Every case of breast cancer is different and so is every treatment plan. Your cancer care team will go over all your options and offer recommendations based on the stage of your cancer, specific characteristics of the tumor, recent research, and their own experience. But ultimately your treatment path is up to you. The choices can be a little complex, but this overview of potential options can help you get a clearer picture of the road ahead.
So you’ve got breast cancer (or maybe someone you know does). And you’re looking for the best, quickest route back to good health. There are three main types of treatment you’ll want to consider: Surgery, radiation, and medication (such as chemotherapy). Surgery is often the first step after diagnosis. After a surgeon performs the operation, the patient works with a medical oncologist to figure out if further treatments such as radiation, hormonal medications, immunotherapy, or chemotherapy are necessary to help kill remaining cancer cells and/or help prevent the tumor from growing back.
Because most people with breast cancer need to have surgery to remove the cancerous cells, let’s start there.
Breast Cancer Surgery
There are two main surgical options for breast cancer: lumpectomy and mastectomy. Survival rates for women who have a lumpectomy plus radiation versus a mastectomy are the same. But about 20% of people need additional surgery after having a lumpectomy. Most of them will have another lumpectomy to remove more cancer cells; a very small percentage go on to have a mastectomy and remove all the breast tissue.
Sometimes called breast-conserving surgery or partial mastectomy, a lumpectomy means only the part of the breast with the cancer is removed. The amount of breast tissue that is affected varies based on how big the tumor is and where it’s located. Because it is a simpler surgery than a mastectomy, with a quicker recovery time and less chance for complications, many breast surgeons prefer a lumpectomy when possible.
- Procedure: The operation is fairly quick—it usually takes between 15 and 40 minutes. The surgeon may also remove a few nearby lymph nodes, called sentinel nodes, to check and see if the cancer cells have spread. A lumpectomy is usually an outpatient procedure, and you can go home from the hospital the same day.
- Recovery: Every woman heals differently, but you’ll likely be able to return to your usual routine a few days to a week after surgery. (Healing goes quicker if you haven’t had any lymph nodes removed.) You might feel soreness, numbness, and tickling sensations in the area for a few months after surgery.
- Follow-up treatment: Most women who have lumpectomies will also need radiation—high-energy rays delivered directly to breast—a few weeks after surgery. Some will also need medications such as chemotherapy or hormonal therapies. (See more on these treatments, below.)
During a mastectomy, all of your breast tissue is removed. There are few reasons a surgeon may recommend a mastectomy over a lumpectomy, including multiple areas of cancer in the breast, a tumor that’s large compared to the size of the breast, or if you have an especially aggressive type of cancer such as inflammatory breast cancer.
Depending on how large and how many tumors there are, and where the cancer is located in the breast, a surgeon will opt for one of three kinds of mastectomy surgery:
- Simple mastectomy (or “total mastectomy”), in which the whole breast is removed, including the nipple, areola, and most of the skin.
- Skin-sparing mastectomy, in which the surgeon removes all of the breast tissue, nipple, and areola, but leaves the original “envelope” of skin ready to be reconstructed with a breast implant or other plastic surgery procedure.
- Nipple-sparing mastectomy, in which a surgeon leaves the nipple and areola intact. (The nerves, ducts, and tissues that attach to them will be gone, however, so the nipple will likely be numb and no longer function as it did.) During a mastectomy, the surgeon may also remove nearby lymph nodes to see if cancer cells have spread.
Here’s what happens if you opt for the mastectomy route:
- Procedure: Surgery typically takes two to three hours and you might spend one to three days in the hospital. Before closing you up, your surgeon will insert thin tubes to help drain fluid as your incisions heal.
- Recovery: Full recovery typically takes two to three weeks, although some people go back to work before that. The drain tubes are usually removed after a couple of weeks, but you won’t be able to drive or lift your arms above your head until they’re removed.
- Follow-up treatment: Some women will need additional treatment such as hormonal medications, chemotherapy, radiation, or other targeted medications.
Side Effects of Breast Cancer Surgery
If you have breast cancer surgery, it’s possible you will experience temporary side effects like pain and swelling. It should go away once you’ve healed.
Other longer-lasting—even lifelong—side effects of surgery include loss of sensation in the skin or nipple or a type of swelling called lymphedema. Lymphedema happens in between 5 and 25% of breast cancer surgeries, typically in the arm, breast, torso, or hand on the side of the body that was operated on.
Mild lymphedema can often be reversed, but sometimes it comes and goes and needs to be managed with treatments like pressure sleeves, pumps, bandages, and lifestyle changes. Lymphedema can also cause tingling, achiness, and general discomfort.
Radiation Therapy for Breast Cancer
Radiation can sound a little intense—and it is: Treatments use high-energy X-rays to kill cancer cells and help lower the chances that the cancer will come back. The really good news is that in combo with surgery, getting radiation lowers the odds of your breast cancer returning to less than 5% in the next 10 years, according to the American Society of Clinical Oncology.
In rare cases, your doctor might recommend radiation before surgery in order to shrink a tumor so it’s easier to operate on. But most of the time, radiation is given after you’ve had the cancerous tissue removed.
Types of radiation therapy:
- External-beam radiation. This is the most common type of radiation therapy. It’s delivered externally by a machine that is aimed at either the whole breast, or just the part of the breast where the cancer was. If cancer cells have spread to the lymph nodes in the neck or underarm, you may need radiation in those areas as well. Treatment take a while—typically every day for between three and six weeks. Some cancer treatment centers offer accelerated therapy that lasts about one week, but this shorter schedule is still being studied and it’s not clear yet how the results stack up with the traditional, longer treatment.
- Brachytherapy. In this treatment, a metal wand and plastic tubes are placed in the breast right after lumpectomy surgery. The tubes are then hooked up to a machine and a radioactive “seed” is pushed through the tubes to dose the specific area of the breast where the tumor was located with radiation—from the inside out. Sometimes this is done once; other times, it’s repeated every day for several days. This type of radiation is still being studied and isn’t available to everyone.
- Intensity-modulated radiation therapy. In this type of external-beam radiation, the intensity of the radiation is varied in order to better target the tumor area and decrease possible damage to other tissues and side effects such as peeling skin, swelling, and hardening of breast tissue. Again, this type of radiation isn’t available to everyone, and isn’t always automatically covered by insurance.
- Proton therapy. This still-experimental type of external-beam radiation uses protons to irradiate the breast instead of X-rays, in order to reduce potential damage to the heart and other tissues.
Radiation Side Effects
Radiation therapy does have potential short-term side effects, including breast swelling, redness, skin discoloration, blistering, and peeling skin. Your doctor can prescribe topical medications to help soothe these issues. There are some potential long-term side effects, too, including shrinkage or hardening of the breast. There is also a small risk that the radiation may damage tissues in the nearby heart, lungs, and nerves.
Breast Cancer Medications
There was a time when breast cancer medications meant really tough side effects and a big hit to your quality of life. It’s not like that anymore. Not that breast cancer meds are a walk in the park (they’re definitely not), but they are a lot more tolerable than they used to be.
For one, medications are becoming more precise and personalized. Doctors choose which ones to prescribe based on detailed genetic and hormonal info, as well as additional testing of the tumor cells.
And for another thing, the whole approach today centers on the concept of “de-escalating” treatment—that is, giving patients the minimal medication they need to lower the risk of breast cancer coming back, but not over-treating them. This approach saves patients unnecessary side effects and longer-lasting complications associated with some treatments.
Medication can be given after surgery (this is called “adjuvant” therapy), or before surgery (called “neoadjuvant” therapy) in order to shrink the cancer and/or stop it from growing. Because tumors can adapt to medications and stop responding, your doctor may switch you to a new drug or combination of drugs part-way through your treatment.
The type of breast cancer doctor who devises a medication plan and supervises treatment is called a medical oncologist. Your medical oncologist will usually work as a team with the surgeon (surgical oncologist), and if necessary, a radiation oncologist to determine which of four main types of medication may be used to treat your breast cancer: chemotherapy, hormone therapy, targeted therapy, and immunotherapy.
Types of Breast Cancer Medications
It’s probably the best known of the bunch, but not every woman with breast cancer needs chemo. It depends on the stage of your cancer and the exact type of tumor you have. Although some chemo medicines are in pill form, chemo is usually delivered directly into the bloodstream through an IV infusion or injection at a clinic or doctor’s office. Doses are given in bursts or “cycles” of a few weeks at a time so that patients are able to rest and recover from each treatment before having another. The length of time a person will need chemotherapy treatments can vary, but it often lasts between three and six months. You’ve probably heard about chemotherapy’s less-than-great side effects, including nausea, hair loss, mouth sores, and brain fog, but there are now other medications that can be prescribed at the same time to help make treatment easier for patients.
About two-thirds of breast cancer tumors rely on the hormones estrogen or progesterone to grow. In these cases, hormone therapy drugs that lessen or cut off the supply of these hormones to the tumor can be used to help treat the disease and keep the cancer from growing back. These medications are usually taken for between five and 10 years. There are two main categories of hormone therapy drugs used to treat breast cancer, and each of them work in different ways. One type blocks estrogen receptors so that less estrogen can get into the breast tissues and/or tumor, and the other type lowers estrogen levels in the body.
Medications that work on specific proteins and genes in breast cancer tumors, such as the HER2/neu protein, are called targeted therapies. Rather than killing cancer cells and other tissues like chemotherapy, targeted therapies typically don’t damage healthy cells as much. Depending on the size and type of tumor, your doctor may prescribe one of a number of different targeted therapies. Targeted therapies can be given as injections, IV infusions, or in pill form and some may be given for up to a year. A few of the most common targeted drugs for breast cancer are those that work on HER2/neu-positive breast cancers such as Herceptin (trastuzumab), pertuzumab, neratinib, and ado-trastuzumab emtansine.
Sometimes called “biologics,” immunotherapy drugs boost your immune system’s ability to recognize and kill breast cancer cells on its own. The approach is still being explored, and some research suggests that hormonal/targeted therapies are as effective with fewer side effects than immunotherapy for many cases of breast cancer. That said, there are some cases in which other treatments don’t help, and that’s often where immunotherapy comes in. As of 2019, there are just two immunotherapy medications approved by the Food and Drug Administration for use in breast cancer. They are Tecentriq (atezolizumab), an IV drug typically used for advanced, triple-negative breast cancers, and Keytruda (pembrolizumab), which is FDA-approved for use in stage IV, or metastatic, cancers that have spread to other parts of the body.
That’s a lot to take in, and if you find some of the terminology confusing, you’re not alone. If you can, enlist the help of a friend or family member to go to appointments with you at first—it can be hard to keep everything straight when you are feeling unwell or are nervous. Compare notes, share ideas, and always ask your medical team questions—that’s what they’re there for.