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.

This section starts with general comments about the types of treatments used for breast cancer. This is followed by a discussion of the typical treatment options based on the stage of the cancer and a small section on breast cancer treatment during pregnancy.

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 (mas-tek-tuh-me), or to relieve symptoms of advanced cancer. The following is a summary 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.

Lumpectomy (lump-ek-tuh-me): This surgery involves removing 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 delayed until the chemo is finished.

Partial (segmental) mastectomy (quadrantectomy): This surgery involves removing 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, temporary swelling, tenderness, and hardness due to scar tissue that forms in the surgical site.

Mastectomy

Mastectomy involves removal 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 as a preventive measure. Most women, if they are hospitalized, 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 extensive removal of entire breast, lymph nodes, and the chest wall muscles under the breast. This surgery is rarely done now because modified radical mastectomy has proven to be just as effective 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), 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.

Choosing Between Lumpectomy and Mastectomy

One advantage of lumpectomy is that it saves the way the breast looks. A downside is the need for several weeks of radiation after surgery. But some women who have a mastectomy will still need radiation. 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.

Possible side effects of mastectomy and lumpectomy include infection and blood or fluid collecting at the place where the incision is made. If lymph nodes are removed, there could be other side effects as well, such as swelling of the arm (lymphedema).

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 present 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. See the American Cancer Society document, Lymphedema and Breast Cancer.

Sentinel Lymph Node Biopsy

This is a way to look at the lymph nodes without having to remove all of them first. 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 receive 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 is complex, so it is best to have it done by a team known to have experience with it.

Reconstructive or Breast Implant Surgery

These operations are not meant to treat the cancer but 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.

If you would like to talk to another woman who has had breast cancer, we encourage you connect with a volunteer in our Reach to Recovery program. A specially trained volunteer can provide information, comfort, and support. Learn more about Reach to Recovery.

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 two 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 largely 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. 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. Usually 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 you are having. 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 and whether you have any other medical problems, how well you do during the surgery, and how you feel after the surgery. Decisions about the length of your stay should be made by you and your doctor and not dictated by what your insurance will pay, but 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.

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 a week or two. Once the flow has gone down to about one ounce a day, the drain will be removed.

Most doctors will want you to start moving the arm soon after surgery so that it won’t get stiff. Women who have a lumpectomy or mastectomy are usually 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’ll probably 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
• 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
• how to contact a Reach to Recovery volunteer -- These specially trained women can provide information, comfort, and support.

You will see your doctor a week or 2 after surgery. He or she should explain the results of your pathology report and talk to you about whether you will need further treatment.

Pain after a mastectomy

Nerve pain after a mastectomy or lumpectomy is called post-mastectomy pain syndrome or PMPS. The signs of PMPS are chest wall pain and tingling down the arm. Pain may also be felt in the shoulder, scar, arm, or armpit. Other common complaints include numbness, shooting or pricking pain, or unbearable itching.

It is important to talk to your doctor about any pain you are having. PMPS can cause you to not use your arm the way you should and over time you could lose the ability to use it normally.

PMPS can be treated. Medicines commonly used to treat pain may not work well for nerve pain. But there are other medicines and treatments that do work for this kind of pain. Talk to your doctor to get the pain control you need.

Radiation Therapy

Radiation therapy is treatment with high-energy rays (such as x-rays) to kill cancer cells and shrink tumors. 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 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. 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, a single large dose of radiation is given in the operating room right after lumpectomy (before the breast incision is closed). Most doctors still consider this approach 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 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 lymphedema.

Brachytherapy

Another way to give radiation is to place radioactive seeds (pellets) into the breast tissue next to the cancer. It may be given 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 with this method before it 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 for 5 days. Then the balloon is deflated and removed.

Chemotherapy

Chemotherapy (commonly called just "chemo") is the use of cancer-killing drugs injected into a vein, given as a shot, or taken as a pill or liquid. These drugs enter the bloodstream and go throughout the body, making the 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 several situations in which 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: Chemotherapy 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 given. So far, there is no evidence, however, that neoadjuvant chemo improves survival.

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 Chemotherapy Given?

In most cases chemo works best if more than one drug is used. Studies over the last 30 years have found which combinations of drugs work well. However, the "best" combination may not have yet been discovered, so research is still going on.

Doctors give chemo in cycles, with each period of treatment followed by a rest period. The time between giving the drugs is generally 2 or 3 weeks and varies according 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:

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

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

Permanent side effects can include early change of life (menopause) and not being able to become pregnant. 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.

Heart damage: Adriamycin and some other 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.

Chemobrain: Many women who have had chemo notice a change in concentration and memory. This is often called “chemobrain.” It may last a long time. Research has not confirmed these findings. Still, women can and do function well after chemo. In studies that have found “chemobrain” to be a side effect of treatment, the symptoms most often go away in a few years. For more information, see the separate American Cancer Society document, Chemobrain.

Increased risk of leukemia: Very rarely, years after treatment for breast cancer, certain chemo drugs may cause another cancer called acute myeloid leukemia. But 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 received chemo. This may last up to several years, but it can be helped. Talk to your doctor if fatigue is a problem for you.

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, several methods to block the effect of estrogen or to lower its levels are used to treat breast cancer.

Tamoxifen: A drug such as tamoxifen can be given to counter the effects of estrogen. Tamoxifen is taken in pill or liquid form, usually daily for 5 years after surgery, to reduce the risk the cancer will come back. Recent studies have clearly shown that this drug helps about half of women with early breast cancer if their cancer has estrogen receptors. 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. Tell your doctor right away if you have any unusual vaginal bleeding. 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 approved for use in women with advanced breast cancer.

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 risk of the breast cancer coming back. They don’t cause uterine cancer and very rarely cause blood clots. They can, however, 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.

There are several other treatments and drugs that affect female hormones which are being used for breast cancer. Your doctor can give you more details about any recommended treatments.

Targeted Therapy

As we have learned more about the gene changes that cause cancer, researchers have been able develop newer drugs that are aimed directly at these changes. These targeted drugs work differently than 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 that attaches to a growth-promoting protein called HER2/neu. This protein is found in small amounts on the surface of normal breast cells and most breast cancer cells. Some breast cancers have too much of this protein, which can cause the cancer to 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. (Monoclonal antibodies are man-made versions of immune system proteins the body makes to fight diseases.)

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 temporary and has improved when the drug is stopped. If you are having this treatment, 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 trastuzumab. 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 discomfort of hands and feet.

Drugs That Target Tumor Blood Vessels

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 prevent tumors from forming new blood vessels to feed the tumor. Bevacizumab is given by intravenous infusion. There can be some rare, though serious, side effects.

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 Chemotherapy With Bone Marrow or Peripheral Blood Stem Cell Transplant

In the past, it was thought that very high doses of chemotherapy followed by a method called stem cell transplant might offer some women the best chance for a cure--especially for those women with a high risk of the cancer coming back or with advanced cancer. But doctors have found that the women who received 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.

Last Medical Review: 09/16/2008
Last Revised: 05/06/2009