Treatment for breast cancer

Doctors base treatment recommendations for breast cancer on several factors, including:

• Stage of cancer
• Subtype based on pathology
• Additional testing, including biomarkers and other tests
• How fast the cancer is growing or how likely it is to spread
• Whether the cancer is newly-diagnosed or has recurred after one or more treatments

Local and systemic therapy

Treatment for breast cancer focuses on two approaches:

• Local therapy treats the breast and the surrounding lymph nodes to prevent the cancer from recurring. Local breast cancer therapies include:
  • surgery
  • radiation 
• Systemic therapy treats the entire body in order to prevent or control spread to other areas outside the breast. Treating the entire body with medications to destroy cancer cells that may have traveled in the body can help prevent future metastases. Systemic therapy is also used to treat cancer that is already metastatic and has spread to distant organs. Systemic therapies include:
  • chemotherapy 
  • hormonal (endocrine) therapy 
  • targeted therapy (e.g., Herceptin and other anti-HER2 therapies, Piqray)
  • PARP inhibitors (a type of targeted therapy)
  • immunotherapy

Timing of treatment

Breast cancer treatment may be given:

• before surgery (called neo-adjuvant or pre-operative therapy)
• after surgery in early stage cancer (called adjuvant therapy or maintenance therapy)
• for treatment of recurrent or advanced cancers

Treatment for DCIS

DCIS is usually treated with:

• Surgery: Lumpectomy (surgery to remove the cancer but not the entire breast) followed by radiation or mastectomy. Lymph nodes may be removed during surgery to see if the cancer has spread beyond the milk duct.
• Hormonal therapy: Most DCIS is ER-positive. Most people receive hormone therapy after surgery for DCIS. 

Treatment for invasive cancer

Invasive breast cancer has spread beyond the milk duct or lobules into the surrounding tissue. Invasive breast cancer can spread within the breast, to the lymph nodes, the chest wall and to other parts of the body. It is usually treated by:

• Surgery: Lumpectomy (surgery to remove the cancer but not the entire breast) followed by radiation or mastectomy (removal of the entire breast). Lymph nodes are removed to see how much the cancer has spread.
• Hormonal therapy (also called endocrine therapy): Most people with hormone sensitive tumors (HR-positive) cancers receive hormone therapy after surgery. The most common types of hormonal therapies are: 
  • Selective estrogen receptor modulators (SERM) block cells from using estrogen. Example of common SERMs include tamoxifen and raloxifene.
  • Selective estrogen receptor degraders (SERD) damage the receptors that cancer cells use to bind to estrogen. The SERDs with FDA approval include Faslodex (fulvestrant) and Oserdu (elacestrant).
  • Aromatase inhibitors (AI) block cells from making estrogen. Examples of aromatase inhibitors include Arimidex (anastrozole), Femara (letrozole) and Aromasin (exemestane). 
• Chemotherapy: Chemotherapy is often used to treat breast cancer that is not hormone sensitive (ER-negative and PR-negative). Chemotherapy may be given before surgery (neo-adjuvant) to shrink the size of the cancer and number of lymph nodes affected and after surgery (adjuvant) to kill any remaining cancer cells that may have escaped the breast area. In the case of metastatic breast cancer, chemotherapy is often given to keep the cancer from growing.
• The most common chemotherapy agents used to treat newly-diagnosed breast cancer include one or more of the following:
  • Cytoxan (cyclophosphomide)
  • Taxotere (Docetaxol) or Abraxane (nab-paclitaxel)
  • Adriamycin (Doxorubicin) 
• In recurrent breast cancer or other situations, oncologists may use the following chemotherapy:
  • Xeloda (capecitabine)
  • Carboplatin
• Radiation therapy: Radiation therapy is used to treat the breast and sometimes surrounding lymph nodes after surgery to prevent recurrence. In people with metastatic breast cancer which has spread to their bones, brain or other sites, radiation is often given to reduce the size of the tumor and manage pain or other symptoms.
• Anti-HER2 therapy: HER2-positive breast cancer is usually treated with medications that target the HER2 protein. 
• Other therapies such as immunotherapy, PARP inhibitors and other targeted therapies may be used to treat invasive breast cancer. Additional biomarker or genetic testing is often needed to help choose the patients most likely to respond to these treatments.