Treatments for Breast Cancer
Breast cancer is treated both locally (with surgery and radiation) and systemically (hormone therapies, chemotherapy, and targeted therapies).
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Chemotherapy involves drugs used to kill cancer cells. Today it is given with anti-nausea medication to reduce this debilitating side effect. Specific kinds of chemotherapy are:
- Anthracyclines, such as doxorubicin (Adriamycin) and epirubicin (Ellence)
- Taxanes, such as paclitaxel (Taxol) and docetaxel (Taxotere)
- 5-fluorouracil (5-FU)
- Cyclophosphamide (Cytoxan)
- Carboplatin (Paraplatin)
Not all women with breast cancer will receive chemotherapy.
Hormone (endocrine) therapy is a systemic, targeted treatment available for certain women who have estrogen positive (ER+ (ER positive, estrogen receptor positive) or PR+ (PR positive, progesterone receptor positive)) tumors. It can be given along with chemotherapy, or in place of it. It is used to prevent estrogen from fueling the growth of those tumors or any residual or recurrent tumor cells in the body. These therapies do not work for estrogen and progesterone negative tumors. Although standard treatment is 5 years, it has been extended in many circumstances to 10 years based on the risk of tumor recurrence.
A woman with early stage hormone receptor positive cancer can be treated with aromatase inhibitors like Arimidex (anastrozole) Aromasin (exemestane) or Femara (letrozole), which reduce estrogen by blocking an enzyme called aromatase and keeping it from converting androgens into estrogen; or Tamoxifen, which occupies estrogen receptors so that estrogen can’t get to the cell.
Radiation therapy is almost always recommended if the surgical choice is lumpectomy, since research has shown this reduces the risk of recurrence within the breast if you have an invasive breast cancer. If lymph nodes are involved, then radiation may be recommended after mastectomy or if the tumor is larger than 5cm or the tumor is at or close to margins.
Radiation may be optional in those with a diagnosis of DCIS or intraductal cancer. With this diagnosis, it is important to explore whether the risk of local recurrence is high enough to warrant radiation.
Different types of radiation for breast cancer include: intraoperative radiation (radiation given during breast surgery), internal radiation (where small pieces of radioactive material, are placed in the area that had cancer; this therapy is currently still under study), and external radiation, the most common type.
There are side effects of radiation for breast cancer, including breast pain, skin soreness, redness, or peeling, fatigue, and nausea. There can be long term side effects of radiation for breast cancer too, including lymphedema, or severe swelling, in the arm, hands, fingers, or chest. The risk of lymphedema from radiation therapy is greater in women who have also had many axillary nodes removed during their surgery, and/or who are overweight.
Surgery options include breast conserving surgery (called BCS or lumpectomy) or removal of the breast (mastectomy). In addition, lymph nodes may be removed from under the arm to check for the presence of cancer cells. Currently, a sentinel node biopsy can identify lymph node involvement with much less of a chance of the debilitating effect of arm swelling or lymphedema which may result after having lymph nodes removed.
Breast reconstruction in conjunction with mastectomy is an option. It may involve a woman’s own tissue (flaps, as in DIEP-flap reconstruction) or a saline or silicone implant. Some women are opting for nipple sparing mastectomy or skin sparing mastectomy. Talk to your doctor to determine if you are a candidate for these procedures. Other women may have reconstruction after radiation instead.
Targeted cancer therapies are drugs or other substances that block the growth and spread of cancer. Targeted therapies select specific cells to attack, leaving healthy cells alone. They are often used with other types of therapy suited to specific types of breast cancer. Targeted therapies are a cornerstone of precision medicine, a form of medicine that uses information about a person’s genes and proteins to prevent, diagnose, and treat disease.
Most targeted therapies focus on HER2-positive breast cancer. About 25% of cancers express the Her 2 protein gene. HER2 positive breast cancers make too much of the HER2 protein, which accepts signals that tell the cancer to keep dividing and spreading. Herceptin and Perjeta are drugs that attach themselves to the HER2 receptors on the surface of breast cancer cells and block them from receiving growth signals; they can also alert the immune system to destroy cancer cells onto which it is attached.
Other targeted therapies are used in women with late stage or metastatic breast cancer.
Triple negative breast cancer is hormone receptor negative (ER- and PR-) and HER2 negative, which disqualifies it from being treated with most targeted therapies and hormone therapies. This kind of cancer is usually treated with chemotherapy, sometimes in the neoadjuvant (pre-surgery) setting, although more research is needed to determine if neoadjuvant chemo actually improves response. Sometimes, triple negative breast cancer responds better to traditional chemotherapy than hormone positive breast cancer. But in general, more treatment options need to be developed for this kind of cancer.
Written by: Anna Szilagyi. Reviewed by: Dr. James Speyer, NYU Langone.