The treatments that are the standard of care for early-stage and locally advanced breast cancer. “Standard of care” means the best treatments known. When making treatment plan decisions, patients are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment.
Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug and how often it should be given, a new combination of standard treatments, or new doses of standard drugs or other treatments.
In cancer care, doctors specializing in different areas of cancer treatment—such as surgery, radiation oncology, and medical oncology—work together to create a patient’s overall treatment plan that combines different types of treatments.
Cancer care teams include a variety of other health care professionals, such as physician assistants, oncology nurses, social workers, pharmacists, counselors, nutritionists, and others. For people older than 65, a geriatric oncologist or geriatrician may also be involved in care.
Ask the doctor in charge of your treatment which health care professionals will be part of your treatment team and what they do. This can change over time as your health care needs change.
A treatment plan is a summary of your cancer and the planned cancer treatment. It is meant to give basic information about your medical history to any doctors who will care for you during your lifetime. Before treatment begins, ask your doctor for a copy of your treatment plan.
The biology and behavior of breast cancer affects the treatment plan. Some tumors are smaller but grow fast, while others are larger and grow slowly. Treatment options and recommendations are very personalized and depend on several factors, including:
- The tumor’s subtype, including hormone receptor status (ER, PR) and HER2 status
- The stage of the tumor
- Genomic markers, such as Oncotype DX™ (if appropriate) (See Diagnosis)
- The patient’s age, general health, menopausal status, and preferences
- The presence of known mutations in inherited breast cancer genes, such as BRCA1 or BRCA2
Even though the breast cancer care team will specifically tailor the treatment for each patient and the breast cancer, there are some general steps for treating early-stage and locally advanced breast cancer.
For both DCIS and early-stage invasive breast cancer, doctors generally recommend surgery to remove the tumor. To make sure that the entire tumor is removed, the surgeon will also remove a small area of healthy tissue around the tumor. Although the goal of surgery is to remove all of the visible cancer, microscopic cells can be left behind, either in the breast or elsewhere. In some situations, this means that another surgery could be needed to remove remaining cancer cells.
For larger cancers, or those that are growing more quickly, doctors may recommend systemic treatment with chemotherapy or hormonal therapy before surgery, called neoadjuvant therapy. There may be several benefits to having other treatments before surgery:
- Women who may have needed a mastectomy could have breast-conserving surgery (lumpectomy) if the tumor shrinks before surgery.
- Surgery may be easier to perform.
- Your doctor may find out if certain treatments work well for the cancer.
- Women may also be able to try a new treatment through a clinical trial.
After surgery, the next step in managing early-stage breast cancer is to lower the risk of recurrence and to get rid of any remaining cancer cells. These cancer cells are undetectable but are believed to be responsible for recurrences of cancer as they can grow over time. Treatment given after surgery is called adjuvant therapy. Adjuvant therapies may include radiation therapy, chemotherapy, targeted therapy, and/or hormonal therapy (see below for more information on each of these treatments).
Whether adjuvant therapy is needed depends on the chance that any cancer cells remain in the breast or the body and the chance that a specific treatment will work to treat the cancer. Although adjuvant therapy lowers the risk of recurrence, it does not completely get rid of the risk.
Along with staging, other tools can help estimate prognosis and help you and your doctor make decisions about adjuvant therapy. This includes tests that can predict the risk of recurrence by testing your tumor tissue.
When surgery to remove the cancer is not possible, it is called inoperable. The doctor will then recommend treating the cancer in other ways. Chemotherapy, targeted therapy, radiation therapy, and/or hormonal therapy may be given to shrink the cancer.
For recurrent cancer, treatment options depend on how the cancer was first treated and the characteristics of the cancer mentioned above, such as ER, PR, and HER2.
Descriptions of the most common treatment options for early-stage and locally advanced breast cancer are listed below. Your care plan should also include treatment for symptoms and side effects, an important part of cancer care. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear.
Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. It is also important to check with your health insurance company before any treatment begins to make sure it is covered.
Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. Surgery is also used to examine the nearby axillary lymph nodes, which are under the arm. A surgical oncologist is a doctor who specializes in treating cancer with surgery.
The types of surgery include the following:
- Lumpectomy. This is the removal of the tumor and a small, cancer-free margin of healthy tissue around the tumor. Most of the breast remains. For invasive cancer, radiation therapy to the remaining breast tissue is generally recommended after surgery. For DCIS, radiation therapy after surgery may be an option depending on the patient and the tumor. A lumpectomy may also be called breast-conserving surgery, a partial mastectomy, quadrantectomy, or a segmental mastectomy.
- Mastectomy. This is the surgical removal of the entire breast. There are several types of mastectomies. Talk with your doctor about whether the skin can be preserved, called a skin-sparing mastectomy, or the nipple, called a total skin-sparing mastectomy.