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Treatments and drugs
By Mayo Clinic staff
CLICK TO ENLARGE
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Lumpectomy |
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Simple mastectomy and modified radical mastectomy |
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Sentinel node biopsy |
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Radiation therapy |
Your doctor determines your breast cancer treatment options based on your type of breast cancer, its stage, whether the cancer cells are sensitive to hormones, your overall health and your own preferences. Most women undergo surgery for breast cancer and also receive additional treatment, such as chemotherapy, hormone therapy or radiation.
There are many options for breast cancer treatment, and you may feel overwhelmed as you make complex decisions about your treatment. Consider seeking a second opinion from a breast specialist in a breast center or clinic. Talk to other women who have faced the same decision.
Breast cancer surgery
Operations used to treat breast cancer include:
- Removing the breast cancer (lumpectomy). During lumpectomy, which may be referred to as breast-sparing surgery or wide local excision, the surgeon removes the tumor and a small margin of surrounding healthy tissue. Lumpectomy is typically reserved for smaller tumors that are easily separated from the surrounding tissue.
- Removing the entire breast (mastectomy). Mastectomy is surgery to remove all of your breast tissue. Mastectomy can be simple, meaning the surgeon removes all of the breast tissue — the lobules, ducts, fatty tissue and some skin, including the nipple and areola. Or mastectomy can be radical, meaning the underlying muscle of the chest wall is removed along with breast tissue and surrounding lymph nodes in the armpit. Radical mastectomies are less commonly done today. Some women may be able to undergo a skin-sparing mastectomy, which leaves the skin overlying the breast intact and may help with reconstruction options.
- Removing one lymph node (sentinel node biopsy). Breast cancer that spreads to the lymph nodes may spread to other areas of the body. Your surgeon determines which lymph node near your breast tumor receives the lymph drainage from your cancer. This lymph node is removed using a procedure called sentinel node biopsy and tested for breast cancer cells. If no cancer is found, the chance of finding cancer in any of the remaining lymph nodes is small and no other nodes need to be removed.
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Removing several lymph nodes (axillary lymph node dissection). If cancer is found in the sentinel node, your surgeon may remove additional lymph nodes in your armpit. However, there is good evidence that removal of additional affected lymph nodes does not improve survival in cases of early breast cancer following a lumpectomy, chemotherapy and whole-breast irradiation for tumors less than 2 inches (5 centimeters) in size, and where the cancer has spread to just a few lymph nodes in the armpit. In such cases, chemotherapy and radiation treatment after the lumpectomy have proved to be equally effective. This avoids the serious side effects, including chronic swelling of the arm (lymphedema), that often occur after lymph node removal.
However, axillary lymph node dissection may still be performed if the sentinel lymph node contains cancer following a mastectomy, in the case of larger breast tumors or when a lymph node is large enough to be felt on physical exam. It may also be performed in situations when a woman elects to receive partial breast irradiation.
Complications of breast cancer surgery depend on the procedures you choose. Surgery carries a risk of bleeding and infection.
Some women choose to have breast reconstruction after surgery. Discuss your options and preferences with your surgeon. Consider a referral to a plastic surgeon before your breast cancer surgery. Your options may include reconstruction with a synthetic breast implant or reconstruction using your own tissue. These operations can be performed at the time of your mastectomy or at a later date.
Radiation therapy
Radiation therapy uses high-powered beams of energy, such as X-rays, to kill cancer cells. Radiation therapy is typically done using a large machine that aims the energy beams at your body (external beam radiation). But radiation can also be done by placing radioactive material inside your body (brachytherapy).
External beam radiation is commonly used after lumpectomy for early-stage breast cancer. Doctors may also recommend radiation therapy after mastectomy for larger breast cancers. When external beam radiation is used after a woman has tested negative on a sentinel node biopsy, there is evidence that the chance of cancer occurring in other lymph nodes is significantly reduced.
Side effects of radiation therapy include fatigue and a red, sunburn-like rash where the radiation is aimed. Breast tissue may also appear swollen or more firm. Rarely, more-serious problems may occur, including arm swelling (lymphedema), broken ribs, and damage to the lungs or nerves.
Chemotherapy
Chemotherapy uses drugs to destroy cancer cells. If your cancer has a high chance of returning or spreading to another part of your body, your doctor may recommend chemotherapy to decrease the chance that the cancer will recur. This is known as adjuvant systemic chemotherapy.
Chemotherapy is sometimes given before surgery in women with larger breast tumors. Doctors call this neoadjuvant chemotherapy. The goal is to shrink a tumor to a size that makes it easier to remove with surgery. This may also increase the chance of a cure. Research is ongoing into neoadjuvant chemotherapy to determine who may benefit from this treatment.
Chemotherapy is also used in women whose cancer has already spread to other parts of the body. Chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer is causing.
Chemotherapy side effects depend on the drugs you receive. Common side effects include hair loss, nausea, vomiting, fatigue and a small increased risk of developing infection.
Hormone therapy
Hormone therapy — perhaps more properly termed hormone-blocking therapy — is often used to treat breast cancers that are sensitive to hormones. Doctors sometimes refer to these cancers as estrogen receptor positive (ER positive) and progesterone receptor positive (PR positive) cancers.
Hormone therapy can be used after surgery or other treatments to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control it.
Treatments that can be used in hormone therapy include:
- Medications that block hormones from attaching to cancer cells. Tamoxifen is the most commonly used selective estrogen receptor modulator (SERM). SERMs act by blocking estrogen from attaching to the estrogen receptor on the cancer cells, slowing the growth of tumors and killing tumor cells. Tamoxifen can be used in both pre- and postmenopausal women. Possible side effects include fatigue, hot flashes, night sweats and vaginal dryness. More significant risks include cataracts, blood clots, stroke and uterine cancer.
- Medications that stop the body from making estrogen after menopause. One group of drugs called aromatase inhibitors blocks the action of an enzyme that converts androgens in the body into estrogen. These drugs are effective only in postmenopausal women. Aromatase inhibitors include anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin). Side effects of aromatase inhibitors include joint and muscle pain, as well as an increased risk of bone thinning (osteoporosis). Another drug, fulvestrant (Faslodex), directly blocks estrogen, which keeps tumors from getting the estrogen they need to survive. Fulvestrant is generally used in postmenopausal women for whom other hormone-blocking therapy is not effective or who can't take tamoxifen. Side effects that may occur include fatigue, nausea and hot flashes. Fulvestrant is given by injection once a month.
- Surgery or medications to stop hormone production in the ovaries. In premenopausal women, surgery to remove the ovaries or medications to stop the ovaries from making estrogen can be an effective hormonal treatment. This type of surgery is known as prophylactic oophorectomy and may be called surgical menopause.
Targeted drugs
Targeted drug treatments attack specific abnormalities within cancer cells. Targeted drugs approved to treat breast cancer include:
- Trastuzumab (Herceptin). Some breast cancers make excessive amounts of a protein called human growth factor receptor 2 (HER2). Trastuzumab targets this protein that helps breast cancer cells grow and survive. If your breast cancer cells make too much HER2, trastuzumab may help block that protein and cause the cancer cells to die. Side effects may include heart damage, headaches and skin rashes.
- Lapatinib (Tykerb). Lapatinib targets the HER2 protein and is approved for use in advanced metastatic breast cancer. Lapatinib is reserved for women who have already tried trastuzumab and their cancer has progressed. Potential side effects include nausea, vomiting, diarrhea, fatigue, mouth sores, skin rashes, and painful hands and feet.
- Bevacizumab (Avastin). Bevacizumab is a drug designed to stop the signals cancer cells use to attract new blood vessels. Without new blood vessels to bring oxygen and nutrients to the tumor, the cancer cells die. Possible side effects include fatigue, high blood pressure, mouth sores, headaches, slow wound healing, blood clots, heart damage, kidney damage, high blood pressure and congestive heart failure. Research suggests that although this medication may help slow the growth of breast cancer, it doesn't appear to increase survival times. For this reason, bevacizumab isn't approved by the Food and Drug Administration to treat breast cancer. But doctors may prescribe it for what's known as off-label use. Use of bevacizumab in breast cancer is controversial.
Side effects of targeted drugs depend on the drug you receive. Targeted drugs can be very expensive and aren't always covered by health insurance.
Clinical trials
Clinical trials are used to test new and promising agents in the treatment of cancer. Clinical trials represent the cutting edge of cancer treatment, but they're by definition unproven treatments that may or may not be superior to currently available therapies. Talk with your doctor about clinical trials to see if one is right for you.
Examples of treatments being studied in breast cancer clinical trials include:
- New combinations of existing drugs. Researchers are studying new ways of combining existing chemotherapy, hormone therapy and targeted-therapy drugs. Testing new combinations may help determine if certain breast cancers are more susceptible to specific combinations.
- Bone-building drugs to prevent breast cancer recurrence. Previous research found that adding a bone-building drug to hormone therapy treatment after surgery for premenopausal women reduced the risk of breast cancer recurrence. The drug used in the study, zoledronic acid (Reclast, Zometa), is a type of drug called a bisphosphonate that's used to treat bone loss (osteoporosis) and other bone diseases. The group of women who received zoledronic acid experienced fewer cancer recurrences than did the group that didn't receive the drug during the study, which lasted four years. But, newer studies haven't shown that zoledronic acid improves breast cancer risk of recurrence.
- Using higher doses of radiation over a shorter period of time on a smaller portion of the breast. Researchers are studying partial breast irradiation in women who've undergone lumpectomy. Partial breast irradiation involves higher doses of radiation aimed at only a portion of the breast, rather than the entire breast. Radiation used in partial breast irradiation can come from a machine outside your body, or it can come from tubes or catheters placed within the breast tissue.
- Breast cancer. American Cancer Society. http://www.cancer.org/acs/groups/cid/documents/webcontent/003090-pdf.pdf. Accessed March 17, 2011.
- What you need to know about breast cancer. National Cancer Institute. http://www.cancer.gov/cancertopics/wyntk/breast/AllPages/Print. Accessed March 19, 2011.
- Chlewbowski RT, et al. Estrogen plus progestin and breast cancer incidence and mortality in postmenopausal women. Journal of the American Medical Association. 2010;304:1684.
- Giuliano AE, et al. Axillary dissection vs. no axillary dissection in women with invasive breast cancer and sentinel node metastasis. Journal of the American Medical Association. 2011;305:569.
- Van Wely BJ, et al. Systematic review of the effect of external beam radiation therapy to the breast on axillary recurrence after negative sentinel lymph node biopsy. British Journal of Surgery. 2011;98:326.
- Robert NJ, et al. RIBBON-1: Randomized, double-blind, placebo-controlled, phase III trial of chemotherapy with or without bevacizumab for first-line treatment of human epidermal growth factor receptor 2-negative, locally recurrent or metastatic breast cancer. Journal of Clinical Oncology. In Press. Accessed March 22, 2011.
- Burstein HJ. Bevacizumab for advanced breast cancer: All tied up with a RIBBON? Journal of Clinical Oncology. In Press. Accessed March 22, 2011.
- Choueiri TK, et al. Congestive heart failure risk in patients with breast cancer treated with bevacizumab. Journal of Clinical Oncology. 2011;29:632.
- Petrelli F, et al. Bevacizumab in advanced breast cancer: An opportunity as second-line therapy? Medical Oncology. In Press. Accessed March 22, 2011.
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- Pruthi S (expert opinion). Mayo Clinic, Rochester, Minn. March 22, 2011.
- Unexpected AZURE results lead to rethink for Zometa. Expert Review of Anticancer Therapy. 2011;11:329.
- Moynihan TJ (expert opinion). Mayo Clinic, Rochester, Minn. April 3, 2011.
- FDA commissioner removes breast cancer indication from Avastin label. Food and Drug Administration. http://www.fda.gov/NewsEvents/Newsroom/ucm279485.htm. Accessed Nov. 18, 2011.
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