Breast-conserving surgery is often appropriate for earlier-stage invasive breast cancers if the cancer is small enough, although mastectomy is also an option. If the cancer is too large, a mastectomy will be needed, unless pre-operative (neoadjuvant) chemotherapy can shrink the tumor enough to allow breast-conserving surgery. In either case, the lymph nodes will need to be checked and removed if they contain cancer. Radiation will be needed for almost all patients who have breast-conserving surgery and some who have mastectomy. Adjuvant systemic therapy after surgery is typically recommended for all cancers larger than 1 cm (about 1/2 inch) across and for some that are smaller.

Stage I

These cancers are still relatively small and have not spread to the lymph nodes or elsewhere.

Local therapy: Stage I cancers can be treated with either breast-conserving surgery (lumpectomy, partial mastectomy) or modified radical mastectomy. The lymph nodes will also need to be evaluated, with a sentinel lymph node biopsy or an axillary lymph node dissection. Breast reconstruction can be done either at the same time as surgery or later.

Radiation therapy is usually given after breast-conserving surgery. Women who may consider breast-conserving surgery without radiation therapy typically have all of the following:

• they are age 70 years or older
• they have a tumor 2 cm or less across that has been completely removed
• they have a tumor that contains hormone receptors and hormone therapy is given
• none of the lymph nodes that were removed contained cancer

Although some women who do not meet these criteria may be tempted to avoid radiation, studies have shown that not getting radiation increases the chances of the cancer coming back.

Adjuvant systemic therapy: Most doctors will discuss the pros and cons of adjuvant hormone therapy (either tamoxifen or an aromatase inhibitor) with all women who have a hormone receptor–positive (estrogen or progesterone) breast cancer, no matter how small the tumor. Women with tumors larger than 0.5 cm (about 1/4 inch) across may be more likely to benefit from it.

If the tumor is smaller than 1 cm (about 1/2 inch) across, adjuvant chemotherapy is not usually offered. Some doctors may suggest it if a cancer smaller than 1 cm has any unfavorable features (such as being high-grade, estrogen receptor–negative, HER2-positive, or having a high score on one of the gene panels). Adjuvant chemotherapy is usually recommended for larger tumors.

For HER2-positive cancers larger than 1 cm across, adjuvant trastuzumab (Herceptin) is usually recommended as well.

See below for more information on adjuvant therapy.

Stage II

These cancers are larger and/or have spread to a few nearby lymph nodes.

Local therapy: Surgery and radiation therapy options for stage II tumors are similar to those for stage I tumors, except that in stage II, radiation therapy may be considered even after mastectomy if the tumor is large (more than 5 cm across) or the cancer is found after surgery to have spread to several lymph nodes.

Adjuvant systemic therapy: Adjuvant systemic therapy is recommended for women with stage II breast cancer. It may involve hormone therapy, chemotherapy, trastuzumab, or some combination of these, depending on the patient's age, estrogen-receptor status, and HER2/neu status. See the following section for more information on adjuvant therapy.

Neoadjuvant therapy: An option for some women who would like to have breast-conserving therapy for tumors larger than 2 cm (about 4/5 inch across) is to have neoadjuvant (before surgery) chemotherapy, hormone therapy, and/or trastuzumab to shrink the tumor.

If the neoadjuvant treatment shrinks the tumor enough, women may then be able to have breast-conserving surgery (such as lumpectomy) followed by radiation therapy, as well as hormone therapy if the tumor is hormone receptor-positive. Further chemotherapy may also be considered. If the tumor does not shrink enough for breast-conserving surgery, then mastectomy may be required. This may be followed by different chemotherapy. Radiation therapy may be needed if the tumor is large (more than 2 inches across) or if lymph nodes contain cancer. Radiation is usually given after surgery Also, hormone therapy may be given if the tumor is estrogen receptor–positive. Hormone therapy can be given both before and after surgery. A woman's chance for survival from breast cancer does not seem to be affected by whether she gets her chemotherapy before or after her breast surgery.

Stage III

Local treatment for some stage IIIA breast cancers is largely the same as that for stage II breast cancers. They may be removed by breast-conserving surgery (such as lumpectomy) followed by radiation therapy, or by modified radical mastectomy (with or without breast reconstruction). Sentinel lymph node biopsy or axillary lymph node dissection is also done. Radiation therapy may be used after mastectomy if the tumor is large (more than 5 cm across) or is found to have spread to several lymph nodes. Neoadjuvant therapy may be an option for some women who would like to have breast-conserving therapy.

Surgery is usually followed by adjuvant systemic chemotherapy, and/or hormone therapy, and/or trastuzumab. (See the following section for more information on adjuvant therapy.)

More advanced stage IIIA, as well as stage IIIB and IIIC cancers, are often treated with chemotherapy before surgery. Then a modified radical mastectomy is done, with or without reconstruction. Breast-conserving surgery may be an option for some women. The nearby lymph nodes will be sampled. Surgery is followed by radiation therapy, even if a mastectomy is done. Adjuvant chemotherapy may also be given, and adjuvant hormone therapy is offered to all women with hormone receptor–positive breast cancers.

Adjuvant therapy for stages I to III breast cancer

Adjuvant drug therapy may be recommended, based on the tumor's size, spread to lymph nodes, and other prognostic features. If it is, you may get chemotherapy, trastuzumab (Herceptin), hormone therapy, or some combination of these.

Hormone therapy: Hormone therapy is not likely to be effective for women with hormone receptor-negative tumors. Hormone therapy is frequently offered to all women with hormone receptor–positive invasive breast cancer regardless of the size of the tumor or the number of lymph nodes involved.

Women who are still having periods and have hormone receptor–positive tumors can be treated with tamoxifen, which blocks the effects of estrogen being made by the ovaries. Some doctors also give a luteinizing hormone-releasing hormone (LHRH) analog, which makes the ovaries temporarily stop functioning. Another (permanent) option is surgical removal of the ovaries (oophorectomy). If the woman becomes post-menopausal within 5 years of starting tamoxifen (either naturally or because her ovaries are removed), she may be switched from tamoxifen to an aromatase inhibitor.

Sometimes a woman will stop having periods after chemotherapy or while on tamoxifen. But this does not necessarily mean she is truly post-menopausal. The woman's doctor can do blood tests for certain hormones to determine her menopausal status. This is important because the aromatase inhibitors will only benefit post-menopausal women.

Women no longer having periods, or who are known to be in menopause at any age, and who have hormone receptor–positive tumors will generally get adjuvant hormone therapy either with an aromatase inhibitor (typically for 5 years), or with tamoxifen for several years followed by an aromatase inhibitor. For women who can't take aromatase inhibitors, an alternative is tamoxifen for 5 years.

As mentioned before, there are still many unanswered questions about the best way to use these drugs. For example, it's not clear if starting adjuvant therapy with one of these drugs is better than giving tamoxifen for some length of time and then switching to an aromatase inhibitor. Nor has the optimal length of treatment with aromatase inhibitors been determined. Studies now under way should help answer these questions. You might want to discuss these newer treatments with your doctor.

If chemotherapy is to be given as well as a general rule, hormone therapy is started after chemotherapy is completed.

Chemotherapy: Chemotherapy is usually recommended for all women with an invasive breast cancer whose tumor is hormone receptor-negative, and for women with hormone receptor-positive–tumors who may get additional benefit from having chemotherapy along with their hormone therapy, based on the stage and characteristics of their tumor.

Adjuvant chemotherapy can decrease the risk of the cancer coming back, but it does not remove the risk completely. Before deciding if it's right for you, it is important to understand the chance of your cancer returning and how much adjuvant therapy will decrease that risk.

The specific drug regimens and the length of treatment are often determined by the stage and grade of the cancer. The typical chemotherapy regimens are listed in the chemotherapy section. The length of these regimens usually ranges from 4 to 6 months. In some cases, dose dense chemotherapy may be used.

Trastuzumab (Herceptin): Women who have HER2-positive cancers are usually given trastuzumab along with chemotherapy as part of their treatment.

A common chemotherapy regimen is doxorubicin (Adriamycin) and cyclophosphamide together for about 3 months, followed by paclitaxel (Taxol) and trastuzumab. The paclitaxel is given for about 3 months, while the trastuzumab is given for about 1 year.

A concern among doctors is that giving the trastuzumab so soon after doxorubicin may lead to heart problems, so heart function is watched closely during treatment with tests such as echocardiograms.

To try to lessen the possible effects on the heart, doctors are also looking for effective chemotherapy combinations that don't contain doxorubicin. One such regimen is called TCH. It uses the chemotherapy drugs docetaxel (Taxotere) and carboplatin given every 3 weeks along with weekly trastuzumab (Herceptin) for 6 cycles. This is followed by trastuzumab every 3 weeks for a year.

Aids for adjuvant therapy decision making: Some doctors may use newer gene pattern tests to help decide whether to give adjuvant chemotherapy to women with certain stage I or II breast cancers. Examples of such tests include Oncotype DX^® and MammaPrint^®, which are described in more detail in the section "How is breast cancer diagnosed?" These tests are done on a sample of your breast cancer tissue. They look at the function of several genes within the cancer to help predict the risk of it returning after treatment. The tests will not tell your doctor which is the best hormone therapy or chemotherapy to recommend. Clinical trials are now being done to see if these tests can really tell which women can do without adjuvant chemotherapy in situations where doctors are often uncertain, such as in women with small tumors and uninvolved lymph nodes.

For help in deciding if adjuvant therapy is right for you, you might want to visit the Mayo Clinic Web site at www.mayoclinic.com and type "adjuvant therapy for breast cancer" into the search box. You will find a page that will help you to understand the possible benefits and limits of adjuvant therapy.

Other online guides, such as www.adjuvantonline.com, are designed to be used by health care professionals. This Web site provides information about your risk of the cancer returning within the next 10 years and what benefits you might expect from hormone therapy and/or chemotherapy. You may want to ask your doctor if he or she uses this site.

Stage IV

Stage IV cancers have spread beyond the breast and lymph nodes to other parts of the body. Although surgery and/or radiation may be useful in some situations (see below), they are very unlikely to cure these cancers, so systemic therapy is the main treatment. Depending on many factors, this may consist of hormone therapy, chemotherapy, targeted therapies such as trastuzumab (Herceptin) or bevacizumab (Avastin), or some combination of these treatments.

Trastuzumab may help women with HER2-positive cancers live longer if it is given with the first chemotherapy for stage IV disease. It is not yet known whether it also should be given at the same time as hormone therapy, or how long a woman should remain on therapy.

Bevacizumab, a drug that blocks new tumor blood vessel growth, has been shown to slow the progression of advanced breast cancer when it is combined with the chemotherapy drug paclitaxel (Taxol). See the section "Targeted therapy" for more information on this drug.

All of the systemic therapies given for breast cancer -- hormone therapy, chemotherapy, and the newer targeted therapies -- have potential side effects, which were described in previous sections. Your doctor will explain to you the benefits and risks of these treatments before prescribing them.

Radiation therapy and/or surgery may also be used in certain situations, such as to treat a small number of metastases in a certain area, to prevent bone fractures or blockage in the liver, or to provide relief of pain or other symptoms. If your doctor recommends such local treatments, it is important that you understand their goal -- whether it is to try to cure the cancer or to prevent or treat symptoms.

In some cases, regional chemotherapy (where drugs are delivered directly into a certain area, such as the fluid around the brain) may be useful as well.

Treatment to relieve symptoms depends on where the cancer has spread. For example, pain from bone metastases may be treated with external beam radiation therapy and/or bisphosphonates such as pamidronate (Aredia) or zoledronic acid (Zometa). Most doctors recommend bisphosphonates (along with calcium and vitamin D) for all patients whose breast cancer has spread to their bones. (For more information about treatment of bone metastases, see the American Cancer Society document, Bone Metastasis.)

Advanced cancer that progresses during treatment: Although treatment for advanced breast cancer can often shrink or slow the growth of the cancer (often for many years), it may stop working after a time. Further treatment at this point depends on several factors, including previous treatments, where the cancer is located, and a woman's age, general health, and desire to continue getting treatment.

For hormone receptor–positive cancers that were being treated with hormone therapy, switching to another type of hormone therapy is sometimes helpful. If not, chemotherapy is usually the next step.

For cancers that are no longer responding to one chemotherapy regimen, trying another may be helpful. There are many different drugs and combinations that can be used to treat breast cancer. However, each time a cancer progresses during treatment it becomes less likely that further treatment will have an effect.

HER2-positive cancers that no longer respond to trastuzumab may respond to lapatinib (Tykerb), another drug that attacks the HER2 protein. This drug is usually given along with the chemotherapy drug capecitabine (Xeloda). Both of these drugs are taken as pills.

Because current treatments are very unlikely to cure advanced breast cancer, patients in otherwise good health are encouraged to think about taking part in clinical trials of other promising treatments.

Recurrent breast cancer

Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in the same breast or near the mastectomy scar) or in a distant area. Cancer that is found in the opposite breast is not a recurrence -- it is a new cancer that requires its own treatment.

Local recurrence: Treatment of women whose breast cancer has recurred locally depends on their initial treatment. If the woman had breast-conserving therapy, local recurrence in the breast is usually treated with mastectomy. If the initial treatment was mastectomy, recurrence near the mastectomy site is treated by removing the tumor whenever possible. This is followed by radiation therapy, but only if none had been given after the original surgery. (Radiation can't be given to the same area twice.) In either case, hormone therapy, trastuzumab, chemotherapy, or some combination of these may be used after surgery and/or radiation therapy.

Distant recurrence: In general, women who have a recurrence involving organs such as the bones, lungs, brain, etc., are treated the same way as those found to have stage IV breast cancer in these organs when they were first diagnosed (see treatment for stage IV). The only difference is that treatment may be affected by previous treatments a woman has had.

Should your cancer come back, the American Cancer Society document, When Your Cancer Comes Back: Cancer Recurrence can provide you with more general information on how to manage and cope with this phase of your treatment.

Last Medical Review: 09/18/2009
Last Revised: 09/18/2009