A diagnosis of breast cancer is one of the most difficult experiences you can face. In addition to coping with a potentially life-threatening illness, you must make complex decisions about treatment.
Talk with your health care team to learn as much as you can about your treatment options. Consider a second opinion from a breast specialist in a breast center or clinic. Talking to other women who have faced the same decision also may help.
Treatments exist for every type and stage of breast cancer. Most women will have surgery and an additional (adjuvant) therapy such as radiation, chemotherapy or hormone therapy. Experimental treatments are also available at cancer treatment centers.
SurgeryToday, radical mastectomy is rarely performed. Instead, the majority of women are candidates for simple mastectomy or lumpectomy. If you decide on mastectomy, you may opt for breast reconstruction
decide on mastectomy, you may opt for breast reconstruction.
Breast cancer operations include the following:
§ Lumpectomy. This operation saves as much of your breast as possible by removing only the lump plus a surrounding area of normal tissue. Many women can have lumpectomy — often followed by radiation therapy — instead of mastectomy, and in most cases survival rates for both operations are similar. But lumpectomy may not be an option if a tumor is very large, deep within your breast, or if you have already had radiation therapy, have two or more widely separated areas of cancer in the same breast, have a connective tissue disease that makes you sensitive to radiation, or if you have inflammatory breast cancer. If you have a large tumor but still want to consider the possibility of lumpectomy, chemotherapy before surgery may be an option to shrink the tumor and make you eligible for the procedure.
In general, lumpectomy is almost always followed by radiation therapy to destroy any remaining cancer cells. But when very small, noninvasive cancers are involved, some studies question the role and benefits of radiation therapy — especially for older women. These studies haven't shown that lumpectomy plus radiation prolongs a woman's life any better than does lumpectomy alone.
§ Partial or segmental mastectomy. Another breast-sparing operation, partial mastectomy involves removing the tumor as well as some of the breast tissue around the tumor and the lining of the chest muscles that lie beneath it. In almost all cases, you'll have a course of radiation therapy following your operation, similar to if you had a lumpectomy.
§ Simple mastectomy. During a simple mastectomy, your surgeon removes all your breast tissue — the lobules, ducts, fatty tissue and skin, including the nipple and areola. Depending on the results of the operation and follow-up tests, you may also need further treatment with radiation to the chest wall, chemotherapy or hormone therapy.
§ Modified radical mastectomy. In this procedure, a surgeon removes your entire breast, including the overlying skin, and some underarm lymph nodes (axillary lymph node dissection), but leaves your chest muscles intact. This makes breast reconstruction less complicated.
Sentinel lymph node biopsyBecause breast cancer first spreads to the lymph nodes under the arm, all women with invasive cancer need to have these nodes examined. Rather than remove as many lymph nodes as possible, surgeons now focus on finding the sentinel nodes — the first nodes to receive the drainage from breast tumors and therefore the first place cancer cells will travel. If a sentinel node is removed, examined and found to be normal, the chance of finding cancer in any of the remaining nodes is small and no other nodes need to be removed. This spares many women the need for a more extensive operation and greatly decreases the risk of complications.
Axillary lymph node dissectionIf the sentinel lymph node does show the presence of cancer, then your surgeon removes additional lymph nodes in your armpit (axilla). The removal of these lymph nodes does increase the risk of serious arm swelling (lymphedema), but newer surgical techniques make this complication much less likely. Knowing if cancer has spread to the lymph nodes is important in determining the best course of treatment, including whether you'll need chemotherapy or radiation therapy.
Reconstructive surgeryIf you want to have breast reconstruction done, discuss this with your surgeon before you have any surgery done. Not all women are candidates for reconstruction. A plastic surgeon can describe the various procedures, show you photos of women who have had different types of reconstruction, and discuss which type of reconstruction might be best in your case. Your options include reconstruction with a synthetic breast implant or reconstruction using your own tissue. These operations can be performed at the time of your mastectomy or at a later date.
§ Reconstruction with implants. This technique uses artificial material — silicone gel or saline, in an implantable, leak-proof shell — to replace surgically removed breast tissue. If you don't have enough muscle and skin to cover an implant, your doctor may use a tissue expander, which is an empty implant shell that inflates as fluid is injected. It's placed under your skin and muscle, and your doctor gradually fills it with fluid — usually over a period of several months. When your muscle and skin have stretched enough, the expander is removed and replaced with a permanent implant.
§ Reconstruction with a tissue flap. Known as a transverse rectus abdominal muscle (TRAM) flap, this surgery reconstructs your breast using tissue, including fat and muscle, from your abdomen, although surgeons sometimes may use tissue from your back or buttocks instead. Because the procedure is fairly complicated, recovery may take six to eight weeks. Complications include the risk of infection and tissue death. If you have a low percentage of body fat, this type of reconstruction may not be an option for you.
§ Deep inferior epigastric perforator (DIEP) reconstruction. In this procedure, fat tissue from your abdomen is used to create a natural-looking breast. But because your abdominal muscles are left intact, you're less likely to experience complications than you are with traditional TRAM flap breast reconstruction. You may also have less pain, and your healing time may be reduced.
§ Reconstruction of your nipple and areola. After initial surgery with either tissue transfer or an implant, you may have further surgery to make a nipple and areola. Using tissue from elsewhere in your body, your surgeon first creates a small mound to resemble a nipple. He or she may then tattoo the skin around the nipple to create an areola. Your surgeon may also take a skin graft from elsewhere on your body, place it around the reconstructed nipple to slightly raise the skin and then tattoo the skin graft.
Radiation therapyRadiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. It's administered by a radiation oncologist at a radiation center. In general, radiation is the standard of care following a lumpectomy for both invasive and noninvasive breast cancers. Oncologists are also likely to recommend radiation following a mastectomy for a large tumor, for inflammatory breast cancer, for cancer that has invaded the chest wall or for cancer that has spread to more than four lymph nodes in your armpit.
If you won't be receiving chemotherapy, radiation is usually started three to four weeks after surgery. If your doctors recommend chemotherapy, it's usually administered before you undergo radiation therapy. You'll typically receive radiation treatment five days a week for five to six consecutive weeks. The treatments are painless and are similar to getting an X-ray. Each takes about 30 minutes. The effects are cumulative, however, and you may become tired toward the end of the series. Your breast may be pink, puffy and somewhat tender, as if it had been sunburned.
In a small percentage of women, more serious problems may occur, including arm swelling, damage to the lungs, heart or nerves, or a change in the appearance and consistency of breast tissue. Radiation therapy also makes it somewhat more likely that you'll develop another tumor. For these reasons, it's important to learn about the risks and benefits of radiation therapy when deciding between lumpectomy and mastectomy. You may also want to talk to a radiation oncologist about clinical trials investigating shorter courses of radiation or focal application of radiation.
ChemotherapyChemotherapy uses drugs to destroy cancer cells. The size of the tumor, characteristics of the cancer cells, and extent of spread of the cancer help determine your need for chemotherapy. If your cancer has a high chance of returning or spreading to another part of your body, your doctor may recommend chemotherapy after surgery to decrease the chance that the cancer will recur. This is known as adjuvant chemotherapy. If your cancer has already spread to other parts of your body, chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer is causing.
Treatment often involves receiving two or more drugs in different combinations. These may be administered intravenously, in pill form or both. You may have between four and eight treatments spread over three to six months.
Because chemotherapy affects healthy cells as well as cancerous ones, side effects are common. Your digestive tract, hair and bone marrow — all composed of fast-growing cells — tend to take the brunt of this toxicity, leading to hair loss, nausea, vomiting and fatigue. Not everyone has all of these side effects, however, and methods to control chemotherapy side effects have improved greatly in the past few decades. Notably, more effective drugs are now available to help prevent or reduce nausea and vomiting.
Depending on the chemotherapy drugs your doctor recommends, other side effects may occur, including possible damage to the heart, nerves, kidneys and other organs. Chemotherapy may also temporarily affect your white blood cells — cells that fight off infection.
Another recently described side effect is "chemobrain," the common term for memory and concentration problems that happen to some people during and after chemotherapy. Chemobrain is associated with difficulties involving specific thought processes, including word finding, memory and multitasking.
Premature menopause and infertility also are potential side effects of chemotherapy. The older you are when you begin treatment, the greater the likelihood that your reproductive cycle will be affected. In rare cases, certain chemotherapy medications may lead to cancer of the white blood cells (acute myeloid leukemia) — often years after treatment ends.
Hormone therapyHormone therapy — perhaps more properly termed hormone blocking therapy — is often used to treat women whose cancers are sensitive to hormones — estrogen and progesterone receptor positive cancers. Similar to chemotherapy, this form of therapy can be used to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control it.
Two classes of medications are used in hormone therapy: selective estrogen receptor modulators (SERMs) and aromatase inhibitors.
§ Selective estrogen receptor modulators (SERMs). SERMs act by blocking any estrogen present in the body from attaching to the estrogen receptor on the cancer cells, slowing the growth of tumors and killing tumor cells. SERMs can be used in both pre- and postmenopausal women.
The most common SERM prescribed for hormone therapy is tamoxifen (Nolvadex). Tamoxifen is used as a treatment for women with hormone-sensitive metastatic breast cancer, as an adjuvant therapy for women with early-stage estrogen receptor positive breast cancer, and as a preventive agent in some high-risk women. You take tamoxifen daily, in pill form, for up to five years. It may reduce the risk of recurrence of breast cancer and is less toxic than most anti-cancer drugs.
But tamoxifen isn't trouble-free. Women taking tamoxifen may experience menopausal symptoms such as night sweats, hot flashes, and vaginal itching, discharge or dryness. More serious side effects, including blood clots and endometrial cancer, occur infrequently. Older women, especially those with other medical conditions, may be at greater risk of more serious side effects than are younger women.
§ Aromatase inhibitors. This class of drugs, which includes anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin), blocks the conversion of a hormonal substance (androstenedione) into estrogen. This effectively stops estrogen production in cells other than the ovaries. Fat cells, the adrenal gland and other normal cells all make small amounts of estrogen. These drugs are only effective in postmenopausal women.
In several randomized, controlled trials, women receiving aromatase inhibitors have fared slightly better than have those receiving tamoxifen. Women treated with aromatase inhibitors also had a lower incidence of blood clots and endometrial cancer. To date, the primary drawback of aromatase inhibitors is an increased risk of osteoporosis. The main question about aromatase inhibitors seems to be whether women should take tamoxifen first and then switch to an aromatase inhibitor or simply take an aromatase inhibitor from the start.
Biological therapyAs scientists learn more about the differences between normal cells and cancer cells, treatments aimed at these differences — called biological therapy — are being developed. Three biological therapies are now available for breast cancer. They include:
§ Trastuzumab (Herceptin). This FDA-approved biological therapy uses monoclonal antibody technology to attack a protein — called HER2-neu — that's overproduced in about one out of every three breast cancers. By attacking this protein, Herceptin kills cancer cells on its own and in conjunction with chemotherapy or hormone therapy. Herceptin can be used as an adjuvant therapy or to treat advanced disease.
§ Bevacizumab (Avastin). Now approved for treating metastatic breast cancer, Avastin also uses monoclonal antibody technology to target new blood vessels and stop them from growing. Cancer cells need to grow new blood vessels in order to survive. This therapy halts that process and kills the cancer cells.
§ Lapatinib (Tykerb). Like Herceptin, Tykerb zeros in on and blocks the effects of the HER2 protein. But while Herceptin blocks HER2's action from the outside of the cell, Tykerb is a smaller molecule that works on the inside of the cell. Tykerb works for some women for whom Herceptin is no longer effective. This drug is only approved for use in conjunction with chemotherapy and in women with advanced, metastatic breast cancers.
Clinical trialsClinical trials are used to test new and promising agents in the treatment of cancer. Clinical trials represent the cutting edge of technology, but they're often unproven treatments that may or may not be superior to currently available therapies. Talk with your doctor about clinical trials to see if one is right for you.
Clinical trials involve more than just new medications. For example, breast surgeons and radiologists are developing nonsurgical methods of destroying cancerous breast tissue. One of these techniques, radiofrequency ablation, uses ultrasound to locate the tumor. Then a metal probe about the size of a toothpick is inserted into the tumor. Inside the tumor, the probe creates heat that destroys cancer cells. Although early tests of radiofrequency ablation have been promising, not all women would be candidates for the procedure if it eventually were approved for widespread use