Treatment

Women with breast cancer have many treatment options. Treatment options include…

• Surgery
• Radiation therapy
• Hormone therapy
• Chemotherapy
• Targeted therapy

You may receive more than one type of treatment.

The treatment that's best for one woman may not be best for another. The treatment that's right for you depends mainly on…

• The stage of breast cancer
• Whether the tumor has hormone receptors
• Whether the tumor has too much HER2
• Your general health

In addition, your treatment plan depends on…

• The size of the tumor in relation to the size of your breast
• Whether you have gone through menopause

At any stage of disease, care is available to control pain and other symptoms, to relieve the side effects of treatment, and to ease emotional concerns. You can get information about coping on NCI's website at http://www.cancer.gov/cancertopics/coping.

Also, you can get information about coping from NCI's Cancer Information Service at 1-800-4-CANCER (1-800-422-6237). Or, chat using NCI's instant messaging service, LiveHelp.

Doctors Who Treat Breast Cancer

Your health care team will include specialists. There are many ways to find doctors who treat breast cancer:

• Your doctor may be able to refer you to specialists.
• You can ask a local or state medical society, or a nearby hospital or medical school for names of specialists.
• NCI's Cancer Information Service can give you information about treatment centers near you. Call 1-800-4-CANCER (1-800-422-6237). Or, chat using LiveHelp, NCI's instant messaging service.
• Other sources can be found in the NCI fact sheet How To Find a Doctor or Treatment Facility If You Have Cancer.

Your health care team may include the following specialists:

• Surgeon: This type of doctor can perform surgery. You may want to find a breast cancer surgeon.
• Medical oncologist: A medical oncologist is a doctor who specializes in treating cancer with drugs, such as chemotherapy, hormone therapy, and targeted therapy.
• Radiation oncologist: A radiation oncologist is a doctor who specializes in treating cancer with radiation therapy.

Your health care team may also include a plastic surgeon or reconstructive surgeon, an oncology nurse, a physical therapist, a social worker, and a registered dietitian.

Your health care team can describe your treatment choices, the expected results of each treatment, and the possible side effects. Because cancer treatments often damage healthy cells and tissues, side effects are common. These side effects depend on many factors, including the type of treatment. Side effects may not be the same for each woman, and they may even change from one treatment session to the next.

Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities.

You and your health care team can work together to develop a treatment plan that meets your medical and personal needs.

You may want to talk with your health care team about taking part in a research study (clinical trial) of new treatment methods. Research studies are an important option for women at any stage of breast cancer. See the Cancer Treatment Research section.

Second Opinion

Before starting treatment, you might want a second opinion about your treatment plan. Some women worry that the doctor will be offended if they ask for a second opinion. Usually the opposite is true. Most doctors welcome a second opinion. And many health insurance companies will pay for a second opinion if you or your doctor requests it. Some companies actually require a second opinion.

If you get a second opinion, the second doctor may agree with your first doctor's treatment plan. Or, the second doctor may suggest another approach. Either way, you have more information and perhaps a greater sense of control. You can feel more confident about the decisions you make, knowing that you've looked at all of your options.

It may take some time and effort to gather your medical records and see another doctor. In most cases, it's not a problem to take several weeks to get a second opinion. The delay in starting treatment usually will not make treatment less effective. To make sure, you should discuss this delay with your doctor.

Surgery

Surgery is the most common treatment for breast cancer. There are several kinds of surgery.

Your surgeon can describe each kind of surgery, compare the benefits and risks, and help you decide which kind might be best for you:

• Removing part of the breast: Breast-sparing surgery is an operation to remove the cancer and a small amount of the normal tissue that surrounds it. This is also called breast-conserving surgery. It can be a lumpectomy or a segmental mastectomy (also called a partial mastectomy). A woman usually has radiation therapy after breast-sparing surgery to kill cancer cells that may remain in the breast area.
  
  Some women will have more tissue removed but not the whole breast. For these women, the surgeon will remove lymph nodes under the arm and some of the lining over the chest muscles below the tumor.

• Removing the whole breast: Surgery to remove the whole breast (or as much of the breast tissue as possible) is a mastectomy. In some cases, a skin-sparing mastectomy may be an option. For this approach, the surgeon removes as little skin as possible.
  • In total (simple) mastectomy, the surgeon removes the whole breast but not the underarm lymph nodes.
  • In modified radical mastectomy, the surgeon removes the whole breast and most or all of the lymph nodes under the arm. Often, the lining over the chest muscles is removed. A small chest muscle may also be taken out to make it easier to remove the lymph nodes.

The choice between breast-sparing surgery and mastectomy depends on many factors:

• The size, location, and stage of the tumor
• The size of your breast
• Certain features of the cancer
• How you feel about how surgery will change your breast
• How you feel about radiation therapy
• Your ability to travel to a radiation treatment center for daily treatment sessions

The surgeon usually removes one or more lymph nodes from under the arm to check for cancer cells. If cancer cells are found in the lymph nodes, other cancer treatments will be needed. (For more about information about lymph node biopsy, see the Tests section.)

After mastectomy, you may choose to have breast reconstruction. This is plastic surgery to rebuild the shape of the breast. If you're considering breast reconstruction, talk with a plastic surgeon before having cancer surgery. See the Breast Reconstruction section.

It's common to feel tired or weak for a while after surgery for breast cancer. The time it takes to heal is different for each woman.

Surgery causes pain and tenderness, and the skin where your breast was removed may feel tight. Your arm and shoulder muscles may feel stiff and weak, and your neck and back may hurt. Medicine can help control your pain. Before surgery, discuss the plan for pain relief with your health care team. After surgery, they can adjust the plan if you need more pain control.

Any kind of surgery carries a risk of infection, bleeding, or other problems. Tell your health care team right away if you develop any problems.

Removing the underarm lymph nodes slows the flow of lymph fluid. The fluid may build up in your arm and hand and cause swelling. This swelling is called lymphedema. It can develop soon after surgery or months or even years later.

Always protect the arm and hand on the treated side of your body from cuts, burns, or other injuries. Remind nurses not to measure your blood pressure or give you injections on the treated side of your body. Information about preventing and treating lymphedema is available on NCI's website at http://www.cancer.gov/cancertopics/coping and from NCI's Cancer Information Service at 1-800-4-CANCER (1-800-422-6237) or LiveHelp.

The doctor, nurse, or physical therapist can suggest exercises to help you regain movement and strength in your arm and shoulder. Exercise can also reduce stiffness and pain. You may be able to begin gentle exercise within days of surgery.

Because nerves may be injured or cut during surgery, you may have numbness and tingling in your chest, underarm, shoulder, or upper arm. These feelings may go away within a few weeks or months.

You can find pictures and more information about breast cancer surgery on NCI's website at http://www.cancer.gov/cancertopics/types/breast.

Radiation Therapy

Radiation therapy uses high-energy rays to kill cancer cells. It affects cells only in the part of the body that is treated.

Radiation therapy may be used after surgery to destroy breast cancer cells that remain in the chest area. Women usually have radiation therapy after breast-sparing surgery, but it's sometimes used after mastectomy too.

You can get radiation therapy to treat breast cancer in two ways:

• Machine outside the body (external radiation therapy): The radiation comes from a large machine outside the body. You'll go to a hospital or clinic for treatment. Usually, women get treatment once a day, 5 days a week for 3 to 6 weeks. Each treatment session lasts only a few minutes. External radiation is the most common type used for breast cancer.
• Material inside the body (brachytherapy): The doctor will place one or more thin tubes inside the breast through a tiny incision. A radioactive substance is loaded into the tube. The treatment session may last for a few minutes, and the substance is removed. When it's removed, no radioactivity remains in your body. This method of radiation therapy may be repeated every day for a week.

Side effects depend mainly on the type of radiation and how much is given. Ask your health care team to describe what you can expect.

It's common for the skin in the treated area to become red, dry, tender, and itchy. Check with your doctor before using lotion, cream, or deodorant on the treated area. After treatment is over, the skin will slowly heal. However, there may be a lasting change in the color of your skin.

With either type of radiation therapy, your breast may feel heavy and tight. Internal radiation therapy may make your breast look red or bruised. These problems usually go away over time.

Bras and tight clothes may rub your skin and cause soreness. You may want to wear loose-fitting cotton clothes during this time.

You're likely to become tired during radiation therapy, especially in the later weeks of treatment. Although getting enough rest is important, most people say they feel better when they exercise every day. Try to go for a short walk, do gentle stretches, or do yoga.

You may wish to discuss with your doctor the possible long- term effects of radiation therapy. For example, radiation therapy to the chest may harm the lung or heart. Also, it can change the size of your breast and the way it looks. If any of these problems occur, your health care team can tell you how to manage them.

The NCI booklet Radiation Therapy and You has helpful ideas for coping with side effects.

Hormone Therapy

Hormone therapy can also be called anti-hormone treatment. If lab tests show that your breast cancer cells have hormone receptors, then hormone therapy may be an option. (See the part about Lab Tests with Breast Tissue.) Hormone therapy keeps the cancer cells from getting or using the natural hormones (estrogen and progesterone) they need to grow.

If you have not gone through menopause, the options for hormone therapy include…

• A drug that blocks estrogen's activity in the body (tamoxifen)
• Surgery to remove your ovaries (which make estrogen)
• A drug that reduces the amount of estrogen made by the ovaries (LH-RH agonist)

If you have gone through menopause, the options include…

• A drug that prevents the body from making estrogen (aromatase inhibitor)
• Tamoxifen

The side effects of hormone therapy depend on the type used. The most common side effects are hot flashes, vaginal discharge, and nausea.

The NCI fact sheet Hormone Therapy for Breast Cancer has information about the use and side effects of hormone therapy.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. It may be given to women with Stage I, II, III, or IV breast cancer. Chemotherapy may be given before or after surgery.

The drugs for breast cancer are usually given directly into a vein (intravenously) through a thin needle or as a pill. You may receive a combination of drugs.

You may receive chemotherapy in a clinic, at the doctor's office, or at home. It's unusual for a woman to need to stay in the hospital during treatment.

The side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly:

• Blood cells: When drugs lower the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of the drug. There are also medicines that can help your body make new blood cells.
• Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back after treatment, but the color and texture may be changed.
• Cells that line the digestive tract: Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Your health care team can give you medicines and suggest other ways to help with these problems.

Some drugs used for breast cancer can cause tingling or numbness in the hands or feet. This problem often goes away after treatment is over.

Other problems may not go away. For example, some of the drugs used for breast cancer may weaken the heart. Your doctor may check your heart before, during, and after treatment. A rare side effect of chemotherapy is that years after treatment, a few women have developed leukemia (cancer of the blood cells).

If you have not yet gone through menopause, some anticancer drugs may damage the ovaries and cause hot flashes, vaginal dryness, and other menopause symptoms. Your menstrual periods may no longer be regular or may stop, and you may lose the ability to become pregnant. The older you are, the more likely that this damage to the ovaries will be permanent. Women who may want to get pregnant later on should ask their health care team about ways to preserve their eggs before treatment starts.

On the other hand, other anticancer drugs don't damage the ovaries and you may remain able to become pregnant during chemotherapy. Before treatment begins, talk with your doctor about birth control because many anticancer drugs given during the first trimester are known to cause birth defects.

The NCI booklet Chemotherapy and You has ideas for coping with side effects.

Targeted Therapy

Women whose lab tests show that their breast cancer cells have too much HER2 protein may receive targeted therapy. The targeted therapies used to treat breast cancer block cancer cell growth by blocking the action of the extra HER2 protein.

These drugs may be given intravenously or as a pill. The side effects depend mainly on which drug is given. Possible side effects include nausea, vomiting, and diarrhea. The drugs may also cause heart damage, heart failure, and serious breathing problems. During treatment, your doctor will watch for signs of heart and lung problems.

You may want to read the NCI fact sheet Targeted Cancer Therapies.