How is breast cancer treated?

Breast cancer is treated by several different methods: surgery, radiation treatment, chemotherapy and hormone treatment. The treatment choice, using just one treatment or a combination, depends on the actual breast cancer: its type, size, and whether or not it has spread; and the individual woman: her age, general health and personal choice.

Understand the options

Before any treatment begins, make sure you have discussed the choices with your doctor. Your doctor may advise that one method of treatment is better than another. Make sure you understand the reasons for this advice. Ask for a second opinion if you want one.

You may find it useful to have your husband or partner or another friend with you when you talk to the doctor. You may also find it helpful to make a list of questions before your visit. See also Questions to ask your doctor when you have cancer

The treatment team

From the time you are first diagnosed with breast cancer you will be cared for by one or more of a team of health professionals including: 

• your family doctor, who will often be the first person you see
• a breast surgeon who specialises in breast diseases, and sometimes a plastic (reconstructive) surgeon
• a pathologist, a doctor who diagnoses disease by studying cells and tissues under a microscope
• a radiation oncologist, a doctor who specialises in the use of radiation in the treatment of cancer
• a medical oncologist, a doctor who specialises in the use of drug treatments for cancer
• a radiation therapist, who prepares you and gives you your radiation treatment
• oncology nurses and breast care nurses, who will help you through all stages of your cancer experience
• dietitians, who will recommend the most suitable foods to eat
• social workers, physiotherapists, and occupational therapists, who will advise you on the support services available, and help you get back to normal activities.

Ideally, your hospital should have all available means of diagnosis and treatment, although this will not be the case in some areas.

Surgery for breast cancer

The first treatment for breast cancer is usually surgery. This includes surgery on the breast and, for most women, on the glands in the armpit (the axillary lymph nodes). Examination of these lymph glands by the pathologist will indicate whether further treatment should be considered after the surgery.

The aim of surgery is to remove all of the cancer. The type of surgery depends on a number of factors, including the size of the cancer, the size of the breast, the position of the cancer in the breast, and the patient’s choice. Surgery may involve removing the cancer and a rim of breast tissue around it (wide local excision) or removing the whole breast (mastectomy). At the same time some of the lymph glands in the armpit are also removed.

Mastectomy

Mastectomy is the removal of the whole breast including some of the skin and the nipple. The chest muscles are not removed. Some lymph glands in the armpit are also removed during the operation. Usually the lymph nodes are removed through the same incision during this operation (called axillary node clearance - or dissection).

Mastectomy is less disfiguring than the radical mastectomy of the past. The new type of mastectomy performed today allows for easier breast reconstruction. After mastectomy, most women will have a horizontal scar across their chest.

Breast reconstruction can be performed at the same time as mastectomy (immediate reconstruction) or after all the treatments for cancer are completed, as a separate operation (delayed reconstruction).

Breast-conserving treatment

For many women it is now possible to have smaller operations, such as partial mastectomy (or wide local excision). A breast-conserving operation involves removing the breast lump with some surrounding normal breast tissue to ensure a good clearance.

Surgery is then followed by radiation treatment to the remaining part of the breast - this is usually 6 to 8 weeks after surgery. This makes sure any cancer cells that are still present in the breast are treated, and significantly reduces the risk of cancer recurring in the remaining breast tissue. Lymph glands are also removed for examination in these smaller operations, and this is often through a separate incision (cut) in the armpit. 

Breast-conserving operations have been routinely performed now for many years. Studies show that both mastectomy and breast-conserving operations with radiation treatment are equally effective in the treatment of early breast cancer. However, breast-conserving surgery is not suitable for every woman with breast cancer.

Sentinel node biopsy

Many New Zealand patients were involved in a study that the Australian and New Zealand College of Surgeons undertook to find out the accuracy of sentinel node sampling in detecting the spread of breast cancer, and the procedure’s safety. During this study, many New Zealand breast surgeons became skilled in the technique.

A sentinel node biopsy locates the first lymph node(s) that drains from the area where the breast cancer developed. This node(s) is detected after injecting a blue dye and a radioactive tracer into the breast tissue where the cancer was found. The node(s) is then removed surgically so the tissue can be examined.

It is thought that removing this node(s) alone may avoid larger operations in the armpit and reduce the chance of arm swelling (lymphoedema) and other potential side effects, such as shoulder stiffness and nerve pain/numbness in the upper arm.

If the sentinel node is involved, under the same anaesthetic, the surgeon will proceed to remove the nodes below the pectoral minor muscle, usually 10-20 nodes. The higher lymph nodes in the armpit are not removed. Extending the operation, to what was standard treatment before sentinel node biopsy, has a risk of lymphoedema of less than 5%.

Drainage after breast surgery

After your operation you will have one or two tubes (drains) coming from the area of your operation into small bags. These drain fluid, which if not drained can cause discomfort, delay wound healing, and may cause an infection. They are usually left in place for a few days. Some women are discharged with their drains in place.

If this happens, your nurse will show you how to care for them at home and your doctor will make an appointment for you to have them removed at a later date. Removing the drains is quick and causes only mild discomfort. It can be done at the doctor’s rooms or at the outpatients’ clinic.

Advantages and disadvantages of surgical methods

While many women may want a breast-conserving operation, the choice between a mastectomy and a breast-conserving operation depends on the size of the breast cancer and the size of the breast.

It is also helpful to weigh up the advantages and disadvantages of each method for yourself.

Radiation treatment with smaller operation
The main advantage of the smaller operation is that the breast is saved. However, a disadvantage is that further treatment with radiation treatment is almost always needed. This can take up to 6 weeks.

In the future, some patients with small tumours may be candidates for partial breast irradiation given on only one to five days. This treatment is still under investigation but may become a more common practice in the future. Following radiation treatment, the breast may feel different.

Small-breasted women may also find that the smaller operation still leaves them with a big change in their breast shape and a potentially poor cosmetic result.

Radiation may not be needed with mastectomy
An advantage of mastectomy is that radiation treatment may not be needed. However, in some cases if the tumour is large, close to the underlying muscle or if there are many involved lymph nodes, radiation treatment is still recommended to reduce the risk of cancer recurring.

The main disadvantage of mastectomy is the loss of the breast, though reconstruction is possible. In some small-breasted women, mastectomy and reconstruction will give a better cosmetic result than breast-conserving surgery.

Side effects of breast surgery

Side effects of surgery for breast cancer may include:

• wound infection - the wound may feel tender, swollen, warm to touch. There may be redness in the area and/or discharge from the wound. You may feel unwell with fever and need antibiotics.
• bruising and haematoma (a collection of blood within the tissues surrounding the wound causing swelling, discomfort and hardness). The body will reabsorb the blood within a few weeks.
• pain - if you have lymph glands removed you are more likely to have pain in the armpit or down the arm. You will be advised about exercises to reduce pain and improve arm movement after surgery.
• cording - a pain like a tight cord running from your armpit, down your upper arm and through to the back of your hand. Cording is thought to be due to hardening of the lymph vessels. Cording may restrict movement and may continue for many months (physiotherapy and exercise may help)
  
• reduced sensitivity of the inner side of your upper arm due to nerve damage, may sometimes occur. This is usually temporary and improves or disappears about 3 months after surgery.
  
• some women have a swelling caused by fluid build up (seroma) that may need to be drained for days, and in some cases several weeks.
• swelling of the arm (lymphoedema) may occur in some women after lymph glands have been removed from the armpit. On rare occasions this swelling can extend into the chest wall.
• reduced range of movement in the shoulder. You will be given an exercise programme to improve this after surgery. Sometimes a physiotherapist will help you with this.

Discuss possible side effects with your doctor before your operation. Report any problems that occur after surgery to your breast care nurse or doctor.

After your cancer has been removed, your surgeon will discuss your tumour with other specialists to decide what further treatment, if any, will be recommended.

Radiation treatment

Radiation treatment is the use of radiation (rays of energy called 'photons' or little particles called 'electrons') to destroy cancer cells, usually using a machine called a 'linear accelerator'. You will see a radiation oncologist who will discuss this treatment with you.

Treatment is carefully planned to reduce any effect on normal cells. Treatment is given 4 to 5 days a week, over about 4 to 5 weeks. It is painless and only takes a few minutes for each treatment. An extra radiation ‘boost dose’ may be given to the area where the breast cancer was located, taking the overall treatment time up to 5 to 6 weeks. Partial breast irradiation is currently being investigated as an alternative to whole breast irradiation in certain patients.

Sometimes radiation is given after mastectomy and axillary surgery to reduce the likelihood of developing recurrence in/over the chest wall or in the axillary or supraclavicular (above the collar bone) lymph nodes. This decision is usually made once the results of the surgery are available and the risks for recurrence in these sites have been assessed.

Radiation may also be used for the treatment of recurrence or cancers that cannot be removed, either in the area of the breast or in other parts of the breast. The aim is to try to control the disease or reduce symptoms. This usually requires fewer visits. 

If you live a long way from the nearest oncology (cancer) centre, you will need to stay nearby during your radiation treatment. Oncology centres have special accommodation close by.

See also radiation treatment

Side effects of radiation treatment

Side effects of radiation treatment may include:

• general tiredness
• some reddening or 'sunburning' of the skin - follow the advice of your radiation therapists regarding skin care and underarm hygiene
• your breast may feel firmer.

Late side effects, which develop many months or years later, may include skin changes, changes in size, shape, colour, or feel of the breast. Radiation to the lymph nodes can increase the risk of developing lymphoedema.

If you are having radiation treatment you should get both extra rest and regular exercise to help cope with tiredness. Try to wear loose cotton clothing whenever possible to reduce any irritation to the area having the radiation. Talk with your doctor or the radiation therapy staff about any possible side effects and how to manage them.

See also radiation treatment side effects

Chemotherapy

Chemotherapy is the treatment of cancer by drugs. The aim is to destroy cancer cells while having the least possible effect on normal cells. The drugs are usually given intravenously via a drip and, therefore, circulate around the body.

Chemotherapy is a systemic treatment (treating the whole body) compared with surgery and radiation treatment, which are local treatments to a specific area in the body (breast, chest wall, axilla, etc). There are different regimens or combinations of drugs used in breast cancer.

Treatment is often in cycles at three-weekly intervals, and may last for 6 cycles (nearly 6 months). A medical oncologist will discuss all aspects of the treatment with you. 

Chemotherapy is offered to some women with early breast cancer as an additional treatment to surgery, radiation treatment or both. This is called adjuvant chemotherapy.

Adjuvant chemotherapy aims to destroy cancer cells that remain in the body but which cannot be detected. The purpose of this treatment is to reduce the chance of the breast cancer coming back (known as a recurrence).

Radiation treatment, if it is necessary, comes after chemotherapy, starting about 4 weeks after the last cycle of chemotherapy. Hormone therapy, if recommended, comes after the radiation treatment.  

The women who are most likely to benefit from chemotherapy are those in whom the lymph glands in the armpit do have cancer cells. There is also a benefit from chemotherapy in women who do not have spread into armpit glands, but have more aggressive cancers (Grade 3 and oestrogen receptor negative). Women who are HER2 positive will benefit greatly from chemotherapy. 

Women with large tumours or a type of cancer called inflammatory breast cancer may be offered chemotherapy pre-surgery. This is called neo-adjuvant chemotherapy.
See also chemotherapy

Side effects of chemotherapy

Chemotherapy side effects vary according to the particular drugs used. When adjuvant chemotherapy is given to women with breast cancer, side effects may include:

• infections – the drugs can lower your ability to fight infections (see below re fever)
• sore mouth
• nausea and vomiting
• loss of appetite or taste changes 
• feeling off-colour and tired
• thinning or loss of hair
  
• if you are still having periods, you may find that your periods become irregular or stop while you are having treatment. If you are approaching the menopause, your periods may not return once the treatment has stopped
• your ability to become pregnant may be affected by chemotherapy; however, this is not always certain. If you are sexually active with a male partner, you and your partner should use a reliable contraceptive, such as a diaphragm or condom during treatment because the drugs can cause birth defects or miscarriage
• infertility – some women may be permanently infertile after chemotherapy
• hot flushes, vaginal dryness, mood swings or other symptoms of menopause
• individual chemotherapy drugs may have particular side effects, and these will be discussed with you.

If you are feverish (your temperature is 38 degrees C or more), or if you feel unwell in any way – do not wait to see what happens – take action quickly. Contact your cancer doctor or nurse, and follow the advice given.

Discuss any side effects with your doctor. Side effects are usually temporary and there are ways of reducing the impact of any unpleasant symptoms. If you have temporary hair loss you are entitled to a benefit to buy a wig.

See also chemotherapy side effects

Monoclonal antibodies

Monoclonal antibodies are drugs that recognise and bind to specific proteins (receptors) that are found in particular cancer cells or in the bloodstream.

Trastuzumab (Herceptin) is given intravenously once every week or 3 weeks, and is usually well tolerated. It may cause some impairment of heart pumping function, especially when used with a chemotherapy drug which affects the heart. A heart echo test will be done every 12 weeks to check this.

Hormone treatments

Many breast cancers appear to be influenced by the female hormones, oestrogen and progesterone.

Pre-menopausal women may be offered tamoxifen, a hormone treatment taken as a tablet. They may also have menopause induced to stop their own production of hormones. This can be done by four-weekly injections with goserelin (Zoladex) or by surgical removal (laparoscopic oophorectomy) of the ovaries. Once you stop taking goserelin your periods will usually return.

Post-menopausal women may be offered oral hormone treatments – either tamoxifen or aromatase inhibitors anastrozole (Arimidex) or letrozole (Femara), which reduce the production of hormones in the body (other than from the ovaries). 

General side effects of hormone treatments

Side effects of hormone treatments may include:

• menopausal symptoms such as hot flushes, vaginal dryness, mood swings
• effects on fertility – if you have not reached menopause it may still be possible to become pregnant while you are taking hormone therapies. If you are sexually active with a male partner, it is recommended you use reliable contraception, such as a diaphragm or condom. Sometimes you may have permanent menopause as a result of your hormone therapy.

Hormone drugs may cause additional side effects. Discuss these with your doctor.

Aromatase inhibitors can cause loss of minerals from bones (osteoporosis). It may be recommended you have a bone density study before starting or some time during treatment. Treatment may be given for several years. Osteoporosis can be treated with oral bisphosphonates (bone hardening drugs).  

Taking part in a clinical trial

Research into the causes of breast cancer and into ways to prevent, detect and treat it, is continuing. Your doctor may suggest you consider taking part in a clinical trial. It is always your decision to take part in a clinical trial. If you do not wish to take part, your doctor will discuss the best current treatment option for you.

After treatment

During your illness you will be monitored frequently. After the completion of your treatment you will have regular check-ups, and your doctor will decide how often these are required. Check-ups will gradually become less frequent if you have no further problems.

Many people worry that any pain or illness is a sign the cancer is coming back. This is usually not the case, but if you are worried, ask your doctor what to expect.

You may find it helpful to join, or continue in, a cancer support group.

Also see After breast cancer

Arm care

Following your surgery, it may take some time to regain the full use of your arm. Your physiotherapist or breast care nurse will give you instructions for exercises.

You may be concerned that your arm will swell after your lymph glands have been removed. This is much less common today because of the better methods of surgery and radiation treatment.

However, a few women will still develop problems with arm swelling (called lymphoedema). To reduce the risk of this happening, you should try to avoid injury or infection to your arm or hand.

Some simple measures will help:

• wear gardening gloves when gardening, use an oven glove when handling hot dishes, and use a thimble for sewing. If you're out in the sun, protect your arm from sunburn by wearing a long-sleeved shirt. Use a good sunscreen (SPF 30+) on uncovered areas
• get help with heavy jobs like moving furniture or carrying heavy luggage, handbags, and avoid using heavy backpacks for any length of time
• it is suggested that it may be beneficial to wear a support sleeve when flying 
• if it can be avoided, do not have your blood pressure or blood taken from that arm. Avoid having an intravenous drip in that arm and ask that any injections, including acupuncture or anaesthetics, be given elsewhere
  
• if you have a cut, clean it well and use an antiseptic dressing. See your doctor quickly if you think it is infected.
• be aware of swelling in the arms at any point in the future. Contact your doctor if this occurs.

Lymphoedema therapists and physiotherapists can also advise about the need to wear a support sleeve if swelling occurs.

Breast forms (prosthesis)

If you have had a mastectomy it is important to know about a breast form (prosthesis). A breast form can give a good cosmetic appearance as well as helping your balance and posture. Many women choose to use a breast form although some women prefer not to.

Breast forms are also available for women who have had lesser surgery (partial mastectomy). Immediately after surgery, temporary prostheses are available from your local Cancer Society or breast care nurse. About six weeks post-operatively, you may choose to wear a permanent prosthesis.

You are entitled to a benefit for a permanent breast form. Ask your surgeon or breast care nurse for a medical certificate of entitlement.

Reconstruction of the breast

After a mastectomy your breast can be reconstructed either immediately or at a later date. A surgeon's decision about which method of reconstruction to recommend is based on many different factors. Reconstruction should be discussed fully with your specialist, and you may be referred to a plastic (or reconstructive) surgeon. 

Many women do not wish to have a reconstruction. Speaking with a breast care nurse or with women who have had breast cancer may be helpful. Information is available from the Cancer Society and their Cancer Information Helpline (contact details under 'Further information and support' at end of article).

Breast care nurses

A breast care nurse may be available in your hospital and can provide specialist support and guidance.

Possibility of cancer recurrence

Sometimes, breast cancer can come back (a recurrence). Most recurrences appear within five years after the initial treatment. Regular check-ups are necessary during this period.

You should also regularly examine your remaining breast and mastectomy area and report any unusual breast symptoms or general symptoms to your doctor. You will need a yearly mammogram.

Treatment of recurrent breast cancer may be by surgery, radiation treatment, chemotherapy or hormone treatment, or combinations of these. It aims to control the disease.

Successful treatment of recurrent breast cancer will allow many women to continue leading normal lives.

Relationships and sexuality

The anxiety and/or depression felt by some women after diagnosis or treatment can affect their sexual desire. Tiredness following an anaesthetic, major surgery, radiation treatment or chemotherapy will also reduce sexual desire. If you have had a mastectomy, looking at yourself in the mirror can be difficult.

Sometimes women feel nervous about showing their mastectomy scar to their partners. It helps if you are able to discuss your feelings openly so that your partner understands your fears and concerns. However, sometimes partners may be unsure of their own reactions to the breast surgery. 

If you and your partner need to make changes, it is important to remember that sexual intercourse is only one of the ways you can express affection for each other. Gestures of affection, gentle touches, cuddling and fondling also reassure you of your need for each other.

Talk to someone you trust if you are experiencing ongoing problems with sexual relationships. Friends, family members, nurses or your doctor may be able to help. Your Cancer Society can also provide information about counsellors who specialise in this area. See also Cancer and sex

Related topics

See Breast cancer and Breast cancer diagnosis

What does that term mean? See Cancer glossary

Original material provided by the Cancer Society, June 2007. Reviewed by everybody, July 2010.