Breast cancer is the most common invasive cancer in women and the second leading cause of cancer death in women after lung cancer. Regular screenings are important to reduce the risks of breast cancer. The first symptoms of breast cancer usually appear as an area of thickened tissue in the breast or a lump in the breast or an armpit. When making treatment plan decisions, you are strongly encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug and how often it should be given, a new combination of standard treatments, or new doses of standard drugs or other treatments. Some clinical trials also test giving less treatment than what is usually done as the standard of care. Clinical trials are an option to consider for treatment and care for all stages of cancer. Your doctor can help you consider all your treatment options. It’s important to discuss all of your treatment options, including their goals and possible side effects, with your doctors to help make the decision that best fits your needs. It’s also very important to ask questions if there’s anything you’re not sure about.
If time permits, it is often a good idea to seek a second opinion. A second opinion can give you more information and help you feel more confident about the treatment plan you choose.
In cancer care, doctors specializing in different areas of cancer treatment—such as surgery, radiation oncology, and medical oncology—work together with radiologists and pathologists to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team.
Early-stage invasive breast cancer, doctors generally recommend surgery to remove the tumor. To make sure that the entire tumor is removed, the surgeon will also remove a small area of healthy tissue around the tumor, called a margin. Although the goal of surgery is to remove all visible cancer in the breast, microscopic cells can be left behind. In some situations, this means that another surgery could be needed to remove remaining cancer cells. There are different ways to check for microscopic cells that will ensure a clean margin. It is also possible for microscopic cells to be present outside of the breast, which is why systemic treatment with medication is often recommended after surgery. For larger cancers or those that are growing more quickly, doctors may recommend systemic treatment with chemotherapy or hormonal therapy before surgery, called neoadjuvant therapy.
After surgery, the next step in managing early-stage breast cancer is to lower the risk of recurrence and to get rid of any remaining cancer cells in the body. These cancer cells are undetectable with current tests but are believed to be responsible for cancer recurrence as they can grow over time. Treatment given after surgery is called “adjuvant therapy.” Adjuvant therapies may include radiation therapy, chemotherapy, targeted therapy, and/or hormonal therapy. Although adjuvant therapy lowers the risk of recurrence, it does not completely get rid of the risk. Depending on the subtype of breast cancer, this includes tests that can predict the risk of recurrence by testing your tumour tissue. Such tests may also help your doctor better understand whether chemotherapy will help reduce the risk of recurrence.
When surgery to remove the cancer is not possible, it is called inoperable. The doctor will then recommend treating cancer in other ways. Chemotherapy, targeted therapy, radiation therapy, and/or hormonal therapy may be given to shrink cancer.
Surgery is the removal of the tumour and some surrounding healthy tissue during an operation. Generally, the smaller the tumour, the more surgical options a patient has. The types of surgery for breast cancer include the following:
- Lumpectomy- This is the removal of the tumor and a small, cancer-free margin of healthy tissue around the tumor. Most of the breast remains. Radiation therapy after surgery may be an option depending on the patient, the tumor, and the type of surgery. A lumpectomy may also be called breast-conserving surgery, a partial mastectomy.
- Mastectomy- This is the surgical removal of the entire breast. There are several types of mastectomies. Talk with your doctor about whether the skin can be preserved, called a skin-sparing mastectomy, or whether the nipple can be preserved, called a nipple-sparing mastectomy or total skin-sparing mastectomy. Your doctor will also consider how large the tumor is compared to the size of your breast in determining the best type of surgery for you.
2. Lymph node removal and analysis
Cancer cells can be found in the axillary lymph nodes in some cancers. It is important to find out whether any of the lymph nodes near the breast contain cancer.
- Sentinel lymph node biopsy- In a sentinel lymph node biopsy (also called a sentinel node biopsy or SNB), the surgeon finds and removes 1 to 3 or more lymph nodes from under the arm that receive lymph drainage from the breast. This procedure helps avoid removing a larger number of lymph nodes with an axillary lymph node dissection for patients whose sentinel lymph nodes are mostly free of cancer. To find the sentinel lymph node, the surgeon usually injects a dye and/or a radioactive tracer behind or around the nipple. The injection, which can cause some discomfort, lasts about 15 seconds. The dye or tracer travels to the lymph nodes, arriving at the sentinel node first. If dye is used, the surgeon can find the lymph node when it turns color. If a radioactive tracer is used, it will give off radiation which helps the surgeon find the lymph node. The pathologist then examines the lymph nodes for cancer cells. If the sentinel lymph node(s) are cancer-free, research has shown that it is likely that the remaining lymph nodes will also be free of cancer. This means that no more lymph nodes need to be removed. If only 1 or 2 sentinel lymph nodes have cancer and you plan to have a lumpectomy and radiation therapy to the entire breast, an axillary lymph node dissection may not be needed.
- Axillary lymph node dissection– In an axillary lymph node dissection, the surgeon removes many lymph nodes from under the arm. These are then examined for cancer cells by a pathologist. The actual number of lymph nodes removed varies from person to person. An axillary lymph node dissection may not be needed for all women with early-stage breast cancer with small amounts of cancer in the sentinel lymph nodes.
3. Radiation therapy
Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time, such as 5 days a week for 3 to 6 weeks. Radiation therapy often helps lower the risk of recurrence in the breast. There are several different types of radiation therapy:
- External-beam radiation therapy. This is the most common type of radiation treatment and is given from a machine outside the body. This includes whole breast radiation therapy and partial breast radiation therapy, as well as accelerated breast radiation therapy, which can be several days instead of several weeks.
- Intraoperative radiation therapy. This is when radiation treatment is given using a probe in the operating room.
- Brachytherapy. This type of radiation therapy is given by placing radioactive sources into the tumo.
Radiation therapy may be given after or before surgery:
- Adjuvant radiation therapy is given after surgery. Most commonly, it is given after a lumpectomy, and sometimes, chemotherapy. Patients who have a mastectomy may or may not need radiation therapy, depending on the features of the tumor. Radiation therapy may be recommended after mastectomy if a patient has a larger tumor, cancer in the lymph nodes, cancer cells outside of the capsule of the lymph node, or cancer that has grown into the skin or chest wall, as well as for other reasons.
- Neoadjuvant radiation therapy is radiation therapy given before surgery to shrink a large tumor, which makes it easier to remove. This approach is uncommon and is usually only considered when a tumor cannot be removed with surgery.
Radiation therapy can cause side effects, including fatigue, swelling of the breast, redness and/or skin discolouration, and pain or burning in the skin where the radiation was directed, sometimes with blistering or peeling.
Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing. It may be given before surgery to shrink a large tumour, make surgery easier, and/or reduce the risk of recurrence, called neoadjuvant chemotherapy. It may also be given after surgery to reduce the risk of recurrence, called adjuvant chemotherapy. Common drugs include:
- Docetaxel (Taxotere)
- Paclitaxel (Taxol)
- Doxorubicin (available as a generic drug)
- Epirubicin (Ellence)
- Pegylated liposomal doxorubicin (Doxil)
- Capecitabine (Xeloda)
- Carboplatin (available as a generic drug)
- Cisplatin (available as a generic drug)
- Cyclophosphamide (available as a generic drug)
- Eribulin (Halaven)
- Fluorouracil (5-FU)
- Gemcitabine (Gemzar)
- Ixabepilone (Ixempra)
- Methotrexate (Rheumatrex, Trexall)
- Protein-bound paclitaxel (Abraxane)
- Vinorelbine (Navelbine)
The side effects of chemotherapy depend on the individual, the drug(s) used, whether the chemotherapy has been combined with other drugs, and the schedule and dose used. These side effects can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, diarrhoea, constipation, numbness and tingling, pain, early menopause, weight gain, and chemo-brain or cognitive dysfunction.
5. Hormonal therapy
Hormonal therapy, also called endocrine therapy, is an effective treatment for most tumours that test positive for either estrogen or progesterone receptors. Blocking the hormones can help prevent cancer recurrence and death from breast cancer when hormonal therapy is used either by itself or after chemotherapy. Hormonal therapies used in breast cancer treatment act as “anti-hormone” or “anti-estrogen” therapies. They block hormone actions or lower hormone levels in the body. Hormonal therapy may be given before surgery to shrink a tumour, make surgery easier, and/or lower the risk of recurrence. This is called neoadjuvant hormonal therapy. When given before surgery, it is typically given for at least 3 to 6 months before surgery and continued after surgery. It may also be given solely after surgery to reduce the risk of recurrence. This is called adjuvant hormonal therapy.
6. Targeted therapy
Targeted therapy is a treatment that targets cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. These treatments are very focused and work differently than chemotherapy. This type of treatment blocks the growth and spread of cancer cells and limits damage to healthy cells.
Not all tumours have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumour. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them.
Immunotherapy also called biologic therapy, is designed to boost the body’s natural defences to fight cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. Different types of immunotherapy can cause different side effects. Common side effects include skin rashes, flu-like symptoms, diarrhoea, and weight changes. Other severe but less common side effects can also occur.
- Reconstructive (plastic) surgery
Women who have a mastectomy or lumpectomy may want to consider breast reconstruction. This is surgery to recreate a breast using either tissue taken from another part of the body or synthetic implants. Reconstruction is usually performed by a plastic surgeon. A person may be able to have reconstruction at the same time as the mastectomy, called immediate reconstruction. They may also have it at some point in the future, called delayed reconstruction. for patients having a lumpectomy, reconstruction may be done at the same time to improve the look of the breast and to make both breasts look similar. This is called oncoplastic surgery.
Talk with your doctor for more information about reconstruction options and a referral to a plastic surgeon. When considering a plastic surgeon, choose a doctor who has experience with a variety of reconstructive surgeries, including implants and flap procedures. They can discuss the pros and cons of each procedure.