Breast Cancer - Treatment choices by stage

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Breast Cancer - Treatment choices by stage

Treatment choices by stage

Your treatment options depend on the stage of your disease and these factors:

The size of the tumor in relation to the size of your breast


The results of lab tests (such as whether the breast cancer cells need hormones to grow)


Whether you have gone through menopause


Your general health
Below are brief descriptions of common treatments for each stage. Other treatments may be appropriate for some women. Clinical trials can be an option at all stages of breast cancer.

Stage 0

Stage 0 breast cancer refers to lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS):

LCIS: Most women with LCIS do not have treatment. Instead, the doctor may suggest regular checkups to watch for signs of breast cancer.

Some women take tamoxifen to reduce the risk of developing breast cancer. Others may take part in studies of promising new preventive treatments.

Having LCIS in one breast increases the risk of cancer for both breasts. A very small number of women with LCIS try to prevent cancer with surgery to remove both breasts. This is a bilateral prophylactic mastectomy. The surgeon usually does not remove the underarm lymph nodes.


DCIS: Most women with DCIS have breast-sparing surgery followed by radiation therapy. Some women choose to have a total mastectomy. Underarm lymph nodes are not usually removed. Women with DCIS may receive tamoxifen to reduce the risk of developing invasive breast cancer.
Stages I, II, IIIA, and operable IIIC

Women with Stage I, II, IIIA, and operable (can treat with surgery) IIIC breast cancer may have a combination of treatments. Some may have breast-sparing surgery followed by radiation therapy to the breast. This choice is common for women with Stage I or II breast cancer. Others decide to have a mastectomy.

With either approach, women (especially those with Stage II or IIIA breast cancer) often have lymph nodes under the arm removed. The doctor may suggest radiation therapy after mastectomy if cancer cells are found in 1 to 3 lymph nodes under the arm, or if the tumor in the breast is large. If cancer cells are found in more than 3 lymph nodes under the arm, the doctor usually will suggest radiation therapy after mastectomy.

The choice between breast-sparing surgery (followed by radiation therapy) and mastectomy depends on many factors:

The size, location, and stage of the tumor


The size of the woman's breast


Certain features of the cancer


How the woman feels about saving her breast


How the woman feels about radiation therapy


The woman's ability to travel to a radiation treatment center
Some women have chemotherapy before surgery. This is neoadjuvant therapy (treatment before the main treatment). Chemotherapy before surgery may shrink a large tumor so that breast-sparing surgery is possible. Women with large Stage II or IIIA breast tumors often choose this treatment.

After surgery, many women receive adjuvant therapy. Adjuvant therapy is treatment given after the main treatment to increase the chances of a cure. Radiation treatment can kill cancer cells in and near the breast. Women also may have systemic treatment such as chemotherapy, hormone therapy, or both. This treatment can destroy cancer cells that remain anywhere in the body. It can prevent the cancer from coming back in the breast or elsewhere.

Stages IIIB and inoperable IIIC

Women with Stage IIIB (including inflammatory breast cancer) or inoperable Stage IIIC breast cancer usually have chemotherapy. (Inoperable cancer means it cannot be treated with surgery.)

If the chemotherapy shrinks the tumor, the doctor then may suggest further treatment:

Mastectomy: The surgeon removes the breast. In most cases, the lymph nodes under the arm are removed. After surgery, a woman may receive radiation therapy to the chest and underarm area.


Breast-sparing surgery: The surgeon removes the cancer but not the breast. In most cases, the lymph nodes under the arm are removed. After surgery, a woman may receive radiation therapy to the breast and underarm area.


Radiation therapy instead of surgery: Some women have radiation therapy but no surgery. The doctor also may recommend more chemotherapy, hormone therapy, or both. This therapy may help prevent the disease from coming back in the breast or elsewhere.
Stage IV

In most cases, women with Stage IV breast cancer have hormone therapy, chemotherapy, or both. Some also may have biological therapy. Radiation may be used to control tumors in certain parts of the body. These treatments are not likely to cure the disease, but they may help a woman live longer.

Many women have supportive care along with anticancer treatments. Anticancer treatments are given to slow the progress of the disease. Supportive care helps manage pain, other symptoms, or side effects (such as nausea). It does not aim to extend a woman's life. Supportive care can help a woman feel better physically and emotionally. Some women with advanced cancer decide to have only supportive care.

Recurrent breast cancer

Recurrent cancer is cancer that has come back after it could not be detected. Treatment for the recurrent disease depends mainly on the location and extent of the cancer. Another main factor is the type of treatment the woman had before.

If breast cancer comes back only in the breast after breast-sparing surgery, the woman may have a mastectomy. Chances are good that the disease will not come back again.

If breast cancer recurs in other parts of the body, treatment may involve chemotherapy, hormone therapy, or biological therapy. Radiation therapy may help control cancer that recurs in the chest muscles or in certain other areas of the body.

Treatment can seldom cure cancer that recurs outside the breast. Supportive care is often an important part of the treatment plan. Many patients have supportive care to ease their symptoms and anticancer treatments to slow the progress of the disease. Some receive only supportive care to improve their quality of life.


What about breast reconstruction?

Some women who plan to have a mastectomy decide to have breast reconstruction. Other women prefer to wear a breast form (prosthesis). Others decide to do nothing. All of these options have pros and cons. What is right for one woman may not be right for another. What is important is that nearly every woman treated for breast cancer has choices.

Breast reconstruction may be done at the same time as the mastectomy, or later on. If you are thinking about breast reconstruction, you should talk to a plastic surgeon before the mastectomy, even if you plan to have your reconstruction later on.

There are many ways to reconstruct the breast. Some women choose to have implants. Implants may be made of saline or silicone. The safety of silicone breast implants has been under review by the Food and Drug Administration (FDA) for several years. If you are thinking about having silicone implants, you may want to talk with your doctor about the FDA findings. Your doctor can tell you if silicone implants are an option. You also can read information from the FDA on breast implants at http://www.fda.gov/cdrh/breastimplants/.

You also may have breast reconstruction with tissue that the plastic surgeon moves from another part of your body. Skin, muscle, and fat can come from your lower abdomen, back, or buttocks. The surgeon uses this tissue to create a breast shape.

Which type of reconstruction is best depends on your age, body type, and the type of surgery you had. The plastic surgeon can explain the risks and benefits of each type of reconstruction.

You may want to ask your doctor these questions about breast reconstruction:

What is the latest information about the safety of silicone breast implants?
Which type of surgery would give me the best results? How will I look afterward?
When can my reconstruction begin?
How many surgeries will I need?
What are the risks at the time of surgery? Later?
Will I have scars? Where? What will they look like?
If tissue from another part of my body is used, will there be any permanent changes where the tissue was removed?
What activities should I avoid? When can I return to my normal activities?
Will I need follow-up care?
How much will reconstruction cost? Will my health insurance pay for it?



What about complementary and alternative medicine?

Some women with breast cancer use complementary and alternative medicine (CAM):

An approach is generally called complementary medicine when it is used along with standard treatment.
An approach is called alternative medicine when it is used instead of standard treatment.

You may want to ask the doctor these questions before you decide to use CAM:

What benefits can I expect from this approach?
What are its risks?
Do the expected benefits outweigh the risks?
What side effects should I watch for?
Will the approach change the way my cancer treatment works? Could this be harmful?
Is this approach under study in a clinical trial? If so, who sponsors the trial?
Will my health insurance pay for this approach?


Acupuncture, massage therapy, herbal products, vitamins or special diets, visualization, meditation, and spiritual healing are types of CAM.

Many women say that CAM helps them feel better. However, some types of CAM may change the way standard treatment works. These changes could be harmful. And some types of CAM could be harmful even if used alone.

Some types of CAM are expensive. Health insurance may not cover the cost.

You also may request materials from the Federal Government's National Center for Complementary and Alternative Medicine. You can reach their clearinghouse toll-free at 1-888-644-6226 (voice) and 1-866-464-3615 (TTY). In addition, you can visit the Center's Web site at http://www.nccam.nih.gov, or send an email to info@nccam.nih.gov.

Nutrition and physical activity

It is important for women with breast cancer to take care of themselves. Taking care of yourself includes eating well and staying as active as you can.

You need the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy.

Sometimes, especially during or soon after treatment, you may not feel like eating. You may be uncomfortable or tired. You may find that foods do not taste as good as they used to. In addition, the side effects of treatment (such as poor appetite, nausea, vomiting, or mouth sores) can make it hard to eat well. Your doctor, dietitian, or other health care provider can suggest ways to deal with these problems.

Many women find they feel better when they stay active. Walking, yoga, swimming, and other activities can keep you strong and increase your energy. Exercise may reduce nausea and pain and make treatment easier to handle. It also can help relieve stress. Whatever physical activity you choose, be sure to talk to your doctor before you start. Also, if your activity causes you pain or other problems, be sure to let your doctor or nurse know about it.


What about follow-up care?

Follow-up care after treatment for breast cancer is important. Recovery is different for each woman. Your recovery depends on your treatment, whether the disease has spread, and other factors.

Even when the cancer seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment. Your doctor will monitor your recovery and check for recurrence of the cancer.

You should report any changes in the treated area or in your other breast to the doctor right away. Tell your doctor about any health problems, such as pain, loss of appetite or weight, changes in menstrual cycles, unusual vaginal bleeding, or blurred vision. Also talk to your doctor about headaches, dizziness, shortness of breath, coughing or hoarseness, backaches, or digestive problems that seem unusual or that don't go away. Such problems may arise months or years after treatment. They may suggest that the cancer has returned, but they can also be symptoms of other health problems. It is important to share your concerns with your doctor so problems can be diagnosed and treated as soon as possible.

Follow-up exams usually include the breasts, chest, neck, and underarm areas. Since you are at risk of getting cancer again, you should have mammograms of your preserved breast and your other breast. You probably will not need a mammogram of a reconstructed breast or if you had a mastectomy without reconstruction. Your doctor may order other imaging procedures or lab tests.


What about support for women with breast cancer?

Learning you have breast cancer can change your life and the lives of those close to you. These changes can be hard to handle. It is normal for you, your family, and your friends to have many different and sometimes confusing feelings.

You may worry about caring for your family, keeping your job, or continuing daily activities. Concerns about treatments and managing side effects, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful if you want to talk about your feelings or concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, or emotional support.

Friends and relatives can be very supportive. Also, you may find it helps to discuss your concerns with others who have cancer. Women with breast cancer often get together in support groups to share what they have learned about coping with their disease and the effects of their treatment. It is important to keep in mind, however, that each woman is different. Ways that one woman deals with cancer may not be right for another. You may want to ask your health care provider about advice you receive from other women with breast cancer.

Several organizations offer special programs for women with breast cancer. Women who have had the disease serve as trained volunteers. They may talk with or visit women with breast cancer, provide information, and lend emotional support. They often share their experiences with breast cancer treatment, breast reconstruction, and recovery.

You may be afraid that changes to your body will affect not only how you look but also how other people feel about you. You may worry that breast cancer and its treatment will affect your sexual relationships. Many couples find it helps to talk about their concerns. Some find that counseling or a couples' support group can be helpful.


What is being done to better understand and prevent breast cancer?

Doctors all over the country are conducting many types of clinical trials (research studies in which people volunteer to take part). They are studying new ways to prevent, detect, diagnose, and treat breast cancer. Some are also studying therapies that may improve the quality of life for women during or after cancer treatment.

Clinical trials are designed to answer important questions and to find out whether new approaches are safe and effective. Research already has led to advances and researchers continue to search for more effective methods for dealing with cancer.

Women who join clinical trials may be among the first to benefit if a new approach is effective. And even if people in a trial do not benefit directly, they still make an important contribution by helping doctors learn more about breast cancer and how to control it. Although clinical trials may pose some risks, researchers do all they can to protect their patients.

If you are interested in being part of a clinical trial, talk with your doctor. Trials are available for all stages of breast cancer.

Research on prevention

Scientists are looking for drugs that may prevent breast cancer. For example, they are testing several different drugs that lower hormone levels or prevent a hormone's effect on breast cells.

In one large study, the drug tamoxifen reduced the number of new cases of breast cancer among women who were at an increased risk of the disease. Doctors are studying whether the drug raloxifene is as effective as tamoxifen. This study is called STAR (Study of Tamoxifen and Raloxifene).

Research on detection, diagnosis, and staging

At this time, mammograms are the most effective tool we have to detect changes in the breast that may be cancer. In women at high risk of breast cancer, researchers are studying the combination of mammograms and ultrasound. Researchers are also exploring positron emission tomography (PET) and other ways to make detailed pictures of breast tissue.

In addition, researchers are studying tumor markers. Tumor markers may be found in blood, in urine, or in fluid from the breast (nipple aspirate). High amounts of these substances may be a sign of cancer. Some markers may be used to check breast cancer patients for signs of disease after treatment. At this time, however, no tumor marker test is reliable enough to be used routinely to detect breast cancer.

Ductal lavage also is under study. This technique collects cells from breast ducts. A liquid flows through a catheter (very thin, flexible tube) into the opening of a milk duct on the nipple. The liquid and breast cells are withdrawn through the tube. A pathologist checks the cells for cancer or changes that may suggest an increased risk of cancer.

Research on treatment

Researchers are studying many types of treatment and their combinations:

Surgery: Different types of surgery are being combined with other treatments.


Radiation therapy: Doctors are studying whether radiation therapy can be used instead of surgery to treat cancer in lymph nodes. They are looking at the effectiveness of radiation therapy to a larger area around the breast. In women with early breast cancer, doctors are studying whether radiation therapy to a smaller part of the breast may be helpful.


Chemotherapy: Researchers are testing new anticancer drugs and doses. They are working with drugs and combinations of drugs. They are looking at new drug combinations before surgery. They are also looking at new ways of combining chemotherapy with hormone therapy or radiation therapy.


Hormone therapy: Researchers are testing several types of hormone therapy, including aromatase inhibitors.

Biological therapy: New biological treatments also are under study. For example, researchers are studying cancer vaccines that help the immune system kill cancer cells.
In addition, researchers are looking at ways to lessen the side effects from treatment, such as lymphedema from surgery. They are looking at ways to reduce pain and improve quality of life. One method under study is sentinel lymph node biopsy. Today, surgeons have to remove many lymph nodes under the arm and check each of them for cancer. Researchers are studying whether checking only the node to which cancer is most likely to spread (sentinel lymph node) will allow them to predict whether cancer has spread to other nodes. If this new procedure works as well as standard treatment, surgeons may be able to remove fewer lymph nodes. This could reduce lymphedema for many patients.

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