Breast Cancer

content developed with: http://www.mayoclinic.org/

The best treatment outcomes occur when you work with your doctor and your team of breast experts—breast specialist, surgeon, plastic surgeon, medical oncologist, radiation oncologist, pathologist, and radiologist—to develop a strategy based upon the available treatment options, your individual preferences, and your overall health. A team approach is important, because breast cancer management and treatment can be complicated. A comprehensive focus is ideal so that your care is coordinated in an efficient and timely way. Your doctor will determine your treatment options based on the type of cancer, size, whether the lymph nodes are involved, and sensitivity of cancer cells to hormones. New research has also given insights into how the genetic characteristics of the tumor itself can influence how the breast cancer responds to certain treatments. Most treatments have side effects; be sure to discuss the potential short term and long term effects of each option with your doctor.

The decisions facing breast-cancer patients can be complex and may warrant seeking out a second opinion from a breast specialist or breast clinic. Speaking to other patients who have faced a similar situation can also help you develop a treatment strategy that is best suited to your individual situation.

This section discusses:

  • Surgical treatment options
  • Radiation therapy
  • Neoadjuvant chemotherapy
  • Chemotherapy
  • Hormonal therapy
  • Biological or targeted therapy
  • Complementary and alternative therapies
  • Treatment of inflammatory breast cancer
  • Treatment of male breast cancer
  • Surgical Treatment Options

    Surgical removal of the tumor is an essential first step in treating most breast cancers. Surgery not only removes the source of the cancer but also allows the doctor to collect the information needed to stage the cancer and identify treatment options. If cancer cells are found, the surgeon also will evaluate the sentinel lymph node (the first lymph node draining the cancerous region). If the sentinel lymph node is negative for cancer, no further nodes are removed. However, if it is positive for cancer, an axillary dissection is done to assess the degree to which the cancer has spread to other lymph nodes in the armpit.

    The removal of the tumor often involves removing the entire breast in a procedure called a mastectomy. There are several types of mastectomies. In special cases, the tumor can be excised with a margin of normal tissue and the rest of the breast conserved, in a procedure known as a lumpectomy. The surgeon will use information from the breast imaging evaluation, breast biopsy, and the pathology report to identify your surgical management options. Surgical management is highly individualized based upon the patient's overall health, personal values, and tumor characteristics.

    Women with early-stage cancer may be presented with both options as a first course of treatment. Bear in mind that there is no "correct" choice. Below are some factors to consider in addition to the medical advice when developing your treatment strategy:

    The importance to the woman of preserving her breast. Some women fear they will feel disfigured by the complete removal of a breast. Others are concerned that their intimate relationship will suffer if their breast isn't preserved.

    Concerns about radiation. In most cases, if you have a mastectomy, you don't need radiation therapy, which in itself carries a very small risk for the development of a new tumor and, in a very small percentage of patients, damage to the heart or lungs.

    Concerns about a feeling of imbalance after mastectomy. Some women worry that they will feel uneven after a mastectomy. Women who have had the procedure, however, typically report that using a prosthesis inside the bra or having breast reconstruction with a silicone or saline implant ameliorates this problem.

    Concerns about lingering symptoms. Following mastectomy, some women find that the tissue around the scar remains numb.

    This section includes information on:

    • Breast-conserving surgeries
    • Simple or total mastectomy
    • Axillary dissection
    • Breast reconstruction
    • Breast reconstruction with the patient's tissue
    • Breast-Conserving Surgeries

      The most common form of breast-conserving surgery, lumpectomy, removes the cancerous lump or area of abnormal cells and and the surrounding margins of healthy tissue. The primary advantage of lumpectomy is that most of the breast is preserved, including the areola and nipple region. When used to treat cancer, a lumpectomy is often part of a two-stage treatment plan: surgery to remove the cancer and a sentinel node biopsy followed by radiation. In cases involving a small, discrete lesion of DCIS, some surgeons may recommend that women can forgo radiation therapy because the risk of lingering cells becoming invasive is low.

      Less commonly, segmental or partial mastectomy may be performed to remove more of the breast tissue. This procedure excises the tumor as well as surrounding breast tissue. Lymph nodes may also be taken from the underarm in an axillary dissection. This procedure is generally followed by radiation therapy.

      As with any surgery, there is the risk of bleeding and infection at the incision. Other complications of a lumpectomy may include pain, temporary swelling, formation of hard scar tissue at the surgical site, change in the breast shape, and, if an axillary dissection is performed, numbness of the upper arm and lymphedema, the accumulation of fluid in the arm.

      Simple or Total Mastectomy

      A mastectomy is the surgical removal of all the breast tissue including the nipple and areola. A mastectomy may be warranted if:

      • Two or more tumors exist in different quadrants of the breast.
      • Cancer is distributed throughout the breast.
      • The patient is not a candidate for radiation because of previous courses of radiation, having no access to radiation, or pregnancy.
      • The tumor is large compared with the size of the breast.
      • The patient chooses a mastectomy.
      • The patient has had scleroderma, systemic lupus erythematosus, a chronic inflammatory disease, or other diseases of the connective tissue that can complicate radiation treatment.
      • The patient has a skin condition, xeroderma pigmentosa, in which the skin is extremely sensitive to ultraviolet light.
      • There are several different types of mastectomy procedures. Simple or total mastectomy is a surgical procedure in which the entire breast—including the lobules, ducts, stroma, nipple, and areola (the darker-colored area of skin around the nipple) is removed. This procedure typically is performed when the tumor is large relative to the size of the breast. Patients who undergo a simple mastectomy also often have a sentinel node biopsy. If the sentinel node biopsy shows cancer cells, an axillary dissection may be needed to collect additional lymph nodes from the underarm area.

        Women who undergo a simple mastectomy most often do not require radiation therapy. However, radiation may be recommended to the chest wall after the mastectomy (also known as post-mastectomy radiation) if surgery uncovers any of the following:

        • The tumor is larger than 2 inches (4 centimeters).
        • Cancer cells are found in lymph nodes.
        • The cancer cells are close to the chest wall, which increases the likelihood that the cancer may recur on the chest wall.
        • A simple mastectomy without reconstruction usually requires one to two hours of surgery followed by a 24- to 48-hour stay in the hospital. A single incision, six to eight inches long, across half the chest usually allows the surgeon to remove the breast and any lymph nodes necessary for an evaluation.

          After the surgeon completes the mastectomy, a plastic tube about the width of a pen is gently sewn into place to allow fluids to drain. The end of this drain is attached to a pocket-size suction device. The patient is instructed in the care of the drain and monitoring of draining fluids until the device is removed seven to 10 days after surgery.

          Most women do not experience excessive pain following a simple mastectomy. It is common, though, to use some pain medication—whether over-the-counter or prescription—for the first three to seven days. Like all surgeries, there is a risk of infection and bleeding at the incision. Other complications of a mastectomy can include numbness under the arm, for women who also had the lymph node surgery. There is less numbness and arm swelling following a sentinel lymph node biopsy than an axillary node dissection. Some of this numbness fades as nerve cells regenerate, but some may be permanent. The arm swelling may improve over time or may persist.

          In a modified radical mastectomy the entire breast is removed, including the ducts, lobules, stroma, skin, areola, and nipple, as well as most of the lymph nodes under the arm. This surgery is commonly recommended if the tumor is large and the doctor suspects that the cancer has spread to the lymph nodes.

          A modified radical mastectomy without reconstruction requires two to four hours of surgery followed by an overnight hospital stay. The surgery is performed using a single incision across half the chest. During the surgery, the doctor will gently sew into place two plastic tubes, each about the width of a pen, to drain the fluids. The ends of these drains are attached to a pocket-size suction device that allows patients to monitor the fluids that drain from the incision over a period of seven to 10 days after surgery. Although some women find the tubes an irritant, they usually are not painful.

          Although a modified radical mastectomy usually does not result in excessive pain, some pain medication for the first week or two after surgery helps minimize the discomfort. After this period an over-the-counter pain reliever can be used, as needed. Other complications include numbness of the upper arm due to the loss of small nerves during the removal of the lymph nodes. In some cases, the numbness is temporary; in others, it persists. Other complications include infection and excessive bleeding.

          Radiation may be recommended if surgery uncovers any of the following:

          • The tumor is larger than two inches.
          • Cancer cells are, in fact, found to be in the lymph nodes.
          • Cancer cells are close to the chest wall, which increases the likelihood that the cancer cells may recur in the chest wall.
          • Skin-sparing or nipple-sparing mastectomy is the removal of the entire breast, including the ducts, lobules, and stroma, but retaining the breast skin or the nipple and areola. These procedures are commonly performed when a breast reconstruction is scheduled to occur during the same surgery. These procedures are typically performed in patients undergoing a preventive mastectomy. Candidates for a nipple-sparing procedure generally have a small tumor that is located away from the nipple.

            A skin-sparing or nipple-sparing mastectomy, with reconstruction, can last up to eight hours depending on the type of breast reconstruction to be performed. Instead of a large incision across half the chest, the surgeon makes a small incision to preserve the breast skin and/or nipple, to make the cosmetic reconstruction look as good as possible. Surgeons at large breast cancer centers are generally more experienced with this delicate surgery. If a sentinel lymph node biopsy is needed, the surgeon will make another incision under the arm. As with other mastectomies, drainage tubes will be placed and the patient will be instructed on how to monitor the drainage from her incision. A hospital stay after skin-sparing mastectomy and reconstruction may be one to two nights, depending on the type of reconstruction.

            The pain level following skin-sparing or nipple sparing mastectomy is generally greater than for a simple or modified radical mastectomy. Most patients use prescription pain medication for the first one to two weeks after surgery, followed by an over-the-counter pain reliever as needed.

            The complications from a skin-sparing or nipple-sparing mastectomy are similar to those from a simple mastectomy. There is a risk of infection and bleeding at the incision. If an axillary dissection is needed, there is a risk of developing numbness in the upper arm. In some cases, the numbness is temporary; in others, it persists.

            Cancer surgery is emotionally draining and physically taxing. It's a good idea to plan a lighter schedule for the weeks following surgery and allow yourself plenty of time to recover.

            Axillary Dissection

            Axillary dissection is the removal of, on average, 15 to 25 lymph nodes from the axillary area, or armpit. Once removed, the lymph nodes are analyzed under a microscope by a pathologist to look for abnormal or cancerous cells. The presence of cancer in these lymph nodes may indicate an increased likelihood that the cancer has spread to other parts of the body. Today, it is usually only performed if there is an indication that the lymph nodes under the arm contain cancer cells.

            This procedure is not performed as frequently as it used to be due to the advent of the sentinel node biopsy. The results of the sentinel lymph node biopsy are used to assess the likelihood that the cancer has spread to other lymph nodes. If the sentinel lymph node biopsy is positive for cancer then the axillary node dissection will be performed.

            The complications following a sentinel lymph node biopsy are significantly less compared to an axillary dissection. The complications of an axillary dissection include long-term swelling, or lymphedema, and numbness in the upper arm. Small nerves are sometimes removed along with the lymph nodes during the procedure. The resulting numbness may be temporary or persist indefinitely.

            Breast Reconstruction

            Breast reconstruction surgery can be performed immediately at the time of mastectomy or delayed for months or more and performed in a separate operation. Immediate reconstruction after a skin-sparing or nipple-sparing mastectomy offers the advantage of minimized scarring. For some women, breast reconstruction may need to be delayed until radiation treatment is complete. Your oncologist or breast specialist may recommend that you meet with a radiation oncologist and plastic surgeon before surgery to discuss your options with regards to radiation and how it may impact the reconstruction options.

            Either implants or the patient's own tissue can be used to replace the breast tissue. Neither of these interferes with doctors' ability to detect a recurrence of cancer. For some women, reconstruction is not an option either due to medical conditions or personal choice. In this case, they are able to use a prosthesis that is worn in the bra.

            Reconstruction with implants uses a silicone shell filled with either saline solution or silicone gel. It is placed under the muscle of the chest to create a breast mound. The primary difference between the two implants is the consistency of the fill material. Saline implants contain salty water that can feel hard or unnatural to some women. Recent advances in surgical techniques have lessened these complaints. If saline implants rupture, the saline water is absorbed into the surrounding tissue with no health risk. This is immediately evident and the implant will need to be replaced.

            Silicone implants use a sticky gel that is designed to feel like fat tissue; these implants tend to look and feel more like natural breast tissue. If a silicone implant ruptures, it is unlikely that it will be noticed immediately; over time the symptoms may include breast pain or a change in the shape of the breast. In this situation, the implant will need to be replaced. Although long term studies are ongoing, both saline and silicone breast implants are considered safe and are FDA-approved for general use in breast reconstruction.

            A third implant made of a more cohesive silicone gel known as a "gummy bear" is being developed. These implants are designed to hold their shape longer. Currently, gummy bear implants are only available to women participating in a clinical trial to test the safety and effectiveness of these implants.

            No matter what type of implant is used, breast reconstruction begins with the placement of a balloonlike device called a tissue expander under the skin and muscle of the chest. This is done at the time of the mastectomy or later. The completion of the breast reconstruction with tissue expanders may need to be delayed if radiation therapy to the chest wall is recommended. It is important to discuss the risks and limitations of radiation treatment to the chest wall following implant placement with your doctor.

            The expander slowly stretches the overlying skin and chest muscle at the breast site to accommodate the implant. The patient then receives serial injections of saline, usually every two to three weeks, into the expander on an outpatient basis until the desired breast volume is achieved. This volume is greater than the reconstructed breast will be. The breast is left over-expanded for one to six months to help create a more natural appearance after implantation. After the expansion, the expander is reduced to the correct size to accommodate the implant. The expander is then removed and a permanent implant is put in place. In general, an implant makes the breast firmer than a natural breast.

            Like all surgeries, breast reconstruction carries some risk. Initially, there is the risk of infection and bleeding at the incision. The long-term effects may include breast tenderness, permanent changes in the nipple or breast sensation, formation of scar tissue that distorts the shape of the breast, and leakage of the implant. Breast implants are not guaranteed to last a lifetime; it is likely that additional surgery will be needed to correct a leakage or cosmetic issue. Currently the FDA recommends monitoring of silicone implants with an MRI every two years to detect any potential leakage.

            Breast Reconstruction With the Patient's Tissue

            Breast reconstructions can also be done with the patient's own tissues from the abdomen. For patients having radiation therapy, this option will be delayed, especially in situations where the tumor was large and multiple lymph nodes were positive for cancer.

            In a reconstruction using a TRAM flap surgery technique, surgeons reconstruct the breast after a mastectomy using skin and muscle from the lower abdomen. The relocated tissue either remains connected to its original blood supply or is reattached to blood vessels in the chest area. While this operation offers a bonus—a trimmer abdomen—it affects the abdominal muscle and can result in a loss of muscle tone. The breast can also be reconstructed using tissue from the upper back in a similar procedure known as the latissimus flap.

            Reconstruction using the DIEP flap surgery rebuilds the breast mound immediately after the mastectomy using abdominal tissue. This procedure is similar to the TRAM but does not involve the muscle and retains abdominal muscle function. To be a good candidate for this procedure, the patient must have an adequate supply of blood to the skin and fatty tissue. The DIEP procedure has a faster recovery period than traditional TRAM flap surgery with no loss of abdominal muscle tone while preserving the "effect" of a tummy tuck because excess tissue is removed from the abdomen to reconstruct the breast.

            Reconstruction using the SIEA surgery involves the superficial inferior epigastric artery (SIEA), found in the lower abdominal area, to reconstruct the breast. The major benefit of this surgery is that the muscle is left intact, preserving the muscle function. The blood supply to the relocated tissue must be reconnected, which poses the risk of tissue death, or losing the flap, at the time of surgery or within the first few days. The primary factor in determining the likelihood of flap loss is the experience of the surgeon. Not everyone is a candidate for a flap procedure. Flap reconstruction procedures typically are not recommended to patients who:

            • Have had previous abdominal surgery
            • Are obese
            • Smoke
            • Have a history of blood clots
            • Have other major medical conditions
            • The process of surgically re-creating a nipple and areola begins about six to eight weeks after the implant has been put in place or reconstruction has been done using a woman's own tissues. The surgeon creates a slight mound of tissue from skin. A tattoo may be applied to color the nipple and to create an areola. Both of these procedures are done on an outpatient basis.

              Radiation Therapy

              Radiation therapy uses high-energy radioactive beams to kill cancer cells. The radiation destroys the genetic material controlling cell growth in every cell it encounters, both cancerous and healthy cells. It is vital that the radioactive beams are directed to the specific area where the cancer was removed to minimize the impact on healthy cells.

              The treatment is generally given daily over a period of five to seven weeks and is guided by a radiation oncologist. Radiation therapy may be used as the only treatment to destroy cancer cells or in combination with other therapies for patients who had a tumor larger than four centimeters, have undergone a lumpectomy or mastectomy, and whose lymph nodes contain cancer cells.

              The standard method, known as external beam, delivers X-rays, gamma rays, or particle beams painlessly to the site of the lumpectomy. The type of beam used will depend on how large an area is to be radiated and how deeply the treatment must penetrate.

              Brachytherapy or internal beam therapy may be used to direct a high dose of radiation to a small area. This technique uses implanted small seeds or pellets of radioactive material to radiate the site. These seeds are placed in tubes that have been inserted into the breast tissue in a minor surgical procedure, either concurrently with the surgery to remove the tumor or at a later time. Generally, the seeds are placed in the tubes for a short time twice a day for about a week, though sometimes they are left in place for a period of days. Once the patient has received the prescribed radiation treatment, the tubes are taken out in a procedure that causes relatively little pain.

              Another partial breast radiation option following lumpectomy involves a catheter balloon where more intense radiation is delivered over five days. Some radiation centers are able to offer more intense whole breast radiation over three to four weeks.

              Radiation therapy can produce side effects that build up over time depending on which part of your body is exposed to radiation and how much radiation is used. Some people experience no side effects; others have several. Usually the side effects are temporary. The most common include fatigue, skin irritation, darkening or shrinking of the breast, and swelling of the breast. Less frequently, patients experience cough, shortness of breath, a rib fracture, or damage to the chest wall muscle and heart. Very rarely, radiation may foster the development of an additional tumor. Be sure to discuss the potential short- and long-term side effects with your radiation oncologist.

              Neoadjuvant or Preoperative Chemotherapy

              For some patients, chemotherapy may be recommended before surgery. If the tumor is large, the neoadjuvant chemotherapy shrinks the cancer so that a lumpectomy procedure can be performed. The oncologist will recommend chemotherapy medications and length of treatment depending on the type of tumor. During chemotherapy, the oncologist will monitor the size of the tumor with breast MRI or ultrasound. Neoadjuvant therapy is the first line of treatment for inflammatory breast cancer.

              Chemotherapy

              Chemotherapy is the use of drugs to kill cancer cells. These drugs may be administered intravenously, in pill form, or as a combination of the two. The drugs circulate in the bloodstream to all parts of the body, where they can destroy cells that have spread from the primary tumor. The course of treatment usually takes several months, with the patient receiving treatment in periodic cycles. Each cycle includes a treatment period followed by a recovery period, the timing of which depends on the treatment objectives and the individual's situation.

              A physician may recommend chemotherapy before surgery to shrink the size of the tumor or after surgery to kill any cancer cells that may have spread outside the breast. Chemotherapy may be recommended after surgery even if there is no evidence of any cancer cells in the body. Or it may be used in advanced stages of cancer as the main treatment. Typically, it is recommended if the invasive breast cancer is aggressive and larger than one centimeter in diameter in women who are still menstruating, the tumor has spread to the lymph nodes or chest wall muscles, or the patient has rapidly spreading inflammatory breast cancer.

              There are a large number of different chemotherapy drugs, and new ones are under development. These drugs attack cancer cells in a variety of different ways and interfere with various processes necessary to the cell's life. The drugs may prevent the cell's DNA from replicating, prevent the cells from dividing, or block the actions of crucial enzymes. Because they have different mechanisms of action, chemotherapy drugs are often given in combinations, or "cocktails," to subject cancer cells to several simultaneous kinds of attack.

              Though chemotherapy drugs target cancer cells, they can be also toxic to normal cells. They tend to affect the cells that reproduce rapidly, such as those in the hair follicles, bone marrow, blood, immune system, and lining of the digestive tract, among others. Side effects vary in kind and severity from patient to patient. Some patients experience minor effects; others may experience hair loss, nausea, vomiting, diarrhea, mouth sores, fatigue, and a suppressed immune system. If you experience any side effects, let your health care team know as there are ways to help alleviate them.

              Other less common side effects include early onset of menopause, infertility, changes in sensation in the hands and feet, damage to the heart muscle, slight decrease in mental functioning known as chemo brain, and increased risk of leukemia. These risks are relatively low and usually are outweighed by the benefits of preventing a recurrence of breast cancer.

              Hormonal Therapy

              The female hormones estrogen and progesterone play a role in the growth of breast cells. Estrogen stimulates growth of about 2 of every 3 breast cancers. Breast cells normally have special receptors that permit the hormones to connect to the cells. Breast cancer cells that have such receptors are known as "hormone-receptor positive." The goal of hormonal therapy is to reduce the amount of these hormones available to the cancer cells, which may cause them to cease growing or die.

              After cancerous cells are surgically removed, they are tested for hormone receptors. If the tumor is receptor positive, hormonal therapy may lower the risk that cancer will recur in breast tissue or other parts of the body by either preventing the hormones from acting on the cell or lowering the amounts of hormones in the body. Patients with receptor-positive tumors usually experience fewer local recurrences and longer overall survival than those with receptor-negative tumors. Hormonal therapy does not help patients with cancers that are not receptor positive.

              Tamoxifen, the most a widely used hormonal treatment for breast cancer, is an anti-estrogen medication. It acts by blocking the ability of the hormones to attach to cancer cell receptors and prevents the growth of new tumors. Studies have shown that for patients with hormone receptor-positive cancer, taking tamoxifen in a pill form by mouth for five years after surgery can reduce the risk of recurrence of breast cancer by about one half. Tamoxifen is also used to treat women with metastatic breast cancer or as a preventive therapy for women who are at high risk for developing breast cancer.

              Tamoxifen is not without side effects. Some of the more common side effects include night sweats and hot flashes, mood changes, loss of sex drive, nausea, menstrual irregularity (when taken before menopause), vaginal discharge, and a dry, itchy vagina. Rare but serious side effects can include increased risk for uterine cancer and increased risk for blood clots, which can lead to heart attack, stroke, or pulmonary embolism. Contact your health care team immediately if you develop pain, redness, shortness of breath chest pain, sudden severe headache, confusion, or trouble speaking or moving.

              New research has found that tamoxifen is broken down or metabolized to the active form of the drug in the body by an enzyme called CYP 2D6. This active form strongly binds to the hormone receptor and prevents cells from growing. It is becoming more important to test for this enzyme's activity before prescribing tamoxifen in postmenopausal women. Doctors are able to test your blood to assess for this enzyme's activity. A normal functioning enzyme is a good indicator that the tamoxifen will be appropriately metabolized and will work effectively to reduce the risk of recurrence. The enzyme's function can be inhibited by certain medications or not function for other reasons, which could result in tamoxifen not being effective at reducing breast cancer recurrence. Contact your health care provider to make sure that you are not on any medications that may interfere with tamoxifen's metabolism.

              In postmenopausal women, another approach to hormonal therapy is the use of aromatase inhibitors. These medications reduce the amount of estrogen that the body produces. Three different aromatase inhibitors are approved for breast cancer therapy and may be prescribed for five years. Other treatment options include taking tamoxifen for two to three years and then switching to an aromatase inhibitor for a total of five years of hormonal therapy. Aromatase inhibitors may also be recommended for five years after completing five years of tamoxifen treatment. The research shows that using these drugs alone, in combination with tamoxifen, or after tamoxifen reduces the risk of cancer recurrence better than using tamoxifen alone for five years.

              Aromatase inhibitors tend to have fewer side effects than tamoxifen. The primary side effects are joint or muscle pain and an increased risk of osteoporosis. To offset the bone-thinning effects, women on aromatase inhibitors may be prescribed medicines to strengthen their bones.

              Another method of lowering the amount of estrogen in the body and slowing or stopping the growth and spread of breast cancer is removing or stopping the function of the ovaries, the main source of estrogen for women. The ovaries can be removed surgically or stopped from working with drugs known as luteinizing hormone-releasing hormone (LHRH). These drugs stop the body's signal to the ovaries to make estrogen. LHRH drugs are sometimes recommended for premenopausal women to be used alone or along with tamoxifen. The use of LHRH along with aromatase inhibitors in pre-menopausal women is currently being studied.

              Biological or Targeted Therapy

              Targeted therapies are drug treatments that zero in on specific aspects of cancer cell development to either slow down cells' growth or kill them. These drugs have the benefit of fewer and less severe side effects than chemotherapy. Today, they are used in conjunction with chemotherapy. Although three drugs have been approved as targeted therapies for breast cancer, their use is not always covered by health insurance.

              Trastuzumab (Herceptin) targets a protein called HER2 that drives the growth of breast cancer cells. One out of 5 breast cancers makes an abnormal amount of HER2, which allows the cancers to grow and spread more aggressively. Trastuzumab can help limit their growth and stimulate the immune system to attack the cancer. A simple test of breast cancer cells can tell if the cancer is HER2 positive. If it is, your doctor may recommend using trastuzumab intravenously. Typically, it is injected into a vein once a week or it can be used less frequently at higher dosages. The optimal dosage and duration of therapy has not yet been determined.

              The most common side effects of trastuzumab include fever and chills, weakness, nausea, vomiting, cough, diarrhea, and headache. These effects are typically the greatest after the first dose and diminish with subsequent dosages. A more serious and rare side effect is heart damage that can lead to congestive heart failure. Usually this effect is temporary and improves when the drug is stopped. Symptoms that should trigger a call to your healthcare team include shortness of breath, leg swelling, and severe fatigue.

              Lapatinib (Tykerb) targets the HER2 protein as well. It is approved by the FDA for use in women with advanced breast cancer who have already tried trastuzumab and whose cancer has progressed. Currently, researchers are evaluating its effectiveness as an adjuvant therapy in HER2-positive patients.

              Administered in a pill, lapatinib carries several side effects, the most common of which is diarrhea, which can be severe. Other side effects include nausea, vomiting, rash, and changes in the sensations of the hand and feet, together known as the hand-foot syndrome. The hand-foot syndrome may include numbness, tingling, redness, swelling, and discomfort. Occasionally, lapatinib may affect the functions of the liver and heart, but usually this goes away after the completion of treatment.

              Bevacizumab (Avastin) targets the development of blood vessels in tumors in patients with metastatic breast cancer. This drug interrupts the signals used to attract new blood vessels, thus depriving the tumors of nutrients needed to grow and ultimately causing the cancer cells to die.

              The most common side effect is high blood pressure. Less frequently, patients can develop fatigue, blood clots, low white blood cell counts, headaches, mouth sores, loss of appetite, and diarrhea. Other rare but possible side effects include bleeding, slow wound healing, and formation of holes in the colon that require surgery.

              Complementary and Alternative Therapies

              Along with the standard therapies that physicians prescribe to treat breast cancer, a number of unproven approaches have attracted public attention, either as a means of attacking the cancer itself or of improving the patient's quality of life. These treatments include herbal or vitamin preparations, dietary supplements, various chemicals, acupuncture, and massage therapy. When such treatments are used along with standard medical care, they are called complementary. When they take the place of standard care, they are called alternative.

              Currently, there is no alternative medicine treatment to cure breast cancer. But a number of complementary treatments have shown merit in helping cancer patients feel more comfortable and countering the side effects of standard therapies. Before using any of them, however, patients should talk with their physicians to be sure that the additional therapies are safe, can be used along with the standard treatments without reducing their effectiveness, and will not cause troublesome side effects.

              Although some complementary treatments are gaining acceptance, alternative therapies used in place of regular medical care pose serious dangers. A patient who opts for alternative therapies in lieu of regular treatment will not gain the benefits of proven methods of care. In addition, alternative treatments may use substances that can be harmful in themselves.

              Complementary therapies that help combat fatigue during and after your treatment include gentle exercise, relaxation techniques, and stress management. Discuss with your doctor when you can start an exercise program. Some options may include walking, swimming, or tai chi. Be sure to balance activity with periods of relaxation. Listening to music, writing, meditating, or even a warm bath may help relax you. Muscle relaxation, visualization, and taking time for friends and family can help alleviate stress in your life.

              Treatment of Inflammatory Breast Cancer

              Inflammatory breast cancer is considered an advanced stage of cancer. Treatment usually begins with neoadjuvant chemotherapy to shrink the cancer, followed by surgery and radiation therapy. After these treatments are complete, your doctor may recommend hormone therapy and targeted therapy.

              Male Breast Cancer Treatment

              Breast cancer treatment for men has the same treatment options as women: surgery, chemotherapy, radiation therapy, hormone therapy, and targeted or biological therapy. For most men, treatment begins with surgery followed by any combination of chemotherapy, radiation therapy, hormone therapy, or targeted therapy.

              Last reviewed on 3/28/10

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