While surgery is often the main treatment for both early and locally advanced breast cancer, you may have other treatments before surgery. Called neoadjuvant treatment, it may be discussed at an Multidisciplinary Team meeting.

Chemotherapy is often used before surgery (neoadjuvant chemotherapy or NAC). Or, you may have hormone therapy, targeted therapy or immunotherapy, or a combination of these treatments.

Neoadjuvant treatment can help to reduce the size of the cancer before surgery and improve your chance of having a good outcome. It may also mean you can have less complex surgery.

For locally advanced breast cancer, for example, neoadjuvant treatment may mean you can choose to have breast-conserving surgery rather than a mastectomy.

In some cases – particularly for people with HER2+ or triple negative cancers – neoadjuvant treatment can kill all cancer cells. Called a complete pathological response, it improves the chance of a good outcome.

Ask your doctor if neoadjuvant treatment is an option for you. People with early breast cancer may find the Neoadjuvant Patient Decision Aid helpful.

After surgery, you may have radiation therapy, chemotherapy, hormone therapy, targeted therapy or immunotherapy. This is called adjuvant treatment. It helps to destroy any cancer cells that remain after surgery

Removing only part of the breast is called breast-conserving surgery. It is also known as a lumpectomy or wide local excision. The surgeon removes the tumour and some of the healthy tissue around it, so that you can keep as much of your breast as possible.

The operation will leave a scar, and it may change the size and shape of the breast and the position of the nipple.

Pathology tests on breast tissue

A pathologist looks at the removed tissue under a microscope to check for an area of healthy cells around the cancer (called a clear margin).

The pathologist will also give information about: 

• the size and grade of the cancer
• whether the cells are hormone receptor positive and/or HER2+ or triple negative 
• whether the cancer has spread to any lymph nodes.

If your removed tissue shows multiple cancers, each cancer will be tested separately. The pathology report will help your doctors work out what other treatment may be best for you.

If there are cancer cells found close at the edge of the tissue (which is called an involved or positive margin), there is a higher risk of the cancer returning. You may need to have further surgery to remove more tissue (a re-excision or wider excision).

Your doctor may also suggest that you have a mastectomy. After having breast-conserving surgery, you will usually then have radiation therapy to destroy any cancer cells that may be left in the breast or armpit.

Surgery to remove the whole breast is called a mastectomy. One breast may be removed (single or unilateral mastectomy) or both breasts (double or bilateral mastectomy). A mastectomy may be recommended if:

• there is cancer in more than one area of the breast
• the cancer is large compared with the size of the breast
• it is difficult to get a clear margin around the tumour
• you have inflammatory breast cancer
• you have had radiation therapy to the same breast before and so cannot have it again
• the cancer has come back or you have a new cancer in the same breast
• you have the BRCA1 or BRCA2 gene mutation.

You may prefer to have a mastectomy instead of breast-conserving surgery – even if you have a very small cancer. You will not usually have radiation therapy after a mastectomy, although it may be offered in some situations.

The nipple is often removed in a mastectomy. In some cases, however, the surgeon may perform a skin-sparing or nipple-sparing mastectomy. This means that more of the normal skin (with or without the nipple) is kept.

If you have decided to have a reconstruction, and can have a skin-sparing or nipple-sparing mastectomy, the reconstruction is sometimes done at the same time.

If you don’t have a reconstruction, you have the option of wearing a soft breast form with a specially designed bra while your surgical wound heals. Breast Cancer Network Australia (BCNA) provides a free bra and temporary soft form.

Speak to your breast care nurse for more details. After the wound has healed and the area is comfortable, you have the option to be fitted for a permanent breast prosthesis.

If you need a mastectomy because of cancer in one breast, you may think it’s safer to have the other breast removed as well. For most people, the risk of getting cancer in the other breast is low.

If you have the BRCA1 or BRCA2 gene or another rare breast cancer gene mutation, this does increase the risk of developing another breast cancer, so you may choose to have a double mastectomy (bilateral mastectomy) to remove both breasts.

Whether to have a double mastectomy is a complex decision. It is best to talk with your treatment team about the risks and benefits before making a final decision.

Breast reconstruction is surgery to make a new breast shape (also called a breast mound). There are different ways to construct a breast shape. It can be done using:

• implants
• a flap of your own skin, fat or muscle (an autologous reconstruction)
• a breast implant and your own tissue.

A breast reconstruction can be done at the same time as a mastectomy (immediate reconstruction); or you may prefer to wait for several months or years before having a reconstruction (delayed reconstruction).

If you are not having an immediate reconstruction but might consider it in the future, discuss this with your surgeon before surgery. This will help them to plan the mastectomy.

Some people decide not to have a reconstruction and prefer to “go flat”, while others choose to wear a breast prosthesis.

Cancer cells that spread from the breast usually first spread to the axillary lymph nodes, which are in and around the armpit. Removing some or all of these lymph nodes helps your doctor to check for any cancer spread.

The operation to remove lymph nodes is called axillary surgery. It is usually done during breast surgery but may be done in a separate operation. There are two main types of axillary surgery.

• Sentinel lymph node biopsy (SLNB) – When breast cancer spreads outside the breast, it first goes to a particular lymph node or nodes in the armpit or near the breastbone (sternum). These are called the sentinel nodes. A sentinel node biopsy finds and removes them so they can be tested for cancer cells . If there are no cancer cells in the sentinel nodes, no more lymph nodes are removed. If there is more than a small amount of disease in the sentinel nodes, you may have axillary lymph node dissection or radiation therapy.
• Axillary lymph node dissection (ALND) – If cancer is found in the lymph nodes, then most or all of the axillary lymph nodes (usually 10–25) may be removed to reduce the risk of the cancer coming back (recurrence) in the armpit. The nodes are tested and the results guide what other treatment may be needed. ALND is also called axillary lymph node clearance (AC). Radiation therapy may be used instead of ALND.
• Side effects – You may have arm or shoulder stiffness, weakness and pain; numbness in the arm, shoulder, armpit and parts of the chest; fluid collecting near the surgical scar (seroma); lymphoedema; and cording. Side effects are usually worse after ALND than after an SLNB because more lymph nodes are removed in an ALND.

To work out which lymph nodes are sentinel nodes, one or a combination of these procedures is used:

1. Lymphatic mapping  – A small amount of a harmless radioactive solution is injected into the skin over the breast cancer tumour. A CT scan is then taken to show which lymph nodes the radioactive solution flows to first. These are most likely to be the sentinel nodes. Lymphatic mapping is done either the day before or on the day of the surgery.
2. Dye injection (not always used) – If dye is being used, it will be injected into the breast. The dye, which may be blue or green, moves into the lymphatic vessels and stains the sentinel nodes first. This is done under general anaesthetic during the surgery. Because of the dye, you may notice blue-green urine (wee) and bowel movements (poo) when you go to the toilet the next day. You may also have a blue patch on the breast for weeks or longer. Your skin may look a bit grey but will fade once the dye washes out in your urine.   
3. Handheld probe – As well as looking at where the dye travels to first (if used), the surgeon uses a small handheld device called a probe during the surgery to detect the radioactive solution injected during the lymphatic mapping. This helps to check that the sentinel nodes have been located and the surgeon can then remove them for testing.

Scars or changes to how your breast looks can affect how you feel about yourself (self-image and self-esteem). If you have had a mastectomy (or part of your breast removed), it’s common to feel a sense of loss. It may also affect your sense of identity.

Talking to someone who has had breast cancer surgery can be helpful. Cancer Council’s Cancer Connect program may be able to link you to others who have had a similar experience.

Speaking with a counsellor or psychologist for emotional support and coping strategies can also help. Call Cancer Council 13 11 20 for details.

What your breast will look like after surgery varies from person to person. It will depend on the type of surgery you have and how much tissue is removed.

The pictures below give some examples of how your breast might look but ask your surgeon for more photographs to help you choose the best approach for you.

Treatment is carefully planned to cause the most harm to the cancer cells and to limit damage to the surrounding healthy tissues. Planning involves several steps, which may occur over a few visits. You will have a planning session at the radiation therapy centre.

During this appointment, you will have a planning CT scan of the area to be treated. Sometimes marks are put on your skin so the radiation therapists can ensure you are lined up correctly each time you are treated.

These marks are usually small dots (tattoos), and they may be temporary or permanent. Talk to your radiation therapists if you are worried about these tattoos. Invisible tattoos are available in some centres.

If you have had breast-conserving surgery, the surgeon can sometimes place tiny markers (called fiducial markers) in your breast tissue to show where the cancer used to be.

This helps the radiation oncology team to deliver the radiation therapy more precisely. You may be asked to try a deep inspiration breath hold (DIBH) technique. This involves taking and holding a deep breath for 20–30 seconds during treatment.

DIBH helps to inflate the lungs and move the heart away from the radiation field, reducing the risk of heart damage.

You will probably have radiation therapy daily from Monday to Friday for 1–6 weeks. Most people have radiation therapy as an outpatient and go to the treatment centre each day. Each radiation therapy session will be in a treatment room.

Setting up the machine can take 10–30 minutes, but the actual treatment takes only 1–5 minutes. You will lie on a table under the machine and your breast will be exposed.

The radiation therapist will leave the room and then switch on the machine, but you can talk to them through an intercom. Radiation therapy is not painful, but you will need to lie still while it is given.

Most people will be lying on their back with their arms up. If DIBH is recommended for you, the radiation beam will only be turned on when you are in the DIBH position.

If you are having radiation therapy at a private centre, Medicare will cover some of the cost, but your private health insurance may not, so you may have to pay some of the cost yourself (out-of-pocket costs).

If you are worried about the cost, speak to your treatment team about having treatment in a public hospital.

Radiation therapy may cause the following side effects:

• Skin problems – You may have some redness around the treated area. The skin may become dry and itchy, blister, or become moist and weepy. It usually returns to normal 4–6 weeks after radiation therapy ends. Sometimes skin can become very irritated or peel (radiation dermatitis). You may need dressings, or special creams or gels, to help the area heal.
• Tiredness – You may start to feel tired 1–2 weeks after radiation therapy begins. Fatigue usually gets better a few weeks after treatment finishes.
• Aches – You may feel minor aches or shooting pain in the breast area during or after radiation therapy. It should ease over time.
• Swelling – Some people have swelling or fluid build-up in the breast (breast oedema or lymphoedema) that can last for up to a year or longer. Radiation therapy to the armpit increases the risk of swelling in the arm (lymphoedema).
• Hair loss – Radiation therapy to the breast won’t make you lose the hair on your head, but you will usually lose hair from the treated armpit.
• Other side effects – Late effects can develop months or years after radiation therapy. Part of the lung behind the treatment area may become inflamed, causing a dry cough or shortness of breath. There is a slight risk of heart problems, but this usually happens only if you have treatment to your left breast or if you smoke. Hardening of tissues (fibrosis) may happen months or years after treatment. In rare cases, radiation therapy may cause a second cancer.

Different types of chemotherapy drugs are used. The choice of drugs will depend on the type of cancer, how far it has spread and what other treatments you are having. Usually, you will have a combination of drugs.

Common drugs include carboplatin, cyclophosphamide, docetaxel, doxorubicin, epirubicin and paclitaxel. Your treatment team may also refer to the drugs by their brand names, or letters like AC or TC.

Your medical oncologist will talk to you about the most suitable types of chemotherapy drugs, as well as their risks and side effects.

Generally, 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. Chemotherapy is usually given once every 1–3 weeks for 3–6 months.

Chemotherapy damages cells as they divide. This makes the drugs effective against cancer cells, which divide rapidly. However, some normal cells – such as hair follicles, blood cells and cells inside the mouth or bowel – also divide rapidly.

Side effects happen when chemotherapy damages these normal cells. Unlike cancer cells, normal cells can recover, so most side effects are temporary. 

• Nausea – You may feel sick for a few hours or days after each treatment. Not everyone feels sick, and you’ll be given medicine to help prevent it. Some medicines may cause constipation; talk to your doctor about this.
• Diarrhoea – You may have loose, watery stools and feel like you urgently need to go to the toilet. You may be given medicine to manage diarrhoea.
• Hair loss – You may lose the hair from your head and other areas of the body (e.g. eyebrows, underarms and pubic area). Cold caps may prevent hair loss on your head in some cases.
• Swelling (oedema) – Some medicines used with chemotherapy drugs can cause excess fluid (fluid retention) to build up in the body. This can affect the arms and the trunk, but it usually gets better when treatment ends.
• Changes to fertility – Chemotherapy can cause infertility in females and males. If you may want to have children in the future, it’s essential that you talk to your cancer specialists about your options and ask for a referral to a fertility specialist before treatment starts.
• Heart problems – The risk is small but chemotherapy can sometimes damage the heart muscle (cardiomyopathy). Your heart health will be checked before, during and after treatment. If you are at risk of heart damage, you may be offered other types of drugs.
• Peripheral neuropathy – You might develop tingling in your hands or feet. This is called peripheral neuropathy.
• Other side effects – These include an increased infection risk, fatigue, mouth ulcers, constipation, and memory changes.

For early or locally advanced HER2+ breast cancer, the most common targeted therapy drug used is trastuzumab. Your treatment team may refer to trastuzumab by a brand name (e.g. Herzuma, Kanjinti or Ogivri).

It is also known as Herceptin, although this version is now rarely used in Australia.

Trastuzumab works by attaching itself to HER2+ breast cancer cells, destroying the cells or reducing their ability to divide and grow. It also encourages the body’s own immune cells to help find and destroy cancer cells.

Usually used in combination with chemotherapy drugs for early breast cancer, trastuzumab can increase the effect of the chemotherapy. Trastuzumab can be given through a drip into a vein (infusion) or as an injection under the skin.

The first infusion takes about 90 minutes (called the loading dose). The following infusions each take 30–60 minutes.

You will usually have a dose every 3 weeks, for up to 12 months. The first 4–6 doses are given while you are having chemotherapy treatment.

Side effects

Side effects are usually caused by the chemotherapy drugs, and often ease once chemotherapy finishes and you are having trastuzumab only.

Side effects from trastuzumab are uncommon, but can include headache, fever and diarrhoea. In some cases, trastuzumab can affect how the heart works, so you will have tests to check your heart function before and during treatment.

Other drugs

Several new drugs have been developed to treat HER2+ breast cancer with or after trastuzumab. These include: pertuzumab, which is given before surgery (neoadjuvant); and trastuzumab emtansine (T-DM1), which is given after surgery (adjuvant).

Your doctor will let you know if these drugs are appropriate for you.

Abemaciclib is a type of cyclin-dependent kinase (CDK) inhibitor. It is used with hormone therapy.

Abemaciclib may be used after surgery and chemotherapy for larger, high-risk ER+, HER2– breast cancers, for cancers involving several lymph nodes, or cancers at high risk of returning.

Another drug (ribociclib) may soon become more widely available.

Side effects

Nausea or diarrhoea may occur, but this can be managed. Your blood count may be affected, so regular blood tests are needed.

There are several new drugs for people who have inherited a BRCA mutation, or whose cancer has developed BRCA mutations. These are called poly (ADP-ribose) polymerase (PARP) inhibitors and include the drug olaparib.

Ask your doctor if this may be suitable for you.