Treatment of Inflammatory Breast Cancer

Inflammatory breast cancer (IBC) is an uncommon type of invasive breast cancer that typically makes the skin on the breast look red and feel warm. It might also give the breast skin a thick, pitted appearance that looks a lot like an orange peel.

These changes are caused by cancer cells blocking lymph vessels in the skin.

Because inflammatory breast cancer has reached these lymph vessels and caused changes in the skin, it is considered to be at least a stage III when it is diagnosed. IBC that has spread to other parts of the body is considered stage IV.

These cancers usually grow quickly and can be challenging to treat.

Treating stage III inflammatory breast cancer

Inflammatory breast cancer (IBC) that has not spread to distant parts of the body is stage III. This includes cases where nearby lymph nodes are involved.

• Treatment usually starts with chemotherapy (chemo) to try to shrink the tumor.
• If the cancer is HER2-positive, targeted therapy is given along with the chemo.
• This is usually followed by mastectomy and lymph node dissection to remove the cancer.
• Radiation therapy often follows surgery.

Sometimes, more chemo is given after surgery but before radiation. If your cancer is hormone receptor-positive, you will also get hormone therapy. This usually starts after chemo is finished.

Combining these treatments has improved survival significantly over the years.

Chemotherapy (possibly with targeted therapy)

Using chemo before surgery is called neoadjuvant or preoperative treatment. Most people with IBC will get more than one type of chemo medicine, though not always at the same time. 

A common approach includes:

• An anthracycline, such as doxorubicin (Adriamycin) or epirubicin (Ellence), often given together with cyclophosphamide (Cytoxan)
• Followed by a taxane, such as paclitaxel (Taxol) or docetaxel (Taxotere)

Other chemo medicines may be used as well.

In some situations, targeted therapy or immunotherapy is given along with chemo:

Surgery and further treatments

If the cancer improves with chemo, a modified radical mastectomy is usually the next step.

• This surgery removes the entire breast and the lymph nodes under the arm.
• Breast-conserving surgery (lumpectomy) and skin-sparing mastectomy are not options because IBC affects so much of the breast and skin.
• Sentinel lymph node biopsy is also not used for IBC because it has a high rate of missing cancer in the lymph nodes. A full axillary lymph node dissection is standard.

If the cancer does not respond to chemo and the breast is still very swollen and red, surgery cannot be done.

• At this point, other chemo medicines will be tried or the breast may be treated with radiation.
• Surgery may be an option if the cancer responds to these treatments, meaning the breast shrinks and is no longer red.

Radiation therapy after surgery

Most people get radiation therapy after surgery even if no cancer appears to remain. This is called adjuvant radiation. It lowers the chance of the cancer coming back at the breast cancer area (chest wall, armpit, skin).

Radiation is usually given 5 days a week for 6 weeks. A more intensive schedule, twice a day, may be used in some cases.

If significant tumor was found in the tissue removed during surgery, your radiation may be delayed until you complete additional chemotherapy and/or targeted therapy. If you plan to have breast reconstruction, this is usually delayed until after radiation is done.

Additional treatments after surgery

After surgery, additional systemic treatment is typically recommended. This type of treatment reaches most areas of your body. The type of systemic treatment you get may depend on the features of your cancer.

• If additional treatment is needed, you might get chemotherapy.
• If the cancer is hormone receptor-positive, you might get hormone therapy with tamoxifen or an aromatase inhibitor after you finish all chemo. A CDK4/6 inhibitor may also be added.
• If the cancer is triple-negative and residual disease was found at surgery, you might get the oral chemo medicine capecitabine (Xeloda).
• If you have a BRCA mutation and residual disease at surgery, you might get the targeted drug olaparib (Lynparza).
• If your cancer is HER2-positive, you might get trastuzumab (Herceptin), pertuzumab (Perjeta), ado-trastuzumab emtansine (Kadcyla), or trastuzumab deruxtecan (Enhertu). These are targeted drugs.

Treating stage IV inflammatory breast cancer

People with metastatic (stage IV) inflammatory breast cancer are treated with systemic therapy. This might include:

• Chemotherapy
• Hormone therapy, if your cancer is hormone receptor-positive. This is often given along with targeted drugs such as CDK4/6 inhibitors, PI3K inhibitors, or other agents used for hormone receptor-positive metastatic breast cancer.
• Targeted therapy with a drug that targets HER2, if your cancer is HER2-positive
• Immunotherapy if the cancer makes a protein called PD-L1
• PARP inhibitors, such as olaparib (Lynparza) or talazoparib (Talzenna), if you have a BRCA mutation

You might get one or more of these treatments. Targeted drugs are often combined with chemotherapy or hormone therapy. Surgery and radiation may also be options in certain situations.

See Treatment of Stage IV (Metastatic) Breast Cancer for more information.

Considering a clinical trial

Regardless of the stage of your cancer, participating in a clinical trial of new treatments for IBC is also a good option. IBC is rare and has a poor prognosis (outcome). These studies often give you access to medicines not available for standard treatment.