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Treatment for breast cancer

Treatment for early or locally advanced breast cancer varies from person to person. The treatment that’s best 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 treatment you want to have.

Research shows that exercising before, during and after treatment can help people diagnosed with breast cancer.

Treatment options by stage of breast cancer

You will usually have more than one treatment, and they could be given in different orders or combinations.

Early breast cancer – The main options are either breast-conserving surgery with radiation therapy, or a mastectomy (surgery to remove the whole breast).

Often surgery for breast cancer is followed by a combination of chemotherapy, radiation therapy, hormone therapy or targeted therapy, depending on the features of the cancer. The treatment that is given after you have surgery is called adjuvant therapy, and it reduces the risk of the cancer coming back.

Chemotherapy or targeted therapy given before surgery is neoadjuvant therapy. Usually suggested for HER2+, triple negative and inflammatory breast cancers, it is also sometimes advised for hormone positive cancer.

Locally advanced breast cancer – Often treated with chemotherapy before surgery (called neoadjuvant therapy) to shrink the cancer. If the cancer is HER+, you’ll also usually have targeted therapy before surgery. It is common to be offered a mastectomy. If the chemotherapy has shrunk the cancer, you may be offered breast-conserving surgery instead. Surgery is usually followed by radiation therapy, hormone therapy and/or targeted therapy, depending on the cancer type.

Surgery

Treatment for early or locally advanced breast cancer usually includes surgery. Which surgery your doctor suggests will depend on the type and stage of the  cancer, where it is in the breast, the size of your breast, and what you prefer. In most cases, you will have one or more lymph nodes removed from the armpit. This is called axillary surgery. Some people also choose to have a new breast shape made during the operation (breast reconstruction).

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 usually not suitable for males because there is not enough breast tissue in the male breast. Research has shown that for most early breast  cancer, having breast-conserving surgery followed by radiation therapy works just as well 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. The Neoadjuvant Patient Decision Aid may help you decide on any pre-surgery therapy.

When only part of the breast is removed, it is called breast-conserving surgery. It is also known as a lumpectomy or wide local excision.

The surgeon removes the tumour and some of the healthy tissue around it, so that you can keep as much of your breast as possible. The operation will leave a scar, and may change the size and shape of the breast and the position of the nipple.

A pathologist looks at the tissue under a microscope to check for an area of healthy cells around the cancer – known as a clear margin. The  pathologist will also give 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+ 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 guide your doctors on what other treatment may be best for you. If there are cancer cells found close to the edge of the removed tissue (which is called an involved or positive margin), there is a higher risk of the cancer returning. You may need to have further surgery for more tissue to be removed (called a re-excision or wider excision). Your doctor may also suggest that you have a mastectomy.

After breast-conserving surgery, you’ll usually have radiation therapy to destroy any cancer cells that may be left in the breast or armpit.

Surgery to remove the whole breast is called a mastectomy or single mastectomy. Removal of both breasts is called a bilateral mastectomy. A mastectomy may be recommended if:

  • you have the BRCA1 or BRCA2 gene mutation
  • 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 have inflammatory breast cancer
  • cancer has come back or you have a new cancer in the same breast.

You may prefer to have a mastectomy instead of breast-conserving surgery – even if you have a very small cancer. You won’t usually be given radiation therapy after a mastectomy, though it may be offered in some situations.

The nipple is usually removed in a mastectomy. In some cases, the surgeon may 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, and can have a skin-sparing or nipple-sparing mastectomy, the reconstruction is usually done at the same time.

If you don’t have a reconstruction, you have the option of wearing a soft breast form with 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 then be fitted for a permanent breast prosthesis.

Read more about breast prostheses

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, this does increase the risk of developing another breast cancer, so your surgeon may recommend a double mastectomy (bilateral mastectomy) to remove both breasts.

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. Then you can make a final decision once you are informed about all your options.

Breast reconstruction is surgery to make a new breast shape, which is also called a breast mound. The surgery may be done using a silicone implant, using tissue from another part of your body, or a combination of the two.

It may be possible to 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. Some people decide not to have a reconstruction and prefer to “go flat”, while others choose to wear a breast prosthesis.

Download our booklet ‘Breast Prostheses and Reconstruction’

The axillary lymph nodes, which are in and around the armpit, are where cancer cells from the breast usually spread to first. Removing some or all of these lymph nodes helps your doctor to check for any cancer 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 lymph node biopsy (SLNB) – When breast cancer spreads outside the breast, it first goes to particular lymph nodes in the armpit or near the breastbone (sternum). These are called 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, the rest of the lymph nodes are left in place. If there is more than a small amount of disease in the sentinel nodes, you may have axillary lymph node dissection or radiation therapy.

Axillary lymph node dissection (ALND) – Also called axillary lymph node clearance (AC). If cancer is found in the lymph nodes, then most or all of the axillary lymph nodes (usually 10–25) will be removed to reduce the risk of the cancer coming back (recurrence) in the armpit. The results also guide what other treatment your doctor recommends.

Side effects – You may have arm or shoulder stiffness, weakness, reduced movement and pain; numbness in the arm, shoulder, armpit and parts of the chest; seroma – which is fluid collecting near the surgical scar; lymphoedema; and cording.  Side effects are usually worse after axillary lymph node dissection because more lymph nodes are removed.

Finding the sentinel nodes

To work out which lymph nodes are sentinel nodes, one or a combination of these procedures is used:

1) Lymphatic mapping

A small amount of a harmless radioactive material is injected into the skin over the breast cancer tumour.

A CT scan is then taken to show which lymph nodes the radioactive material flows to first. These are most likely to be the sentinel nodes.

Lymphatic mapping is done either on the day of the biopsy, or the day before the biopsy.

2) Blue dye injection (not always used)

If dye is being used, it will be injected into the breast. The dye moves into the lymphatic vessels and stains the sentinel nodes first. This is done under general anaesthetic during the biopsy.

Because of the dye, you may notice blue-green urine (wee) and bowel movements (poo) when you go to the toilet the next day. You may also have a blue patch on the breast for weeks or longer. Your skin may look a bit grey, but will fade once the dye washes out in your urine.

3) Handheld probe

As well as looking at where the blue dye travels to first (if used), the surgeon uses a small handheld device called a probe during the biopsy to detect the radioactive substance injected during the lymphatic mapping.

This helps to check that the sentinel nodes have been located and the surgeon can then remove them for testing.

If you have any questions about your recovery and how best to look after yourself when you get home, ask the doctors and nurses caring for you. If you are referred to a breast care nurse, they can give you information about what to expect after surgery and provide support.

Your hospital stay will depend on the surgery you have and how well you recover.

  • Breast-conserving surgery – You usually go home that day, or stay overnight.
  • Mastectomy – You usually stay in hospital overnight.
  • Reconstruction after mastectomy – You usually stay in hospital for several days.

Dressings and tubes – A dressing will cover the wound to keep it clean. This may be changed while in hospital but is usually removed after about a week. You may have one or more drainage tubes to drain fluid from the surgical site into a bag. These can stay in for 1–2 weeks. Nurses will show you how to look after the drains and wound at home, or a community nurse or GP may help you.

A wound infection can happen at any time. If you have any redness, pain, heat, fever, swelling or wound discharge let your doctor, breast care nurse or surgeon know right away. You may need antibiotics to manage the infection.

Recovery time – The time it takes to recover from breast surgery will depend on the type of surgery you’ve had and your own health. 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 relief – Pain after an axillary lymph node dissection or a mastectomy is more likely than after breast-conserving surgery. You’ll have pain relief through a drip (intravenous or IV), an injection or as tablets. You’ll also be given pain medicine when you go home.

Preventing blood clots – While in bed, you should try to do some deep breathing exercises, and move your legs around to help prevent blood clots in the deep veins of your legs (deep vein thrombosis or DVT). As soon as you’re able, you’ll be asked to get up and walk around. You may wear elastic  (compression) stockings or use other devices to help prevent clots. Your doctor might also prescribe medicine that lessens the risk of any blood clots forming.

Avoid cuts – Your treatment team may advise you to wait for a time if you want to shave or wax your armpits.

Shower carefully – Keep the wound clean, and gently pat it dry after showering. Avoid baths.

Moisturise – Gently massage the area with moisturiser once any stitches or adhesive strips are removed and the wound has completely healed.

Don’t use deodorant – If the wound is under your arm, avoid using deodorant until it has completely healed.

How your breast will look after surgery depends on the type of surgery that you have, as well as the size of your breast and your body shape. It can take up to a few weeks for any bruising and swelling of the surgery area to go away.

After breast-conserving surgery – The size and position of the scar will depend on how much tissue is removed. The scar will usually be less than 10 cm and near where the cancer was or along the areola. But this can vary depending on your breast size and how much cancer needs to be removed. It can also change if you need to have further surgery to remove more tissue. If a larger area needs to be removed, surgical techniques known as oncoplastic surgery can reshape the breast after breast-conserving surgery.

After a mastectomy – The scar will be across the skin of the chest. If you have surgery to the lymph nodes, the scar will also 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.

Impact on self-esteem – Scars or changes to how your breast looks can affect how you feel about yourself (self-image and self-esteem. It’s common to feel a sense of loss if you’ve had a mastectomy (or part of your breast removed), and you may find that your sense of femininity or sense of identity has been affected.

Seeking support – Talking to someone who has had breast cancer surgery can be helpful. Cancer Council’s Cancer Connect program may be able to link you to others who’ve had a similar experience. Speaking with a counsellor or psychologist for emotional support and coping strategies can also help. Call Cancer Council 13 11 20 for details.

Breast appearance after surgery

What your breast looks like after surgery will vary from person to person, and depend on the type of breast surgery and how much tissue is removed. The pictures below give some examples, however ask your surgeon for more photographs to help you choose the surgery that’s right for you.

Breast-conserving surgery

Two years after surgery to left breast. The scar can still be seen but has healed and faded a little. The size of the scar varies but can be around 10 cm. The surgery was followed by radiation therapy.

Mastectomy

Left breast removed, with no reconstruction. All possible breast tissue has been removed and the scar runs horizontally across the chest wall. This photo is some time after surgery and shows results once the scar has healed.

Nipple-sparing mastectomy with implant reconstruction

Left breast removed with a nipple-sparing mastectomy, followed by reconstruction using an implant. If it is not possible to keep the nipple, there is  the option of having a nipple reconstruction later.

Mastectomy with a flap reconstruction

Right breast removed, followed by a breast reconstruction using tissue from the back. Tissue from the abdomen, buttock or thigh can also be used for a reconstruction. You can choose to have a nipple reconstruction later.

Some common side effects are discussed below. Talk to your health care team about the best ways to deal with them. 

Fatigue – Cancer treatment and the emotional impact of the diagnosis can be tiring. Fatigue is common and may continue for weeks or months.  Research shows that exercise during and after cancer treatment is safe and can help improve fatigue. YWCA offers a free exercise program for people who’ve had breast cancer surgery – call 0449 904 011 or visit ywcaencore.org.au. Your GP may be able to create a management plan for Medicare-funded exercise physiology or physiotherapy.

Download our fact sheet ‘Fatigue and Cancer’

Download our booklet ‘Exercise for People Living with Cancer’

Shoulder stiffness – Arm and shoulder pain, weakness, stiffness and reduced movement are common after surgery and after radiation therapy. Ask your treatment team when you can start exercising your arm. A physiotherapist can show you exercises to reduce shoulder stiffness or pain. This may move fluid near the surgical scar (seroma) and help prevent lymphoedema.

Download our poster ‘Arm & shoulder exercises after surgery’

Numbness and tingling – Surgery can bruise or injure nerves and cause numbness and tingling in the armpit, upper arm or chest area. You may also notice a loss of feeling in your breast or nipple. These changes often improve within a few weeks, but may take longer. Sometimes the numbness or tingling may not go away completely. A physiotherapist or occupational therapist can give you 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 an axillary lymph node dissection. The build-up of fluid can be uncomfortable, but is not harmful. 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.

Lymphoedema – Fluid building up in the tissue of the arm or breast may cause swelling after any lymph node surgery. It’s common to have some swelling of your arm or breast after surgery, but this usually settles in the weeks afterwards. If this swelling builds up over weeks or months, this usually means you have lymphoedema. It can happen any time, even years after surgery (or radiation therapy) to the lymph nodes.

Download our fact sheet ‘Understanding Lymphoedema’

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 or cause pain.

Radiation therapy

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 usually 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 has cancer cells – 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 3–4 weeks after chemotherapy has finished. In some cases, radiation therapy 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 sometimes marks are put on your skin so the radiation therapists treat the exact same area each time. These marks are usually 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. Most people 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.

If you are having radiation therapy in a private centre, the cost is not usually covered by private health insurance, so you may have to pay a gap fee. Speak to your treatment team about whether you can have treatment in a public hospital if you are worried about the cost. 

Radiation therapy may cause the following side effects:

Red and dry skin – Most people have some redness around the treated area. The skin may become dry and itchy, look sunburnt, blister, or become moist and weepy. It usually returns to normal 4–6 weeks after radiation therapy ends. The nurses will show you how to care for your skin. Ask them which moisturiser would be most helpful for you.

Skin problems – Sometimes skin may become very irritated or peel (radiation dermatitis). The treatment team will monitor your skin, and you may need dressings, or special creams or gels, to help the area heal.

Tiredness – You may start to feel tired or lack energy for day-to-day activities 1–2 weeks after radiation therapy begins. Fatigue usually gets better a few weeks after treatment finishes.

Aches – You may feel minor aches, twinges or shooting pain in the breast area during or after treatment. It should ease and become less frequent.

Swelling – Some people have swelling or fluid (breast oedema) that can last for up to a year or longer. Radiation therapy to the armpit increases the risk of swelling in the arm.

Hair loss – Radiation therapy to the breast won’t make you lose the hair on your head, but you will usually lose hair from the treated armpit.

Other side effects – These are called late effects and can develop months or years after radiation therapy. 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 heart problems, but this usually happens only if you have treatment to your left breast or if you smoke. Hardening of tissues (fibrosis) may happen months or years after treatment. In rare cases, radiation therapy may cause a second cancer.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells or slow their growth. It is called systemic treatment because the drugs circulate throughout the bloodstream.

When chemotherapy is used before surgery to shrink or control the cancer it’s called neoadjuvant chemotherapy. When used after surgery to reduce the risk of the cancer returning it’s called adjuvant chemotherapy.

Chemotherapy is often used for breast cancers that aren’t sensitive to hormone therapy, are HER2+ or triple negative, or for inflammatory breast cancers. It is sometimes used for hormone sensitive breast cancers.

Different types of chemotherapy drugs are used to treat early and locally advanced breast cancer. The choice of drugs 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, epirubicin and paclitaxel. Your treatment team may also refer to the drugs by their brand names, or letters like AC or FEC. Your medical oncologist will talk to you about the most suitable types of chemotherapy drugs, 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. Drugs are usually 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.

Nausea – You may feel sick or have vomiting for a few hours after each treatment. It’s common to also feel sick a few days after a first treatment. Not everyone feels sick and you’ll be given medicine to help prevent it.

Diarrhoea – You may have loose, watery stools and feel like you urgently need to go to the toilet. Talk to your treatment team if you feel unwell. You may be given medicine to manage diarrhoea.

Hair loss – You may lose the hair on your head, your eyebrows, eyelashes, underarm hair, pubic hair and facial hair.

Hair loss often begins 2–3 weeks after starting treatment. It starts gradually, and becomes more rapid 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. Cold caps may cause discomfort during chemotherapy, so speak to your treatment team for advice. Generally, hair starts to grow back after your treatment ends.

The Look Good Feel Better program can help you to manage the appearance-related effects of cancer treatment and boost self-esteem. This may include sessions on make-up, skin care and hair styling. Call 1800 650 960 or visit lgfb.org.au.

Download our fact sheet ‘Hair loss’

Swelling – This is also called oedema. Some medicines used alongside chemotherapy drugs can cause the body to hold on to excess fluid (also called fluid retention). This can affect the arm and the trunk, but it is usually temporary and goes away when treatment ends.

Changes to fertility – Your periods may become irregular or stop during chemotherapy. This may be temporary with periods returning to normal after treatment. Sometimes periods may stop permanently, causing infertility. Chemotherapy can lower the number of sperm produced, which can cause temporary or permanent infertility. If you may want to have children in the future, talk to your cancer specialists about your options and ask for a referral to a fertility specialist before your treatment starts.

Download our booklet ‘Fertility and Cancer’

Other side effects – Tiredness, mouth ulcers and constipation are all common side effects. Chemotherapy can also lower your immune system, increasing the risk of infection. You might notice changes in thinking and memory (cancer-related cognitive impairment or “chemo brain”, or tingling in your hands or feet (peripheral neuropathy). Anti-nausea or anti-allergy medicines given with chemotherapy can disturb sleep for a few nights. Talk to your treatment team about how to manage any of these side effects.

Although the risk is small, sometimes chemotherapy can damage the heart muscle, which can affect how blood is pumped around the body  (cardiomyopathy). Your heart health will be assessed before, during, and after treatment.

Rarely, chemotherapy can cause a type of blood cancer.

Hormone therapy

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. It is also used to reduce the risk of certain conditions, including LCIS and some DCIS, developing into invasive breast cancer.

There are different types of hormone therapy – the one you have depends on your age, type of breast cancer and if you have reached menopause.

Tamoxifen is suitable for anyone, whether you have been through menopause or not. You need to take a daily tablet for 5–10 years.

Side effects – In females, tamoxifen can cause menopausal symptoms, although it doesn’t bring on menopause. In males, the side effects can include low sex drive (libido) and erection problems. Tamoxifen increases the risk of blood clots – see a doctor immediately if you have swelling, soreness or warmth in an arm or leg. There is a very small risk of developing cancer of the uterus (also called endometrial cancer), particularly if you have gone through menopause. Let your treatment team know if you have any unusual vaginal bleeding.

You are unlikely to have all of these side effects, and they usually improve as treatment continues and after it ends. Your doctor and breast care nurse can help you to manage any side effects.

Tell your doctor if you take an antidepressant. Some (but not all) may affect how well tamoxifen works, and you may need to look at which medicine is best for your situation.

After menopause, the ovaries stop making oestrogen. However, both females and males make small amounts of oestrogen in body fat and the adrenal glands. Taking aromatase inhibitors will help reduce how much oestrogen is made in the body. This is important because oestrogen can cause some cancers to grow.

Aromatase inhibitors are mostly used if you have been through menopause, have had your ovaries removed or are male. They are sometimes used if you haven’t been through menopause, but have a high risk of the cancer returning. In this case, you may also be given an injection of goserelin, at least a week before chemotherapy starts, to stop your ovaries producing oestrogen. Examples of aromatase inhibitors include anastrozole, exemestane and letrozole. They are taken daily as a tablet, usually for 5–10 years.

Side effects – Aromatase inhibitors can cause thinning and weakening of the bones (osteoporosis). Your bone health will be monitored during  treatment and you may be prescribed a drug to protect your bones. Consider seeing a physiotherapist or exercise physiologist for an exercise plan. Other side effects 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.

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 stops oestrogen production. It 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 help protect the ovaries during chemotherapy, so it is often given to people who want to preserve their fertility.

Permanent ovarian treatment – Ovarian ablation permanently stops the ovaries from producing oestrogen. It usually involves surgery to remove the ovaries (oophorectomy). Sometimes radiation therapy is used. Ovarian ablation will bring on permanent menopause. This means you will no longer be able to fall pregnant naturally.

Targeted therapy

Targeted therapy drugs attack specific features of cancer cells to stop the cancer growing and spreading. The drugs that are currently available do not work for all types of breast cancer. They are mostly useful for HER2+ breast cancers. The drug abemaciclib is used for both HER2+ and HER2– breast cancers. For early or locally advanced breast cancer, the most common targeted therapy drug used is trastuzumab.

Your treatment team may refer to trastuzumab by a brand name, such as Herzuma, Kanjinti or Ogivri. It is also known by the brand name Herceptin, though this version is now rarely used in Australia. Trastuzumab works by attaching itself to HER2+ breast cancer cells, destroying the cells or reducing their ability to divide and grow. Trastuzumab also encourages the body’s own immune cells to help find and destroy the cancer cells.

Trastuzumab is used in combination with chemotherapy. It has been shown to increase the effect of chemotherapy drugs on early breast cancer. Most people have trastuzumab 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, for up to 12 months. The first four doses are given while you are having chemotherapy treatment.

Side effects – 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 trastuzumab only, 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 trastuzumab itself are uncommon, they can include headache, fever and diarrhoea. In some people, trastuzumab can affect how the heart works, so you will have tests to check your heart function before and during treatment.

Several new drugs have been developed as additional treatments after trastuzumab for people with HER2+ breast cancer, including pertuzumab and trastuzumab emtansine (T-DM1). Your doctor will advise if these are appropriate for you.

PARP inhibitors

There are a number of new drugs for people who have inherited a BRCA mutation, or whose cancer has developed BRCA mutations. These are called PARP inhibitors. Ask your doctor whether these drugs may be appropriate for you.

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This information is reviewed by

This information was last reviewed July 2022 by the following expert content reviewers: A/Prof Elisabeth Elder, Specialist Breast Surgeon, Westmead Breast Cancer Institute and The University of Sydney, NSW; Collette Butler, Clinical Nurse Consultant and McGrath Breast Care Nurse, Cancer Support Centre, Launceston, TAS; Tania Cercone, Consumer; Kate Cox, 13 11 20 Consultant, Cancer Council SA; Dr Marcus Dreosti, Radiation Oncologist and Medical Director, GenesisCare, SA; Dr Susan Fraser, Breast Physician, Cairns Hospital and Marlin Coast Surgery Cairns, QLD; Dr Hilda High, Genetic Oncologist, Sydney Cancer Genetics, NSW; Prof David W Kissane AC, Chair of Palliative Medicine Research, The University of Notre Dame Australia, and St Vincent’s Hospital Sydney, NSW; Prof Sherene Loi, Medical Oncologist, Peter MacCallum Cancer Centre, VIC; Dr W Kevin Patterson, Medical Oncologist, Adelaide Oncology and Haematology, SA; Angela Thomas, Consumer; Iwa Yeung, Physiotherapist, Princess Alexandra Hospital, QLD.