The first type of treatment for breast cancer is usually surgery. The type of surgery depends on the type of breast cancer you have. Surgery is usually followed by chemotherapy or radiotherapy or, in some cases, hormone or biological treatments. Again, the treatment you will have depends on the type of breast cancer. Your doctor will discuss the best treatment plan with you. Sometimes, chemotherapy or hormone therapy will be the first treatment.
Secondary breast cancer
Most breast cancers are discovered in the early stages of the disease. However, a small proportion of women discover that they have breast cancer after it has spread to other parts of the body (metastasis). If this is the case, the type of treatment you have may be different. Secondary cancer, also called advanced or metastatic cancer, is not curable and treatment aims to achieve a remission, where the cancer shrinks or disappears, making you feel normal and able to enjoy life to the full.
There are two types of surgery for breast cancer. These are surgery to remove just the cancerous lump (tumour), known as breast-conserving surgery, and surgery to remove the whole breast, which is called a mastectomy. In many cases, a mastectomy can be followed by reconstructive surgery to recreate the breast that was removed.
Studies have shown that breast-conserving surgery followed by radiotherapy is as successful as total mastectomy at treating early-stage breast cancer.
Breast-conserving surgery ranges from a lumpectomy or wide local excision, in which just the tumour and a little surrounding breast tissue is removed, to a partial mastectomy or quadrantectomy, in which up to a quarter of the breast is removed.
If you have breast-conserving surgery, the amount of breast tissue you have removed will depend on:
- the type of cancer you have
- the size of the tumour and where it is in your breast
- the amount of surrounding tissue that needs to be removed
- the size of your breasts
Your surgeon will always remove an area of healthy breast tissue around the cancer, which will be tested for traces of cancer. If there is no cancer present in the healthy tissue, there is less chance that the cancer will recur. If cancer cells are found in the surrounding tissue, you may need to have more tissue removed from your breast.
After breast-conserving surgery, you will usually be offered radiotherapy to destroy any remaining cancer cells.
A mastectomy is the removal of all the breast tissue, including the nipple. If there are no obvious signs that the cancer has spread to your lymph nodes, you may have a mastectomy, in which your breast is removed, along with a sentinel lymph node biopsy (SLNB).
If the cancer has spread to your lymph nodes, you will probably need more extensive removal (clearance) of lymph nodes from the axilla (under your arm).
Breast reconstruction is surgery to make a new breast shape that looks as much as possible like your other breast. Reconstruction can be carried out at the same time as a mastectomy (immediate reconstruction) or it can be carried out later (delayed reconstruction). It can be done either by inserting a breast implant or by using tissue from another part of your body to create a new breast.
Lymph node surgery
To find out if the cancer has spread, a procedure called a sentinel lymph node biopsy (SLNB) may be carried out. The sentinel lymph nodes are the first lymph nodes that the cancer cells reach if they spread. They are part of the lymph nodes under the arm (axillary lymph nodes). The position of the sentinel lymph nodes varies, so they are identified using a combination of a radioisotope and a blue dye.
The sentinel lymph nodes are examined in the laboratory to see if there are any cancer cells present. This provides a good indicator of whether the cancer has spread.
If there are cancer cells in the sentinel nodes, you may need further surgery to remove more lymph nodes from under the arm.
Radiotherapy uses controlled doses of radiation to kill cancer cells. It is generally given after surgery and chemotherapy to kill any remaining cancer cells.
If you need radiotherapy, your treatment will begin within 12 weeks of your surgery or within a month of your chemotherapy if you receive chemotherapy. Radiotherapy treatment is typically given five days a week and may last for three to five weeks. Each treatment session will only last a few minutes.
The type of radiotherapy you have depends on the type of cancer and the type of surgery you have. Some women may not need to have radiotherapy at all.
- Breast radiotherapy. After breast-conserving surgery, radiation is applied to the whole of the remaining breast tissue.
- Chest wall radiotherapy. After a mastectomy, radiotherapy is applied to the chest wall.
- Breast boost. Some women may be offered a boost dose radiotherapy. This means an additional dose of radiotherapy to the area of the breast where they cancer was removed. Having a boost may mean that you are more likely to get radiotherapy side effects.
- Radiotherapy to the lymph nodes. Lymph nodes behind the collar bone (supraclavicular fossa) or under the arm (axilla) may be treated to kill any cancer cells that may be present.
The side effects of radiotherapy include:
- The skin inside the area treated with radiotherapy may become red and irritated and occasionally may peel. These effects heal after radiotherapy but the skin colour may be permanently darker or lighter in the treated area.
- fatigue (extreme tiredness)
- lymphoedema (excess fluid build-up in your arm caused by blockage of the lymph nodes under your arm)
- The breast may become tender and sensitive. In the long-term the breast may appear smaller in size and the breast tissue may harden (fibrosis)
Chemotherapy involves using anti-cancer (cytotoxic) drugs to kill the cancer cells. Chemotherapy is usually used after surgery to destroy any cancer cells that have not been removed. This is called adjuvant chemotherapy. In some cases, you may have chemotherapy before surgery, which is generally used to shrink a large tumour. This is called neo-adjuvant chemotherapy.
Several different drugs are used for chemotherapy and often three are given at once. The choice of drugs and the combination depends on the type of breast cancer and how much it has spread.
Chemotherapy is usually given as an outpatient treatment, which means you will not have to stay in hospital overnight. The drugs are usually given through a drip straight into the blood through a vein. In some cases, you may be given tablets that you can take at home. You may receive chemotherapy sessions once every two to three weeks, over a period of four to eight months, to give your body a rest in between treatments.
The main side effects of chemotherapy are caused by their influence on normal, healthy cells, such as immune cells. Side effects include:
- loss of appetite
- nausea and vomiting
- hair loss
- sore mouth
Many side effects can be prevented or controlled with medicines that your doctor can prescribe.
Chemotherapy drugs can also stop the production of oestrogen in your body. Oestrogen is known to encourage the growth of some breast cancers. If you have not been through the menopause, your periods may stop while you are undergoing chemotherapy treatment. After you have finished the course of chemotherapy, your ovaries should start producing oestrogen again. However, in some cases this does not happen and you will enter an early menopause. This is more likely in women over the age of 40, as they are closer to menopausal age. Your doctor will discuss with you the impact that any treatment will have on your fertility.
Chemotherapy for secondary breast cancer
If your breast cancer has spread beyond the breast and lymph nodes to other parts of the body, chemotherapy will not cure the cancer but it may shrink the tumour, relieve your symptoms and help lengthen your life.
Some breast cancers are stimulated to grow by the hormones oestrogen or progesterone, which are found naturally in your body. These types of cancer are known as hormone-receptor-positive cancers. Hormone therapy works by lowering the levels of hormones in your body or by stopping their effects.
The type of hormone therapy you have will depend on the stage and grade of your cancer, which hormone it is sensitive to, your age, whether you have been through the menopause and what other type of treatment you are having. You will probably have hormone therapy after surgery and chemotherapy, but it is sometimes given before surgery to shrink a tumour, making it easier to remove.
Hormone therapy may be used as the only treatment for breast cancer if your general health prevents you from having surgery, chemotherapy or radiotherapy.
In most cases, you will need to take hormone therapy for up to five years after your surgery.
If your breast cancer is not sensitive to hormones, hormone therapy will have no effect.
Tamoxifen stops oestrogen from binding to oestrogen-receptor-positive cancer cells. Tamoxifen is taken every day as a tablet or liquid. It can cause several side effects, including:
- changes to your periods
- nausea and vomiting
- hot flushes
- aching joints
- weight gain
If you have been through the menopause, you may be offered an aromatase inhibitor. This drug works by blocking aromatase, a substance that helps to make oestrogen in the body after the menopause. Before the menopause, oestrogen is made by the ovaries.
Three aromatase inhibitors may be offered. These are anastrozole, exemestane and letrozole. These are taken as a tablet once a day. Side effects include:
- hot flushes and sweats
- loss of interest in sex
- nausea and vomiting
- aching joints and bone pain
- skin rashes
Ovarian ablation or suppression
In women who have not been through the menopause, oestrogen is produced by the ovaries. Ovarian ablation or suppression stops the ovaries from working and from producing oestrogen.
Ablation can be carried out using surgery or radiotherapy. This stops the ovaries working permanently and means that you will go through the menopause early.
Ovarian suppression involves using a drug called goserelin, which is a luteinising hormone-releasing hormone agonist (LHRHa). Your periods will stop while you are taking it, although they should start again once your treatment is complete. If you are approaching the menopause (around the age of 50), your periods may not start again once you stop taking goserelin.
Goserelin is taken as an injection once a month and can cause menopausal side effects, including:
- hot flushes and sweats
- mood swings
- trouble sleeping
Biological therapy (targeted therapy)
Some breast cancers are stimulated to grow by a protein called human epidermal growth factor receptor 2 (HER2). These cancers are called HER2-positive. Biological therapy works by stopping the effects of HER2 and by helping your immune system to fight off cancer cells.
If you have high levels of the HER2 protein and are able to have biological therapy, you will probably be prescribed a medicine called trastuzumab. Trastuzumab, also known by the brand name Herceptin, is usually used after chemotherapy.
Trastuzumab is a type of biological therapy known as a monoclonal antibody. Antibodies occur naturally in your body and are made by your immune system to destroy harmful cells, such as viruses and bacteria. The trastuzumab antibody targets and destroys cancer cells that are HER2-positive.
Trastuzumab is given intravenously, through a drip, and you will have the treatment in hospital. Each treatment session takes up to one hour and the number of sessions you need will depend on whether you have early or more advanced breast cancer. On average, you will need a session once every three weeks for early breast cancer and weekly sessions if your cancer is more advanced.
Trastuzumab can cause side effects, including heart problems. This means that it is not suitable if you have a heart problem, such as angina, uncontrolled high blood pressure (hypertension) or heart valve disease. If you need to take trastuzumab, you will need regular tests on your heart to make sure it is not causing any problems. Other side effects of trastuzumab may include:
- an initial allergic reaction to the drug, which can cause nausea, wheezing, chills and fever
- aches and pains
A great deal of progress has been made in breast cancer treatment and more women now live longer and have fewer side effects of treatment. These advances were discovered in clinical trials, where new treatments and treatment combinations are compared with standard ones.
All cancer trials in Ireland are carefully overseen to ensure the trial is worthwhile and safely conducted. In fact, participants in clinical trials can do better overall than those in routine care.
If you are asked to take part in a trial, you will be given an information sheet and, if you want to take part, you will be asked to sign a consent form. You can refuse or withdraw from a clinical trial without it affecting your care.
Dealing with cancer can be a huge challenge, for both patients and their families. It can bring emotional and practical difficulties. Many women have to cope with the removal of part or all of a breast, which can be very upsetting.
It often helps to talk about your feelings or other difficulties with a trained counsellor or therapist. You can ask for this kind of help at any stage of your illness. There are various ways to find help and support:
- Your hospital doctor, specialist nurse or GP can refer you to a counsellor. If you are feeling depressed, talk to your GP. A course of antidepressant drugs may help or your GP can arrange for you to see a counsellor or psychotherapist.
- It can help to talk to someone who has been through the same thing as you. Many organisations have helplines and online forums. They can also put you in touch with other people who have had cancer treatment.
Complementary therapies are holistic therapies that can promote physical and emotional wellbeing. They are given alongside conventional treatments and include relaxation techniques, massage, aromatherapy and acupuncture.
Complementary therapy can help some women cope with diagnosis and treatment and provide a break from the treatment plan.
Your hospital or breast unit may be able to provide access to complementary therapies or suggest where you can get them. It is important to speak to your breast cancer specialist nurse about any complementary therapy you wish to use to make sure it does not interfere with your conventional treatment.
- Chemotherapy is a treatment of an illness or disease with a chemical substance, for example in the treatment of cancer.
- Lymph nodes
- Lymph nodes are small oval tissues that remove unwanted bacteria and particles from the body. They are part of the immune system.
- A mastectomy is an operation to remove a breast and most of the skin covering it. It is usually done to treat or prevent breast cancer.
- Radiotherapy uses X-rays to treat disease, especially cancer.