Breast Cancer Treatment Overview
Responsible breast cancer specialists advise their new patients to weigh their options carefully before rushing into treatment. If you have breast cancer, you're likely to need a combination of therapies. These will depend on the type and size of the tumor, your age, and the degree to which the cancer has spread. Take your time as you think over each option, and consider taking your partner, a friend, or a relative to your doctor's appointments to help you ask questions and remember the answers.
When is surgery recommended?
The first line of defense against most breast cancer is surgery. If your cancer is small and confined to one portion of the breast, the surgeon may take out only the lump and possibly a little bit of surrounding tissue. This is called a lumpectomy. If the cancer was detected early, chances are good you'll have a lumpectomy, possibly with removal of some underarm lymph nodes followed by radiation to kill any undetected cancer cells remaining in the area. (If a sentinel node biopsy found no cancer in the sentinel nodes, you may not need lymph node surgery.)
There is also a radiation option for women with early-stage breast cancers. Instead of the usual six-week course of radiation following a lumpectomy, the new treatment, called brachytherapy, takes about five days. In this therapy, radioactive "seeds" are temporarily inserted into the area where the tumor was removed. This technique allows the radiation to be more precisely focused than radiation from an external beam. Brachytherapy has been used to treat other cancers, like prostate cancer, but it's a new option for breast cancer patients. Initial studies on its effectiveness have been promising, but long-term results are not yet available to determine how this radiation treatment compares with traditional, external beam radiation.
If the cancer is more widespread, your surgeon may recommend a mastectomy -- removal of the whole breast. Radical mastectomies, which involved the sometimes disfiguring removal of the breast and the muscles of the chest wall, are rare today. A modified radical mastectomy -- removal of the visible breast, all breast tissue, and the lymph nodes in the armpit -- is the most commonly performed mastectomy. You may decide to have your breast reconstructed after this surgery. If you choose reconstruction, this can be done either at the same time as your mastectomy or at a later time. A newer procedure known as skin-sparing mastectomy may be an option for women with smaller tumors. Most of the skin over the breast is left intact in this procedure.
Will I need chemotherapy?
Women who've been through a breast cancer diagnosis and surgery are naturally apprehensive about the possibility of chemotherapy. The side effects of hair loss and nausea spring to mind for most, although new techniques have mitigated some of the side effects. It's important to note that chemotherapy isn't necessary for all women with breast cancer. However, if your doctor thinks there's a chance the cancer has migrated to other parts of your body, he or she is likely to recommend chemotherapy, hormone therapy, or both. Generally, chemotherapy works best in pre-menopausal women, and hormone therapy is more effective for women who are past menopause.
Chemotherapy uses drugs that kill all fast-growing cells -- cancerous ones, but also the cells that produce hair and those that spring to action in the immune system. It may be used prior to surgery as a way to shrink a large tumor or may be prescribed after surgery, if the tumor was invasive, to kill any remaining cancer cells. One of the most widely used drugs in chemotherapy is Cytoxan. Another is Taxol, now produced synthetically but originally derived from the bark of yew trees. Once used only to treat advanced breast and ovarian cancer, Taxol is now approved for treatment of early breast cancer. Other widely used chemotherapy drugs are Adriamycin, Methotrexate, and 5-Fluorouracil.
Is there an option to watch and wait?
Some doctors believe you should start treatment no matter what type of breast cancer you have, but others now think that in the case of DCIS, a non-invasive breast cancer confined to the milk ducts, women should have the option of watchful waiting -- that is, having mammograms alternating with MRIs twice a year to see if there is any change.
A drug named Herceptin, known as a monoclonal antibody, inhibits tumor growth by binding to the breast cancer cell at a site important to the regulation of cell growth. For this treatment to be effective, a woman's cancer cells must have an over-abundance of a protein called HER2/neu on the cell surface, which is the case in about 1 in 5 breast cancer patients. These cancers tend to spread more aggressively, and Herceptin can help slow the growth and may bolster the immune system to attack the cancer more effectively. The drug is given intravenously usually once a week or as a larger dose every three weeks.
Herceptin may produce serious side effects in some women, including damage to the heart muscle, breathing problems, and severe allergic reactions. In fact, the federal Food and Drug Administration (FDA) issued a formal warning for Herceptin in 2005 because it was linked to serious heart problems in about four percent of women who participated in a major government study. However, in most cases these complications are temporary and improve once treatment is stopped.
Tamoxifen, the most commonly used hormone-related drug, interferes with estrogen's effect on tumor cells and inhibits tumor growth. While the National Cancer Institute stresses that the benefits of tamoxifen greatly outweigh the risks, the drug does increase a woman's risk of developing two types of uterine cancer -- endometrial cancer and uterine sarcoma. Toremifene is similar to tamoxifen, but is used primarily in post-menopausal women with advanced cancers.
For post-menopausal women with estrogen and/or progesterone receptor-positive tumors, aromatese inhibitors including letrozole (Femara), anastrozole (Arimidex), and exemestane (Aromasin) are now usually used at some point during treatment, either after tamoxifen treatment or instead of it. Studies are still under way to determine the optimal length of treatment and whether one of these drugs is better than the others. In a study of 9,300 women over five years, researchers found that anastrozole reduced the recurrence of tumors by 70 percent, compared to tamoxifen's 50 percent. It also had a lower associated risk of strokes, blood clots and uterine cancers than tamoxifen. Women on anastrozole did have a higher risk of osteoporosis, but researchers said drugs can be prescribed to reduce that risk.
Another study of over 5,000 women published in the New England Journal of Medicine found that letrozole reduced a woman's risk of subsequent breast tumors by 40 percent. The women in the study all had estrogen-sensitive breast cancer and had gone through a five-year regimen of tamoxifen. Half were given a dummy pill and half were given letrozole. Because the letrozole group experienced such positive benefits from the drug, the study was stopped early so that the other women in the study would be able to receive the treatment as well. The known side effects of letrozole are increased risk of osteoporosis, pain in the joints and bones, hot flashes, night sweats, and allergic reactions, but most people seem to experience only minor problems.
Still another drug that appears to work after tamoxifen is no longer effective is Fulvestrant (Faslodex). It damages the estrogen receptor and is approved for treatment of post-menopausal women with advanced breast cancer that no longer responds to tamoxifen or toremifene and women with HER2-negative breast cancer that has spread.
In addition, a group of drugs called LHRH agonists suppress the ovaries when offered to pre- and perimenopausal women with breast cancer. The aim is to protect fertility during chemotherapy by preserving the ovaries. Medicines in this class are goserelin (Zoladex), leuprolide (Lupron), and triptorelin (Trelstar).
With all of these treatments, and more being developed all the time, it may seem daunting to figure out what's best. By reviewing your medical history, your doctor can help you weigh the benefits of a treatment against any side effects that might be of concern to you, and decide on the appropriate treatment.
What other treatments are in the pipeline?
Some promising research includes:
- A vaccine to stimulate the immune system to attack breast cancer cells is now in clinical trials.
- Compounds that can cause a tumor to destroy its own cells and others that cut off a tumor's blood supply by inhibiting the growth of nearby blood vessels.
- A treatment called PARP that helps fight cancer caused by BCRA mutations
- More targeted therapies that spare healthy cells while zeroing in on cancer cells
- Oncoplasty, which combines breast cancer surgery with reconstruction of the breast in the same operation
What does alternative medicine have to offer?
No alternative remedies have been proven to cure cancer, and it's wise to check with your physician before turning to complementary therapies. However, certain unconventional treatments may help you feel better and recover faster. In many cases, acupuncture has proven to ease cancer-related nausea and pain. Some people report that smoking marijuana reduces chemotherapy-induced nausea and vomiting; the drug may be appropriate for some patients not helped by anti-nausea drugs, according to the Institute of Medicine under the National Academy of Sciences. Marijuana for medical purposes is available in some states. Guided imagery and meditation can help you relax and tolerate pain better. And research has shown that women in weekly support groups generally have a better quality of life than those who receive standard treatments alone.
There's no evidence that following a macrobiotic diet or any other food regimen will cure you of cancer; it may even keep you from getting the nutrition you need. But a varied diet that's low in saturated fat and loaded with fruits, vegetables, grains, and legumes can't hurt. You might also try drinking green tea; one preliminary study showed that breast cancer patients who drank four cups a day cut their chances of a recurrence in half. Though, after reviewing scientific data, the FDA concluded that it was highly unlikely that green tea reduced the risk of breast cancer.
Beware of herbal remedies that claim to cure cancer. Anything potent enough to affect tumor cells is likely to have serious side effects and should be taken only under a doctor's supervision.
A study reported in the Journal of the American Medical Association found that something as simple as taking a walk a few times a week may improve your chances of surviving breast cancer. Women in the study who walked from 3 to 5 hours per week at about 3 miles per hour were half as likely to die from the disease than women who didn't exercise. And you don't even have to work up much of a sweat -- the study didn't find any evidence that increasing the intensity of the exercise resulted in a significantly greater benefit.
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American Cancer Society, http://www.cancer.org
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O'Conner, Siobhan. Why Doctors Are Re-Thinking Breast Cancer Treatment. TIME Health, September 30, 2015.
McVea, KL, Minier WC. Low-income women with early-state breast cancer: physician and patient decision making styles. Psychonocology (2):137-46.
Breast Cancer: The Complete Guide by Yashar Hirshaut, M.D., and Peter Pressman, M.D., Bantam Books.
National Cancer Institute: Treatment Option Overview.
American Cancer Society. Breast Cancer: Treatment
Tamoxifen: Questions and answers. National Cancer Institute.
Herceptin: Questions and answers. National Cancer Institute.
Goss PE, et al. A randomized trial of letrozole in postmenopausal women after five years of tamoxifen therapy for early-stage breast cancer. N Engl J Med .
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Holmes MD, et al. Physical activity and survival after breast cancer diagnosis;293:2441.
Preserving ovarian function after breast cancer treatment. Fertility and Sterility; 91: 694-697.
LHRH Agonists. Living Beyond Breast Cancer.
Breastcancer.org. FDA Tells Doctors About Potential Heart Problems with Herceptin.
Breastcancer.org. Herceptin Plus Chemotherapy After Surgery improves Survival of Women with Early-Stage HER-2-Positive Breast Cancer.
Imaginis. First Clinical Trial for Advanced Breast Cancer Vaccine Underway at UNC.
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