Treatment:

The three major treatments of breast cancer are surgery, radiation, and drug therapy. No one treatment fits every patient, and combination therapy is usually required. The choice is determined by many factors, including the age of the patient, menopausal status, the kind of cancer (ductal verses lobular), its stage, and whether or not the tumor contains hormone-receptors.

Breast cancer treatments are defined as local or systemic:

• Local Treatment. Surgery and radiation are considered local therapies because they directly treat the tumor, breast, lymph nodes, or other specific regions. Surgery is usually the standard initial treatment.
• Systemic Treatment. Drug treatment is called systemic therapy, because it affects the whole body. Drugs may include either chemotherapy or hormone therapy. Drug therapy may be used as primary therapy for patients for whom surgery or radiation therapy is not appropriate, neoadjuvant therapy (before surgery or radiation) to shrink tumors to a size that can be treated with local therapy, or as adjuvant therapy (following surgery or radiation) to reduce the risk of cancer recurrence. For metastatic cancer, drugs are used not to cure but to improve quality of life and prolong survival.

Any or all of these therapies may be used separately or, most often, in different combinations. For example, radiation alone or with chemotherapy or hormone therapy may be beneficial before surgery, if the tumor is large or not easily removed at prevention. Surgery followed by radiation and hormone therapy is usually recommended for women with early-stage, hormone-sensitive cancer. There are numerous clinical trials investigating new treatments and treatment combinations. Patients, especially those with advanced stages of cancer, may wish to consider enrolling in a clinical trial.

Cancer Stage and Treatment Options

Treatment strategies depend in part on the stage of the cancer.

Stage 0 (Carcinoma in Situ). Stage 0 breast cancer is considered non-invasive (‘in situ"), meaning that the cancer is still confined within breast ducts or lobules and has not yet spread to surrounding tissues. Stage 0 cancer is classified as either:

• Ductal carcinoma in situ (DCIS). These are cancer cells in the lining of a duct that have not invaded the surrounding breast tissue.
• Lobular carcinoma in situ (LCIS). These are cancer cells in the lobules of the breast. LCIS rarely develops into invasive breast cancer, but having it in one breast increases the risk of developing cancer in the other breast.

Treatment options for DCIS include:

• Breast-conserving surgery and radiation therapy (followed by hormone therapy for women with hormone-sensitive cancer). Many doctors recommend this approach.
• Total mastectomy (followed by hormone therapy for women with hormone-sensitive cancer)
• Breast-conserving surgery without radiation therapy

Treatment options for LCIS include:

• Regular exams and mammograms to monitor any potential changes (observation treatment)
• Hormone therapy to prevent development of breast cancer (for women with hormone-sensitive cancer)
• Mastectomy of both breasts was previously used as treatment, but is now rarely recommended

Stage I and II (Early-Stage Invasive). In stage I cancer, cancer cells have not spread beyond the breast, and the tumor is no more than 2 cm (about 3/4 of an inch) across.

Stage II cancer is classified as either stage IIA or stage IIb.

In stage IIA cancer the tumor is either:

• No more than 2 centimeters and has spread to the underarm lymph nodes (axillary lymph nodes)
• Between 2 - 5 centimeters and has not spread to the underarm lymph nodes

In stage IIB cancer the tumor is either:

• Larger than 2 centimeters and less than 5 centimeters and has spread to 1 - 3 axillary lymph nodes
• Larger than 5 centimeters but has now spread to lymph nodes

Treatment options for stage I and stage II breast cancer may include:

• Breast-conserving surgery (such as lumpectomy) followed by radiation therapy
• Modified radical mastectomy with or without breast reconstruction
• Post-surgical therapy (adjuvant therapy), including radiation of lymph nodes, chemotherapy, or hormone therapy
• Trastuzumab (Herceptin) given along with or following adjuvant chemotherapy for women with HER2-positive cancer

Stage III (Locally Advanced). Stage III breast cancer is classified into several sub-categories: Stage IIIA, stage IIIB, and stage IIIC (operable or inoperable).

In stage IIIA breast cancer, the tumor is either:

• Not more than 5 centimeters and has spread to 4 - 9 axillary lymph nodes
• Larger than 5 centimeters and has spread to 1 - 9 axillary nodes or to internal mammary nodes.

Treatment options for stage IIIA breast cancer are the same as those for stages I and II.

In stage IIIB breast cancer, the tumor has spread to either:

• Tissues near the breast (including the skin or chest wall)
• Lymph nodes within the breast or under the arm

Stage IIIB treatment options may include:

• Chemotherapy, and possibly hormone therapy (sometimes in combination with chemotherapy)
• Chemotherapy followed by surgery (breast-conserving surgery or total mastectomy) with lymph node dissection followed by radiation therapy and possibly more chemotherapy or hormone therapy
• Clinical trials

Stage IIIC breast cancer is classified as either operable or inoperable.

In operable stage IIIC, the cancer may be found in:

• 10 or more of the underarm lymph nodes
• Lymph nodes beneath the collarbone and near the neck on the same side of the body as the affected breast
• Lymph nodes within the breast as well as underarm lymph nodes

Treatment options for operable stage III breast cancer are the same as those for stage I and II breast cancers.

In inoperable stage III breast cancer, the cancer has spread to lymph nodes above the collarbone and near the neck on the same side of the body as the affected breast. Treatment options are the same as those for stage IIIB.

Stage IV (Advanced Cancer). In stage IV, the cancer has spread (metastasized) from the breast to other parts of the body. In about 75% of cases, the cancer has spread to the bone. The cancer at this stage is considered to be chronic and incurable, and the usefulness of treatments is limited. The goals of treatment for stage IV cancer are to stabilize the disease and slow its progression, as well as to reduce pain and discomfort.

Treatment options for stage IV cancer include:

• Surgery or radiation for any localized tumors in the breast.
• Chemotherapy, hormone therapy, or both. Targeted therapy with trastuzumab (Herceptin) or lapatinib (Tykerb) should be considered for women with HER2-positive cancer.
• Cancer that has spread to the brain may require radiation and high-dose steroids.
• Cancer that has spread to the bone may be helped by radiation or bisphosphonate drugs. Such treatments can relieve pain and help prevent bone fractures.
• Clinical trials of new drugs or drug combinations, or experimental treatments such as high-dose chemotherapy with stem cell transplant.

Post-Treatment Care

The American Society of Clinical Oncology (ASCO) recommends follow-up care for patients who have been treated for breast cancer:

• Visit your doctor every 3 - 6 months for the first 3 years after your first cancer treatment, every 6 - 12 months during the fourth and fifth year, and once a year thereafter.
• Have a mammogram 1 year after the mammogram that diagnosed your cancer (but no earlier than 6 months after radiation therapy), and every 6 - 12 months thereafter.
• Perform a breast self-exam every month (however, this is no substitute for a mammogram).
• See your gynecologist regularly (women taking tamoxifen should be sure to report any vaginal bleeding).
• A year after diagnosis, you can either continue to see your oncologist or transfer your care to your primary care physician.
• If you are on hormone therapy, discuss with your oncologist how often to schedule follow-up visits for re-evaluation of your treatment.

ASCO does not recommend the use of laboratory blood tests (complete blood counts, carcinoembryonic antigen) or imaging tests (bone scans, chest x-rays, liver ultrasound, FDG-PET scan, CT scan) for routine breast cancer follow-up.

Genetic counseling may be helpful if you have:

• Ashkenazi Jewish heritage
• Personal or family history of ovarian cancer
• Personal or family history of cancer in both breasts
• Any first-degree female relative (mother, sister, daughter) diagnosed with breast cancer before age 50
• Two or more first-degree or second-degree (grandparent, aunt, uncle) diagnosed with breast cancer
• History of breast cancer in a male relative

Pregnancy after Breast Cancer Treatment. There are no definite recommendations on how long a woman should wait to become pregnant after breast cancer treatment. Because of the connection between estrogen levels and breast cancer cell growth, some doctors recommend delaying pregnancy until 2 years after treatment in order to reduce the risk of cancer recurrence and improve odds for survival. However, other studies indicate that conceiving 6 months after treatment does not negatively affect survival. Discuss with your doctor your risk for recurrence, and when it may be safe to attempt pregnancy.

Recurrent Breast Cancer

Recurrent breast cancer is considered to be an advanced cancer. In such cases, the disease has come back in spite of the initial treatment. Most recurrences appear within the first 2 - 3 years after treatment, but breast cancer can recur many years later. Treatment options are based on the stage at which the cancer reappears, whether or not the tumor is hormone responsive, and the age of the patient. Between 10 - 20% of recurring cancers are local. Most recurrent cancers are metastatic. All patients with recurring cancer are candidates for clinical trials.

Because most breast cancer recurrences are discovered by patients in between doctor visits, it is important to notify your doctor if you experience any of the following symptoms. These symptoms may be signs of breast cancer recurrence:

• New lumps in the breast
• Bone pain
• Chest pain
• Abdominal pain
• Shortness of breath or difficulty breathing
• Persistent headaches or coughing
• Rash on breast
• Nipple discharge