cells from getting the hormones they need to grow. The needed hormones are the major female sex hormones: estrogen and progesterone. A simple lab test can determine if your tumor has receptors for theses hormones, which is an indication that it may be hormone-dependent. If so, hormone therapy may be a treatment option for you.

Selective estrogen receptor modulators (SERMs) are a type of hormone therapy drug that acts by blocking estrogen that is present in the body from attaching to the estrogen receptor in the cancer cells, killing cancer cells and slowing the growth of the tumor. SERMs can be used in both pre- and postmenopausal women. Tamoxifen (Nolvadex) is the most common SERM prescribed for hormone therapy. Because it blocks estrogen, tamoxifen can cause symptoms of menopause such as night sweats, hot flashes, and vaginal itching or dryness even in younger, premenopausal women. Rarely, tamoxifen may cause cancer of the uterus.

Aromatase inhibitors are a class of hormone therapy drugs which block the production of estrogen by inhibiting the enzyme responsible for making it (called aromatase). This stops estrogen production in cells other than the ovaries. The aromatase inhibitors include anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin). These drugs are only effective in postmenopausal women. The only major side effect of aromatase inhibitors is an increased risk of osteoporosis.

If you have not gone through menopause, you may be able to have surgery to remove your ovaries as a type of hormone therapy. Since the ovaries are the main source of the body’s estrogen before menopause, their removal dramatically reduces body levels of estrogen. It is like having menopause happen overnight. This obviously causes infertility because there are no longer any eggs left to be fertilized after the ovaries are removed. A woman who has already undergone menopause cannot benefit from ovary removal because her ovaries already make far lower levels of estrogen.

Biological Therapy

Biological therapy helps the immune system fight cancer. This is the only type of therapy capable of distinguishing between cancer cells and normal body cells. It can specifically target the cancer cells and destroy them while leaving healthy cells alone, reducing the side effects that normally occur when healthy cells die.

Trastuzumab (Herceptin) is a biological therapy that uses antibodies to target a protein (HER2-neu) that is made in very high amounts in about one quarter of all breast cancer tumors. An antibody is a molecule normally produced by the immune system to fight invaders. However, Herceptin is a monoclonal antibody made in the laboratory that seeks out HER2-neu specifically and destroys the cells that overexpress it. Normal cells do not have this protein in great amounts so they are mostly spared by the treatment. The most common side effects of Herceptin are fever and chills, while some women experience pain, weakness, nausea, vomiting, or diarrhea. Herceptin also may cause heart damage that can lead to heart failure and may affect the lungs so patients on this drug should be monitored carefully.

Like Herceptin, Lapatinib (Tykerb) targets cells that have the HER2-neu protein. But it is not an antibody. Instead, it works from the inside of the cell. It is a small molecule that can slip inside of cells and block the signaling that normally occurs through the HER2-neu protein. Tykerb works for some women who no longer respond to Herceptin. It is only approved for use in conjunction with chemotherapy in women with advanced, metastatic breast cancers.

Bevacizumab (Avastin) uses monoclonal antibodies like Herceptin but instead of targeting the cancer cells themselves, it targets the new blood vessels that a tumor needs to thrive. Avastin prevents new blood vessels from forming within tumors and so stops tumor growth. The drug is approved for treating metastatic breast cancer that has spread throughout the body.