Treatment for early breast cancer aims to remove the cancer and reduce the risk of the cancer spreading or coming back (recurring).
Treatment may include surgery, chemotherapy, radiotherapy, targeted therapy and hormone (endocrine) therapy. Usually more than one treatment is used, and treatments can be given in different combinations.
As there are different types of breast cancer, treatment varies from person to person. Your doctors will consider several factors to recommend the most suitable treatment for you.
The choice of treatment will depend on:
Men diagnosed with early breast cancer have similar treatment options to women. Some men feel embarrassed that they have what is considered a woman’s disease. Resources for men with breast cancer are available at the Cancer Australia website.
Surgery for breast cancer will involve either breast conserving surgery, where part of the breast is removed, or mastectomy, where the whole breast is removed. In most cases, breast surgery also involves removing one or more lymph nodes from the armpit (see below).
Some women will be offered a choice between breast conserving surgery and a mastectomy. Men don’t usually have breast conserving surgery.
Research has shown that breast conserving surgery with sentinel lymph node biopsy (see below), followed by radiotherapy, is as effective as mastectomy for most women with early breast cancer. The chance of a recurrence is the same regardless of which surgery you have.
The operations have different benefits, side effects and risks. Talk to your doctor about the best option for you.
Surgery to remove the breast cancer and some surrounding healthy tissue is called breast conserving surgery. It is also called lumpectomy or wide local excision. Breast conserving surgery is recommended if the cancer is small compared to the size of your breast.
The surgeon removes the smallest amount of breast tissue possible.
This will leave a scar and may change the size and, potentially, the shape of the breast, and it may affect the position of the nipple.
Oncoplastic breast conserving surgery combines oncological surgery (to remove the cancer) with plastic surgery (to reshape the breast and preserve its appearance as much as possible). This specialised surgical technique is performed by oncoplastic breast surgeons and some breast surgeons.
The removed breast and lymph node tissue is sent to a laboratory. A specialist called a pathologist checks it under a microscope to see if there is an area of healthy cells around the cancer – this is known as a clear margin. The pathologist will create a report, which will include information about the size and grade of the cancer, whether it has spread to any lymph nodes (the stage), whether the margins contain cancer cells, and whether the cells are hormone and/or HER2 receptor positive or negative.
If cancer cells are found at the edge of the removed tissue (an ‘involved’ or ‘positive’ margin), there is a greater chance of the cancer returning. You may need more tissue removed (re-excision or wider excision), or your doctor may recommend you have a mastectomy (see below).
After breast conserving surgery, radiotherapy to the whole breast is usually recommended to destroy any undetected cancer cells that may be left in the breast or armpit, and to keep the cancer from coming back (recurrence). For some women, radiotherapy may not be required.
Some women also need chemotherapy, targeted therapy or hormone therapy.
Surgery to remove the whole breast is called a mastectomy. You may be offered a mastectomy if:
You may decide that you would prefer to have a mastectomy rather than breast conserving surgery, particularly if you are unable to have radiotherapy. Some women choose to have a mastectomy even if the cancer is very small.
During a mastectomy, the nipple and some or all of the lymph nodes in the armpit closest to the affected breast are also usually removed. In some cases, the surgeon may be able to perform a skin-sparing or nipple-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. The reconstruction may be done with either a temporary implant (tissue expander) or a permanent implant, or it may use tissue from another part of your body.
If you don’t have an immediate reconstruction, you can wear a soft breast form inside your bra while your surgical wound heals. After this time, you can be fitted for a permanent breast prosthesis.
Breast conserving surgery
This woman has had breast conserving surgery followed by radiotherapy. This is how the scar looks two years after surgery.
Oncoplastic breast conserving surgery
This woman has had breast conserving surgery to her left breast. There is a scar around the areola. One year after surgery, the left breast is a slightly different size. Surgery was followed by radiotherapy.
This woman has had her left breast removed and has not had a reconstruction.
Mastectomy with an implant reconstruction
This woman has had a right mastectomy and a reconstruction using an implant. She has not had a nipple reconstruction.
A breast reconstruction is a type of surgery in which a breast shape is created using a silicone or saline implant, tissue from another part of your body, or a combination of both.
Some women have a breast reconstruction at the same time as a mastectomy (immediate reconstruction). Others are advised or prefer to wait for several months or longer before having a reconstruction (delayed reconstruction). Some women choose not to have a reconstruction at any stage.
If you’re not having an immediate reconstruction but you think you might consider it in the future, mention this to your surgeon before surgery, as it will help them to plan the mastectomy.
For more information about breast reconstruction, talk to your surgeon, see Breast Prostheses and Reconstruction or call Cancer Council 13 11 20.
The lymph nodes in the armpit are often the first place breast cancer cells spread to outside the breast. To see whether the cancer has spread, some or all of the lymph nodes are removed and checked for cancerous cells. The operation is called axillary surgery. It is usually performed during breast surgery, but it may be done in a separate operation. There are different types of axillary surgery:
The first lymph node that breast cancer cells may spread to outside the breast is the sentinel node. There can be more than one sentinel node. Usually it is in the armpit, but it can also be found near the breastbone (sternum).
To find the sentinel node, a small amount of radioactive material is injected into the breast around the nipple and areola before surgery. A scan is taken to show which node the substance flows to first. During surgery, a blue dye is injected around the areola or near the cancer. The dye moves into the lymphatic vessels. The nodes that are radioactive or become blue first are the sentinel lymph nodes. The surgeon will remove them for testing.
If the sentinel nodes are clear of cancer cells, no further surgery is needed. If one or more sentinel nodes contain cancer cells, axillary dissection or radiotherapy to the armpit may be considered.
Sentinel node biopsy can cause similar side effects to axillary dissection (see below), but they are usually less severe.
The surgeon will remove most or all of the lymph nodes (usually 10–20 nodes). If cancer cells are present, your doctor may recommend further treatment with chemotherapy, targeted therapy or hormone therapy. Possible side effects of axillary dissection include: arm or shoulder stiffness; numbness in the arm, shoulder, armpit and parts of the chest; lymphoedema; and seroma (fluid collecting near the surgical scar). Your surgeon will discuss these side effects with you before the operation.
The length of your hospital stay will depend on the type of breast surgery you have and how well you recover. Most people are able to walk around and shower the day after surgery. If you have any questions about your recovery, ask the doctors and nurses caring for you. Many people are referred to a breast care nurse for information and support.
You may have one or more drainage tubes in place to remove fluid from the surgical site. These may remain for up to two weeks, depending on the type of surgery.
A dressing will cover the wound to keep it clean, and it will usually be removed after about a week.
Some people are discharged from hospital with drains still in place, but this will depend on your situation and your doctor’s advice. Nursing staff will teach you how to manage the drains at home, or you may be referred to a community nurse or your GP.
While you are in hospital, it’s important to move your legs when you are in bed to help prevent blood clots. When you are able, get up and walk around. You may have to wear graduated compression stockings or use other devices to help prevent blood clots in the deep veins of your legs (deep vein thrombosis or DVT). Your doctor might also prescribe you medicine that lowers the risk of clots.
You will be given pain relief through an intravenous (IV) drip, via an injection, or as tablets, and you will be given pain medicine when you go home. Any bruising and swelling at the surgery site will usually settle down in 2–3 weeks.
Breast surgery may change the appearance of your breast, and this can affect how you feel about yourself (self-image and self-esteem). You may feel a sense of loss if you’ve had a mastectomy. It is normal to grieve the loss of your breast.
Talking to someone who has had breast surgery might be helpful. Cancer Connect may be able to link you to someone who has had a similar experience to you. Call Cancer Council 13 11 20 for details.
After surgery, you can slowly begin to exercise your arm on the advice of your treatment team. This will help it feel better and get back to normal more quickly. Arm exercises will also move any fluid that has collected near the surgical scar (seroma) and help to prevent lymphoedema.
For a guide to arm exercises you can do after breast surgery, call Cancer Council 13 11 20 for a copy of Cancer Council’s Exercises after surgery poster.
Recovering from breast surgery will take time. If you need home nursing care, ask hospital staff about services that are available in your area.
Talk to your doctor or breast care nurse about ways to deal with the side effects of surgery. Most side effects can be managed. For more information, see the living with breast cancer section.
Feeling tired and having no energy is common. Cancer treatment and the emotional impact of the diagnosis can be tiring. Fatigue may continue for a few weeks or months.
Gentle exercises can help prevent or manage shoulder stiffness. Ask your breast care nurse, a physiotherapist or an occupational therapist about suitable exercises.
Surgery can cause bruising or injury to nerves, which may cause numbness and tingling in the chest and arm. This often improves within a few weeks, but it may take longer. For some people, it may not go away completely. A physiotherapist or occupational therapist can suggest exercises that may help.
Fluid may collect in or around the surgical scar. A breast care nurse, your specialist or GP or a radiologist can drain the fluid using a fine needle and a syringe. This procedure isn’t painful, but it may need to be repeated over a few appointments.
This is usually temporary, but it may be permanent for some people.
Fluid build-up may cause swelling after lymph node surgery. See ways to manage lymphoedema.
Chemotherapy uses drugs to kill cancer cells or slow their growth. It is usually given before radiotherapy and may be used if:
Many different types of chemotherapy drugs are used to treat early breast cancer. The drug combination you are given will depend on the type of cancer, how far it has spread and what other treatments you are having. Common drugs include doxorubicin, cyclophosphamide, fluorouracil, docetaxel and paclitaxel. Your medical team may also refer to the drugs by their brand names.
Chemotherapy is given through a vein (intravenously). You will usually be treated as an outpatient, but occasionally you may have to stay in hospital overnight. The number of chemotherapy sessions varies depending on the combination of drugs prescribed by your oncologist.
Most people will have chemotherapy for 3–6 months. Some drugs are given once every three weeks, some are given each week (e.g. once a week for 12 weeks), and some are given on an accelerated schedule (e.g. once every two weeks instead of once every three weeks). Not every person with early breast cancer will have the same chemotherapy treatment on the same schedule.
Chemotherapy kills healthy cells as well as cancer cells, which can cause side effects. The side effects caused by chemotherapy depend on the drugs used. Most side effects are temporary, and they can often be prevented or managed by your treatment team.
Side effects may include tiredness, mouth ulcers, taste changes, nausea and vomiting, and constipation. Chemotherapy can also lower your immune system, increasing the risk of infection.
Most people who have chemotherapy for breast cancer lose their head and facial hair. Some treatment centres provide cold caps, which may prevent total head hair loss, but this depends on the drugs used. For information about cold caps, speak to your treatment team. See information about wigs .
For some women, periods can become irregular or stop during chemotherapy. Periods may return to normal after treatment, or they may stop permanently (menopause), causing infertility. For men, chemotherapy can lower the number of sperm that are produced, which can cause temporary or permanent infertility. If you would like to have children in the future, ask your doctor for a referral to a fertility specialist before your treatment starts.
For more information see Understanding Chemotherapy or call Cancer Council 13 11 20.
Radiotherapy uses radiation, such as x-rays, to kill cancer cells or injure them so they cannot grow and multiply. It is recommended:
You will usually start radiotherapy about four weeks after surgery. If you’re having chemotherapy after surgery, radiotherapy treatment will begin about four weeks after chemotherapy has finished.
If you live in a regional or rural area, you may need to travel for radiotherapy treatment.
Every state and territory has a scheme that provides financial help to people who need to travel long distances to access specialist medical treatment not available in their local area. Assistance with accommodation costs may also be given.
Patient transport schemes are not usually full subsidy schemes – you are often required to contribute a certain amount towards the cost.
For details, talk to the hospital social worker or call Cancer Council 13 11 20. Also visit ruralhealthaustralia.gov.au, search for ‘PATS’ and click on ‘Patient Assisted Travel Schemes’.
Treatment is carefully planned to have the greatest effect on the cancer cells and to limit the damage to the surrounding healthy body tissues. Planning consists of several steps, which may occur over a few appointments.
You will have a planning session at the radiotherapy centre. During this appointment, you will have a CT scan to pinpoint the area to be treated, and marks will be put on your skin so the radiation therapists treat the same area each time. These marks are small dots (tattoos) and they may be temporary or permanent. Talk to your radiation therapists if you are uncomfortable having a permanent tattoo.
You will probably have radiotherapy daily from Monday to Friday for 4–6 weeks. In some cases, you may have a larger dose each day for about three weeks. Usually you can have radiotherapy as an outpatient and go to the treatment centre each day.
Each radiotherapy session will be in a treatment room. Although you will only get radiation for 1–5 minutes, you might be in the treatment room for 10–30 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 therapists will leave the room and then switch on the machine, but you can talk to them through an intercom. Radiotherapy is not painful, but you need to lie still while the treatment is given.
Radiotherapy may cause the following side effects:
You may feel tired or fatigued (lacking energy for day-to-day activities) 1–2 weeks after radiotherapy starts, and during treatment. This usually eases a few weeks after treatment finishes.
The skin at the treatment site may become red and dry after a few weeks of treatment. It usually returns to normal 4–6 weeks after treatment ends. Radiotherapy nurses will show you how to care for your skin. Sorbolene cream applied twice a day can be helpful.
Less commonly, your skin may become itchy and/or very irritated. This will be closely monitored by the treatment team, who will recommend creams you can apply to the area.
You may feel minor aches or shooting pains that last for a few moments during treatment. Some people develop fluid in the breast (breast oedema).
These changes to the breast may be ongoing for up to 12 months, but, in some cases, they can last up to five years. Radiotherapy may also increase the chance of developing lymphoedema in the arm on the same side as the affected breast. Talk to your doctor about any changes you experience. You will have regular appointments with your radiation oncologist and radiotherapy nurse throughout your treatment.
Radiotherapy to the breast does not cause you to lose hair from your head, although you may lose hair from the treated armpit. The radiation will not make you radioactive because the radiation does not stay in your body during or after treatment, and so it is safe for you to spend time with friends and family.
For more information and ways to deal with side effects see Understanding Radiotherapy or call Cancer Council 13 11 20.
The main targeted therapy for breast cancer stops the growth of cancer cells that have a higher than normal level of the HER2 protein, which stimulates cancer cells to grow.
Trastuzumab (Herceptin) is a type of targeted therapy for early breast cancer. It works by attaching itself to HER2 positive breast cancer cells, destroying the cells or reducing their ability to divide and grow. Herceptin also encourages the body’s own immune cells to help destroy the cancer cells.
Herceptin increases the effect of chemotherapy drugs on early breast cancer. Several trials have shown that Herceptin used in combination with chemotherapy for women with HER2 positive breast cancer works much better than chemotherapy alone. Some men also receive Herceptin for early breast cancer.
Some people receive Herceptin as an injection, but most are given it via an infusion into a vein. You will usually have a dose every three weeks, although some people may have weekly doses. The first infusion may take up to 90 minutes. This is called the loading dose. The following infusions take 30–60 minutes each, and they will continue for up to 12 months. The first four doses are given while you are having chemotherapy treatment.
Your medical team will monitor you for side effects. Although side effects are uncommon with this treatment, they can include fever, diarrhoea, headache and a rash.
In some people, Herceptin can affect the way the heart works. This is more common in older people and people with pre-existing heart problems. You will have tests to check your heart function before starting Herceptin, and at regular intervals during treatment. Ask your doctor for more information about these tests.
Hormone therapy, also called endocrine therapy or hormone- blocking therapy, is used to treat hormone receptor positive cancers. The aim of hormone therapy is to slow or stop the growth of hormone receptor positive cancer cells.
There are different ways of reducing the level of female hormones in the body. This will depend on your age, the type of breast cancer and − for women − whether you have reached menopause. There are different types of hormone therapies to treat early breast cancer.
A rare side effect of tamoxifen is an increased risk of uterine cancer in postmenopausal women. See your doctor if you notice any unusual bleeding. If you’re taking tamoxifen for more than five years, you should have annual gynaecological examinations.
Tamoxifen is known as an anti-oestrogen drug. It works by stopping cancer cells responding to oestrogen. Tamoxifen is usually started after surgery, radiotherapy or chemotherapy. It is commonly taken as a daily tablet for 5–10 years. It can be given to women of any age, regardless of whether they have reached menopause, and to men.
Your doctor will probably recommend that you use contraception while you are taking tamoxifen, as the drug may be harmful to a developing baby.
Tamoxifen does not cause menopause, but it causes similar symptoms to menopause. The most common side effects of tamoxifen include hot flushes and sweating, trouble sleeping (insomnia), vaginal dryness or discharge, muscle cramps, low mood, weight gain and irregular periods. In men, side effects can include low sex drive (libido) and erection problems.
You may also be at an increased risk of blood clots – see your doctor immediately if you have any swelling, soreness or warmth in your arm or leg. If you are having further surgery or travelling long distances, you may need to stop taking tamoxifen beforehand to lower the risk of blood clots. You can resume taking it when surgery or travel is completed.
You will probably not experience all of these side effects. Side effects usually improve as treatment continues and after it has finished. Your doctor and breast care nurse can give you information about ways to manage the side effects of tamoxifen.
Aromatase inhibitors help prevent the growth of oestrogen- dependent cancer cells by reducing the amount of oestrogen the body produces. They are recommended only for postmenopausal women, who are already producing smaller amounts of oestrogen.
Examples of aromatase inhibitors include anastrozole, exemestane and letrozole. They are taken daily as a tablet, usually for five years. Clinical trials are researching whether the drugs should be taken for 10 years.
Side effects of aromatase inhibitors may include joint and muscle pain, bone thinning and weakening (osteoporosis), vaginal dryness, low mood, hot flushes and weight gain. For women with arthritis, aromatase inhibitors may worsen joint stiffness and pain. Exercise or medication may help with this.
Before starting treatment with an aromatase inhibitor, you will have a bone density scan to check your bone health.
For women who have not reached menopause, treatments that stop the ovaries from producing oestrogen, either temporarily or permanently, may be recommended.
Also called ovarian suppression, this treatment includes the drug goserelin (Zoladex®), which stops oestrogen production. Zoladex is suitable for women who have breast cancer that is sensitive to oestrogen. The drug is given as an injection by a nurse or your GP once a month for 2–5 years to bring on a temporary menopause.
You may experience side effects such as low sex drive (libido), hot flushes, mood swings, trouble sleeping (insomnia), vaginal dryness and headaches. Ask your doctor or nurse for ways to manage these side effects.
Ovarian ablation is treatment that permanently stops the ovaries from producing oestrogen. The treatment usually involves surgery to remove the ovaries (oophorectomy) or, occasionally, radiotherapy to the ovaries.
Ovarian ablation will bring on permanent menopause. This means you will no longer be able to become pregnant. You may have some menopausal symptoms, including hot flushes and vaginal dryness, and your risk of osteoporosis may increase. If you would like to become pregnant in the future, ask your doctor for a referral to a fertility specialist before treatment starts.
"I was 31 when I was diagnosed with breast cancer. It was pure chance that I found a lump – I was putting on my bra and I felt it. I saw my GP, who examined me and sent me for tests.
I had a mammogram, an ultrasound and a fine needle biopsy. The biopsy showed that it was cancer and that it was oestrogen receptor positive, and the ultrasound showed some spread.
I wasn’t happy with the treatment option recommended by the first specialist my GP referred me to, so I asked for a second opinion. I decided it was my life and my choice. The new specialist suggested I have a mastectomy followed by chemotherapy and radiotherapy.
I had a reconstruction at the same time as the mastectomy. The surgeon used muscle and some skin from my back to create a pocket for an implant.
Recovering from surgery was a slow process, but I felt a little better each day. Because the muscle was removed from my back, I’m still weaker on that side of my body. At one point, I couldn’t stretch my arm properly and I panicked, but gradually I was able to move it again.
I had chemo for eight months, and I worked during treatment because I wanted to maintain a normal life. I lost my hair and a lot of weight, and it felt like I was constantly nauseous. I was also very tired – I would go to bed really early.
I chose not to have radiotherapy because my doctor told me there was a chance the scarring from the reconstruction might not heal as well if I did.
It’s important to play an active role in your treatment, because it’s your life and body. This is especially important when you’re diagnosed young, like I was."
Please note: This information is about early breast cancer. For information about secondary breast cancer (also called metastatic or advanced breast cancer), visit Breast Cancer Network Australia or Cancer Australia.
Reviewed by: A/Prof Meagan Brennan, Breast Physician, Westmead Breast Cancer Institute, NSW; Carole Andary, Cancer Council Nurse, Cancer Council SA; Tracey Bretag, Consumer; Terri-lee Cooper, McGrath Breast Care Nurse, Cancer Screening and Control Services, Tasmanian Health Service, TAS; Dr Richard de Boer, Medical Oncologist, Royal Melbourne and Epworth Hospitals, VIC; Miss Jane O’Brien, Specialist Breast and Oncoplastic Surgeon, Epworth Breast Service, VIC; Susan Schwabe, Breast Cancer Care: Clinical Nurse Consultant, W.P. Holman Clinic, Launceston General Hospital, TAS; Dr Anita Taylor, Deputy Director, The Wesley Breast Clinic, QLD.