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Breast Cancer Treatment Your doctor will recommend treatment based on the size and aggressiveness of your tumor and the extent to which it has spread. This section discusses:
Treatment by stage Your doctor will recommend treatment based on the size and aggressiveness of your tumor and the extent to which it has spread. You can visit our pages on staging in the Tests section and breast cancer types in the About section for more information on the different stages and kinds of breast cancer. Lesions (not "tumors" because usually they haven't developed into actual lumps) discovered at Stage 0, when they are noninvasive or precancerous, are almost always treated successfully. Many women with ductal carcinoma in situ (DCIS) opt for a lumpectomy followed by radiation treatment to kill lingering cells that could develop into invasive cancer. Others choose mastectomies and so are able to forgo radiation therapy. Many surgeons also recommend a sentinel node biopsy for women with DCIS, especially if there is reason to believe that DCIS is distributed throughout the breast or it is a high-grade lesion. Most women with precancerous lobular carcinoma in situ (LCIS) don't undergo surgery, but tamoxifen or a similar hormonal treatment known to reduce the likelihood of future cancers may be prescribed. At Stage I (early-stage invasive cancer), breast-conserving surgery such as lumpectomy, followed by radiation to kill any remaining cells, is often appropriate. If chemotherapy is recommended based on the patient's age or the aggressiveness of the tumor, it most often is given prior to radiation. Besides radiation or chemotherapy, lumpectomy patients may use tamoxifen or another hormonal medication to reduce the risk of recurrence if the tumor is hormone-receptor positive. Another approach involves a simple mastectomy to remove the entire breast. Women who opt for mastectomy generally do not undergo radiation therapy, though they still may receive chemotherapy or hormonal therapy after the surgery. Breast cancer surgery generally also entails a procedure to check for the spread of cancer cells to the lymph nodes in the underarm. A technique known as sentinel node biopsy, which examines the first nodes to be affected by lymph draining from the breast, is increasingly used for this purpose. At Stage II, when a tumor is fairly large or a small tumor is accompanied by lymph-node involvement, lumpectomy with subsequent radiation may be appropriate, as may be simple mastectomy. Chemotherapy and hormonal treatment are also commonly prescribed. Stage III cancers often require more extensive surgery and more aggressive accompanying or "adjuvant" therapies, as the cancer has spread from the breast into the nearby lymph nodes or chest wall. Stage IV cancers have metastasized to the lungs, liver, bones, or brain. Treatment of these advanced cancers is unlikely to result in a cure. The emphasis is on chemotherapy, radiation, and hormonal medications to slow the disease's progression. Surgical options Surgical removal of the tumor is an essential step in treating breast cancer, as is examination of the tumor tissue to come to a decision about treatment options. Either the whole breast can be removed in a procedure called mastectomy, or the tumor alone can be excised and the rest of the breast conserved, usually in a procedure called lumpectomy. Surgical removal of at least some of the lymph nodes from the underarm is also generally done to determine whether the cancer has spread to the nodes. In addition, many women choose to have reconstructive surgery to create a new breast form after mastectomy. This section discusses:
Weighing lumpectomy versus mastectomy A mastectomy may be indicated medically if:
However, in many cases, a woman's doctors may feel that both procedures are reasonable from a medical point of view. Women with early-stage cancer especially may be presented with both options. As women struggle with choosing between the two they should bear mind that there is no "correct" choice and that what feels right to one woman may not feel right to another in a seemingly similar situation. Below are some factors to consider when making the choice:
Breast-conserving surgeries The most common form of breast-conserving surgery, lumpectomy, removes just the cancerous lump and a surrounding area of normal tissue. If women choose lumpectomy, generally they are signing up for a two-stage treatment plan: surgery to remove the cancer and evaluate the axillary lymph nodes (located in the underarm area) followed by radiation. A lumpectomy without radiation is not typically recommended because the risk of local recurrence is thought to be too high. Increasingly, however, in cases involving a small, discrete lesion of DCIS, some surgeons say women can forgo radiation therapy because the risk of lingering cells becoming invasive is so low. The primary advantage of lumpectomy is that most of breast is preserved, including the areola and nipple region. A less commonly performed procedure, segmental or partial mastectomy, removes more breast tissue. This procedure excises the tumor as well as surrounding breast tissue and the lining of chest muscles underneath. Lymph nodes may also be taken from the underarm. Radiation therapy generally follows this procedure, too. Simple or total mastectomy In this procedure, the entire breast--including the nipple and areola (the darker-colored area of skin around the nipple)--is removed. In contrast to a modified radical mastectomy, the axillary (underarm) lymph nodes are not removed (although surgeons often do remove a so-called sentinel node. Simple or total mastectomy is typically offered tumor is large relative to the size of their breast. Patients who undergo this procedure also often have their nodes evaluated with a sentinel node biopsy. A simple mastectomy without reconstruction may be done in one to two hours and usually involves a hospital stay of one or two nights. A single incision 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 draw off fluids. 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. Also, fatigue is to be expected following the surgery, which tends to be emotionally as well as physically taxing. It's a good idea to plan a lighter schedule for the weeks following surgery. Women often experience numbness under the arm when they've also had an axillary dissection to check lymph nodes. Some of this numbness fades as nerve cells regenerate, but some may be permanent. Women who choose mastectomy normally can forgo radiation therapy. However, radiation may be recommended if surgery uncovers any of the following:
Modified radical mastectomy In a modified radical mastectomy, the entire breast is removed, including the skin, areola, and nipple, as well as most of the lymph nodes under the arm. This surgery is most commonly recommended if the tumor is large and cancer is thought to have already spread to the lymph nodes. A modified radical mastectomy without reconstruction takes two to four hours and usually involves a hospital stay of one to two nights. A single incision across half the chest usually allows the surgeon to remove the breast and the lymph nodes. After the surgeon completes the mastectomy, two plastic tubes each about the width of a pen are gently sewn into place to draw off fluids. The ends of these drains are attached to a pocket-size suction device. Patients are instructed in the care of the drains and monitoring of the draining fluids until the tubes are removed seven to 10 days after surgery. Although some women find the tubes an irritant, having them in is usually not painful. Most women do not experience excessive pain following a modified radical mastectomy. It is common to use some pain medication for the first week or two after surgery and then just an over-the-counter pain reliever, if needed. A sensation of numbness can occur in the upper arm, which results from the loss of small nerves where the lymph nodes are removed. Some of this numbness may fade over time. Fatigue is to be expected following the surgery, which tends to be emotionally as well as physically taxing. Patients may need to plan a lighter schedule for the weeks following surgery. Most women with early-stage breast cancer who undergo a modified radical mastectomy can forgo radiation therapy. However, radiation may be recommended if surgery uncovers any of the following:
Skin-sparing mastectomy A skin-sparing mastectomy involves removal of the entire breast, including nipple and areola, without removal of the breast skin. It is commonly performed when a breast reconstruction is scheduled to occur during the same surgery. A skin-sparing mastectomy, with reconstruction, takes two to eight hours. The variation in the length of surgery depends on the type of reconstruction being performed. A hospital stay after skin-sparing mastectomy and reconstruction may be one to four nights, depending on the type of reconstruction. Instead of a large incision across half the chest, the surgeon makes a small incision around the areola that maintains the rest of the breast skin. This is done to optimize the result of the cosmetic reconstruction. Surgeons at large cancer centers generally have more experience with this surgery. If a sentinel node biopsy or axillary dissection is needed to evaluate or remove lymph nodes, a second incision will be made under the arm. After the surgeon completes the skin-sparing mastectomy, one or two plastic tubes about the width of a pen are gently sewn into place to draw off fluids. The ends of these drains are attached to a pocket-size suction device. Patients are instructed in the care of the drain and monitoring of the fluids until the tubes are removed several days after surgery. The pain level following skin-sparing mastectomy is generally greater than for a simple mastectomy. After a skin-sparing mastectomy with reconstruction it is common to use prescription pain medication for the first week or two after surgery and then an over-the-counter pain reliever as needed. Women often experience numbness under the arm when they've also had an axillary dissection to check lymph nodes. Some of this numbness may fade over time. Fatigue is to be expected following the surgery, which tends to be emotionally as well as physically taxing. Patients are advised to plan a lighter schedule for the weeks following the surgery. Axillary dissection If a sentinel lymph node is found to contain cancer during a mastectomy or lumpectomy procedure, the standard treatment is to also perform an axillary dissection to remove the remaining lymph nodes under the arm. These nodes also will be examined, and if they are found to contain cancer, the chances that the cancer has spread to other parts of the body will be greater. In these situations more aggressive medications or treatment will be recommended. Breast reconstruction Below are several procedures that may be used to re-create a breast mound following mastectomy: Reconstruction with implants: An implant is a silicone shell filled with saline (saltwater) solution or silicone gel. It is placed under the skin and muscle of the chest to create a breast mound. Silicone-gel-filled implants are under review by the Food and Drug Administration but may be used for patients undergoing reconstruction following mastectomy. Reconstructing a breast with an implant can take nine months to a year. Usually, the first step is to place a balloonlike device called a tissue expander under the skin and muscle of the chest. This is done at the time of the mastectomy. The expander slowly stretches the skin and chest muscle at the breast site to accommodate the implant. The patient then receives serial injections of saline, usually once a week, 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 overexpanded 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. TRAM flap surgery: One way to reconstruct the breast after a mastectomy is to use the transverse rectus abdominis mycutaneous (TRAM) flap procedure, which takes skin and fat from the abdomen. Sometimes surgeons leave the tissue connected to its own blood supply and pull it under the skin into position on the chest. Alternatively, the tissue may be moved to the chest and attached to different blood vessels. While this operation offers a bonus--a trimmer abdomen--it affects the abdominal muscle and can result in a loss of muscle tone. A variation of the operation has been developed that leaves much of the muscle intact. It is also possible to reconstruct the breast using tissue from the upper back in a similar procedure known as the latissimus flap. DIEP flap surgery: The deep inferior epigastric perforator (DIEP) flap procedure is another option for women who would like a breast mound present immediately after their mastectomy and reconstruction with their own tissues. The DIEP is a small branch of a major artery. To be a good candidate for this procedure the patient must have an adequate supply of blood to the skin and fatty tissue. If so, no muscle needs to be taken, and muscle function is maintained. The DIEP procedure has several benefits: 1. A faster recovery period than traditional TRAM flap surgery; 2. No loss of abdominal muscle tone; 3. The "effect" of a tummy tuck because excess tissue is removed from the abdomen to reconstruct the breast. This procedure carries the risk of tissue death, or losing the flap. SIEA surgery: This procedure involves the superficial inferior epigastric artery (SIEA), which is found in the lower abdominal area. The major benefit of this surgery is that the muscle is left intact; only skin and fat are removed, so muscle function is preserved. The blood supply must be reconnected, which means that there is a risk of tissue death, or losing the flap, at the time of surgery or within the first few days. The biggest factor in determining the likelihood of flap loss is the experience of the surgeon. Inadequate size of the patient's arteries often prevents the SIEA flap from being performed. Nipple and areola reconstruction: The process of surgically re-creating a nipple and areola (the darker-colored skin around the nipple) begins about six to eight weeks after the implant has been put in place or reconstruction using a woman's own tissues has taken place. 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 radioactive beams to kill cancer cells. The standard method, known as external beam, delivers high-energy X-rays, gamma rays, or particle beams painlessly to the site of the cancer. The type of beam used will depend on how large an area is to be radiated and how deeply the treatment must penetrate. Radiation therapy is generally given daily for five to seven weeks. A method called brachytherapy or internal beam therapy may be used to direct a high dose of radiation to a small area. The technique radiates the site using implanted small seeds or pellets of radioactive material. 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. Radiation therapy can produce side effects that build up over time. They include fatigue, skin irritation, and darkening or shrinking of the breast. Less common side effects include rib fractures, lung inflammation, and damage to the nerves and heart. Very rarely, radiation may foster an additional tumor. Chemotherapy Chemotherapy drugs are often used following surgery to kill cancer cells that may have spread outside the breast. These drugs may be administered intravenously, in pill form, or both ways. An oncologist might also recommend chemotherapy before surgery if the breast tumor is large (has a diameter greater than 5 centimeters), if the tumor is attached to the chest wall muscles, or if the patient has rapidly spreading inflammatory breast cancer. Women whose cancers respond well to chemotherapy before surgery often are able to have surgeries in which more of the breast is conserved. In chemotherapy, the patient receives chemicals that move through 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. 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 harm cells that are rapidly dividing, damaging the cells of hair follicles, blood, the immune system, and the lining of the digestive tract, among others. Side effects vary in kind and severity from patient to patient. Depending on the chemotherapy drugs used, patients could experience hair loss, nausea, vomiting, diarrhea, mouth sores, fatigue, and a suppressed immune system. The current antinausea drugs are far more effective than a generation ago. Most patients receive chemotherapy after they heal from breast surgery and prior to radiation. The physician chooses the chemotherapy drugs and sequence of treatment based on the details of each case. Researchers conduct many clinical trials to find drug combinations and treatment sequences that result in improved outcomes for patients who have breast cancer. You might ask your oncologist if you would be a good candidate for a clinical trial. Researchers are also examining the phenomenon known as "chemo brain"--problems with memory and concentration that may be triggered by chemotherapy and that may persist after treatment ends. Hormonal therapy The female hormones estrogen and progesterone play a role in the growth of breast cells. To make use of these hormones, breast cells normally have special receptors that permit the hormones to connect to the cells. Breast cancer cells that also have such receptors are known as "hormone-receptor positive." Reducing the amount of these hormones available to the cancer cells, the goal of hormonal therapy, 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 has little effect on cancers that are not receptor positive. Tamoxifen is the most widely used hormonal treatment for breast cancer in both premenopausal and postmenopausal women. It acts by blocking the ability of the hormones to attach to cancer cell receptors. Patients take a pill once a day for five years after their surgery. Side effects include night sweats and hot flashes, nausea, menstrual irregularity (when taken before menopause), vaginal discharge, and a dry, itchy vagina. Less common side effects can include depression, loss of appetite, weight gain, headache, and eye problems, such as cataracts. It can also increase the risk of strokes, pulmonary embolism, in which a blood clot lodges in the lung, and cancers of the uterus. In postmenopausal women, another approach to hormonal therapy uses aromatase inhibitors, medications that reduce the amount of estrogen that the body produces. Patients generally take them orally each day for five years. Their effectiveness appears to match that of tamoxifen, but with lower risk of certain side effects, including blood clots and cancer of the uterus. However, women who take these medications may experience joint or muscle pain, and they appear to be at an increased risk of osteoporosis. Another method of lowering the amount of estrogen in the body and slowing or stopping the growth and spread of breast cancer is surgically removing the ovaries. This approach may be suggested if your family history indicates that you are at elevated risk for ovarian as well as breast cancer. Herceptin therapy One out of three breast cancers makes an abnormal amount of a protein known as HER-2/new that helps to drive the growth of the cancer. A simple test of breast cancer cells can tell if the cancer is HER-2/new positive. If it does, a new treatment, Herceptin, is available. Herceptin is a targeted therapy that attacks this protein. 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 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. A number of studies are now underway to investigate the value of some of these therapies in the treatment of breast cancer. Some complementary treatments have shown merit in helping cancer patients feel more comfortable and in 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. |
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