Learn about cancer

Basic information about cancer, examinations, treatments and life after cancer

Treatment methods

Women diagnosed with breast cancer have many treatment options. These include surgery, radiation therapy, chemotherapy, hormone therapy, and biological therapy. Many women may receive more than one type of treatment, depending on certain factors; such as the stage of breast cancer, the size of the tumor in relation to the breast, and whether the patient has gone through menopause.

There are to main types of treatments:

  • Local therapy: The two forms of local therapy are surgery and radiation therapy. These forms of therapy remove or destroy cancer in the breast. When breast cancer has spread to other parts of the body, local therapy may be used to control the disease in those specific areas.
  • Systemic therapy: The forms of systemic therapy are: chemotherapy, hormone therapy, and biological therapy. This form of therapy uses the bloodstream to destroy, or control, cancer throughout the entire body. Systemic therapy is also used to shrink the tumor before surgery or radiation. But systemic therapy can also be used after surgery and radiation, to help prevent the cancer from returning. Systemic therapy is furthermore used for cancer that has metastasized (spread to other organs).
    Because cancer treatments often damage healthy cells and tissues, side effects are common. The side effects depend mainly on the type and extent of the treatment. Not every woman may encounter the same side effects.

Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them.

Surgery

The most common treatment for breast cancer is surgery. There are several different types of surgery:

Conservative surgery (breast-sparing surgery)

This type of surgery aims to take away the cancer, while leaving behind as much healthy breast tissue as possible, ultimately leaving the breasts intact. To try to make sure that all the cancer has been removed the surgeon removes a border of healthy tissue around the tumor. This tissue is then sent to the pathologist, who inspects the healthy layer for signs of cancer cells. If the layer is clear of cancer it will be reported as a ‘healthy margin’ or ‘clear margin’. If the layer is not a ‘clear margin’, you may require further surgery. The surgeon often removes the underarm lymph nodes as well, through a separate incision. This procedure is called an axillary lymph node dissection. It shows whether cancer cells have entered the lymphatic system. The picture illustrates the tissue removed during a conservative surgery. Conservative surgery is sometimes also called lumpectomy, or “wide local excision”. In practice, these two are very similar to the conservative surgery. The surgeon removes the tumour, with a thin layer of healthy tissue around it. Lumpectomy is also used to describe an open biopsy. This is when the doctor does not know if the lump is cancer, and he/she must remove it in order to find out. Segmentectomy (quadrantectomy) is another form of conservative surgery, but is not performed as often as a lumpectomy. It resembles the wide local incision, but the surgeon removes more breast tissue. A segmentectomy removes approximately a quarter of the breast tissue, making the operation more noticeable than lumpectomy. Because the surgery is so noticeable breast reconstruction surgery is often an option. After any of the above mentioned surgeries, patients usually undergo radiotherapy to make sure that there are no breast cancer cells left behind in the remaining breast tissue.

Mastectomy

For some women mastectomy is the more suitable treatment; the complete removing of the breast. Mastectomy is most suitable when:

  • There is a large lump, particularly in a small breast.
  • The lump is located in the middle of the breast.
  • There is cancer in multiple areas of the breast.
  • There are areas of DCIS in the rest of the breast.

As with conservative surgery, there are different types of mastectomy:

  • Simple mastectomy: also known as total mastectomy, this form only removes the breast tissue
  • Radical mastectomy: removes the breast tissue and chest wall muscles
  • Modified radical mastectomy: removes the breast and lymph nodes under the arm, leaves the major chest wall muscles intact

Once you have undergone a mastectomy, you may feel off balance, possibly even more so if you have large breasts. This imbalance may cause discomfort in your neck and back, as muscles will tense to cope with the imbalance. Also, the skin where your breast was removed may feel tighter than usual, and your arm and should muscles may feel stiff and weak. This will usually all go away with time. The doctor, nurse, therapist, often suggests exercises to regain the movement and strength in your muscles; this exercise will also help reduce the stiffness and pain. The removing of the lymph nodes under the arm will slow down the flow of lymph fluid, which can cause build ups and swelling. This swelling is called lymphedema, and can develop right after surgery, but also months or even years later. The lymphs do not repair themselves, and do not grow back. There is also no known cure for lymphedema. Patients who develop lymphedema are often given a compression sleeve and glove, which they are supposed to wear every day. This compression sleeve helps against the swelling.


Conservative surgery

Conservative surgery



Simple mastectomy

Simple mastectomy


Modified radical mastectomy

Modified radical mastectomy



Radiation therapy

Radiation therapy is a treatment that uses high-energy rays to destroy cancer cells. It is much like getting an x-ray, but the radiation administered is much more intense (yet painless). Most women receive radiation therapy after undergoing a form of breast cancer surgery. This form of therapy is used to ensure that any remaining cancer cells are destroyed, thereby reducing the chance that the patient develops breast cancer again. Women sometimes also receive this form of therapy prior to the surgery, in order to destroy cancer cells, and shrink the tumor. It is used when the tumor is large or may be hard to remove. There are two main types of radiation therapy; in certain cases women can receive both forms:

External Radiation

External radiation is the more common of the two types. This therapy focuses the radiation on the area affected by cancer. The radiation is admitted by a machine that is outside the body. The extent of the radiation depends on the surgery the patient received (lumpectomy or mastectomy). If a lumpectomy was preformed, the entire breast receives radiation, and the area where the tumour was is given an extra boost to prevent it from coming back. The radiation may also include the chest wall and underarm, depending on how much damage the cancer did.

If the external radiation is performed after surgery, there is a healing period of about a month, so that the operated tissue has time to recover. If the patient also receives chemotherapy, radiation therapy is postponed till the chemo has been completed.

To make sure that the radiation team beams the right area of the patient, they first make careful measurements to determine the correct angles and the proper dose. They will also make some ink marks on the patient’s body, so that they can use them later as a guide to focus on the right area again (these marks can sometimes be permanent). Patients are often advised not to use lotions, powders, antiperspirants, etc. during the radiation therapy, as these might interfere with the beam.

Patients receiving radiation after a lumpectomy are usually treated about 5 days a week for about 6 or 7 weeks. The treatment itself only lasts a few minutes, but the setup time is much longer.

Potential side effects of radiation therapy are:

  • Swelling and heaviness in the breast
  • Sunburn-like skin changes in the treated areas
  • Fatigue
  • Breasts become smaller and firmer
  • Weaken ribs (very rare)
  • Your doctor will probably also advise you to avoid exposed your treated area to the sun, as this will only increase the changes to your skin. The changes however are only temporary, and usually go away 6 to 12 months after the therapy is complete

Internal Radiation

Also known as brachytherapy, internal radiation is the second method for delivering radiation therapy. The difference between this form and internal radiation is related to the way it is administered. Internal radiation, as the name says, is administered internally (from inside the patient). The doctor places (small) radioactive implants in the breast tissue, next to the tumour site. A woman who has received the implants must stay in the hospital until they are removed, this may take several days. Not everyone can receive internal radiation; it depends, among others, on the tumour size and location. There are two types of internal radiation:

  • Intracavitary branchytherapy: this form of internal radiation uses a small balloon attached to a thin tube. The balloon is inserted (deflated) into the space left by the lumpectomy and is filled with a salt water solution. The balloon and tube are left in place throughout the treatment, with the end of the tube sticking out of the breast. The doctor then places a source of radioactivity in the middle of the balloon, and removes it twice a day. This form of therapy is administered for a 5 day period, after which the balloon is deflated and removed.
  • Interstitial branchytherapy: several small, hollow tubes (catheters) are inserted into the breast around the area of the lumpectomy, and are left there for several days. Radioactive pellets will then be inserted into the catheters for short periods each day and then removed.

Chemotherapy

Chemotherapy is a chemical treatment, which is not only used for breast cancer, but also other forms of cancer. The drugs used during chemo have a high level of toxicity, which is supposed to kill of the cancer cells, but also kills off healthy cells. The chemotherapy drugs are administered through injections into the vein (intravenously) or as tablets. Administering the drugs through an IV usually takes a few hours. Following the treatment, patients receive a rest period of a few weeks; this allows the body to recover from the side effects. Chemotherapy usually takes between 4 and 6 months. There are many different types of chemotherapy drugs, and combination drugs, used to treat breast cancer. Doctors often offer the choice of chemotherapy, because the different combinations have different side effects.

Individual chemotherapy drugs:

  • Capecitabine
  • Gemcitabine
  • Mitoxantrone
  • Chlorambucil
  • Idarubicin
  • Paclitaxel
  • Cyclophosphamide
  • Liposomal doxorubicin
  • Thiotepa
  • Docetaxel
  • Melphalan
  • Vinblastine
  • Epirubicin
  • Methotrexate
  • Vincristine
  • Fluorouracil
  • Mitomycin
Combination chemotherapy drugs:

  • AC chemotherapy
  • CAF chemotherapy
  • CMF chemotherapy
  • Capecitabine and docetaxel chemotherapy
  • EC chemotherapy
  • E-CMF (Epi-CMF) chemotherapy
  • FEC chemotherapy
  • GemTaxol chemotherapy
  • MM chemotherapy
  • TAC chemotherapy

Chemotherapy drugs can cause side effects, but these can usually be controlled through other medicines. Some of the side effects are:

  • Lowered resistance to infection – chemotherapy reduces the production of white blood cells by the bone marrow, making patients more vulnerable to infections. It is important that you contact your doctor immediately if:
    • Your temperature rises above 38ºC (100.5ºF)
    • You suddenly feel ill (even without a fever)
  • Bruising or bleeding – chemotherapy can also reduce the production of platelets, these help against blood clots. This can cause unexplained bruising or bleeding, such as nosebleeds, bloodspots or rashes on your skin, or even bleeding gums. If you encounter any of this during your chemotherapy you must contact your doctor.
  • Low red blood cell count (anemia) – chemotherapy may make you anemic, meaning that you may feel tired and breathless.
  • Nausea and vomiting – certain drugs can make you feel sick, or even be sick. This can be helped by taking anti-emetics (anti-sick drugs), you can contact your doctor for more information about this.
  • Sore mouth – some drugs can make your mouth sore and may cause small ulcers.
  • Poor appetite – the treatment may cause you to lose your appetite. It is important to stay nutritious during the chemo, and you could replace meals with nutritious drinks or a soft diet. View our section on Keeping Healthy for more information.
  • Hair loss – certain drugs may cause hair loss during chemo, which can be very upsetting. But it is only temporary, and should start to grow back within 3-6 months after the end of treatment.

Not every chemotherapy patient will encounter the above side effects, but those who do will notice that they will gradually disappear once treatment is over. Chemotherapy patients must also keep the following in mind:

 

  • Early Menopause – certain drugs might trigger an early menopause for certain women.
  • Contraception – doctors strongly advise against pregnancy during chemotherapy, as the drugs may harm the developing fetus. It is important to use effective contraception during your treatment, and for at least a year after the treatment is completed. It is also very important that condoms are used during sex within the first 48 hours after chemotherapy, this to protect your partner from any of the drug that may be present in vaginal fluid.

Hormone therapy

Certain breast tumors require hormones to grow. Through hormone therapy doctors try to keep cancer cells from obtaining those hormones. There are many different types of hormonal therapy, each working in a slightly different way. Doctors often subscribe hormone therapy after surgery and radiotherapy, or chemotherapy, to reduce the chance of the cancer from returning. This form of therapy is only effective on women whose cancer cells have receptors for estrogen and/or progesterone. This is classified as being estrogen-receptor positive (ER+) or progesterone-receptor positive (PR+).

There are many issues to take into account when choosing which type of hormone therapy a patient should use, including:

  • the stage and grade of the cancer
  • which other treatments are being used
  • whether the cancer cells are HER2-positive

Unlike chemotherapy, hormone therapy is a long-term therapy, sometimes lasting for more than 5 years. Here is a list of hormone therapy drugs:

  • Anastrozole
  • Exemestane
  • Fluvestrant
  • Goserelin
  • Letrozole
  • Medroxyprogesterone
  • Megestrol
  • Tamoxifen
  • Toremifene

Not all women have side effects from hormone therapy, but the side effects that do exist differ per drug, search the above mentioned drugs for more information.

Biological therapy

Biological therapy is a form of breast cancer treatment that strengthens the patients’ immune system. This form of therapy helps fight cancer, but it also controls side effects from other cancer treatments, such as chemotherapy. Many of the biological treatments are still in the experimental stage.

Biological therapy and chemotherapy are both treatment methods for fighting cancer, but they work in different ways. Where chemotherapy is an aggressive drug, that attacks breast cancer; biological therapy strengthens the patients’ immune system and uses antibodies to attack cancer cells. Doctors have not yet been able to determine how biological therapy helps the immune system, but they believe that biological therapy:

  • Helps stop or slow the growth of cancer cells by sticking to special receptors on the cells
  • Makes it easier for the immune system to destroy, cancer cells by signaling its own natural killer cells to attack
  • Can work with chemotherapy medications, stopping damaged cancer cells from repairing themselves

Despite the fact that this form of therapy is labeled biologic, the medication can have side effects, such as:

  • Allergic reactions
  • Difficulty breathing
  • Swelling Nausea
  • Fever or chills
  • Dizziness

Examples of drugs used for biological therapy:

  • Herceptin
  • Angiogenesis inhibitors
  • Signal transduction inhibitors

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