Breast Cancer Treatment Options

When breast cancer is caught early, five-year survival rates are 99%, according to the American Cancer Society. But breast cancer is not just one specific disease; there are many different types. The treatment that’s best for one woman may not be best for another.

Thankfully, women with breast cancer have many more treatment options than ever before. Surgery, chemotherapy, radiation and hormone therapies still play a role in breast cancer treatment, depending on a person’s cancer type and progression. Newer to the arena are targeted therapies, immunotherapies and ongoing clinical trials.

Targeted therapy

Some women with breast cancer may receive drugs called targeted therapy. Targeted therapies can be used to treat breast cancer based on the specific characteristics of cancer cells, such as a specific gene, protein, or tissue environment that allows the cells to grow quickly or abnormally.

For example, targeted therapy may block the action of an abnormal protein (such as HER2) that stimulates the growth of breast cancer cells. 

In general, targeted therapies are often more effective, longer-lasting and less toxic than other therapy options. Breast cancers are evaluated in the pathology lab to determine if they contain receptors - including HER2, estrogen receptors or progesterone receptors. Researchers and oncologists now understand that being able to target a certain aspect of a tumor leads to better outcomes for the patient. Based on the findings in the pathology lab, oncologists are able to determine if the best treatment option is targeted therapy. 

“Because a lot of times, those mutations are what’s driving the tumor—its growth, its replication, its resistance to dying,” says medical oncologist Dr. Jon Gross. “So, if we are able to shut that mutation off, then we can shut off that cancer.”

Trastuzumab (Herceptin™) or lapatinib (TYKERB™) may be given to a woman whose lab tests show that her breast tumor has too much HER2:

  • Trastuzumab: This drug is given through a vein. It may be given alone or with chemotherapy. Side effects that most commonly occur during the first treatment include fever and chills. Other possible side effects include weakness, nausea, vomiting, diarrhea, headaches, difficulty breathing, and rashes. These side effects generally become less severe after the first treatment. Trastuzumab also may cause heart damage, heart failure, and serious breathing problems. Before and during treatment, your doctor will check your heart and lungs. The NCI fact sheet Herceptin™ (Trastuzumab) has more information.
  • Lapatinib: The tablet is taken by mouth. Lapatinib is given with chemotherapy. Side effects include nausea, vomiting, diarrhea, tiredness, mouth sores, and rashes. It can also cause red, painful hands and feet. Before treatment, your doctor will check your heart and liver. During treatment, your doctor will watch for signs of heart, lung, or liver problems.

For cancers that have no positive hormone receptors, including a subtype called triple-negative breast cancer, hormone therapy or targeted therapy are not helpful. Therefore, treatment for those types of breast cancer will often consist of a combination of surgery, chemotherapy, and radiation.

Immunotherapy

Immunotherapy is a class of cancer treatments that boost a person’s own immune system to help kill cancer cells. Several newer studies suggest that immunotherapy has the potential to improve outcomes for breast cancer patients.

Surgery

Surgery is the most common treatment for breast cancer. Your doctor can explain each type, discuss and compare the benefits and risks, and describe how each will change the way you look:

  • Breast-sparing surgery: This is an operation to remove the cancer but not the breast. It’s also called breast-conserving surgery. It can be a lumpectomy or a segmental mastectomy (also called a partial mastectomy). Sometimes an excisional biopsy is the only surgery a woman needs because the surgeon removed the whole lump.
  • Mastectomy: This is an operation to remove the entire breast (or as much of the breast tissue as possible). In some cases, a skin-sparing mastectomy may be an option. For this approach, the surgeon removes as little skin as possible.

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.

You may choose to have breast reconstruction. This is plastic surgery to rebuild the shape of the breast. It may be done at the same time as the cancer surgery or later. If you’re considering breast reconstruction, you may wish to talk with a plastic surgeon before having cancer surgery.

In breast-sparing surgery, the surgeon removes the cancer in the breast and some normal tissue around it. The surgeon may also remove lymph nodes under the arm. The surgeon sometimes removes some of the lining over the chest muscles below the tumor.

In total (simple) mastectomy, the surgeon removes the whole breast. Some lymph nodes under the arm may also be removed.

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 also may be taken out to make it easier to remove the lymph nodes.

Radiation therapy

Radiation therapy (also called radiotherapy) 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 area.

What happens during radiation therapy for breast cancer?

“Radiation treatment is much more elaborate than it was 20 years ago,” says Willamette Valley Cancer Institute radiation oncologist Dr. Emily Dunn.

Dr. Dunn says advances in technology, particularly in the last decade, have made radiation therapy more precise and individualized to each patient’s anatomy.

“For instance, we used to use X-rays to create a radiation plan and now we use a CT scan, which gives a three-dimensional view of the treatment area, allowing us to take into account not only how much radiation is going to the target area—the breast and possibly the surrounding lymph nodes—but also to the area we don’t want to target, including the heart and the lungs.”

“Patients often ask if the radiation hurts, and it doesn’t. What we’re treating you with is high-powered X-rays,” Dr. Dunn says. “You’re not going to feel the radiation treatment. You’ll hear the machine click on and off. You’ll notice you’re the only person in the room receiving treatment, but we can see you and hear you on our private screens and make sure everything is going well.”

As with most cancer treatments, radiation therapy can have side effects, which vary from patient to patient. Some breast cancer patients experienced discomfort under the armpit or close to the treatment site and some fatigue. Some patients may experience mild or intense skin irritation, similar to a sunburn.

How is radiation treatment administered?

Doctors use two types of radiation therapy to treat breast cancer. Some women receive both types:

  • External radiation therapy: This is the most common type of radiation therapy used for breast cancer. A machine is used to aim high-energy rays (or beams) from outside the body into the tumor. You will go to a clinic for treatment. Treatments are usually 5 days a week for 4 to 6 weeks. 
  • Internal radiation therapy (implant radiation therapy or brachytherapy): The doctor places 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. Internal radiation therapy may be repeated every day for a week.

What Happens During Radiation Therapy for Breast Cancer?

Hormone therapy

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

Options before menopause

If you have not gone through menopause, the options include:

  • Tamoxifen: This drug can prevent the original breast cancer from returning and also helps prevent the development of new cancers in the other breast. As treatment for metastatic breast cancer, tamoxifen slows or stops the growth of cancer cells that are in the body. It’s a pill that you take every day for 5 years.

In general, the side effects of tamoxifen are similar to some of the symptoms of menopause. The most common are hot flashes and vaginal discharge. Others are irregular menstrual periods, thinning bones, headaches, fatigue, nausea, vomiting, vaginal dryness or itching, irritation of the skin around the vagina, and skin rash. Serious side effects are rare, but they include blood clots, strokes, uterine cancer, and cataracts. You may want to read the NCI fact sheet Tamoxifen.

  • LH-RH agonist: This type of drug can prevent the ovaries from making estrogen. The estrogen level falls slowly. Examples are leuprolide and goserelin. This type of drug may be given by injection under the skin in the stomach area. Side effects include hot flashes, headaches, weight gain, thinning bones, and bone pain.
  • Surgery to remove your ovaries: Until you go through menopause, your ovaries are your body’s main source of estrogen. When the surgeon removes your ovaries, this source of estrogen is also removed. (A woman who has gone through menopause wouldn’t benefit from this kind of surgery because her ovaries produce much less estrogen.) When the ovaries are removed, menopause occurs right away. The side effects are often more severe than those caused by natural menopause. Your health care team can suggest ways to cope with these side effects.

Options after menopause

If you have gone through menopause, the options include:

  • Aromatase inhibitor: This type of drug prevents the body from making a form of estrogen (estradiol). Examples are anastrazole, exemestane, and letrozole. Common side effects include hot flashes, nausea, vomiting, and painful bones or joints. Serious side effects include thinning bones and an increase in cholesterol.
  • Tamoxifen: Hormone therapy is given for at least 5 years. Women who have gone through menopause receive tamoxifen for 2 to 5 years. If tamoxifen is given for less than 5 years, then an aromatase inhibitor often is given to complete the 5 years. Some women have hormone therapy for more than 5 years. See above for more information about tamoxifen and its possible side effects.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. The drugs that treat breast cancer are usually given through a vein (intravenous) or as a pill. You’ll probably receive a combination of drugs.

You may receive chemotherapy in an outpatient part of the hospital, at the doctor’s office, or at home. Some women need to stay in the hospital during treatment.

Some anticancer drugs can damage the ovaries. If you have not gone through menopause yet, you may have hot flashes and vaginal dryness. Your menstrual periods may no longer be regular or may stop. You may become infertile (unable to become pregnant). For women over the age of 35, this damage to the ovaries is likely to be permanent.

On the other hand, you may remain able to become pregnant during chemotherapy. Before treatment begins, you should talk with your doctor about birth control because many drugs given during the first trimester are known to cause birth defects.

Clinical Trials 

Clinical trials are carefully controlled research studies that test promising new therapies or procedures to advance cancer treatment.

Through its partnership with The US Oncology Network, Willamette Valley Cancer Institute and Research Center provides many investigational drugs through clinical trials, providing patients access to experimental treatments otherwise unavailable. If you’re interested in participating in a trial, your oncologist can help determine if you’re a candidate. To ensure safety, candidates are carefully screened.

Learn more about the latest developments in breast cancer research.