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This information has been reviewed by:
Dr Meron Pitcher (Chair VCOG Breast Cancer Committee), Surgeon, Western Hospital
Choosing between the surgical methods
Additional or ‘adjuvant' treatment
Bilateral mastectomy (preventive)
Many years of treating cancer patients and testing treatments in clinical trials has helped doctors know what is likely to work for a particular type and stage of cancer. Your doctor will advise you on the best treatment for your cancer. This will depend on the full pathology results, your age and general health, and what you want.
Treatments for breast cancer include surgery, radiotherapy, chemotherapy and hormone treatment. Usually more than one is used. Treatment for breast cancer in men is similar to and as effective as the treatment for breast cancer in women.
Surgery is usually the first treatment for breast cancer. Surgery to the breast either removes part of the breast (breast-conserving surgery) or the whole breast (mastectomy).
Most people have axillary surgery at the same time. This removes lymph nodes in the armpit near your affected breast. The number of lymph nodes removed depends on the type of axillary surgery you have.
Before your surgery, your doctor will explain the risks involved and ask you to read and sign a consent form. All surgery and anaesthesia have some risks, including infection, bleeding and deep vein thrombosis (blood clot in the leg). These are not common, but you need to understand the risks.
Women who have a mastectomy may choose to have breast reconstruction surgery at the time of the mastectomy or later.
More information about breast reconstruction
Many women with early breast cancer can have operations that conserve most of their breast.
Lumpectomy removes the breast cancer and some tissue around it. Partial mastectomy removes more breast tissue than a lumpectomy. Axillary surgery is usually done at the same time, leaving a second scar under your armpit.
Women who have breast-conserving surgery usually have 5 to 6 weeks of radiotherapy afterwards. This is to substantially
reduce the risk of breast cancer recurring in the same breast and can be as effective as a mastectomy.
Mastectomy removes your whole breast, usually including some skin and the nipple. The lymph nodes in the armpit closest to your affected breast will probably also be removed. The chest muscles are not removed.
Mastectomy is less disfiguring than the radical mastectomy of the past. The type of mastectomy used today also reduces the chance of your arm swelling (called lymphoedema) and allows for easier breast reconstruction. Sometimes radiotherapy is recommended after mastectomy.
Axillary surgery is usually done at the same time as breast-conserving surgery or mastectomy. It is done to see if there is any cancer in the axillary lymph nodes.
This part of your treatment helps your doctors decide on the best follow-up treatment for you. It also helps to stage the disease. The lymph nodes are looked at under a microscope to see if they contain cancer cells. If they do, this means the cancer may have spread away from the breast. Your doctors will discuss chemotherapy or hormone treatment to follow your surgery.
This is the usual type of axillary surgery. The surgeon removes most of the lymph nodes from the armpit nearest the affected breast. They are checked by the pathologist. This is very effective at stopping cancer from coming back (recurring) in the underarm area.
This surgery can cause minor nerve damage. This can lead to a changed feeling or loss of sensation in the affected armpit. Some people won't sweat again in that area. It can also lead to lymphoedema.
Sentinel lymph node biopsy can show whether cancer has spread to the nodes, and whether axillary dissection is needed. Before your breast surgery, some dye is injected around the cancer. This is carried by the lymphatic vessels in your breast to a ‘sentinel' lymph node. This node is the first to receive lymph from the cancer area. It is the one most likely to contain cancer cells if your breast cancer has begun to spread.
The surgeon can see the sentinel node highlighted by the dye, and can remove just this node at first. A scan may be used to help find the sentinel node.
If there is no cancer in the sentinel node, it is unlikely there will be cancer in other nodes, so axillary dissection may not be necessary. Ask your doctor if you are interested in this surgery.
When you wake up from the general anaesthetic, you will have a wound on your breast where the cancer was removed. If you had surgery on your lymph nodes you will usually have a second wound under your arm. A mastectomy leaves only one scar. You will have dressings on the wounds and may have a drainage tube coming from the wound under your arm. This will stay in for two or more days. You may be in hospital for one to five days, depending on how well you feel and what your doctor suggests.
Most people feel pain, numbness or tingling around the wound areas and upper arm. These feelings usually go away in the months after surgery, although the numbness may last longer. Ask your doctor or nurse for pain relief if you have any pain.
You may have problems moving your arm. Your doctor or the physiotherapist at the hospital will show you exercises which will help you get back the movement in your arm.
After breast-conserving surgery, you will have small scars on your breast and under your arm. Your breast may be a different shape. The change may be small if you didn't have much tissue removed. It may be more noticeable if you had a larger amount of tissue removed.
After mastectomy, most people have a scar across their chest. Some women will choose to have breast reconstruction surgery. Other women may choose to wear a prosthesis. If you are to have radiotherapy, it will start within a few weeks of your operation, unless you have chemotherapy first. For information about radiotherapy, see later in this section.
Lymphoedema affects some people who have lymph nodes removed as part of their breast cancer surgery (about one in 10 people).
Lymphoedema is lymph fluid building up in the arm, causing swelling. It happens when lymph vessels are removed or damaged and no longer drain away the fluid. It may be minor or more troublesome.
It is hard to predict who will get lymphoedema. Lymphoedema can start soon after the operation, or months or years later.
Lymphoedema can be triggered or made worse by infection.
Tell your doctor about any swelling, tightness or injury to your hand or arm. Take extra care with the arm from which lymph nodes have been removed: try not to have injections in that arm, and use gloves when you wash dishes and do the gardening. If you cut your arm and/or hand, let your doctor know if any signs of infection develop. Clean and dress all cuts, burns and scratches. Protect your arm from sunburn and insect bites. Take care if shaving your armpit, so you do not cut the skin.
If you have lymphoedema, speak with a physiotherapist or breast care nurse about what you can do to manage the swelling. Massage exercises and clothes to restrict swelling are available. You can also call the Cancer Council Helpline for more details; telephone 13 11 20.
The choice between mastectomy and breast-conserving surgery depends upon the size and type of the breast cancer and its position in your breast. It also depends on what you want.
Mastectomy with axillary dissection has been compared to breast-conserving surgery and radiotherapy with axillary dissection. Research shows they are equally effective treatments for early breast cancers. There is a slightly greater risk of local breast recurrence with breast-conserving surgery, but long-term survival is the same.
With breast-conserving surgery, you still have most of your breast. However, further treatment with radiotherapy is usually needed. This takes several weeks. Following radiotherapy, your breast may feel slightly different.
Small-breasted women with large lumps can find that the breast-conserving operation causes a big change in breast shape.
Mastectomy may be recommended when:
The main disadvantage of mastectomy is the loss of your breast. Breast reconstruction can be done at the time of the mastectomy or at a later date.
If you have breast-conserving surgery, you will usually be advised to have a course of radiotherapy afterwards. Some women who have mastectomy also have radiotherapy. Radiotherapy aims to get rid of any cancer cells which may still be in the breast or on the chest wall.
Radiotherapy is the use of radiation to destroy cancer cells. The radiation can be precisely targeted at the area requiring treatment.
So that exactly the same area is treated each time, the radiation oncologist makes some marks on your skin. Sometimes tiny tattoos mark particular spots. Tattoos are permanent marks. You could have them removed after treatment is finished-ask your doctor about this if you want to.
The usual course of treatment is:
You have the treatment as an outpatient. It is painless and it takes about 30 minutes for each treatment. Most of this time is used to set you and the machine in the correct position for treatment. The machine is only on for a few minutes to give the treatment. Allow more time in case you have to wait for your treatment.
Side effects of radiotherapy may include tiredness, and some redness or ‘sunburning' of the skin, which usually returns to normal in a few weeks. Rarely, the skin is more severely affected. Radiotherapy nurses can show you how to care for your skin.
After radiotherapy, your breast may feel slightly firmer and may change a little in size or shape. If you are having radiotherapy you should get extra rest. Try to wear loose cotton clothing to reduce any irritation to the area having the radiation. Cover the area when you are in the sun.
Talk with your doctor and the radiotherapy staff about these and other possible side effects and how to manage them.
Some people will be advised to have extra treatment as well as their surgery and/or radiotherapy. These extra or adjuvant treatments aim to reduce the chances of the cancer coming back in other parts of the body, by destroying cancer cells that may have spread outside the breast.
This is the treatment of cancer by anti-cancer drugs. The aim is to destroy cancer cells and not harm normal cells. These drugs travel in the blood to all parts of the body.
Chemotherapy is taken in cycles. Each treatment is followed by a rest period. If you have chemotherapy after surgery, it will usually begin within six weeks of your surgery. You might have your chemotherapy as a tablet, injected into a vein or through a drip, or a mix of these. Chemotherapy is usually started before radiotherapy.
You will have your chemotherapy as an outpatient. Your visit may be a few minutes or it may be a few hours, depending on the drugs you have. The whole course of chemotherapy may last up to six months, sometimes longer.
Sometimes, chemotherapy is given before surgery. This is known as neoadjuvant chemotherapy. It can reduce the size of cancers so that surgery becomes possible, or so that breast-conserving surgery can be done.
People can have side effects from chemotherapy, depending on the drugs they take and their doses. People who have side effects from adjuvant chemotherapy usually cope well with them. Side effects may include nausea, vomiting for a short time, feeling ‘off colour' and tired, and some thinning or loss of hair from your body and head. These side effects are temporary (short term), and steps can be taken to prevent or reduce them.
For women, if you are still having periods, you may find that your periods stop while you are having treatment. Depending on your age, it is possible that your periods may not return once the treatment has stopped. You may want to discuss fertility issues and early onset of menopause with your doctor.
Many breast cancers are helped to grow by the sex hormones oestrogen and progesterone. Some breast cancers can be treated by changing the levels of these hormones in the body.
The most common hormone treatment for breast cancer is tamoxifen. This blocks the effects of oestrogen in the cancer cells. It works in people whose cancers are oestrogen-receptor-positive and/or progesterone-receptor-positive. With a breast cancer like this, tamoxifen reduces the chance of the breast cancer coming back.
Tamoxifen is taken daily as a tablet. If your doctor prescribes tamoxifen, you will begin the tablets after your surgery. If you also have chemotherapy, you will begin tamoxifen when this has finished.
Other hormone treatments such as anastrozole (Arimidex) and letrozole (Femara) are being tested. These aromatase inhibitors act by reducing the amount of oestrigen circulating. Early results suggest these drugs are more effective than tamoxifen. However they only work in women who have had menopause and had a hormone-receptor-positive breast cancer. They are also taken as a daily tablet. They have different side effects from tamoxifen. They are more expensive at this time because they are not subsidised for this sort of treatment. For some women, they may be a better choice than tamoxifen, but tamoxifen is the standard treatment for now.
Side effects of tamoxifen include hot flushes, blood clots, vaginal discharge or irritation and irregular periods (if you are still having periods). You may have none of these side effects, or one or more. Your doctor or breast care nurse will be able to advise you about how to manage them. A small number of postmenopausal women who take tamoxifen have a higher than average risk of developing cancer of the uterus. Tell your doctor if you have any unusual vaginal bleeding.
Some hormone treatments such as anastrozole and letrozole can cause osteoporosis. Bone density tests are recommended for women taking these tablets. Women receiving hormone treatments should have side effects monitored by their doctor.
Some women will be advised to have extra treatment, depending on their risk of cancer coming back and their own wishes. If you want to explore either of the following options, discuss it with your doctor. You may also wish to seek other medical opinions.
Herceptin is a treatment for HER2-positive breast cancer. It is a type of treatment called immunotherapy or a monoclonal antibody. It works in a different way from chemotherapy or hormonal therapy by targeting cancer cells that are HER2-positive. Herceptin stops cancer cells from growing and dividing. It also helps the immune system recognise that a cancer cell is abnormal and should be destroyed. Treatment with Herceptin can reduce the size of a tumour or delay tumour growth, prolong survival and improve quality of life. The benefits of Herceptin therapy will vary from patient to patient.
Herceptin may be used by itself or it may be used in combination with other drugs that treat breast cancer. Herceptin is given as an infusion into a vein, usually in a hospital outpatient clinic. The infusion can be given once a week or every three weeks. Your doctor will decide the dosage and how long you should receive Herceptin. Your doctor will also monitor the side effects you experience. During an infusion you may experience pain or discomfort, chills, fever, nausea and/or vomiting, rashes on the skin or a cough. These side effects are usually mild and may occur less frequently with subsequent infusions. Side effects after an infusion may include difficulty sleeping, shortness of breath, a cough, diarrhoea, and flu and/or cold-like symptoms. Talk to your doctor about possible side effects and how to manage them.
Ovarian ablation stops the ovaries from working. The ovaries are the main producers of oestrogen in premenopausal women. Ovarian ablation is for women who:
Ovarian ablation can be done using surgery, radiotherapy or drug therapy.
In an operation called oophorectomy, a small cut is made above the pubic bone and the ovaries are removed. This is usually done under a general anaesthetic. Most women can go home the next day and return to normal activities in one to two weeks. The surgery can also be done using laparoscopy with smaller skin incisions.
With oophorectomy and radiotherapy, your ovaries stop working. This will bring on menopause. This means you will no longer be able to have children. If this concerns you, ask your doctor before surgery if you have any medical options (for example, storing eggs or embryos). You may have some menopausal symptoms. These can include hot flushes and dry vagina. Your doctor or breast care nurse will be able to advise you on treatments for these symptoms. Your risk of osteoporosis may increase.
Temporary ovarian ablation can also be achieved by using injections of a drug known as goserelin (Zoladex). You have injections every month for two to five years. This type of ovarian ablation is reversible: when the injections are stopped, depending on your age, your periods (and fertility) will usually return.
Some women choose to have both breasts removed (bilateral mastectomy) when cancer has been found in one breast. This is to prevent a new cancer occurring in the second breast.
Not all doctors agree that mastectomy should be done in these cases, since it does not always prevent breast cancer. However, some doctors believe that it is the most effective choice for women with a high genetic risk of breast cancer. For most women treated for breast cancer in one breast, the risk of cancer in the other breast is low. Your doctor may suggest that all that is needed is regular check-ups. Discuss with your doctor any concerns you have about your risk of a cancer in the other breast.
Most cases of breast cancer can be cured if they are found and treated early. All cases of breast cancer can be effectively treated. Even when breast cancer is advanced, effective treatment can reduce symptoms and improve quality of life. For information about your own prognosis, you should talk with your doctor, who knows your cancer details and medical condition.
