Treatment for early or locally advanced breast cancer varies from person to person. The treatment that is best for you will depend on:
- your test results
- where the cancer is in the breast
- the stage and grade of the cancer
- whether the cancer is hormone receptor and/or HER2 positive or triple negative
- your age and general health
- what treatment you want to have.
You will usually have more than one treatment and they could be given in different orders or combinations.
Early breast cancer treatment
The main options are either breast-conserving surgery with radiation therapy or a mastectomy (surgery to remove the whole breast).
Often surgery for breast cancer is followed by a combination of chemotherapy, radiation therapy, hormone therapy or targeted therapy, depending on the features of the cancer. The treatment that is given after you have surgery is called adjuvant therapy, and it reduces the risk of the cancer coming back.
Chemotherapy or targeted therapy given before surgery is neoadjuvant therapy. Usually suggested for HER2+, triple negative and inflammatory breast cancers, it is also sometimes advised for hormone positive cancer.
Locally advanced breast cancer treatment
Often treated with chemotherapy before surgery to shrink the cancer. If the cancer is HER+, you’ll also usually have targeted therapy before surgery. It is common to be offered a mastectomy.
If the chemotherapy has shrunk the cancer, you may be offered breast-conserving surgery instead. Surgery is usually followed by radiation therapy, hormone therapy and/or targeted therapy, depending on the cancer type.
Treatment for early or locally advanced breast cancer usually includes surgery. Which surgery you have depends on the type and stage of the cancer, where it is in the breast, the size of your breast, and what you prefer. In most cases, you will have one or more lymph nodes removed from the armpit (axillary surgery). Some people also choose to have a new breast shape made during the operation (breast reconstruction).
The two types of surgery are breast-conserving surgery and mastectomy. Breast-conserving surgery is usually not suitable for males because there is not enough breast tissue in the male breast. Research has shown that for most early breast cancer, having breast-conserving surgery followed by radiation therapy works just as well as a mastectomy.
The chance of cancer coming back in another part of the body is the same for both types of surgery. Common side effects include fatigue, shoulder stiffness, numbness and tingling, lymphoedema, seroma (balloon-like swelling) and cording (hardened lymph vessels).
When only part of the breast is removed, it is called breast-conserving surgery, 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 may change the size and shape of the breast and the position of the nipple.
A pathologist looks at the tissue to check for an area of healthy cells around the cancer – known as a clear margin. The pathologist will also give information about:
- the size and grade of the cancer
- whether there are cancer cells near the edge (margin) of the removed breast tissue
- whether the cells are hormone receptor positive and/or HER2+ or triple negative, unless this has already been reported on the core biopsy results
- whether the cancer has spread to any lymph nodes.
The pathology report will guide your doctors on what other treatment may be best for you. If there are cancer cells found close to the edge of the removed tissue (called an involved or positive margin), there is a higher risk of the cancer returning. You may need to have further surgery for more tissue to be removed (called a re-excision or wider excision), and a mastectomy may be suggested.
After breast-conserving surgery, you’ll usually have radiation therapy to destroy any remaining cancer cells in the breast or armpit.
Surgery to remove the whole breast is called a mastectomy or single mastectomy. It may be recommended if:
- you have the BRCA1 or BRCA2 gene mutation
- there is cancer in more than one area of the breast
- the cancer is large compared to the size of the breast
- you have had radiation therapy to the same breast before and so cannot have it again
- it’s difficult to get a clear margin around the tumour
- you have inflammatory breast cancer
- cancer has come back or you have a new cancer in the same breast.
The nipple is usually removed in a mastectomy. In some cases, 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 usually 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 provides a free bra and temporary soft form. To order a kit, speak to your breast care nurse.
After the wound has healed and the area is comfortable, you can then be fitted for a permanent breast prosthesis.
Removal of both breasts is called a double or bilateral mastectomy. 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 mutation, this does increase the risk of developing another breast cancer, so your surgeon may recommend a double mastectomy to remove both breasts.
Whether to have a double mastectomy is a complex decision and it’s best to talk with your treatment team about the risks and benefits.
Breast reconstruction is surgery to make a new breast shape, which is also called a breast mound. The surgery may be done using a silicone implant, using tissue from another part of your body, or a combination of the two.
It may be possible to have a breast reconstruction at the same time as a mastectomy (immediate reconstruction). You may prefer to wait for several months or years before having a reconstruction (delayed reconstruction). If you’re not having an immediate reconstruction but might consider it in the future, discuss this with your surgeon before surgery, as it will help them to plan the mastectomy.
Sometimes you may have to travel to a different hospital to have a reconstruction. Some people decide not to have a reconstruction and prefer to go flat, while others choose to wear a breast prosthesis.
Removing lymph nodes
The axillary lymph nodes, which are in and around the armpit, are where cancer cells from the breast usually spread to first. 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 particular lymph nodes in the armpit or near the breastbone called the sentinel nodes. A SLNB finds and removes them so they can be tested for cancer cells. If there are no cancer cells in the sentinel nodes, the rest of the lymph nodes are left in place. 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) will be removed to reduce the risk of the cancer coming back in the armpit. The results also guide what other treatment your doctor recommends.
Side effects include arm or shoulder stiffness, weakness, reduced movement and pain; numbness in the arm, shoulder, armpit and parts of the chest; seroma (fluid collecting near the surgical scar); lymphoedema; and cording.
Side effects are usually worse after axillary lymph node dissection because more lymph nodes are removed.
What to expect after surgery
If you have any questions about your recovery and how best to look after yourself when you get home, ask your treating team. If you are referred to a breast care nurse, they can give you information and provide support.
Your hospital stay will depend on the surgery you have and how well you recover:
- breast-conserving surgery – you usually go home that day or stay overnight
- mastectomy – you usually stay in hospital overnight
- reconstruction after mastectomy – you usually stay in hospital for several days.
What your breast looks like after surgery
How your breast will look after surgery depends on the type of surgery you have, the size of your breast and your body shape. It can take up to a few weeks for any bruising and swelling of the surgery area to go away.
- After breast-conserving surgery – the size and position of the scar will depend on how much tissue is removed. The scar will usually be less than 10 cm and near where the cancer was or along the areola.
- After a mastectomy – the scar will be across the skin of the chest. If you have surgery to the lymph nodes, the scar will also be in the armpit. At first the scar will be firm, slightly raised and red, but it will flatten and fade in a few months.
Scars or changes to how your breast looks can affect how you feel about yourself. It’s common to feel a sense of loss if you’ve had a mastectomy and you may find that your sense of femininity or identity has been affected.
Talking to someone who has had breast cancer surgery or a psychologist can be helpful. Call 13 11 20 to speak to our compassionate cancer nurses.
Other tips for recovering from surgery
- Dressings and tubes – a dressing will cover the wound for about a week to keep it clean. You may have drainage tubes to drain fluid from the surgical site into a bag for 1–2 weeks. A wound infection can happen at any time. If you have any redness, pain, heat, fever, swelling or wound discharge let your treatment team know right away.
- Pain relief – pain after an axillary lymph node dissection or a mastectomy is more likely than after breast-conserving surgery. You’ll have pain relief through a drip, injection or tablets. You’ll also be given pain medicine when you go home.
- Preventing blood clots – do some deep breathing exercises and move your legs around to help prevent blood clots. As soon as you're able, walk around. You may wear elastic (compression) stockings or be prescribed medicine to help.
- Avoid cuts – your treatment team may advise you to wait for a time if you want to shave or wax your armpits.
- Shower carefully – keep the wound clean, and gently pat it dry after showering. Avoid baths.
- Moisturise – gently massage the area with moisturiser once any stitches or adhesive strips are removed and the wound has completely healed.
- Don’t use deodorant – if the wound is under your arm, avoid using deodorant until it has completely healed.
Radiation therapy uses a controlled dose of radiation to kill or damage cancer cells so they cannot grow, multiply or spread. It is usually recommended:
- after breast-conserving surgery
- after a mastectomy – if pathology results suggest the risk of recurrence is high or if the cancer has spread to the lymph nodes, you may have radiation to the chest wall and lymph nodes above the collarbone
- if the sentinel node has cancer cells – you may have radiation to the armpit instead of axillary dissection.
You will usually start radiation therapy within eight weeks of surgery. If you’re having chemotherapy after surgery, radiation therapy will begin about 3–4 weeks after chemotherapy has finished. In some cases, radiation therapy may be offered after neoadjuvant chemotherapy and before surgery. You will probably have radiation therapy as an outpatient daily from Monday to Friday for 3–6 weeks.
Chemotherapy uses drugs to kill cancer cells or slow their growth. It is often used for breast cancers that aren't sensitive to hormone therapy, are HER2+ or triple negative, or for inflammatory breast cancers. It is sometimes used for hormone sensitive breast cancers.
Different types of chemotherapy drugs are used to treat early and locally advanced breast cancer. 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. Your medical oncologist will talk to you about the most suitable type, as well as their risks and side effects.
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. Most people will have chemotherapy for 3–6 months. Drugs are usually given once every three weeks, although some are given on a faster schedule.
Hormone therapy, also called endocrine therapy or hormone-blocking therapy, slows or stops the effect of oestrogen. It is used to treat breast cancer that is hormone receptor positive.
Hormone therapy is often used to lower the risk of the cancer coming back and to reduce the risk of certain conditions, including LCIS and some DCIS, developing into invasive breast cancer.
There are different types of hormone therapy – the one you have depends on your age, type of breast cancer and if you have reached menopause.
Tamoxifen is suitable for anyone, whether you have been through menopause or not. You need to take a daily tablet for 5–10 years.
In females, tamoxifen can cause menopausal symptoms, although it doesn’t bring on menopause. In males, the side effects can include low sex drive (libido) and erection problems.
Tamoxifen increases the risk of blood clots – see a doctor immediately if you have swelling, soreness or warmth in an arm or leg. There is a very small risk of developing cancer of the uterus, particularly if you have gone through menopause. Let your treatment team know if you have any unusual vaginal bleeding.
You are unlikely to have all of these side effects, and they usually improve as treatment continues and after it ends. Your doctor and breast care nurse can help you to manage any side effects.
Tell your doctor if you take an antidepressant. Some (but not all) may affect how well tamoxifen works, and you may need to look at which medicine is best for your situation.
After menopause, the ovaries stop making oestrogen. However, both females and males make small amounts of oestrogen in body fat and the adrenal glands. Taking aromatase inhibitors will help reduce how much oestrogen is made in the body. This is important because oestrogen can cause some cancers to grow.
Aromatase inhibitors are mostly used if you have been through menopause, have had your ovaries removed or are male. They are sometimes used if you haven’t been through menopause but have a high risk of the cancer returning. In this case, you may also be given an injection of goserelin, at least a week before chemotherapy starts, to stop your ovaries producing oestrogen.
Examples of aromatase inhibitors include anastrozole, exemestane and letrozole. They are taken daily as a tablet, usually for 5–10 years.
Aromatase inhibitors can cause thinning and weakening of the bones (osteoporosis), joint and muscle pain, vaginal dryness, low mood, hot flushes and weight gain. If you have arthritis, aromatase inhibitors may worsen joint stiffness and pain. Exercise or medicines from your doctor may help.
If you have not been through menopause, drugs or surgery can stop the ovaries from producing oestrogen. This is known as ovarian suppression. It may also be recommended as an additional treatment for people taking tamoxifen or for premenopausal women taking an aromatase inhibitor instead of tamoxifen.
Temporary ovarian suppression – the drug goserelin stops oestrogen production. It is given as an injection into the belly once a month for 2–5 years to bring on temporary menopause. Side effects are similar to those of permanent menopause. The drug may also help protect the ovaries during chemotherapy, so it is often given to people who want to preserve their fertility.
Permanent ovarian treatment – ovarian ablation permanently stops the ovaries from producing oestrogen. It usually involves surgery to remove the ovaries (oophorectomy). Sometimes radiation therapy is used. Ovarian ablation will bring on permanent menopause. This means you will no longer be able to fall pregnant naturally.
Targeted therapy drugs attack specific features of cancer cells to stop the cancer growing and spreading. The drugs that are currently available do not work for all types of breast cancer. They are mostly useful for HER2+ breast cancers.
The drug abemaciclib is used for both HER2+ and HER2– breast cancers. For early or locally advanced breast cancer, the most common targeted therapy drug used is trastuzumab.
Several new drugs have been developed as additional treatments after trastuzumab for people with HER2+ breast cancer, including pertuzumab and trastuzumab emtansine (T-DM1). Your doctor will advise if these are appropriate for you.
Your treatment team may refer to trastuzumab by a brand name, such as Herzuma, Kanjinti or Ogivri. It works by attaching itself to HER2+ breast cancer cells, destroying the cells or reducing their ability to divide and grow. Trastuzumab also encourages the body’s own immune cells to help find and destroy the cancer cells.
Trastuzumab is used in combination with chemotherapy. It has been shown to increase the effect of chemotherapy drugs on early breast cancer. Most people have trastuzumab via a drip into a vein (infusion), but some people have it as an injection under the skin.
The first infusion (called the loading dose) takes about 90 minutes. The following infusions take 30–60 minutes each. You will usually have a dose every three weeks, for up to 12 months. The first four doses are given while you are having chemotherapy treatment.
Although side effects from trastuzumab itself are uncommon, they can include headache, fever and diarrhoea, and sometimes, how the heart works. Side effects are usually caused by the chemotherapy, which means that once chemotherapy finishes and you are continuing with trastuzumab only, most side effects ease.
There are a number of new drugs for people who have inherited a BRCA mutation, or whose cancer has developed BRCA mutations. These are called PARP inhibitors. Ask your doctor whether these drugs may be appropriate for you.
Expert content reviewers:
A/Prof Elisabeth Elder, Specialist Breast Surgeon, Westmead Breast Cancer Institute and The University of Sydney, NSW; Collette Butler, Clinical Nurse Consultant and McGrath Breast Care Nurse, Cancer Support Centre, Launceston, TAS; Tania Cercone, Consumer; Kate Cox, 13 11 20 Consultant, Cancer Council SA; Dr Marcus Dreosti, Radiation Oncologist and Medical Director, GenesisCare, SA; Dr Susan Fraser, Breast Physician, Cairns Hospital and Marlin Coast Surgery Cairns, QLD; Dr Hilda High, Genetic Oncologist, Sydney Cancer Genetics, NSW; Prof David W Kissane AC, Chair of Palliative Medicine Research, The University of Notre Dame Australia, and St Vincent’s Hospital Sydney, NSW; Prof Sherene Loi, Medical Oncologist, Peter MacCallum Cancer Centre, VIC; Dr W Kevin Patterson, Medical Oncologist, Adelaide Oncology and Haematology, SA; Angela Thomas, Consumer; Iwa Yeung, Physiotherapist, Princess Alexandra Hospital, QLD.
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The information on this webpage has been adapted from Understanding Breast Cancer - A guide for people with cancer, their families and friends (2022 edition). This webpage was last updated in July 2022.