This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

General types of treatment

Treatments can be put into broad groups based on how they work and when they are used.

Local vs. systemic treatment

The purpose of local treatment is to treat a tumor without affecting the rest of the body. Surgery and radiation are examples of local treatment.

Systemic treatment is given into the bloodstream or by mouth to go throughout the body and reach cancer cells that may have spread beyond the breast. Chemotherapy, hormone therapy, and immunotherapy are systemic treatments.

Adjuvant and neoadjuvant therapy

When people who seem to have no cancer left after surgery are given more treatment it is referred to as adjuvant therapy. Doctors now think that cancer cells can break away from the main tumor and begin to spread through the bloodstream in the early stages of the disease. It's very hard to tell if this has happened. But if it has, the cancer cells can start new tumors in other organs or the bones. The goal of adjuvant therapy is to kill these hidden cells. But not every patient needs adjuvant therapy.

Some people are given systemic treatment (most likely chemotherapy) before surgery to shrink a tumor. This is called neoadjuvant therapy.

Surgery for breast cancer

Most women with breast cancer will have some type of surgery to treat the main breast tumor. The purpose of surgery is to remove as much of the cancer as possible. Surgery can also be done to find out whether the cancer has spread to the lymph nodes under the arm (axillary dissection), to restore the breast's appearance after a mastectomy, or to relieve symptoms of advanced cancer. Below is a list of some of the most common types of breast cancer surgery.

Breast-conserving surgery

In these types of surgery, only a part of the breast is removed. How much is removed depends on the size and place of the tumor and other factors.

Lumpectomy: This surgery removes only the breast lump and some normal tissue around it. Radiation treatment is usually given after this type of surgery. If chemotherapy is also going to be used, the radiation may be put off until the chemo is finished. If there is cancer at the edge of the piece of tissue that was removed, the surgeon may need to go back and take out more tissue.

Partial (segmental) mastectomy or quadrantectomy: This surgery removes more of the breast tissue than in a lumpectomy. It is usually followed by radiation therapy. Again, this may be delayed if chemotherapy is also going to be given.

Side effects of these operations can include pain, short-term swelling, tenderness, and hardness due to scar tissue that forms in the surgical site.

Mastectomy

Mastectomy involves removing of all of the breast tissue, sometimes along with other nearby tissues.

Simple or total mastectomy: In this surgery the entire breast is removed, but not the lymph nodes under the arm or the muscle tissue beneath the breast. Sometimes both breasts are removed, especially when mastectomy is done to try to prevent cancer. If a hospital stay is needed, most women can go home the next day.

Modified radical mastectomy: This operation involves removing the entire breast and some of the lymph nodes under the arm. This is the most common surgery for women with breast cancer who are having the whole breast removed.

Radical mastectomy: This is a major operation where the surgeon removes the entire breast, underarm (axillary) lymph nodes, and the chest wall muscles under the breast. This surgery was once very common, but it is rarely done now. This is because modified radical mastectomy has proven to work just as well with less disfigurement and fewer side effects.

Possible side effects: Aside from pain after the surgery and the change in the shape of the breast(s), the possible side effects of mastectomy and lumpectomy include wound infection, build-up of blood in the wound, and build-up of clear fluid in the wound. If axillary lymph nodes are also removed, other side effects are possible, such as swelling of the arm (lymphedema).

Choosing between lumpectomy and mastectomy

Many women with early stage cancers can choose between breast-conserving surgery and mastectomy. One advantage of lumpectomy is that it saves the way the breast looks. A downside is the need for many weeks of radiation after surgery. But some women who have a mastectomy will still need radiation.

When choosing between a lumpectomy and mastectomy, be sure to get all the facts. You may have an initial gut preference for mastectomy as a way to "take it all out as quickly as possible." Women tend to prefer mastectomy more often than their surgeons do because of this feeling. But the fact is that for most women with stage I or II breast cancer, lumpectomy or partial mastectomy (along with radiation) is as good as mastectomy. There is no difference in the survival rates of women treated with these 2 methods. Other factors, though, can affect which type of surgery is best for you. And lumpectomy is not an option for all women with breast cancer. Your doctor can tell you if there are reasons why a lumpectomy is not right for you.

Other breast cancer surgeries

Axillary lymph node dissection: This operation is done to find out if the breast cancer has spread to lymph nodes under the arm. Some nodes are removed and looked at under a microscope. Whether or not cancer cells are found in the lymph nodes under the arm is an important factor in choosing adjuvant therapy. It was once believed that removing as many lymph nodes as possible would reduce the risk of spread to other parts of the body and improve the chance of curing the cancer. It is now known that breast cancer cells that have spread beyond the breast and axillary lymph nodes are best treated by systemic therapy. Axillary dissection is used as a test to help guide other breast cancer treatment decisions.

A possible side effect of removing these lymph nodes is swelling of the arm, called lymphedema. This happens in 1 out of 4 women who have had these nodes removed. Women who have swelling, tightness, or pain in the arm after lymph node surgery should be sure to tell their doctor right away. Often there are measures to prevent or reduce the effects of the swelling. You can get more information about lymphedema by calling our toll-free number or looking on our Web site.

Sentinel lymph node biopsy: A sentinel lymph node biopsy is a way to look at the lymph nodes without having to remove all of them. For this test, a radioactive substance and/or a dye are injected near the tumor. This is carried by the lymph system to the first (sentinel) node(s) to get lymph from the tumor. This lymph node (or nodes) is the one most likely to contain cancer cells if the cancer has spread. These nodes (often 2 or 3) are then looked at by the pathologist. If the sentinel nodes contain cancer, more lymph nodes are removed. If they are free of cancer, further lymph node surgery might not be needed. This type of biopsy calls for a great deal of skill, so it is best to have it done by a team who has experience with it.

Reconstructive or breast implant surgery: These operations are not meant to treat the cancer. They are done to restore the way the breast looks after mastectomy. If you are having a mastectomy and are thinking about having breast reconstruction, you should talk to a plastic surgeon before your operation. There are several choices about when the surgery can be done and exactly what type it will be.

You can get more detailed information about each of these types of surgery and their possible side effects in our document, Breast Reconstruction after Mastectomy. You may also find it helpful to talk with a woman who has had the type of reconstruction you are thinking about. Our Reach to Recovery volunteers can help you with this. Call us if you would like to speak to one of these volunteers.

What to expect with surgery

For many women, the thought of surgery can be frightening. But a better understanding of what to expect before, during, and after the operation may help ease your fears.

Before surgery: A few days after your biopsy you will know whether or not you have cancer, but the extent of the disease will not be known until after surgery. You will most likely meet with your surgeon a few days before the operation to talk about what will happen. You will be asked to sign a consent form giving the doctor permission to do the surgery. This is a good time to ask any questions you might have.

You may be asked to donate blood ahead of time in case you need it during the surgery. Your doctor will also ask you about medicines, vitamins, or supplements you are taking. You might need to stop taking some of them a week or 2 before surgery.

Surgery: For your surgery, you may be offered the choice of an outpatient procedure or you may be admitted to the hospital. The type of anesthesia you will have depends on the kind of surgery being done and your own situation. General anesthesia is usually given whenever the surgery involves a mastectomy or an axillary node dissection, and is most often used during breast-conserving surgery, too. You will have an IV line put in (usually into a vein in your arm). It will be used to give medicines that may be needed during the surgery. You will be hooked up to an electrocardiogram (EKG) machine and have a blood pressure cuff on your arm, so your heart rhythm and blood pressure can be checked during the surgery.

How long the surgery will take and how long you will be in the hospital also depends on the type of surgery being done. For example, a mastectomy with lymph node removal will take from 2 to 3 hours. After your surgery, you will be taken to the recovery room, where you will stay until you are awake and your vital signs (blood pressure, pulse, and breathing) are stable.

After surgery: How long you stay in the hospital depends on the type of surgery you had, your overall state of health, whether you have any other medical problems, how well you do during the surgery, and how you feel after the surgery. You and your doctor should decide how long you need to stay in the hospital -- not your insurance company. Still, it is important to check your insurance coverage before surgery.

As a rule, women having a mastectomy stay in the hospital for 1 or 2 nights and then go home. But some women may be placed in a 23-hour, short-stay unit before going home. In this case, a home care nurse may visit you after you leave the hospital.

Less involved operations such as lumpectomy and sentinel lymph node biopsy are usually done on an outpatient basis and do not require an overnight stay in the hospital.

After surgery you will have a bandage over the surgery site that may wrap snugly around your chest. You may have one or more tubes (drains) from the breast or underarm area to remove fluid that collects during the healing process. Most drains stay in place for 1 or 2 weeks. Once the flow has gone down to about 1 ounce a day, the drain will be removed.

Most doctors will want you to start moving your arm soon after surgery so that it won't get stiff. Many women who have a lumpectomy or mastectomy are surprised by how little pain they have in the breast area. But they are less happy with the strange feelings (numbness, pinching/pulling) in the underarm area.

Talk with your doctor about what you should do after the surgery to care for yourself. You should get written instructions that will tell you about the following:

• how to take care of the wound and dressing
• how to take care of the drains
• how to know if you have an infection
• when to call the doctor or nurse
• when to begin using the arm and how to do arm exercises to prevent stiffness
• when to start wearing a bra again
• when and how to wear a breast form (sometimes called a prosthesis)
• what to eat and what not to eat
• what medicines to take (including pain medicines and maybe antibiotics)
• what activities you should or should not do
• what feelings you might have about how you look
• when to see your doctor for a follow-up appointment
• how to contact a Reach to Recovery volunteer -- These specially trained women can provide information, comfort, and support.

Most patients see their doctor about 7 to 14 days after the surgery. Your doctor should explain the results of your pathology report and talk to you about whether you will need further treatment.

Radiation therapy

Radiation therapy is treatment with high-energy rays (such as x-rays) to kill or shrink cancer cells. This treatment may be used to kill any cancer cells that remain in the breast, chest wall, or underarm area after breast-conserving surgery. There are 2 main ways in which radiation therapy can be given.

External beam radiation

Most often, external beam radiation is used for treating breast cancer. It is much like getting a regular x-ray but for a longer period of time. Radiation therapy may be used to destroy cancer cells remaining in the breast, chest wall, or underarm area after surgery or, less often, to reduce the size of a tumor before surgery.

Treatment is usually given 5 days a week in an outpatient center over a period of about 6 or 7 weeks, beginning about a month after surgery. Each treatment lasts a few minutes. The treatment itself is painless. Ink marks or small tattoos may be put on your skin. These will be used as a guide to focus the radiation on the right area. You may want to talk to your health care team to find out if these marks will be permanent. If it is used along with chemotherapy, radiation is usually given after chemotherapy is finished.

Newer techniques now being studied involve giving radiation over a much shorter period of time and to only the part of the breast with the cancer. This is called accelerated radiation. In one approach, larger doses of radiation are given each day, but the course of radiation is shortened to only 5 days. In another approach, one large dose of radiation is given in the operating room right after lumpectomy (before the breast incision is closed). Most doctors still consider accelerated radiation to be experimental at this time.

The main side effects of radiation therapy are swelling and heaviness in the breast, sunburn-like changes in the skin over the treated area, and fatigue. These changes to the breast tissue and skin usually go away in 6 to 12 months. In some women, the breast becomes smaller and firmer after radiation therapy. Radiation therapy of axillary lymph nodes also can cause long-term arm swelling called lymphedema. You can get more information on lymphedema in the "Moving on after treatment" section.

Brachytherapy

Another way to give radiation is to place radioactive seeds (pellets) into the breast tissue next to the cancer. It may be given along with external beam radiation to add an extra “boost” of radiation to the tumor. It is also being studied as the only source of radiation. So far the results have been good, but more study is needed before brachytherapy alone can be used as standard treatment.

One method of brachytherapy being used is called Mammosite^®. It consists of a balloon attached to a thin tube. The balloon is placed into the lumpectomy space and filled with salt water. Radioactivity is added through the tube. The radioactive material is added and removed twice a day (on an outpatient basis) for 5 days. Then the balloon is deflated and removed.

Chemotherapy

Chemotherapy (most often called just "chemo") is the use of cancer-killing drugs. These drugs can be injected into a vein, given as a shot, or taken as a pill or liquid. They enter the bloodstream and go throughout the body, making this treatment useful for cancers that have spread to distant organs. While these drugs kill cancer cells, they also damage some normal cells, which can lead to side effects.

When is chemotherapy used?

There are many cases where chemo may be used.

Adjuvant chemotherapy: Treatment given to patients after surgery who do not seem to have any spread of cancer is called adjuvant therapy. When used this way after breast-conserving surgery or mastectomy, chemo reduces the risk of the breast cancer coming back.

Even in the early stages of the disease, cancer cells can break away from the first breast tumor and spread through the bloodstream. These cells don't cause symptoms, they don't show up on an x-ray, and they can't be felt during a physical exam. But if they are allowed to grow, they can form new tumors in other places in the body. Adjuvant chemo can be given to find and kill these cells.

Neoadjuvant chemotherapy: Chemo given before surgery is called neoadjuvant therapy. The major benefit of this approach is that it can shrink large cancers so that they are small enough to be removed by lumpectomy instead of mastectomy. Another possible advantage is that doctors can see how the cancer responds to the chemo. If the tumor does not shrink, then different drugs may be needed. So far, it is not clear that neoadjuvant chemo improves survival, but it seems to be at least as effective as adjuvant therapy after surgery.

Chemo for advanced breast cancer: Chemo can also be used as the main treatment for women whose cancer has already spread outside the breast and underarm area at the time it is found, or if it spreads after the first treatments.

How is chemo given?

In most cases chemo works best if more than one drug is used. Doctors give chemo in cycles, with each period of treatment followed by a rest period. The time between treatments is most often 2 or 3 weeks and varies according to the drug or combination of drugs being used. The total course of treatment usually lasts for 3 to 6 months. Treatment may be longer for advanced breast cancer.

Possible side effects

The side effects of chemo depend on the type of drugs used, the amount given, and the length of treatment. You could experience some of these short-term side effects:

• hair loss
• mouth sores
• loss of appetite
• nausea and vomiting
• a higher risk of infection (from low white blood cell counts)
• changes in menstrual cycle (this could be permanent)
• easy bruising or bleeding (from low blood platelet counts)
• being very tired (called fatigue, often caused by low red blood cell counts or other reasons)

Most of these side effects go away when treatment is over. For example, your hair will grow back and your blood counts will return to normal. If you have any problems with side effects, be sure to tell your doctor or nurse because there are often ways to help.

Menstrual changes: For younger women, changes in menstrual periods are another possible side effect of chemo. Permanent side effects can include early change of life (menopause) and not being able to become pregnant (infertility). But being on chemo does not always prevent pregnancy and getting pregnant while on chemo can lead to birth defects. If you are having sex, you should discuss birth control with your cancer doctor.

Neuropathy: Several drugs used to treat breast cancer can damage nerves. This can sometimes lead to symptoms (mainly in the hands and feet) such as pain, burning or tingling sensations, sensitivity to cold or heat, or weakness. In most cases this goes away once treatment is stopped, but it may be long-lasting in some women. You can learn more about this in our document Peripheral Neuropathy Caused by Chemotherapy.

Heart damage: Some of the drugs may cause heart damage if used for a long time or in high doses. Doctors are careful to control the doses of these drugs and watch for signs of problems.

Chemo brain: Many women who have had chemo notice a change in concentration and memory. This is often called “chemo brain.” It may last a long time. Still, most women function well after chemo. In studies that have found chemo brain to be a side effect of treatment, the symptoms most often go away in a few years. For more information, see our document, Chemo Brain.

Increased risk of leukemia: Very rarely, years after treatment for breast cancer, certain chemo drugs may cause another cancer called acute myeloid leukemia (AML). But for most women the benefit of treating the breast cancer far outweighs the risk of this rare event.

Feeling unwell or tired: Many women do not feel as healthy after having chemo as they did before. Fatigue can be another long-lasting problem for women who have had chemo. This may last for many years, but it can be helped. Talk to your doctor if fatigue is a problem for you. You can also get more information in our document Fatigue in People with Cancer.

Hormone therapy

Hormone therapy is another form of systemic therapy. It is most often used to help reduce the risk of the cancer coming back after surgery, though it may also be used for more advanced breast cancers.

The female hormone estrogen promotes the growth of breast cancer cells in some women (those who have ER-positive cancers). For these women, things are done to block the effect of estrogen or lower its levels in order to treat breast cancer.

Drugs used to change hormone levels

Tamoxifen and toremifene (Fareston^®): Drugs like tamoxifen can be given to counter the effects of estrogen. Tamoxifen is taken in pill or liquid form, usually every day for up to 5 years after surgery, to reduce the risk the cancer will come back. This drug helps women with early breast cancer if their cancer has estrogen receptors (is ER-positive). It is also used to treat breast cancer that has spread and to reduce the risk of breast cancer in women who are at high risk.

This drug does have known side effects. The most common side effects include fatigue, hot flashes, vaginal discharge, and mood swings. Some studies have shown an increase of early stage cancer of the lining of the uterus among women taking tamoxifen. But this cancer is usually found at a very early stage and is almost always cured by surgery. If you are taking tamoxifen and have any unusual vaginal bleeding you should tell your doctor right away. Blood clots are another possible side effect of tamoxifen. Still, for most women with breast cancer, the benefits of tamoxifen far outweigh the risks.

Fulvestrant: Fulvestrant (Faslodex^®) is a drug that acts by damaging the estrogen receptor instead of blocking it. It often works even if the breast cancer is no longer responding to tamoxifen. It is given by injection once a month. Hot flashes, mild nausea, and fatigue are the major side effects. It is only given to women who are already in menopause. Right now it is only used in post-menopausal women with advanced breast cancer that no longer responds to tamoxifen or toremifene.

Aromatase inhibitors: These are drugs that stop the body from making estrogen. They only work for women who are past menopause and whose cancers are hormone-receptor positive. These drugs may be used after, or even instead of tamoxifen to reduce the chance of the breast cancer coming back. These drugs are taken daily as pills.

They don't cause uterine cancer and very rarely cause blood clots. But they can cause bone thinning and fractures because they remove estrogens from the body. The most common side effect of these drugs is joint stiffness and/or pain like the feeling of having arthritis in many different joints at one time.

Surgery to change hormone levels

Removing the ovaries (ovarian ablation): In pre-menopausal women, the ovaries are the main source of estrogens. Removing them or shutting them down takes away almost all the estrogen and makes the woman post-menopausal. This may allow some other hormone therapies to work better. Ovarian ablation can be done permanently by taking out the ovaries in surgery. It also can be done with drugs. Both of these methods can cause a woman to have symptoms of menopause, including hot flashes, night sweats, vaginal dryness, and mood swings.

Other ways to change hormone levels

Androgens (male hormones) may be used after other hormone treatments for advanced breast cancer have been tried. They sometimes work, but they can cause women to develop male traits, like an increase in body hair and a deeper voice.

Targeted therapy

As we have learned more about the gene changes that cause cancer, researchers have been able develop newer drugs that are aimed right at these changes. These targeted drugs do not work the same as standard chemo drugs. They often have different and less severe side effects. At this time, they are most often used along with chemo.

Trastuzumab (Herceptin)

This is a monoclonal antibody -- a manmade version of a very specific immune system protein. It attaches to the growth-promoting protein called HER2/neu. HER2/neu is found in small amounts on the surface of normal breast cells and in large amounts on some breast cancer cells. Breast cancers that have too much of this protein are called HER2/neu-positive. The protein makes them grow and spread faster. Herceptin can stop this protein from causing breast cancer cell growth. It may also help the immune system to better attack the cancer.

The side effects of this drug are fairly mild. They may include fever and chills, weakness, nausea, vomiting, cough, diarrhea, and headache. These side effects are less common after the first dose. But some women may develop heart damage during treatment. For most (but not all) women, this effect has been short-term and bets better when the drug is stopped. If you are getting Herceptin, you should tell your doctor right away if you have any shortness of breath, swelling, or trouble with physical activities.

Lapatinib (Tykerb)

This is another drug that targets the HER2/neu protein. This drug is given as a pill, most often along with chemo. It is used for some women with cancer that is no longer helped by chemo and Herceptin. The most common side effects with this drug include diarrhea, nausea, vomiting, rash, and hand-foot syndrome, which may include numbness, tingling, redness, swelling, and pain in the hands and feet. Diarrhea is common and can be bad. It is very important to let your health care team know about any changes in your bowel habits as soon as they happen.

Bevacizumab (Avastin)

This is another monoclonal antibody that may be used in patients with breast cancer that has spread. It is always used along with other chemo drugs. This antibody helps to keep tumors from making new blood vessels to feed the tumor. Avastin is given by intravenous (IV) infusion. There can be some rare, though serious, side effects and high blood pressure is very common. It very important that your doctor watches your blood pressure carefully during treatment and that you let your health care team know about any changes in how you feel.

Bisphosophonates

Bisphosphonates are drugs that are used when breast cancer has spread to the bones. These drugs can strengthen bones that have been weakened by invading breast cancer cells and reduce the risk of fractures or breaks. Bisphosphonates may also help prevent bone thinning (osteoporosis) that can result from treatment with aromatase inhibitors (see above) or from early menopause caused by chemo. These drugs are given into a vein (IV).

Bisphosphonates can have side effects, including flu-like symptoms and bone pain. A rare but serious side effect from bisphosphonates is damage in the jaw bone. Doctors don't know why this happens. Some cancer doctors recommend that patients have a dental check-up and have any tooth or jaw problems treated before they start taking bisphosphonates.

High-dose chemo with bone marrow or peripheral blood stem cell transplant

In the past, it was thought that very high doses of chemo followed by a stem cell transplant might offer some women the best chance for a cure--especially those women with a high risk of the cancer coming back or with advanced cancer. But doctors have found that the women who had high-dose therapy did not live any longer than women who had standard dose chemo. And high-dose chemo with stem cell support can cause serious side effects. Research in this area is still going on. For now, experts in the field suggest that women receive this treatment only as part of a clinical trial.

Treatment of breast cancer during pregnancy

Treatment for pregnant women with breast cancer depends on how long the woman has been pregnant.

Radiation therapy during pregnancy is known to increase the risk of birth defects, so it is not recommended for pregnant women with breast cancer. For this reason, breast-conserving therapy (lumpectomy and radiation therapy) is not an option unless treatment can be delayed until it is safe to deliver the baby. A breast biopsy and even modified radical mastectomy are safe for the mother and the fetus.

For a long time it was thought that chemo was dangerous to the fetus. But some recent studies have found that using certain chemo drugs during the fourth to ninth months does not increase the risk of birth defects. The safety of chemo during the first 3 months of pregnancy has not been studied.

Hormone therapy may affect the fetus and should not be started until after the patient has given birth.

Many chemo and hormone therapy drugs can enter breast milk and could be passed on to the baby, so breast-feeding is not usually recommended if the woman is having these treatments.

For more information, see our document, Pregnancy and Breast Cancer.

Last Medical Review: 09/16/2008
Last Revised: 09/16/2008