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Cancer ! Breast Cancer: Types of
Treatment

Breast Cancer: Types of

Treatment

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ON THIS PAGE: You will learn about the different

types of treatments doctors use for people with breast
cancer. Use the menu to see other pages.

This section explains the types of treatments, also

known as therapies, that are the standard of care for
early-stage and locally advanced breast cancer.
“Standard of care” means the best treatments known.
When making treatment plan decisions, you are
encouraged to discuss with your doctor whether
clinical trials are an option. A clinical trial is a research
study that tests a new approach to treatment. Doctors
learn through clinical trials whether a 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 drug or radiation treatment or doing less
extensive surgery than what is usually done as the
standard of care. Clinical trials are an option for all
stages of cancer. Your doctor can help you consider
all your treatment options. Learn more about clinical
trials in the About Clinical Trials and Latest
Research sections of this guide.

How breast cancer is treated

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.
Cancer care teams include a variety of other health
care professionals, such as physician assistants,
nurse practitioners, oncology nurses, social workers,
pharmacists, counselors, nutritionists, and others. For
people older than 65, a geriatric oncologist or
geriatrician may also be involved in their care. Ask the
members of your treatment team who is the primary
contact for questions about scheduling and treatment,
who is in charge during different parts of treatment,
how they communicate across teams, and whether
there is 1 contact who can help with communication
across specialties, such as a nurse navigator. This
can change over time as your health care needs
change.

A treatment plan is a summary of your cancer and the

planned cancer treatment. It is meant to give basic
information about your medical history to any doctors
who will care for you during your lifetime. Before
treatment begins, ask your doctor for a copy of your
treatment plan. You can also provide your doctor with
a copy of the ASCO Treatment Plan form to fill out.

The biology and behavior of breast cancer affects the

treatment plan. Some tumors are smaller but grow
quickly, while others are larger and grow slowly.
Treatment options and recommendations are very
personalized and depend on several factors,
including:

The tumor’s subtype, including hormone

receptor status (ER, PR), HER2 status, and
nodal status (see Introduction)

The stage of the tumor

Genomic tests, such as the multigene panels

Oncotype DX™ or MammaPrint™, if
appropriate (See Diagnosis)

The patient’s age, general health, menopausal

status, and preferences

The presence of known mutations in inherited

breast cancer genes, such as BRCA1 or
BRCA2, based on results of genetic tests

Even though the breast cancer care team will

specifically tailor the treatment for each patient and
tumor, called "personalized medicine," there are some
general steps for treating early-stage and locally
advanced breast cancer.

For both ductal carcinoma in situ (DCIS) and 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 of the 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, as
described below.

For larger cancers, or those that are growing more

quickly, doctors may recommend systemic treatment
with chemotherapy, immunotherapy, and/or hormonal
therapy before surgery, called neoadjuvant therapy.
There may be several benefits to having drug
treatments before surgery:

Surgery may be easier to perform because the

tumor is smaller.

Your doctor may find out if certain treatments

work well for the cancer.

You may be able to try a new treatment

through a clinical trial.

If you have any microscopic distant disease, it

will be treated earlier by the drug therapy that
circulates through the body.

People who may have needed a mastectomy

could have breast-conserving surgery
(lumpectomy) if the tumor shrinks enough
before surgery.

After surgery, the next step in managing early-stage

breast cancer is to lower the risk of recurrence and to
try 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 a 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, immunotherapy,
and/or hormonal therapy (see below for more
information on each of these treatments).

Whether adjuvant therapy is needed depends on the

chance that any cancer cells remain in the breast or
the body and the chance that a specific treatment will
work to treat the cancer. Although adjuvant therapy
lowers the risk of recurrence, it does not completely
get rid of the risk.

Along with staging, other tools can help estimate

prognosis and help you and your doctor make
decisions about adjuvant therapy. Depending on the
subtype of breast cancer, this includes tests that can
predict the risk of recurrence by testing your tumor
tissue (such as Oncotype Dx™ or MammaPrint™;
see Diagnosis). Such tests may also help your
doctor better understand whether chemotherapy will
help reduce the risk of recurrence.

If surgery to remove the cancer is not possible, it is

called inoperable. The doctor will then recommend
treating the cancer in other ways. Chemotherapy,
immunotherapy, targeted therapy, radiation therapy,
and/or hormonal therapy may be given to shrink the
cancer.

For recurrent cancer, treatment options depend on

how the cancer was first treated and the
characteristics of the cancer mentioned above, such
as ER, PR, and HER2.

Take time to learn about all of your treatment options

and be sure to ask questions about things that are
unclear. Talk with your doctor about the goals of each
treatment and what you can expect while receiving
the treatment. These types of talks are called “shared
decision-making.” Shared decision-making is when
you and your doctors work together to choose
treatments that fit the goals of your care. Shared
decision-making is particularly important for breast
cancer because there are different treatment options.
It is also important to check with your health
insurance company before any treatment begins to
make sure the planned treatment is covered.

People older than 65 may benefit from having a

geriatric assessment before planning treatment. Find
out what a geriatric assessment involves and how
it can help people older than 65 with cancer.

Learn more about making treatment decisions.

The common types of treatments used for early-stage

and locally advanced breast cancer are described
below. Your care plan also includes treatment for
symptoms and side effects, which is an important part
of cancer care.

Surgery

Radiation therapy

Chemotherapy

Hormonal therapy

Targeted therapy

Immunotherapy

Neoadjuvant systemic therapy for non-

metastatic breast cancer

Systemic therapy concerns for people age

65 or older

Physical, emotional, and social effects of

cancer

Recurrent breast cancer

Surgery
Surgery is the removal of the tumor and some
surrounding healthy tissue during an operation.
Surgery is also used to examine the nearby axillary
lymph nodes, which are under the arm. A surgical
oncologist is a doctor who specializes in treating
cancer with surgery. Learn more about the basics of
cancer surgery.

The choice of surgery does not affect whether you will

need therapy using medication, such as
chemotherapy, hormone therapy, and/or targeted
therapy (see below). Drug therapies are given based
on the characteristics of the tumor, not the type of
surgery you have.

Generally, the smaller the tumor, 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. For invasive cancer, radiation therapy
to the remaining breast tissue is often
recommended after surgery, especially for
younger patients, patients with hormone
receptor-negative tumors, and patients with
larger tumors. For DCIS, radiation therapy after
surgery is usually given. A lumpectomy may
also be called breast-conserving surgery, a
partial mastectomy, a quadrantectomy, or a
segmental 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.

Lymph node removal, analysis, and

treatment
Cancer cells can be found in the axillary lymph nodes
in some cancers. Knowing whether any of the lymph
nodes near the breast contain cancer can provide
useful information to determine treatment and
prognosis.

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 is not an
option when the doctor already knows based
on clinical evaluation that the lymph nodes
have cancer. Rather, it may be an option for
patients with no obvious clinical evidence of
lymph node involvement. This procedure helps
avoid removing a larger number of lymph
nodes with an axillary lymph node dissection
(see below) for patients whose sentinel lymph
nodes are mostly free of cancer. The smaller
lymph node procedure helps lower the risk of
several possible side effects. Those side
effects include swelling of the arm called
lymphedema, numbness, and arm movement
and range of motion problems with the
shoulder. These are long-lasting issues that
can severely affect a person’s quality of life.
Importantly, the risk of lymphedema increases
with the number of lymph nodes and lymph
vessels that are removed or damaged during
cancer treatment. This means that people who
have a sentinel lymph node biopsy tend to be
less likely to develop lymphedema than those
who have an axillary lymph node dissection
(see below).

Your doctor may recommend imaging of your

lymph nodes with an ultrasound and/or an
image-guided biopsy of the lymph nodes
before a sentinel lymph node biopsy to find out
if the cancer has spread there (see
Diagnosis). This is often done if your lymph
nodes can be felt during clinical examination or
if you are having treatment with chemotherapy
before surgery. However, the American Society
of Clinical Oncology (ASCO) does not
recommend doing this if your cancer is small
and your lymph nodes are not able to be felt
during clinical examination.

To find the sentinel lymph node, the surgeon

usually injects a radioactive tracer and
sometimes a dye 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 a radioactive tracer is
used, it will give off radiation which helps the
surgeon find the lymph node. If dye is used,
the surgeon can find the lymph node when it
turns a blue color.

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
cancer is found in the sentinel lymph node,
whether additional surgery is needed to
remove more lymph nodes depends on the
specific situation. For example, 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.

In general, for most people with early-stage

breast cancer with tumors that can be removed
with surgery and whose underarm lymph
nodes are not enlarged, sentinel lymph node
biopsy is the standard of care. However, in
certain situations, it may be appropriate to not
undergo any axillary surgery. You should talk
with your surgeon about whether this may be
the right approach for you.

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. People
having a lumpectomy and radiation therapy
who have a smaller tumor (less than 5 cm) and
2 or less sentinel lymph nodes with cancer
may avoid a full axillary lymph node dissection.
This helps reduce the risk of side effects and
does not decrease survival.

Usually, the lymph nodes are not evaluated for people

with DCIS and no invasive cancer, since the risk of
spread is very low. However, for patients diagnosed
with DCIS who choose to have or need a
mastectomy, the surgeon may consider a sentinel
lymph node biopsy. If some invasive cancer is found
with DCIS during the mastectomy, which happens
occasionally, the lymph nodes will then need to be
evaluated. However, a sentinel lymph node biopsy
generally cannot be performed if the breast has
already been removed with mastectomy. In that
situation, an axillary lymph node dissection may be
recommended.

Most people with invasive breast cancer will have

either a sentinel lymph node biopsy or an axillary
lymph node dissection. For most people younger than
70 with early-stage breast cancer, a sentinel lymph
node biopsy will be used to determine if there is
cancer in the axillary lymph nodes, since this
information is used to make decisions about
treatment. Many patients 70 and older with small
hormone receptor-positive and HER2-negative
disease and no clinically apparent cancer in the
lymph nodes can avoid a lymph node evaluation, as
the results may not change recommendations for
therapies using medication or radiation therapy.
Patients over age 70 with larger hormone receptor-
positive and HER2-negative tumors, with other types
of breast cancer, or with clinically apparent lymph
nodes will generally be recommended to have
evaluation of their axillary lymph nodes. Patients
should talk with their doctor about recommendations
for their specific situation.

No chemotherapy before surgery, and no cancer

in the sentinel lymph nodes. For most people in this
situation, ASCO does not recommend an axillary
lymph node dissection. A small group of patients with
tumors located in specific places or with high-risk
features may be offered radiation therapy to the
lymph nodes.

No chemotherapy before surgery, but there is

cancer in the sentinel lymph nodes. If there is
cancer in 1 to 2 sentinel lymph nodes, then additional
nodal surgery can generally be avoided if the patient
is planning to undergo a lumpectomy and receive
radiation. If there is cancer in 3 or more sentinel
lymph nodes, then ASCO recommends additional
nodal surgery.

Chemotherapy is given before surgery. Treatment

for people who have received chemotherapy before
surgery depends on whether the chemotherapy has
destroyed the cancer in the lymph nodes. Therefore,
after chemotherapy, patients are often re-staged by
sentinel lymph node biopsy. However, this is not
always the case. If imaging scans or physical exams
suggest abnormal lymph nodes are present, the
patient should have an axillary lymph node dissection
instead.

If there was no evidence of cancer in the lymph

nodes either before or after chemotherapy,
radiation therapy to the lymph node area is not
recommended.

If there was evidence of cancer in the lymph

nodes before chemotherapy and there is no
longer evidence of cancer in the lymph nodes
after chemotherapy, radiation therapy to the
lymph node area is recommended.

If there is evidence of cancer in the lymph

nodes after chemotherapy, then both an
axillary lymph node dissection and radiation
therapy to the lymph node area are
recommended.

This information is based on the Ontario Health

(Cancer Care Ontario) and ASCO guideline,
“Management of the Axilla in Early-Stage Breast
Cancer.” Please note that this link takes you to
another ASCO website.

Reconstructive (plastic) surgery

Patients 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 reconstruction done at the same time as
the mastectomy is called immediate reconstruction.
You may also have this surgery done at some point in
the future, called delayed reconstruction.

For some patients undergoing a lumpectomy,

reconstruction to keep both breasts looking similar is
called oncoplastic surgery. This type of surgery may
be performed by the breast surgeon.

The techniques discussed below are typically used to

shape a new breast.

Implants. A breast implant uses saline-filled or

silicone gel-filled forms to reshape the breast. The
outside of a saline-filled implant is made up of
silicone, and it is filled with sterile saline, which is salt
water. Silicone gel-filled implants are filled with
silicone instead of saline. There were prior concerns
raised that they might be associated with connective
tissue disorders, but clear evidence of this has not
been found. Before having permanent implants, a
patient may temporarily have a tissue expander
placed that will create the correct-sized pocket for the
implant. Implants can be placed above or below the
pectoralis muscle. Talk with your doctor about the
benefits and risks of silicone versus saline implants.
The lifespan of an implant depends on the individual.
However, some people never need to have them
replaced. Other important factors to consider when
choosing implants include:

Saline implants sometimes "ripple" at the top

or shift with time, but many people do not find it
bothersome enough to replace.

Saline implants feel different than silicone

implants. They are often firmer to the touch
than silicone implants. If overfilled, they can be
firmer, but they can also feel squishier if
underfilled.

There can be problems with breast implants. Some

people have problems with the shape or appearance.
The implants can rupture or break, cause pain and
scar tissue around the implant, or get infected.
Implants have also been rarely linked to other types
of cancer, including a type called breast implant-
associated anaplastic large cell lymphoma (BIA-
ALCL). Since the risk of developing BIA-ALCL is low,
the U.S. Food and Drug Administration (FDA) does
not recommend removing textured breast implants or
tissue expanders unless there are symptoms.
Although these problems are very unusual, talk with
your doctor about the risks.

Tissue flap procedures. These techniques use

muscle and tissue from elsewhere in the body to
reshape the breast. Tissue flap surgery may be done
with a “pedicle flap,” which means tissue from the
back or belly is moved to the chest without cutting the
blood vessels. A “free flap” means the blood vessels
are cut and the surgeon needs to attach the moved
tissue to new blood vessels in the chest. There are
several flap procedures:

Transverse rectus abdominis muscle

(TRAM) flap. This method, which can be done
as a pedicle flap or free flap, uses muscle and
tissue from the lower stomach wall.

Latissimus dorsi flap. This pedicle flap

method uses muscle and tissue from the upper
back. Implants are often inserted during this
flap procedure.

Deep inferior epigastric artery perforator

(DIEP) flap. The DIEP free flap takes tissue
from the abdomen, and the surgeon attaches
the blood vessels to the chest wall.

Gluteal free flap. The gluteal free flap uses

tissue and muscle from the buttocks to create
the breast, and the surgeon also attaches the
blood vessels. Transverse upper gracilis
(TUG), which uses tissue from the upper thigh,
may also be an alternative.

Because blood vessels are involved with flap

procedures, these strategies are usually not
recommended for people with a history of diabetes or
connective tissue or vascular disease, or for people
who smoke, as the risk of problems during and after
surgery is much higher.

The DIEP and other flap procedures are longer

procedures with a longer recovery time. However, the
appearance of the breast may be preferred,
especially when radiation therapy is part of the
treatment plan.

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.

External breast forms (prostheses)

An external breast prosthesis or artificial breast form
provides an option for people who plan to delay or
not have reconstructive surgery. These can be
made of silicone or soft material, and they fit into a
mastectomy bra. Breast prostheses can be made to
provide a good fit and natural appearance. Read
more about choosing a breast prosthesis.

Summary of surgical options

To summarize, surgical treatment options include the
following:

Removal of cancer in the breast:

Lumpectomy or partial mastectomy, generally
followed by radiation therapy if the cancer is
invasive. Mastectomy may also be
recommended, with or without immediate
reconstruction.

Lymph node evaluation: Sentinel lymph node

biopsy and/or axillary lymph node dissection.

Patients are encouraged to talk with their doctors

about which surgical option is right for them. Also, talk
with your health care team about the possible side
effects from the specific surgery you will have and
what should be reported to them.

More extensive surgery, such as a mastectomy, is not

always better and may cause more complications.
The combination of lumpectomy and radiation therapy
has a slightly higher risk of the cancer coming back in
the same breast or the surrounding area. However,
the long-term survival of people who choose to have
a lumpectomy is exactly the same as those who have
a mastectomy. Even with a mastectomy, not all breast
tissue can be removed, and there is still a chance of
recurrence or of developing a new breast cancer.

People with a very high risk of developing a new

cancer in the other breast may consider a bilateral
mastectomy, meaning both breasts are removed. This
includes people with BRCA1 and BRCA2 gene
mutations and people with cancer in both breasts.
People with BRCA1 or BRCA2 gene mutations should
talk with their doctor about which surgical option
might be best for them, as they have an increased
risk of developing breast cancer in the opposite
breast and of developing a new breast cancer in the
same breast compared to those without these
mutations. ASCO recommends that people with a
BRCA1 or BRCA2 gene mutation who are being
treated with a mastectomy for the breast with cancer
should also be offered a risk-reducing mastectomy for
the opposite breast, including nipple-sparing
mastectomy. This is because getting a risk-reducing
mastectomy in the opposite breast is associated with
a decreased risk of getting cancer in that breast.
However, not everyone will be a good candidate for
nipple-sparing mastectomy. For those with large
breasts and little nipple projection, for example, a
breast reduction may be done first to get the nipple in
a better position.

To assess your risk of developing cancer in the

opposite breast and determine whether you might be
eligible for a risk-reducing mastectomy, your doctor
will consider several factors:

Age of diagnosis

Family history of breast cancer

The likelihood of recurrence of your breast

cancer or other cancers you may have, such
as ovarian cancer

Your ability to have regular surveillance

studies, such as breast MRI, to look for breast
cancer

Any other diseases or conditions you might

have

Life expectancy

People with a moderate-risk gene mutation, like

PALB2, CHEK2 or ATM, should also talk with their
doctor about their risk of developing breast cancer in
the opposite breast and whether undergoing a risk-
reducing mastectomy, including a nipple-sparing
mastectomy, may be right for them.

People with a high-risk mutation who do not have a

bilateral mastectomy should have regular screening
of the remaining breast tissue with an annual
mammogram and breast MRI for enhanced
surveillance.

For people who are not at very high risk of developing

a new cancer in the future, having a healthy breast
removed in a bilateral mastectomy neither prevents
cancer recurrence nor improves their survival. It also
will not change the recommendation for treatment of
the cancer with medications such as chemotherapy
and hormonal therapy. Although the risk of getting a
new cancer in that breast will be lowered, surgery to
remove the other breast does not reduce the risk of
the original cancer coming back. Survival is based on
the prognosis of the initial cancer. In addition, more
extensive surgery may be linked with a greater risk of
problems. Read more about talking with your
doctor about breast surgery options.

This information is based on ASCO’s

recommendations for the management of hereditary
breast cancer. Please note that this link takes you to a
separate ASCO website.

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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. 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.

Intra-operative 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
tumor.

Although the research results are encouraging,

intra-operative radiation therapy and
brachytherapy are not widely used. Where
available, they may be options for a patient
with a small tumor that has not spread to the
lymph nodes.

Partial breast irradiation. Partial breast

irradiation (PBI) is radiation therapy that is
given directly to the tumor area instead of the
entire breast. It is more common after a
lumpectomy. Targeting radiation directly to the
tumor area usually shortens the amount of time
that patients need to receive radiation therapy.
However, only some patients may be able to
have PBI. Although early results have been
promising, PBI is still being studied. However,
it is already part of routine care in certain
circumstances, including for specific people
with early-stage breast cancer. You may want
to discuss with your radiation oncologist the
pros and cons of PBI compared to whole
breast radiation therapy.

PBI can be done with standard external-beam

radiation therapy that is focused on the area
where the tumor was removed and not on the
entire breast. PBI may also be done with
brachytherapy by using plastic catheters or a
metal wand placed temporarily in the breast.
Breast brachytherapy can involve short
treatment times, ranging from 1 dose to 1
week. It can also be given as 1 dose in the
operating room immediately after the tumor is
removed. These forms of focused radiation
therapy are currently used only for patients
with a smaller, less aggressive, and lymph
node-negative tumor.

Intensity-modulated radiation therapy.

Intensity-modulated radiation therapy (IMRT) is
a more advanced way to give external-beam
radiation therapy to the breast. The intensity of
the radiation directed at the breast is varied to
better target the tumor, spreading the radiation
more evenly throughout the breast. The use of
IMRT lessens the radiation dose and may
decrease possible damage to nearby organs,
such as the heart and lung, as well as lessen
the risks of some immediate side effects, such
as peeling of the skin during treatment. This
can be especially important for people with
medium to large breasts who have a higher
risk of side effects, such as peeling and burns,
compared with people with smaller breasts.
IMRT may also help to lessen the long-term
effects on the breast tissue, such as hardness,
swelling, or discoloration, that were common
with older radiation techniques.

IMRT is not recommended for everyone. Talk

with your radiation oncologist to learn more.
Special insurance approval may also be