Breast cancer in women - Treatment

Treatment-Breast cancer in women




If you have cancer, you should be assigned a multidisciplinary team (MDT), a team of specialists who work together to provide the best treatment and care.
The main treatments for breast cancer are:
You may have one of these treatments, or a combination. The type or combination of treatments you have will depend on how the cancer was diagnosed and the stage it's at.
Breast cancer diagnosed at screening may be at an early stage, but breast cancer diagnosed when you have symptoms may be at a later stage and require a different treatment.
Your healthcare team will discuss with you which treatments are most suitable.

Choosing the right treatment for you 

When deciding what treatment is best for you, your doctors will consider:
  • the stage and grade of your cancer (how big it is and how far it's spread)
  • your general health
  • whether you have experienced the menopause
You should be able to discuss your treatment with your care team at any time and ask questions.

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Treatment overview

Surgery is usually the first type of treatment for breast cancer. The type of surgery you undergo will depend on the type of breast cancer you have.
Surgery is usually followed by chemotherapy or radiotherapy or, in some cases, hormone or biological treatments.
Again, the treatment you'll have will depend on the type of breast cancer.
Your doctor will discuss the most suitable treatment plan with you. Chemotherapy or hormone therapy will sometimes be the first treatment.

Secondary breast cancer

Most breast cancers are discovered in the condition's early stages. But a small proportion of women discover that they have breast cancer after it's spread to other parts of the body (metastasis).
If this is the case, the type of treatment you have may be different. Secondary cancer, also called "advanced" or "metastatic" cancer, isn't curable.
Treatment aims to achieve remission, where the cancer shrinks or disappears, and you feel normal and able to enjoy life to the full.

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Surgery

There are 2 main types of breast cancer surgery:
  • breast-conserving surgery – the cancerous lump (tumour) is removed 
  • mastectomy – surgery to remove the whole breast
In many cases, a mastectomy can be followed by reconstructive surgery to try to recreate a replacement breast.
Studies have shown that breast-conserving surgery followed by radiotherapy is as successful as total mastectomy at treating early-stage breast cancer.

Breast-conserving surgery

Breast-conserving surgery ranges from a lumpectomy or wide local excision, where just the tumour and a little surrounding breast tissue is removed, to a partial mastectomy or quadrantectomy, where up to a quarter of the breast is removed.
If you have breast-conserving surgery, the amount of breast tissue you have removed will depend on:
  • the type of cancer you have 
  • the size of the tumour and where it is in your breast
  • the amount of surrounding tissue that needs to be removed
  • the size of your breasts
Your surgeon will always remove an area of healthy breast tissue around the cancer, which will be tested for traces of cancer.
If there's no cancer present in the healthy tissue, there's less chance that the cancer will return.
If cancer cells are found in the surrounding tissue, more tissue may need to be removed from your breast.
After having breast-conserving surgery, you'll usually be offered radiotherapy to destroy any remaining cancer cells.

Mastectomy

A mastectomy is the removal of all the breast tissue, including the nipple.
If there are no obvious signs that the cancer has spread to your lymph nodes, you may have a mastectomy, where your breast is removed, along with a sentinel lymph node biopsy.
If the cancer has spread to your lymph nodes, you'll probably need more extensive removal (clearance) of lymph nodes from the axilla under your arm.

Reconstruction

Breast reconstruction is surgery to make a new breast shape that looks like your other breast as much as possible.
Reconstruction can be carried out at the same time as a mastectomy (immediate reconstruction), or it can be carried out later (delayed reconstruction).
It can be done either by inserting a breast implant or by using tissue from another part of your body to create a new breast.

Lymph node surgery

To find out if the cancer has spread, a procedure called a sentinel lymph node biopsy may be carried out.
The sentinel lymph nodes are the first lymph nodes that the cancer cells reach if they spread. They're part of the lymph nodes under the arm (axillary lymph nodes).
The position of the sentinel lymph nodes varies, so they're identified using a combination of a radioisotope and a blue dye.
The sentinel lymph nodes are examined in the laboratory to see if there are any cancer cells present. This provides a good indicator of whether the cancer has spread.
If there are cancer cells in the sentinel nodes, you may need further surgery to remove more lymph nodes from under the arm.

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Radiotherapy

Radiotherapy uses controlled doses of radiation to kill cancer cells. It's usually given after surgery and chemotherapy to kill any remaining cancer cells.
If you need radiotherapy, your treatment will begin about a month after your surgery or chemotherapy to give your body a chance to recover.
You'll probably have radiotherapy sessions 3 to 5 days a week, for 3 to 6 weeks. Each session will only last a few minutes.
The type of radiotherapy you have will depend on your cancer and the type of surgery you have. Some women may not need to have radiotherapy at all.
The types available are: 
  • breast radiotherapy – after breast-conserving surgery, radiation is applied to the whole of the remaining breast tissue
  • chest wall radiotherapy – after a mastectomy, radiotherapy is applied to the chest wall
  • breast boost – some women may be offered a boost of high-dose radiotherapy in the area where the cancer was removed; however, the boost may affect the appearance of the breast, particularly if you have large breasts, and can sometimes have other side effects, including hardening of the breast tissue (fibrosis)
  • radiotherapy to the lymph nodes – where radiotherapy is aimed at the armpit (axilla) and the surrounding area to kill any cancer that may be present in the lymph nodes
The side effects of radiotherapy include:
  • irritation and darkening of the skin on your breast, which may lead to sore, red, weepy skin
  • extreme tiredness (fatigue)
  • excess fluid build-up in your arm caused by blockage of the lymph nodes under your arm (lymphoedema)

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Chemotherapy

Chemotherapy involves using anti-cancer (cytotoxic) medication to kill the cancer cells.
It's usually used after surgery to destroy any cancer cells that haven't been removed. This is called adjuvant chemotherapy.
In some cases, you may have chemotherapy before surgery, which is often used to shrink a large tumour. This is called neo-adjuvant chemotherapy.
Several different medications are used for chemotherapy, and 3 are often given at once.
The choice of medication and the combination will depend on the type of breast cancer you have and how much it's spread.
Chemotherapy is usually given as an outpatient treatment, which means you won't have to stay in hospital overnight.
The medications are usually given through a drip straight into the blood through a vein.
In some cases, you may be given tablets that you can take at home. You may have chemotherapy sessions once every 2 to 3 weeks, over a period of 4 to 8 months, to give your body a rest in between treatments.
The main side effects of chemotherapy are caused by their influence on normal, healthy cells, such as immune cells.
Side effects include:
  • infections
  • loss of appetite
  • nausea and vomiting
  • tiredness
  • hair loss 
  • sore mouth
Many side effects can be prevented or controlled with medicines that your doctor can prescribe.
Chemotherapy medication can also stop the production of oestrogen in your body, which is known to encourage the growth of some breast cancers.
If you haven't experienced the menopause, your periodsmay stop while you're undergoing chemotherapy treatment.
After you have finished the course of chemotherapy, your ovaries should start producing oestrogen again.
But this doesn't always happen and you may enter an early menopause. This is more likely in women over 40, as they're closer to menopausal age.
Your doctor will discuss the impact any treatment will have on your fertility with you.

Chemotherapy for secondary breast cancer

If your breast cancer has spread beyond the breast and lymph nodes to other parts of your body, chemotherapy won't cure the cancer, but it may shrink the tumour, relieve your symptoms and help lengthen your life.

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Hormone treatment

Some breast cancers are stimulated to grow by the hormones oestrogen or progesterone, which are found naturally in your body.
These types of cancer are known as hormone receptor-positive cancers. Hormone therapy works by lowering the levels of hormones in your body or by stopping their effects.
The type of hormone therapy you'll have will depend on the stage and grade of your cancer, which hormone it's sensitive to, your age, whether you have experienced the menopause, and what other type of treatment you're having.
You'll probably have hormone therapy after surgery and chemotherapy, but it's sometimes given before surgery to shrink a tumour, making it easier to remove.
Hormone therapy may be used as the only treatment for breast cancer if your general health prevents you having surgery, chemotherapy or radiotherapy.
In most cases, you'll need to take hormone therapy for up to 5 years after having surgery.
If your breast cancer isn't sensitive to hormones, hormone therapy will have no effect.

Tamoxifen

Tamoxifen stops oestrogen from binding to oestrogen-receptor-positive cancer cells. It's taken every day as a tablet or liquid.
It can cause several side effects, including:
  • tiredness
  • changes to your periods
  • nausea and vomiting
  • hot flushes
  • aching joints
  • headaches 
  • weight gain

Aromatase inhibitors

If you have experienced the menopause, you may be offered an aromatase inhibitor.
This type of medication works by blocking aromatase, a substance that helps produce oestrogen in the body after the menopause. Before the menopause, oestrogen is made by the ovaries.
Three aromatase inhibitors may be offered. These are anastrozole, exemestane and letrozole. These are taken as a tablet once a day.
Side effects include:
  • hot flushes and sweats
  • lack of interest in sex (loss of libido)
  • nausea and vomiting
  • tiredness
  • aching joints and bone pain
  • headaches
  • skin rashes

Ovarian ablation or suppression

In women who haven't experienced the menopause, oestrogen is produced by the ovaries.
Ovarian ablation or suppression stops the ovaries working and producing oestrogen.
Ablation can be carried out using surgery or radiotherapy. It stops the ovaries working permanently and means you'll experience the menopause early.
Ovarian suppression involves using a medication called goserelin, which is a luteinising hormone-releasing hormone agonist (LHRHa).
Your periods will stop while you're taking it, although they should start again once your treatment is complete.
If you're approaching the menopause (around the age of 50), your periods may not start again after you stop taking goserelin.
Goserelin is taken as an injection once a month and can cause menopausal side effects, including:

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Biological therapy (targeted therapy)

Some breast cancers are stimulated to grow by a protein called human epidermal growth factor receptor 2 (HER2). These cancers are called HER2-positive.
Biological therapy works by stopping the effects of HER2 and helping your immune system to fight off cancer cells.
If you have high levels of the HER2 protein and are able to have biological therapy, you'll probably be prescribed a medicine called trastuzumab.
Trastuzumab, also known by the brand name Herceptin, is usually used after chemotherapy.

Trastuzumab

Trastuzumab is a type of biological therapy known as a monoclonal antibody.
Antibodies occur naturally in your body and are made by your immune system to destroy harmful cells, such as viruses and bacteria.
The trastuzumab antibody targets and destroys cancer cells that are HER2-positive.
Trastuzumab is usually given intravenously, through a drip. It's also sometimes available as an injection under the skin (a subcutaneous injection).
You'll have the treatment in hospital. Each treatment session takes up to 1 hour, and the number of sessions you need will depend on whether you have early or more advanced breast cancer.
On average, you'll need a session once every 3 weeks for early breast cancer, and weekly sessions if your cancer is more advanced.
Trastuzumab can cause side effects, including heart problems. This means that it's not suitable if you have a heart problem, such as angina, uncontrolled high blood pressure (hypertension), or heart valve disease.
If you need to take trastuzumab, you'll have regular tests on your heart to make sure it's not causing any problems.
Other side effects of trastuzumab may include:
  • an initial allergic reaction to the medication, which can cause nausea, wheezing, chills and fever
  • diarrhoea
  • tiredness
  • aches and pains

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Bisphosphonates

If you have been through the menopause, you may be offered bisphosphonates (zoledronic acid or sodium clodronate).
Recent research has shown they may help to reduce the risk of breast cancer spreading to your bones and elsewhere in your body.
Bisphosphonates will probably be given to you at the same time as chemotherapy, either directly into a vein or as tablets.
Rarely, they can cause kidney problems and osteonecrosis of the jaw (when bone in the jaw dies).
Your doctor will explain the benefits and possible side effects before starting this treatment.

Psychological help

Dealing with cancer can be a huge challenge for both patients and their families. It can cause emotional and practical difficulties.
Many women have to cope with the removal of part or all of a breast, which can be very upsetting.
It often helps to talk about your feelings or other difficulties with a trained counsellor or therapist. You can ask for this kind of help at any stage of your illness.
There are various ways to find help and support. Your hospital doctor, specialist nurse or GP can refer you to a counsellor.
If you're feeling depressed, talk to your GP. A course of antidepressant drugs may help, or your GP can arrange for you to see a counsellor or psychotherapist.
It can help to talk to someone who's been through the same thing as you. Many organisations have helplines and online forums.
They can also put you in touch with other people who have had cancer treatment.

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Clinical trials

A great deal of progress has been made in breast cancer treatment, and more women now live longer and have fewer side effects from treatment.
These advances were discovered in clinical trials, where new treatments and treatment combinations are compared with standard ones.
All cancer trials in the UK are carefully overseen to ensure they're worthwhile and safely conducted.
In fact, participants in clinical trials can do better overall than those in routine care.
If you're asked to take part in a trial, you'll be given an information sheet and, if you want to take part, you'll be asked to sign a consent form.
You can refuse or withdraw from a clinical trial without it affecting your care.

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Complementary therapies

Complementary therapies are holistic therapies that can promote physical and emotional wellbeing.
They're given alongside conventional treatments and include:
Complementary therapy can help some women cope with diagnosis and treatment, and provide a break from the treatment plan.
Your hospital or breast unit may be able to provide access to complementary therapies or suggest where you can get them.
It's important to speak to your breast cancer specialist nurse about any complementary therapy you wish to use to make sure it doesn't interfere with your conventional treatment.

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Will the NHS fund an unlicensed medication?

It's possible for your doctor to prescribe a medication outside the uses it's licensed for if they're willing to take personal responsibility for this "off-licence" use of treatment.
Your local clinical commissioning group (CCG) may need to be involved, as it would have to decide whether to support your doctor's decision and pay for the medication from NHS budgets.
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