When it comes to breast cancer, treatments vary widely. You may have heard of people who need chemotherapy, those who get radiation, and others who get a combination of both.
That’s because a number of factors can impact which one is best for you, including where the cancer started, if it has invaded surrounding breast tissue or spread to other parts of the body, whether certain hormones are fueling its growth, your overall health, and sometimes even your age.
“Women who are diagnosed with breast cancer that’s confined to the breast or lymph nodes are generally treated with three therapies,” explains oncologist Dr Jennifer Specht.
This includes surgery to remove cancer from the breast and lymph nodes, radiation therapy if only part of the breast is removed, and drugs to block hormones like oestrogen or progesterone. Chemotherapy is sometimes needed to kill any leftover cancer cells.
Treatments like surgery and radiation can be categorised as “local treatments,” meaning they treat the tumour without affecting the rest of the body. On the other hand, hormone therapy and chemotherapy are known as “systemic treatments,” meaning they can reach cancer cells throughout the body. Here’s everything you need to know about each breast cancer treatment option out there.
Local breast cancer treatments
Most women will need surgery as part of their breast cancer treatment, says oncologist Dr Megan Kruse. “It can be anything from just removing the cancer itself to removing the whole breast,” she explains.
Breast-conserving surgery (BCS)
Also called a lumpectomy, quadrantectomy, partial mastectomy, or segmental mastectomy, this type of surgery involves only removing the part of the breast that contains the cancer. How much of the breast is removed depends on the size and location of the tumour, but the goal is to ultimately remove the cancer as well as some surrounding normal tissue.
For this surgery, the entire breast is removed, including all of the breast tissue and sometimes other nearby tissues. There are several different types of mastectomies, including:
- Simple (or total) mastectomy: The entire breast is removed, including the nipple, areola, and skin. Some underarm lymph nodes may or may not be removed depending on the situation. If hospitalised, most women can go home the next day.
- Skin-sparing mastectomy: Most of the skin over the breast is left intact. Only the breast tissue, nipple, and areola are removed, and implants or tissue from other parts of the body are used to reconstruct the breast. Many women prefer this type of mastectomy because it results in less scar tissue, but it may not be suitable for certain tumours.
- Nipple-sparing mastectomy: Most often an option for women who have small, early-stage cancer near the outer part of the breast, this type of mastectomy preserves the nipple. However, the surgeon will often remove the breast tissue beneath the nipple (and areola) to check for cancer cells. If cancer cells are found, the nipple must be removed. Some doctors also give the nipple tissue a dose of radiation during or after the surgery to try to reduce the risk of the cancer coming back.
- Modified radical mastectomy: This means the entire breast is removed along with the lymph nodes under the arm (called an axillary lymph node dissection).
- Double mastectomy: For this surgery, both breasts are removed to reduce the chances of getting breast cancer for women who are at a very high risk, such as those with BRCA gene mutation. Most are simple mastectomies, but some may be nipple-sparing.
Should you get a mastectomy?
You’ll likely be able to choose between BCS and a mastectomy if you have an early-stage cancer. While your gut reaction may be to get a mastectomy to remove the cancer quickly, doing so does not provide a better chance of survival than BCS with radiation. Most doctors prefer BCS (with radiation therapy) when possible. However, they may recommend a mastectomy if you’re unable to have radiation therapy, if the breast has been treated with radiation in the past, or if the tumour is too large compared with your breast, amongst other factors.
Many women receive radiation, a treatment with high-energy rays (such as x-rays) or particles that destroy cancer cells, in addition to other breast cancer treatments. Your doctor will determine if you need radiation based on the type of surgery you had, whether your cancer has spread to the lymph nodes or other areas of the body, and in some cases your age, according to the ACS.
You could have just one type of radiation, or a combination of different types. The two main types of radiation to treat breast cancer are: external beam radiation (which comes from a machine) and internal radiation (where a radioactive source is put inside the body for a short time).
External beam radiation is the most common, and it entails a machine focusing the radiation on the part of the body affected by the cancer. If you had a mastectomy and no lymph nodes were involved, radiation is focused on the chest wall, the mastectomy scar, and the places where any drains exited the body after surgery.
If you had BCS, you will most likely have radiation to the entire breast (called whole breast radiation), and an extra boost of radiation to the area in the breast where the cancer was removed (called the tumour bed) to help prevent it from coming back in that area. If cancer was found in the lymph nodes under your arms, you may be given radiation there, as well.
Whether you need external or internal radiation, it’s usually started after your surgery site has healed, which typically takes a month or longer. If you’re getting chemotherapy as well, you’ll usually do radiation after the chemotherapy is complete.
Systemic breast cancer treatments
Administered through your veins or by mouth, chemotherapy utilises cancer-killing drugs that travel through the bloodstream to reach cancer cells throughout the body. Not all women with breast cancer will need chemo, but it is most commonly used after surgery (to kill any cancer cells that may have been left behind), before surgery (to try to shrink the tumour so it may be more readily removed), or for advanced (metastatic) breast cancer.
It’s not always clear if chemotherapy will be helpful, so your doctor may do a test called a Oncotype DX or Mammoprint to help determine if it makes sense for you.
Chemotherapy is typically given in cycles, with time for you to rest and recover in between. Cycles are usually two or three weeks long for a total of three to six months, although it depends on the drugs being used. The length of treatments depends on how well the drugs are working and how well you’re able to withstand the side effects, which includes the following:
Some drugs can help ease these side effects, such as nausea and vomiting, but they usually go away after treatment is finished. For younger women, chemo can cause premature menopause and infertility. Some chemo drugs are more likely to cause this than others, so be sure to talk to your doctor about your options. Older women may also go into menopause or become infertile as a result of chemo; plus, there is an increased risk of bone loss and osteoporosis.
This treatment is recommended for women with hormone receptor-positive (ER-positive and/or PR-positive) breast cancers and it involves taking drugs that stop oestrogen from stimulating breast cancer cell growth. With ER-positive and PR-positive breast cancers, the cancer cells have receptors that attach to oestrogen, which helps them grow. Hormone therapy helps stop oestrogen from attaching to these receptors.
There are several types of hormone therapy, but most either lower oestrogen levels or stop oestrogen from acting on breast cancer cells. Drugs such as Tamoxifen, Toremifene (Fareston), and Fulvestrant (Faslodex) stop oestrogen from stimulating breast cancer cells to grow. Other drugs, called Aromatase inhibitors (AIs), stop oestrogen production altogether.
Hormone therapy is typically used after surgery to help reduce the risk of the cancer coming back, and it’s usually taken for at least five years. Hormone therapy can also be used to treat cancer that has come back after treatment or that has spread to other parts of the body.
As researchers have learned more about changes in cancer cells that cause them to grow out of control, they're developing new types of drugs that target some of these cell changes, according to the ACS. These targeted drugs are designed to block the growth and spread of cancer cells while sparing normal cells. This is different from chemotherapy drugs, which attack all cells that are growing quickly, including cancer cells.
Targeted drugs sometimes work even when chemo drugs do not, and some can help other types of treatment work better. The targeted therapy you receive depends on the type of breast cancer you have. Drugs have been created specifically to treat HER2-positive breast cancer and hormone-receptor positive breast cancer. There’s also targeted therapy for women with BRCA gene mutations.