KEY POINTS

• Breast cancer can be treated in several ways. It depends on the type of breast cancer and how far it has spread.
• People with breast cancer often get more than one kind of treatment.

Treatment options

• Surgery: Is an operation in which doctors cut out the cancer.
• Chemotherapy: Uses special medicines to shrink or kill the cancer. The drugs can be pills you take or medicines given in your veins, or sometimes both.
• Hormonal therapy: Blocks cancer cells from getting the hormones they need to grow.
• Biological therapy: Works with your body's immune system to help it fight cancer cells or to control side effects from other cancer treatments.
• Radiation therapy: Uses high-energy rays (similar to x-rays) to kill the cancer.

For more information, visit the National Cancer Institute's Breast Cancer Treatment Option Overview. This site can also help you find health care services.

Which treatment is right for me?

Talk to your cancer doctor about the treatment options available for your type and stage of cancer. Your doctor can explain the risks and benefits of each treatment and their side effects. Side effects are how your body reacts to drugs or other treatments.

Sometimes people get an opinion from more than one cancer doctor. This is called a "second opinion." Getting a second opinion may help you choose the treatment that is right for you.

Clinical trials

Clinical trials use new treatment options to see if they are safe and effective. If you have cancer, you may want to take part.

Complementary and alternative medicine

Complementary and alternative medicine are medicines and health practices that are not standard cancer treatments. Complementary medicine is used in addition to standard treatments. Alternative medicine is used instead of standard treatments. Acupuncture and supplements like vitamins and herbs are some examples.

Many kinds of complementary and alternative medicine have not been tested scientifically and may not be safe. Talk to your doctor about the risks and benefits before you start any kind of complementary or alternative medicine.

In the past, a positive biopsy was followed immediately by surgical treatment. This was called a one-step process. Currently, when a biopsy confirms that a tumor is malignant, the decision about treatment is deferred for a week or more to allow the patient and family to explore treatment options with the patient's doctor.

Separating the diagnostic test from the surgery is called a two-step process. Although it requires another visit to a hospital and a second procedure, a two-step process allows a woman and her doctor to discuss and contemplate treatment options. Moreover, there is time to seek a second opinion. More definitive laboratory analysis of the biopsied tissue can be done during this time. In some cases, when the tumor is very small, it may be completely removed by the biopsy and additional surgery may not be necessary.

When planning therapy, an oncologist and/or surgeon considers the following factors: the stage of the cancer (that is, the size of the tumor, whether or not the lymph nodes are involved, and the presence of metastases); the tumor's hormone status; the woman's age and menopausal status; and her general health, including whether she has any serious and/or chronic illness or conditions, such as heart disease, that might be complicated by treatment. In some cases, doctors will want to consider other prognostic factors that indicate the tumor's aggressiveness and likelihood of recurrence. Treatment choices may be affected by ominous pathological features such as necrosis or comedeocarincoma or high grade.

Types of breast cancer surgery include lumpectomy, partial (or segmental) mastectomy, total (or simple) mastectomy, modified radical mastectomy, and radical mastectomy.

Lumpectomy and partial mastectomy are breast conserving surgeries. In lumpectomy, the cancerous lump and a margin of normal tissue around it are removed. Depending on the size and location of the cancer, partial (or segmental) mastectomy can conserve much of the breast. The surgeon removes the cancer, some of the breast tissue, the lining over the chest muscles below the tumor, and usually some of the lymph nodes under the arm. In most cases, radiation therapy follows.

The entire breast is removed in total mastectomy. Some lymph nodes under the arm may be removed, also.

Modified radical mastectomy refers to the procedure in which the breast, some of the lymph nodes under the arm, the lining over the chest muscles, and, sometimes, part of the chest wall muscles are removed.

Finally, the surgeon, in radical mastectomy, removes the breast, chest muscles, and all the lymph nodes under the arm. This was the standard operation for many years, but it is now typically only used when a tumor has spread to the chest muscles.

A lumpectomy is followed usually by radiation therapy. During radiation therapy, high-energy x-rays are used to destroy cancer cells that may still be present in the affected breast or in nearby lymph nodes.

Radiation therapy may also be used to shrink tumors before surgery. Radiation therapy alone or in combination with chemotherapy can be used preoperatively or in lieu of surgery to destroy cancer cells and shrink tumors.

Following lumpectomy, radiation therapy to the breast and sometimes to the axilla is administered five days a week for four to six weeks. A concentrated or "boost" dose of radiation may be delivered by special implants (applicators) containing radioactive seeds, or external beam radiation.

There are times when radiation therapy is used postoperatively. This often occurs when the tumor is larger than 2 centimeters, or cancer is found in multiple lymph nodes in the axilla, or the tumor is close to the rib cage or chest wall muscles.

Intense exposure to radiation does have unavoidable side effects, including particularly fatigue, swelling, and skin changes, which gradually disappear in most cases. More serious side effects include heart and lung damage, lymphedema, and an increased risk of second malignancies.

When a tumor is large, identified as aggressive, and/or involves the lymph nodes, some form of systemic adjuvant treatment, such as chemotherapy, is often recommended. This is usually administered postoperatively following surgery to destroy cancer cells that may have escaped into the lymph and blood vessels, thereby reducing the likelihood of a recurrence. On the other hand, a small tumor can shed cancer cells outside the breast.

Studies have shown that a combination of chemotherapy drugs is more effective than a single agent. The combination that has been favored for many years is CMF (cyclophosphamide [Cytoxan], methotrexate, and fluorouracil [5-FU]). Alternating CMF with a therapy that is Adriamycin-based, call CAF (cyclophosphamide [Cytoxan], Doxorubicin (Adriamycin), and flurorouracial [5-FU]), is becoming more common, as research demonstrate improved response rates. There are several other variations that include vincristine (Oncovin) and prednisone. Women who enter clinical trials may be offered new drugs and/or different combinations of widely used ones.

The decision of when to begin chemotherapy and how long treatment should last is very individualized and may vary from one doctor to another. Some combinations may be given in cycles lasting only two to six months; others are given for a year or more.

Investigators are looking at whether giving chemotherapy before surgery can shrink a larger tumor enough not only to permit a lumpectomy instead of a mastectomy but also to destroy cancer cells that have spread to other areas.

Hormonal therapy is used to prevent the growth, spread, or recurrence of breast cancer. A pathology test on a sample of tumor tissue will reveal if the cancer has estrogen and progesterone receptors. If it has estrogen receptors, it is said to be estrogen-receptor positive; if not, it is said to be estrogen negative. The same is true of progesterone receptors.

When a tumor is said to be estrogen-positive or progesterone-positive, it means the tumor depends on the patient's natural hormones to grow.

Research has shown that if a tumor is estrogen-receptor positive, anti-estrogen therapy, such as the drug tamoxifen (Nolvadex), will block the receptor and prevent growth of cancer. Tamoxifen is used with and without chemotherapy primarily to treat women over 50. Some experts believe it is reasonable to give tamoxifen alone to low-risk, postmenopausal women and along with chemotherapy to high-risk, postmennopausal women.

Since Tamoxifen causes side effects similar to those of menopause—weight gain, hot flashes, and mood swings—younger women may choose not to take it. Most women continue on hormone therapy for two to five years, but research has not yet determined the optimal and safe duration of therapy.

There are obvious benefits to tamoxifen, but it is not without risk. Some studies have shown there may be an increased risk of endometrial cancer. Large studies are now being conducted to determine if tamoxifen will prevent cancer entirely in high-risk women. In some rare cases, removal of the ovaries is recommended, resulting in a surgically created menopause.

Clinical trials using aromatase inhibitors such as anastrozole, exemestrane and letrozole alone or in combination with Tamoxifen have shown a signification decrease in recurrence but only a small possible improvement in overall survival.

Ovarian ablation can be accomplished with surgery, radiation or hormones.

The immune system of the body is a natural defense against various diseases, including cancer. It also defends the body against infections and other side effects of cancer treatment. A strong immune system detects the difference between healthy cells and cancer cells, and it can get rid of those that become cancer. The immune system can be strengthened and improved by new immunotherapies. These treatments are designed to repair, stimulate, or increase the body's natural ability to fight infections and cancer.

About 25% of breast cancer patients are noted to have an overexpression of HER2/neu. A recent monoclonal antibody (immunotherapy) treatment called "herceptin" is currently used to reduce the chance of breast cancer recurrence in those patients. Bone marrow transplantation is occasionally recommended for Stage IV breast cancer patients.

As with other types of cancers, immunotherapy is also used as a treatment against breast cancer.

Drugs Commonly Used for Treating Breast Cancer

• Combination Chemotherapy (some combinations include hormones)CMF (cytoxan, methotrexate, 5-FU)
• CMFP (cytoxan, methotrexate, 5-FU, prednisone)
• CAF (cytoxan, adriamycin, 5-FU) (also called FAC)
• CA +/- tamoxifen (cytoxan, adriamycin, tamoxifen) (also called AC +/- tamoxifen)
• CMFVP (cytoxan, methotrexate, 5-FU, vincristine, prednisone)
• PAF (L-pam/melphalan, adriamycin, 5-FU)
• L-pam and 5-FU
• Docetaxel (taxotere)
• Paclitaxel (taxol)

Combination treatments, sometimes called multimodal treatments, refer to the use of two or more kinds of therapies. Different kinds of therapies may be used in sequence, at the same time, or in various timing formats.

Combining two or more types of treatments - such as surgery, radiation, and chemotherapy - may be more effective than a single therapy alone. Under certain conditions, combination therapy not only can achieve a greater likelihood of cure than a single approach, but can do so with less damage to vital organs and tissues.

In the past, cancer treatment relied heavily on surgery, one of the oldest cancer treatment methods. For example, amputation of the affected limb used to be the only treatment for patients with osteosarcoma, a cancer of the bone found most often in young people. Now, radiation therapy directed at the tumor and chemotherapy delivered through the bloodstream may destroy the cancer without loss of the limb containing the tumor.

Due to recent advances in the treatment of early-stage breast cancer, many patients receive lumpectomy (excision of the lump) followed by radiation therapy rather than mastectomy (removal of the entire breast). This has allowed many women to retain their desired natural contour without compromising the possibility of a cure.

Treatments are combined for several reasons:

• One treatment may be more effective at a certain stage of cancer than another.
• One treatment may enhance the effectiveness of another synergy.
• One treatment alone may not affect the tumor.

Depending on the stage of the disease, the oncologist will choose a primary therapy, the one that might have the most effective impact on the cancer. Then one or more other therapies may be selected to increase the possibility of cure.

To enhance the effectiveness of radiation therapy, some chemotherapy drugs are used to make certain kinds of cancer cells more susceptible to the radiation dose. Radiation therapy is generally most effective at the edges (margins) of a tumor but not as effective in the center of a tumor. Surgery can remove the tumor, but it may be unable to eliminate all cancer cells surrounding it without cutting out too much normal tissue. Therefore, the two treatments can be combined to work together, filling in the gaps of each other.

It is uncommon for cancer to be treated by only one method. With new technologies and new drugs discovered almost daily, combination treatments have shown a promising outlook for cancer treatment.

Treatment of breast cancer is among the most widely studied of all cancer therapies. New approaches to therapy and refinements in accepted regimens are constantly being evaluated and may rapidly become part of standard treatment protocols. Geographic practices also influence what is considered standard. Users should continually update their knowledge of cutting edge and standard treatment patterns.

Local control of the cancer occur more often when the tumor is small and can be completely removed by surgery. In the most advanced stages, breast cancer treatment begins with excision of the tumor or destruction of the tumor by radiation therapy. Surgery is frequently accompanied by some type of adjuvant treatment—radiotherapy, chemotherapy, hormonal therapy, immunotherapy, and other therapies.

Below is the information about treatment options by stage. The following sections will provide you with more detailed discussions about different therapies for breast cancer treatment.

Treatment Options by Stage

Intraductal Carcinoma

Total mastectomy; excisional biopsy with radiation therapy

Lobular Carcinoma in situ

Unilateral or bilateral total mastectomies with or without low axillary dissection

Stage I (negative nodes)

Excisional biopsy/lumpectomy or segmental/wedge/partial breast resection with separate axillary node dissection and radiation to breast; modified radical or total mastectomy with axillary dissection. Adjuvant chemotherapy for estrogen receptor negative patients; adjuvant tamoxifen for estrogen receptor positive patients.

Stage II

Excisional biopsy/lumpectomy or segmental/wedge/partial breast resection with separate axillary node dissection and radiation to breast; modified radical or total mastectomy with axillary dissection; radical mastecomy (if needed to accomplish complete resection of tumor). Adjuvant chemotherapy (CMF, CAF, CA+/-tamoxifen, L-PAM + 5-FU, L-PAM, 5-FU + tamoxifen, PAF, CMFVP, tamoxifen alone)

Stage IIIA (operable)

Modified radical mastectomy or radical mastectomy with either radiation or chemotherapy. Radiation could be preoperative external beam radiation or postoperative external beam radiation with a booster dose to primary site. Chemotherapy could be CMF, CA, CAF, CMFP, CMFVP, L-PAM and 5-FU with or without tamoxifen

Stage IIIB (inoperable, including inflammatory)

Incisional biopsy plus external beam radiation to primary and regional nodes, followed by boost to local area plus interstitial implants to primary. Mastectomy thereafter if technically feasible, followed by chemotherapy or endocrine manipulation. Chemotherapy could be CMF, CAF, CMFP, CA, CMFVP. Endocrine therapy could include oophorectomy, tamoxifen, progesterone or androgens.

Stage IV

Biopsy followed by external beam radiotherapy to primary or mastectomy to control local disease. Hormonal therapy if estrogen receptor positive (oophorectomy, tamoxifen or progestational agent). Chemotherapy (CMF, CAF, CMFP, CMFVP, CA)