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Treatment for breast cancer
Treatment for early or locally advanced breast cancer varies from person to person. The most suitable treatment for you will depend on your test results, where the cancer is in the breast, the cancer’s stage and
grade, and whether the cancer is hormone receptor and/or HER2 positive or triple negative. Your doctor
will also consider your age and general health, and what you want.
Treatment options by type of breast cancer
Usually more than one treatment is used, and treatments may be given in different orders and combinations.
Early breast cancer – The main options are either breast-conserving surgery and radiation therapy or a mastectomy. Often surgery is followed by a combination of chemotherapy, hormone therapy or targeted therapy depending on the features of the cancer. This is known as adjuvant therapy and it reduces the risk of the cancer coming back.
Locally advanced breast cancer – Often treated with chemotherapy before surgery. This is known as neoadjuvant chemotherapy. If the cancer is HER positive, you’ll also have targeted therapy. It’s common to be offered a mastectomy. If you have responded well to chemotherapy and the cancer has shrunk, you may be offered breast-conserving surgery. Surgery may be followed by radiation therapy, hormone therapy and/or targeted therapy depending on the features of the cancer.
For most people, treatment for early or locally advanced breast cancer will include surgery. The type of surgery recommended for you will depend on the type and stage of the cancer, where it is in the breast, and the size of your breast as well as your personal preferences.
In most cases, you may have one or more lymph nodes removed from the armpit, known as axillary surgery. Some people also have surgery to make a new breast shape (breast reconstruction) during the operation.
Sometimes chemotherapy is given before surgery to shrink the tumour. This is known as neoadjuvant chemotherapy. It may be recommended for HER2 positive, triple negative or locally advanced breast cancer. Often surgery is followed by other treatments.
Which surgery should I have?
The two types of surgery are breast-conserving surgery and mastectomy. Depending on your situation, you may be offered a choice between the two. Breast-conserving surgery is not usually suitable for males.
Research has shown that for early breast cancer having breast-conserving surgery followed by radiation therapy is as effective as a mastectomy. The chance of the cancer coming back in another part of the body is the same for both types of surgery.
The operations have different benefits, risks and side effects. Talk to your doctor about the best option for you.
Surgery to remove part of the breast is called breast-conserving surgery. It is also called a lumpectomy or wide local excision. The surgeon removes the tumour and some of the healthy tissue around it, so you can keep as much of your breast as possible. This will leave a scar, and may change the size and shape of the breast and the position of the nipple.
The removed tissue is looked at under a microscope by a pathologist to see if there is an area of healthy cells around the cancer – known as a clear margin. The pathologist’s report will include information about:
- the size and grade of the cancer
- whether there are cancer cells near the edge (margin) of the removed breast tissue
- whether the cells are hormone receptor positive and/or HER2 positive or triple negative, unless this has already been reported on the core biopsy results
- whether the cancer has spread to any lymph nodes.
The pathology report will help guide further treatment. If cancer cells are close to the edge of the removed tissue (an involved or positive margin), there is a greater chance of the cancer returning. You may need more tissue removed (re-excision or wider excision), or your doctor may recommend a mastectomy.
After breast-conserving surgery, you will generally be recommended to have radiation therapy to destroy any cancer cells that may be left in the breast or armpit, and to help keep the cancer from coming back. In some cases, radiation therapy is not required.
Surgery to remove the whole breast is called a mastectomy. You may be recommended to have a mastectomy if:
- there is cancer in more than one area of the breast
- the cancer is large compared to the size of the breast
- you have had radiation therapy to the same breast before and so cannot have it again
- it’s difficult to get a clear margin around the tumour
- you find out that you have the BRCA1 or BRCA2 gene mutation at the time of your breast cancer diagnosis.
You may decide that you would prefer a mastectomy rather than breast-conserving surgery. You can choose a mastectomy even for a very small cancer. After a mastectomy, it’s not common to have radiation therapy but it may be offered in some situations.
Usually the nipple is removed with the breast. In some cases, the surgeon may be able to perform a skin-sparing or nipple-sparing mastectomy. This means that more of the normal skin – with or without the nipple – is kept. If you have decided to have a reconstruction, the skin- or nipple-sparing mastectomy is usually done at the same time.
If you don’t have an immediate reconstruction, you can wear a soft breast form and a specially designed bra while your surgical wound heals. Breast Cancer Network Australia provides a free bra and temporary soft form. To order a kit, speak to your breast care nurse. Cancer Council SA can also provide you with a temporary soft prosthesis, call 13 11 20 for more information. After the wound has healed and the area is comfortable, you can be fitted for a permanent breast prosthesis.
What about the other breast?
If you need a mastectomy because of cancer in one breast, you may think it’s safer to have the other breast removed as well.
For most people, the risk of getting cancer in the other breast is low. If you have the BRCA1 or BRCA2 gene mutation, the mutation increases the risk of developing another breast cancer and your surgeon may recommend a double mastectomy. Whether to have a double mastectomy is a complex decision and it’s best to talk with your treatment team about the risks and benefits.
A breast reconstruction is a type of surgery to make a new breast shape. Sometimes the reconstructed breast is called a breast mound. The surgery may be done using a silicone implant, tissue from another part of your body, or a combination of both.
Sometimes you can have a breast reconstruction at the same time as a mastectomy (immediate reconstruction). You may prefer to wait for several months or years before having a reconstruction (delayed reconstruction). If you’re not having an immediate reconstruction but might consider it in the future, discuss this with your surgeon before surgery, as it will help them to plan the mastectomy. Sometimes you may have to travel to a different hospital to have a reconstruction.
If you decide not to have a reconstruction at all, you can choose to wear a breast prosthesis or live with the changes to your body.
The lymph nodes in the armpit (axillary lymph nodes) are often the first place breast cancer cells spread to outside the breast. Removing some or all of the lymph nodes helps check for spread. The operation to remove lymph nodes is called axillary surgery. It is usually done during breast surgery but may be done in a separate operation. There are two main types of axillary surgery.
Sentinel node biopsy – When breast cancer first spreads beyond the breast, it is likely to go to particular lymph nodes in the armpit or sometimes near the breastbone (sternum). These are known as the sentinel nodes. A sentinel node biopsy finds and removes them so they can be tested for cancer cells.
If there are no cancer cells in the sentinel nodes, no other lymph nodes will be removed. If there is more than a small amount of disease in the sentinel nodes, you may have axillary dissection or radiation therapy.
Axillary dissection (clearance) – If cancer is found in the lymph nodes, then most or all of the axillary lymph nodes (usually 10–20) will be removed to minimise the risk of the cancer coming back (recurrence) in the armpit. The results will also guide what other treatments your doctor recommends.
Side effects – These may include arm or shoulder stiffness; numbness in the arm, shoulder, armpit and parts of the chest; seroma (fluid collecting near the surgical scar); lymphoedema;
and cording. Side effects are usually worse after axillary dissection because more lymph nodes are removed.
If you have any questions about your recovery, ask the doctors and nurses caring for you. Many people are referred to a breast care nurse for information and support. How long you stay in hospital will depend on the type of surgery you have and how well you recover. If you have breast-conserving surgery, you can usually go home the same day. If you have a mastectomy, you usually need to stay in hospital overnight. If you have a reconstruction after mastectomy, you will usually need to stay in hospital for several days.
Dressings and tubes – A dressing will cover the wound to keep it clean. This will usually be removed after about a week. You may have one or more drainage tubes in place to drain fluid from the surgical site into a bag. These may remain in place for up to 10 days, depending on the type of surgery.
Some people are discharged from hospital with drains still in place, but this will depend on your situation and your doctor’s advice. Nurses will teach you how to look after the drains and wound at home, or a community nurse or your GP may help you care for the drains.
Moving your legs – While you are in bed, you will be advised to move your legs to help prevent blood clots, and to walk around when you are able. You may have to wear elastic (compression) stockings or use other devices to help prevent blood clots in the deep veins of your legs (deep vein thrombosis or DVT). Your doctor might also prescribe medicine that lowers the risk of clots.
Recovery time – The time it takes to recover from breast surgery will depend on the type of surgery you’ve had. You may feel better after a few days, or it may take a few weeks or longer if you have a mastectomy with a reconstruction.
Pain – Pain after breast-conserving surgery is not common. If you’ve had an axillary clearance
dissection or mastectomy, you are more likely to have pain. You will be given pain relief through a drip (intravenous or IV), an injection or as tablets, and you will be given pain medicine when you go home.
Caring for your wound
After surgery, the wound will need extra care. If you have any questions, ask your health care team.
bathe carefully – It’s okay for the dressing to get wet in the shower. Afterwards gently pat the wound dry with a soft, clean towel. It’s best not to have a bath.
avoid cuts – Talk to your treatment team if you want to shave or wax your armpits. They may advise you to wait for a short time.
follow-up – A wound infection can happen at any time. Report any redness, pain, heat, fever, swelling or wound discharge to your surgeon or breast care nurse. You may need antibiotics to manage the infection.
moisturise – Gently massage the area with moisturiser once the wound has completely healed.
don’t use deodorant – If the wound is under your arm, avoid using deodorant until it has completely healed.
Any bruising and swelling at the surgery area will usually improve after 2–3 weeks.
The position and size of the scar will depend on how much tissue is removed. If you have
breast-conserving surgery, the scar is usually small and near where the cancer was or nearby. If you have a mastectomy, the scar will be across the skin of the chest. If you have surgery to the lymph nodes, the scar will be in the armpit. At first the scar will be firm, slightly raised and red. Over the next few months it will flatten and fade.
Changes to how your breast looks can affect how you feel about yourself (self-image and
self-esteem). You may feel a sense of loss if you’ve had part of your breast removed or a mastectomy and find that your sense of identity has been affected.
Talking to someone who has had breast surgery might be helpful. Cancer Connect may be able to link you to someone who has had a similar experience to you. Speaking with a counsellor or psychologist for emotional support and coping strategies may also help. Call Cancer Council
13 11 20 for details.
Some common side effects are discussed below. Talk to your health care team about ways to deal with the side effects of surgery.
Fatigue – Cancer treatment and the emotional impact of the diagnosis can be tiring. Fatigue is common and may continue for a few weeks or months. Research shows that exercise during and after cancer treatment can help improve fatigue. YWCA offers a free exercise program for people who have had breast cancer surgery – call 1800 305 150 or visit ywcaencore.org.au.
Shoulder stiffness – This is common after surgery. Gentle arm and shoulder exercises can help prevent or manage shoulder stiffness. Ask your treatment team when you can start exercising your arm. A physiotherapist can show you arm and shoulder exercises to prevent or treat shoulder stiffness. These will help move any fluid that has collected near the surgical scar (seroma), prevent shoulder stiffness and help to prevent lymphoedema.
Numbness and tingling – Surgery can cause bruising or injury to nerves, which may cause numbness and tingling in the armpit, upper arm or chest area. This often improves within a few weeks, but it may take longer. Sometimes it may not go away completely. A physiotherapist or occupational therapist can suggest exercises that may help.
Seroma – Fluid may collect in or around the surgical scar and cause a balloon-like swelling. This is most common after a mastectomy. A seroma can also develop in the armpit after axillary dissection. The build-up of fluid is not harmful, but can be uncomfortable. A breast care nurse, your specialist or GP, or a radiologist can drain the fluid using a fine needle and a syringe. This procedure isn’t painful, but it may need to be repeated over a few appointments.
Change in breast, nipple or arm sensation – This is usually temporary, but it may be permanent for some people.
Lymphoedema – Fluid building-up in the tissue of the arm or breast may cause swelling after lymph node surgery.
Cording – Also known as axillary web syndrome, cording is caused by hardened lymph vessels. It feels like a tight cord running from your armpit down the inner arm, sometimes to the palm of your hand. Some people can see and feel raised cord-like structures across their arm, and these cords can limit movement.
Also known as radiotherapy, radiation therapy uses a controlled dose of radiation to kill cancer cells or damage them so they cannot grow, multiply or spread. The radiation is usually in the form of x-ray beams.
Radiation therapy is recommended:
- after breast-conserving surgery
- after a mastectomy – if pathology results suggest the risk of recurrence is high or if the cancer has spread to the lymph nodes you may have radiation to the chest wall and lymph nodes above the collarbone
- if the sentinel node is affected – you may have radiation to the armpit instead of axillary dissection.
You will usually start radiation therapy within eight weeks of surgery. If you’re having chemotherapy after surgery, radiation therapy will begin about three to four weeks after chemotherapy has finished. In some circumstances, radiotherapy may be offered after neoadjuvant chemotherapy and before surgery.
Treatment is carefully planned to have the greatest effect on the cancer cells and to limit damage to the surrounding healthy tissues. Planning involves several steps, which may occur over a few visits.
You will have a planning session at the radiation therapy centre. During this appointment, you will have a CT scan to pinpoint the area to be treated, and marks will be put on your skin so the radiation therapists treat the same area each time. These marks are small dots (tattoos), and they may be temporary or permanent. Talk to your radiation therapists if you are worried about these tattoos.
You will probably have radiation therapy daily from Monday to Friday for 3–6 weeks. Usually you can have radiation therapy as an outpatient and go to the treatment centre each day.
Each radiation therapy session will be in a treatment room. Although you will get radiation for only 1–5 minutes, setting up the machine can take 10–30 minutes. You will lie on a table under the machine. The radiation therapist will leave the room and then switch on the machine, but you can talk to them through an intercom.
Radiation therapy is not painful, but you will need to lie still while it is given. If the cancer is located on the left side, the radiation therapist may ask you to take a deep breath for 20–30 seconds during the treatment. This helps to inflate the lungs and rib cage, to move them away from the radiation field and minimise damage to the heart. This technique is known as deep inspiration breath hold.
Radiation therapy may cause the following side effects:
Tiredness – You may start to feel tired or lack energy for day-to-day activities 1–2 weeks after radiation therapy begins. Fatigue usually eases a few weeks after treatment finishes.
Red and dry skin – The skin at the treatment area may become dry and itchy. Your skin may look red or sunburnt after a few weeks of treatment. It usually returns to normal 4–6 weeks after treatment ends. The nurses will show you how to care for your skin. Sorbolene cream applied twice a day can be helpful.
Skin problems – Less commonly, your skin may peel or become very irritated. The treatment team will closely monitor your skin, and you may need dressings or creams to help the area heal.
Aches – You may feel minor aches or shooting pains that last for a few moments during treatment.
Swelling – Some people develop fluid in the breast (oedema) that can last for up to 12 months or, in some cases, longer. Radiation therapy to the armpit may increase the chance of developing lymphoedema in the arm. Talk to your radiation oncologist or radiation oncology nurse about any changes you experience.
Hair loss – Radiation therapy to the breast may cause you to lose hair from the treated armpit but doesn’t cause you to lose head hair.
Other side effects can develop months or years after radiation therapy. These are called late effects. Part of the lung behind the treatment area may become inflamed, causing a dry cough or shortness of breath. There is a slight risk of radiation therapy causing heart problems, but this usually happens only if you have treatment to your left breast or you smoke. In rare cases, radiation therapy may cause a second cancer.
Chemotherapy uses drugs to kill cancer cells or slow their growth. It may be called systemic treatment because the drugs circulate throughout the bloodstream. Chemotherapy may be used at different times:
- before surgery to shrink or control the cancer (neoadjuvant chemotherapy)
- if the cancer is not sensitive to hormone therapy and/or is HER2 positive
- after surgery to reduce the risk of the cancer returning (adjuvant).
Different types of chemotherapy drugs are used to treat early and locally advanced breast cancer. The choice of drug will depend on the type of cancer, how far it has spread and what other treatments you are having. Usually you will have a combination. Common drugs include doxorubicin, cyclophosphamide, fluorouracil, docetaxel and paclitaxel. Your health professionals may also refer to the drugs by their brand names. Your medical oncologist will talk to you about the most suitable types of chemotherapy, as well as their risks and side effects.
Chemotherapy is given through a vein (intravenously). You will usually be treated as an outpatient, but occasionally you may have to stay in hospital overnight.
Most people will have chemotherapy for 3–6 months. Usually drugs are given once every three weeks, although some are given on a faster schedule (e.g. once every two weeks or once a week).
Chemotherapy damages cells as they divide. This makes the drugs effective against cancer cells, which divide rapidly. However, some normal cells – such as hair follicles, blood cells and cells inside the mouth or bowel – also divide rapidly. Side effects happen when chemotherapy damages these normal cells. Unlike cancer cells, normal cells can recover, so most side effects are temporary.
Hair loss – You may lose the hair on your head, and your eyebrows, eye lashes, underarm hair, pubic hair and beards can also be affected. It’s common for hair loss to begin two to three weeks after starting treatment. You’ll probably lose some hair gradually at first, and then more rapidly over the next few weeks.
Some treatment centres provide cold caps, which may prevent total head hair loss, but this depends on the drugs used. For information about cold caps, speak to your treatment team.
Generally, hair begins to grow back after treatment ends. The Look Good Feel Better program helps people manage the appearance-related effects of cancer treatment. This may include sessions on make-up, skin care and hair styling to boost self-esteem during treatment. Call 1800 650 960 or visit lgfb.org.au.
Nausea – You may feel sick with or without vomiting for several hours after each treatment. You will be given medicine to prevent nausea.
Infertility – Some women find that their periods become irregular or stop during chemotherapy. Periods may return to normal after treatment or they may stop permanently, causing infertility. For men, chemotherapy can lower the number of sperm produced, which can cause temporary or permanent infertility. If you may want to consider having children in the future, talk to your cancer specialists about the options and ask for a referral to a fertility specialist before your treatment starts.
Other side effects – Common side effects include tiredness, mouth ulcers and constipation. Chemotherapy can also lower your immune system, increasing the risk of infection. Some people experience changes in thinking and memory (cancer-related cognitive impairment or “chemo brain”) or pins and needles (peripheral neuropathy). Sometimes chemotherapy can damage the heart muscle, which can affect how blood is pumped around the body (cardiomyopathy). Although the risk is small, your heart health will be assessed before starting treatment and continue during treatment. Rarely, chemotherapy can cause a type of blood cancer.
Hormone therapy, also called endocrine therapy or hormone-blocking therapy, slows or stops the effect of oestrogen. It is used to treat breast cancer that is hormone receptor positive. Hormone therapy is often used to lower the risk of the cancer coming back.
There are different types of hormone therapy. The type you have will depend on your age, the type of breast cancer and whether you have reached menopause.
Tamoxifen can be given to females of any age, regardless of whether they have reached menopause, and to males. It is commonly taken as a daily tablet for 5–10 years.
In females, tamoxifen can cause menopausal symptoms, although it does not cause menopause. In males, the side effects can include low sex drive (libido) and erection problems.
Taking tamoxifen increases the risk of blood clots – see your doctor immediately if you have any swelling, soreness or warmth in an arm or leg. There is a small risk of developing cancer of the uterus (also called endometrial cancer) if you have gone through menopause, so see your doctor if you notice any unusual vaginal bleeding.
You will probably not experience all of these side effects. Side effects usually improve as treatment continues and after it has finished. Your doctor and breast care nurse can give you information about ways to manage the side effects of tamoxifen.
After menopause, the ovaries stop making oestrogen, but small amounts are still made in body fat. Taking aromatase inhibitors will help reduce how much oestrogen is produced in the body.
Aromatase inhibitors are mostly used if you’ve been through menopause or had your ovaries removed. If you have not been through menopause and are at high risk of the cancer coming back, you may have aromatase inhibitors as well as an injection of goserelin (brand name Zoladex) to stop the ovaries producing oestrogen.
Examples of aromatase inhibitors include anastrozole, exemestane and letrozole. They are taken daily as a tablet, usually for 5–10 years.
Aromatase inhibitors can cause thinning and weakening of the bones (osteoporosis). Your bone health will be monitored during treatment and your doctor may prescribe a drug to protect your bones.
Other side effects of aromatase inhibitors may include joint and muscle pain, vaginal dryness, low mood, hot flushes and weight gain. If you have arthritis, aromatase inhibitors may worsen joint stiffness and pain. Exercise or medicines from your doctor may help with this.
If you have not been through menopause, drugs or surgery can stop the ovaries from producing oestrogen. This is known as ovarian suppression. It may also be recommended as an additional treatment for people taking tamoxifen or for premenopausal women taking an aromatase inhibitor instead of tamoxifen.
Temporary ovarian suppression – The drug goserelin (brand name Zoladex) stops oestrogen production. The drug is given as an injection into the belly once a month for 2–5 years to bring on temporary menopause. Side effects are similar to those of permanent menopause. The drug may also be given to people having chemotherapy who wish to preserve their fertility because it helps protect the ovaries.
Permanent ovarian treatment – Ovarian ablation is treatment that permanently stops the ovaries from producing oestrogen. It usually involves surgery to remove the ovaries (oophorectomy). Ovarian ablation will bring on permanent menopause. This means you will no longer be able to become pregnant.
Targeted therapy drugs attack specific targets inside cancer cells. The drugs that are currently available do not work for all types of breast cancer. They are useful only for HER2 positive breast cancers. For early or locally advanced breast cancer, the main targeted therapy drug is trastuzumab (brand name Herceptin). Other drugs are available for advanced breast cancer.
Trastuzumab is usually referred to by the brand name Herceptin although there are other drugs similar to trastuzumab now available in Australia. These are known as biosimilar medicines and include Herzuma, Kanjinti and Ogivri. Herceptin works by attaching itself to HER2 positive breast cancer cells, destroying the cells or reducing their ability to divide and grow. Herceptin also encourages the body’s own immune cells to help destroy the cancer cells. Herceptin is used together with chemotherapy. It has been shown to increase the effect of chemotherapy drugs on early breast cancer. Most people have Herceptin via a drip into a vein (infusion), but some people have it as an injection under the skin.
The first infusion takes about 90 minutes. This is called the loading dose. The following infusions take 30–60 minutes each. You will usually have a dose every three weeks, and they will continue for up to 12 months. The first four doses are given while you are having chemotherapy treatment.
Your medical team will monitor you for side effects. These are usually caused by the chemotherapy. This means that once chemotherapy finishes and you are continuing with Herceptin alone, most side effects ease. For example, hair grows back, there is no nausea or vomiting, and you no longer need regular blood tests.
Although side effects from Herceptin itself are uncommon, they can include headache, fever and diarrhoea. In some people, Herceptin can affect how the heart works, so you will have tests to check your heart function before and during treatment.
A number of new drugs have been developed and tested as additional treatments after Herceptin for people with HER2 positive breast cancer. Talk to your doctor about whether these are appropriate for you.
This information is reviewed by
This information was last reviewed July 2020 by the following expert content reviewers: Prof Bruce Mann, Professor of Surgery, The University of Melbourne, and Director, Breast Tumour Stream, Victorian Comprehensive Cancer Centre, VIC; Dr Marie Burke, Radiation Oncologist, and Medical Director GenesisCare Oncology, QLD; Dr Susan Fraser, Breast Physician, Cairns Hospital and Marlin Coast Surgery Cairns, QLD; Ruth Groom, Consumer; Julie McGirr, 13 11 20 Consultant, Cancer Council Victoria; A/Prof Catriona McNeil, Medical Oncologist, Chris O’Brien Lifehouse, NSW; Dr Roya Merie, Staff Specialist, Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool Hospital, NSW; Dr Eva Nagy, Oncoplastic Breast Surgeon, Sydney Oncoplastic Surgery, NSW; Gay Refeld, Clinical Nurse Consultant – Breast Care, St John of God Subiaco Hospital, WA; Genny Springham, Consumer.