Treatment for breast cancer

Monday 31 October, 2011

This information is about early breast cancer, for other types of breast cancer, visit Cancer Australia's website, or call 13 11 20. See also our genetics and breast cancer, breast reconstruction and prosthesis, breast cancer trials or breast health pages.

On this page: Surgery | Further treatment | Radiotherapy | Chemotherapy | Hormone therapy | Herceptin® | Information reviewed by

Treatment for early breast cancer aims to remove the cancer and reduce the risk of the cancer spreading or coming back. Treatment may include surgery, radiotherapy, chemotherapy, hormone therapy and targeted therapies. Usually more than one treatment is used.

Your doctor will advise you on the best treatment for your breast cancer. The choice of treatment will depend on:

  • your test results
  • where the cancer is
  • if the cancer has spread
  • whether the cancer has the oestrogen, progesterone or HER2 receptor protein
  • your age and general health
  • your preferences.

If you talk to other people with breast cancer, remember there are different categories of breast cancer and the best treatment for one person may not be the best treatment for another. Each person's situation is different.

You may want to read Cancer Australia's booklet, Guide for Women with Early Breast Cancer. For a copy call 1800 624 973.

Men who have early breast cancer have similar treatment options to women.

Surgery

Surgery for breast cancer will involve one of the following:

  • breast conserving surgery - removes part of the breast
  • mastectomy - removes the whole breast.

In most cases, breast surgery also involves removing one or more lymph nodes from the armpit. It can be difficult to decide which type of surgery to have. Some women do not want to have their whole breast removed. Research has shown that breast conserving surgery, with sentinel node biopsy followed by radiotherapy, is as effective as mastectomy for most women with early breast cancer.

The operations have different benefits, side effects and risks. Talk to your doctor or breast care nurse about the best option.

Breast care nurse: a helping hand

During treatment for breast cancer it is natural to feel overwhelmed by what is happening. A breast care nurse can help you make sense of your treatment by offering support, information and resources. They can also coordinate your care across different treatment methods.

Breast care nurses are available at most large hospitals. Ask your doctor if a breast care nurse is part of your multidisciplinary team. If one is not available, ask your treatment team who to contact if you have questions about your ongoing care.

Breast conserving surgery

Surgery to remove the breast cancer and some surrounding healthy tissue is called breast conserving surgery. It is also called lumpectomy, complete local excision, partial mastectomy or wide local excision. Breast conserving surgery is offered if the cancer is small compared to the size of your breast.

The surgeon removes the smallest amount of breast tissue as possible. This will leave a scar and the breast may change slightly in shape and size.

The tissue is sent to a lab for examination by a pathologist. The pathologist examines the removed breast tissue to see if there is an area of healthy cells all around the cancer - this is known as a clear margin. The pathologist will create a report, which will state if the cells are hormone receptor positive or negative.

If cancer cells are found at the edge of the removed tissue, this increases the chance of cancer returning. You may need more tissue removed (re-excision), or a mastectomy may be recommended.

Radiotherapy may be given to the breast after surgery to destroy any cancer cells that may be left in the breast or armpit.

Mastectomy

Surgery to remove the whole breast is called a mastectomy. The nipple is also usually removed. The chest muscles are not removed. Some or all of the lymph nodes in the armpit closest to your affected breast may also be taken out.

You may be offered a mastectomy if the cancer is large compared to the size of the breast or if it is in more than one area. For some small tumours that are not near the nipple, the surgeon may be able to perform a nipple-sparing or skin-sparing mastectomy. This means that more of the normal skin - with or without the nipple - is kept. This allows the surgeon to do an immediate breast reconstruction with a permanent implant or using tissue from another part of your body.

While your surgical wound heals, you can wear a soft temporary breast prosthesis (form) inside your bra. After complete healing (about 6-8 weeks), you may choose to be fitted for a breast form - or schedule a surgical breast reconstruction.

Breast reconstruction

A breast reconstruction is a type of surgery in which a breast shape is created using either a silicone or saline implant, tissue from another part of your body, or a combination of both. Some women have the reconstruction at the same time as the mastectomy (immediate reconstruction). Others prefer to wait for
several months or longer (deferred reconstruction).

For more information about reconstruction, talk to your surgeon or a reconstructive (plastic) surgeon. You can also call Cancer Council Helpline 13 11 20 for more information about breast reconstruction.

Removing lymph nodes

Lymph nodes (glands) are found throughout the body, including the armpit. They are small, bean-shaped collections of lymph cells that protect the body against disease and infection. The lymph nodes are part of the lymphatic system. The lymph nodes in the armpit are often the first place breast cancer cells spread to outside the breast. To check if breast cancer has spread to the lymph nodes, they are removed. There are two ways of removing the lymph nodes.

Sentinel node biopsy - The sentinel node is the first lymph node that breast cancer cells may spread to outside the breast. There can be more than one sentinel node. Usually it is in the armpit but it can also be found near the breast bone (sternum). Removing only the sentinel node/s will cause fewer side effects than axillary surgery.

The sentinel node is found using a combination of techniques. A small amount of radioactive substance is injected around the cancer before surgery. A scan is taken to show which node the substance has travelled to. During surgery, a blue dye is injected around the cancer in your breast. The dye moves into the lymphatic vessels. The nodes that become blue or radioactive first are known as the sentinel nodes, and the surgeon will remove only those nodes so they can be tested for cancer cells.

If the sentinel nodes are clear of cancer cells, no further surgery is needed. If the sentinel nodes contain cancer cells, axillary surgery will be needed.

Axillary (lymph node) surgery - This may be done at the same time as your breast surgery or as a separate operation. The doctor will remove the least possible amount of your lymph nodes. The lymph nodes are sent to a pathologist for examination. The pathologist will provide a report that shows how many nodes were removed and how many contain cancer cells. For instance, if 17 nodes were removed and four contained cancer cells, the report will read: 4/17. These results help your doctor recommend further treatment.

Physical side effects

Seroma - Fluid may collect in, or around, the scar in your breast or lymph nodes. The fluid may be drained using a fine needle and syringe. This can be done by the breast care nurse, your specialist or your GP.

Shoulder stiffness - Exercises can help prevent or manage shoulder stiffness. A physiotherapist or occupational therapist can help.

Numbness of the arm - Surgery may damage nerves, causing your arm, and perhaps shoulder, to feel numb. The numbness will improve but may not go away completely. Shoulder exercises will help improve movement.

Lymphoedema - The arm may swell following lymph node surgery or sometime later.

Fatigue - Feeling tired and having no energy may be a major problem. Treatment and the emotional impact of the diagnosis can be tiring. Your tiredness may continue for quite a while after treatment.

Most side effects can be managed. Talk to your doctor about any side effects you experience.

Recovery after surgery

You may be in hospital for 1 to 7 days, depending on the type of surgery you have, your recovery rate and whether you have any help at home.

You will have several tubes in place after the surgery, and a dressing will cover the wound to keep it clean. An intravenous drip will give you fluid as well as medication. There may also be a drain in your breast to take fluid from the surgical site. The dressing is usually removed after about a week, and the tubes are usually taken out within 3-5 days.

If you have had axillary surgery you will also have a drain from this site, which is usually removed in 3 to 7 days. Some people are discharged with drains still in place, but this will depend on your situation and your doctor's advice.

When you are in hospital, it's important to move your legs when you are in bed, then get up and walk around when you are able.

This helps prevent blood clots. Your doctor may also prescribe you medication to lower the risk of clots. You will be given pain relief by injection or tablets, and you will also be given pain medication when you go home. Any bruising and swelling at the surgery site will clear up in 2-3 weeks.

Exercising your arm as soon as possible after surgery will help it feel better and get back to normal faster.

Overall recovery time after surgery varies. Check with your surgeon about what you can do - for example, some surgeons tell you to avoid driving for a few weeks, until your arm is more agile. Most people start to feel better after about two weeks. Take it easy and only do what is comfortable.

Your feelings about surgery

Breast surgery may change your appearance, and this can affect your self-esteem. You may feel a sense of loss if you have had a mastectomy. It is normal to grieve over the loss of your breast.

Talking to someone who has also had surgery might be helpful. Cancer Council Connect may be able to link you to someone who has also had breast cancer. Call the Helpline 13 11 20 for more information.

Further treatment

A week after your operation, your doctor will have all the test results and will discuss the need for any further treatment such as radiotherapy, chemotherapy or hormone therapy. Further treatment will depend on the stage of the cancer and whether there is a clear margin around the cancer. You should be given a treatment plan and copies of your pathology reports for your own record.

Radiotherapy

Radiotherapy uses high-energy x-rays to kill cancer cells or stop them growing.

This treatment is recommended after breast conserving surgery to help destroy any cancer cells left in the breast and reduce the risk of the cancer coming back. It is also occasionally given after a mastectomy.

It is uncommon to have radiotherapy to the lymph nodes in your armpit after surgery as it may increase the chance of developing lymphoedema.

Treatment is carefully planned to do as little harm as possible to your normal body tissues. Before you start treatment, you will have a planning session at the radiotherapy centre. During this visit, x-rays are taken to pinpoint the area to be treated and marks will be put on your skin so that the radiation oncologist treats the same area each time. These marks are small dots and may be temporary or permanent (tattoos).

Once treatment starts, you will probably have radiotherapy once a day from Monday to Friday for 5 to 6 weeks. Usually you can have outpatient treatment and go to the radiotherapy centre each day.

Each radiotherapy session will be in a treatment room. Although you will only get radiation for 1 to 5 minutes, you might be in the treatment room for 10 to 30 minutes. Most of the time is spent positioning you and the treatment machine.

You will lie on a table under the radiotherapy machine. The radiation therapist will leave the room then turn on the machine, but you can talk to staff through an intercom. Radiotherapy is not painful but you need to lie still while the treatment is given.

Side effects

Radiotherapy may cause the following side effects:

  • Tiredness - You may feel tired or fatigued 1-2 weeks after radiotherapy starts and during treatment. This usually eases a few weeks after treatment finishes.
  • Red and dry skin - The skin near the treatment site may become red and dry after a few weeks of treatment. The skin usually returns to normal 4-6 weeks after your treatment ends. Radiotherapy nurses will show you how to care for your skin.
  • Inflammation and blistering - Less commonly, your skin may become very irritated. This will be closely monitored by the treatment team.

Radiotherapy to the breast does not cause hair loss. It also does not make you radioactive - it is safe to interact with your friends and family. For more information on radiotherapy and ways to deal with side effects, call 13 11 20 for a free copy of Cancer Council's booklet about radiotherapy.

Chemotherapy

Chemotherapy uses drugs to kill or slow the growth of cancer cells. Chemotherapy may be used:

  • if the risk of the cancer returning is high, to try to prevent the breast cancer coming back or spreading to other parts of the body
  • when cancer returns after surgery or radiotherapy, to gain control of the cancer and to relieve symptoms
  • if the cancer doesn't respond to hormone therapy.

There are several different types of chemotherapy drugs used to treat breast cancer. The drug combination you are given will depend on the type of breast cancer you have and what other treatments you are having. Common drugs include cyclophosphamide, docetaxel, doxorubicin, carboplatin and fluorouracil. Your medical team may also refer to the drugs by their brand (trade) names.

Chemotherapy is usually given through a vein (intravenously). You will have about 4 to 6 chemotherapy sessions every 2 to 3 weeks over several months. You usually will be treated as a day patient but occasionally an overnight stay may be recommended. The recovery time after each treatment session is called a cycle. This gives your body time to recover before the next session.

"I was lucky not to have any side effects from radiotherapy and went on with my daily workload. My employer was very supportive of my regular visits to the surgeon and radiotherapy treatment." — Patient

Side effects

The side effects caused by chemotherapy depend on the drugs used. Most side effects are temporary and steps can often be taken to prevent or reduce them.

Side effects may include feeling sick (nauseous), vomiting, tiredness, mouth ulcers or weight changes. Most people who have chemotherapy lose their head and body hair. Some women's periods become irregular or stop during chemotherapy but return to normal after treatment. For others, chemotherapy may cause periods to stop permanently (menopause).

Hormone therapy

Hormone therapy, also called endocrine therapy, is for people who have ER+ hormone receptors on their breast cancer cells. The aim of hormone therapy is to slow or stop the growth of hormone receptor positive cancer cells. Ask your doctor if hormone therapy is suitable for you. This will depend on your age, the type of breast cancer you have and whether you have reached menopause.

Tamoxifen

Tamoxifen is known as an anti-oestrogen drug. It works by stopping cancer cells responding to oestrogen. Tamoxifen is usually started after surgery or following radiotherapy or chemotherapy treatment. It is taken as a daily tablet over five years. This drug can be given to women of any age, regardless of whether they have reached menopause, but it is usually given to premenopausal women.

Tamoxifen does not cause menopause but its side effects may be similar. The most common side effects include hot flushes, headaches, a skin rash, trouble sleeping, vaginal dryness or discharge, weight gain and irregular periods. You may have some or none of the side effects. More serious side effects may include blood clots - see your doctor immediately if you have new swelling or soreness in your arm or leg, or a warm spot in your limb.

Any side effects you experience will usually improve as treatment continues and when it ends. Your doctor and breast care nurse can give you information about ways to manage these side effects.

A rare side effect of tamoxifen is cancer of the uterus. See your doctor as soon as possible if you have any unusual bleeding.

If you're having tamoxifen for more than five years, you should have annual gynaecological examinations.

Ovarian treatments

For women who have not reached menopause, treatments that stop the ovaries from producing oestrogen, temporarily or permanently, may be recommended.

Temporary ovarian treatment - These treatments include the drug goserelin (Zoladex®), which stops oestrogen production. Zoladex® is injected into the body to bring on a temporary menopause. You may experience side effects such as low sex drive, hot flushes, mood swings, trouble sleeping, vaginal dryness and headaches. Ask your doctor for ways to best manage these side effects.

Permanent ovarian treatment - Ovarian ablation can stop the ovaries from producing oestrogen permanently. Ovarian ablation is done by having surgery to remove the ovaries (oophorectomy) or having radiotherapy to the ovaries. These treatments will bring on menopause. This means you will no longer be able to become pregnant. You may have some menopausal symptoms, including hot flushes and a dry vagina, and your risk of osteoporosis may increase.

"I took Zoladex® throughout chemotherapy. When treatment ended, my periods came back normal. I'm hoping to try for a baby soon." — Patient

Aromatase inhibitors

Aromatase inhibitors help prevent the growth of oestrogen-dependent cancer cells by reducing the amount of oestrogen made in the body. They are used in women who have reached menopause.

Examples of aromatase inhibitors include anastrozole (Arimidex®), exemestane (Aromasin®) and letrozole (Femara®). Side effects may include osteoporosis, vaginal dryness, hot flushes and weight gain. 

Herceptin®

Trastuzumab (commonly known as Herceptin®) is a common type of targeted therapy for breast cancer. It works by attaching itself to HER2+ breast cancer cell receptors. This can destroy cells and reduce their ability to divide and grow. Herceptin® also encourages the body's own immune cells to help destroy the cancer cells.

You will receive this drug through an injection or infusion into your vein. You will usually have treatment every three weeks. The first infusion may take up to 90 minutes. You may be given this drug for a few years.

Your medical team will monitor you for side effects. The most common side effects include fever, runny nose, nausea and vomiting, diarrhoea, headache and a rash. Talk to your doctor about what to expect.

Information reviewed by: Professor John Boyages, Executive Director, Westmead Breast Cancer Institute, Westmead Hospital and author, Breast Cancer: Taking Control; Lynn Buglar, Breast Physician, BreastScreen NSW; Bronwyn Chalmers, Cancer Information Consultant, Helpline, Cancer Council NSW; Susan Munro, McGrath Breast Care Nurse, Community Health/Wagga Wagga Base Hospital, Wagga Wagga; and Kathryn Rutkowski, Consumer. 

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