With advancements in research and treatment technologies, the options for breast cancer treatment are as varied as ever. Choosing the right treatment plan involves a careful consideration of the following:

• Stage of the breast cancer
• Type of breast cancer
• Medical history
• Personal wants and needs

Because each case of breast cancer is unique, treatment plans can vary greatly from patient to patient. Patients should carefully consider the risks and benefits of each treatment method before choosing a plan. Breast cancer can be treated either locally or systemically.

Local therapy involves the targeted treatment of a specific cancerous site, such as breast tumors or cancerous lymph nodes. Types of local therapy include:

• Surgery
• Radiation therapy

Systemic (adjuvant) therapy is aimed at the entire body. This type of treatment is useful in eliminating cancer cells that have spread to other areas of the body from the site of the initial tumor. Systemic therapy is also called adjuvant therapy, because it is often used in combination with local therapy. Types of systemic therapy include:

• Chemotherapy
• Hormone therapy
• Targeted therapy

Treatment By Stage

The stage of the breast cancer is one of the most important factors to take into consideration when choosing the proper treatment plan. Treatment for breast cancer is as follows

STAGE 0 (Ductal Carcinoma in Situ, DCIS)

In ductal carcinoma in situ (DCIS), the presence of abnormal cells is limited to the milk ducts and has not yet spread to other areas of the body. This is the earliest and most commonly diagnosed stage of non-invasive breast cancer. Treatment for DCIS typically includes:

• Surgery to remove the abnormal tissue. This may be done either as a lumpectomy (removal of part of the breast) or mastectomy (removal of entire breast), though the lumpectomy is the most commonly performed surgery for DCIS patients.
• Radiation therapy is most often given in combination with a lumpectomy or mastectomy in order to ensure the death of cancerous cells that may remain in the body after surgery.
• Hormone therapy is sometimes given after surgery/radiation treatment to prevent the cancer from recurring and/or progressing. The Susan G. Komen Foundation reports that women who have been treated with lumpectomy and radiation therapy for estrogen receptor-positive (ER+) DCIS may benefit from a five year course of hormone therapy with tamoxifen.

STAGE I & II (Early Breast Cancer)

Stage I breast cancer is characterized by the presence of tumors no larger than 2 centimeters in diameter. In stage IIA breast cancer, tumors are no larger than 2 centimeters in diameter but cancerous growth has been detected in the lymph nodes. Tumors larger than 2 cm but smaller than 5 cm with no evidence of cancerous growth in the lymph nodes are characterized as stage IIB. Treatment for early breast cancer may include:

• Surgery to remove either the entire breast (mastectomy) or part of the breast (lumpectomy). These procedures may or may not include the removal of the lymph nodes. Ideal candidates for lumpectomies have not received previous radiation treatment to the cancerous area, have two or less tumors with definable boundaries in a location that will not significantly disfigure the breast, and have no previous health conditions that might complicate surgery. Patients with a family history of breast cancer or those with more than two tumors may be more suited for a mastectomy.
• Radiation therapy is often given in combination with surgical procedures to prevent cancer progression and eliminate any remaining cancerous cells. The type and dose of the radiation treatment given largely depends on the location and size of the tumor.
• Chemotherapy. Chemotherapy involves the systemic delivery of anti-cancer drugs through the blood stream. Chemotherapy is usually only prescribed in cases tumors are larger than 2 cm in diameter or in especially high-risk cases.
• Targeted therapy. HER2 inhibitors may be helpful in the treatment of stage I and II breast cancers that test positive for the presence of a certain growth factor known as HER2. Frequently prescribed HER2 inhibitors include trastuzumab and pertuzumab.
• Hormone therapy can be used to treat cases of breast cancer that test positive for specific hormone receptors. Hormone therapy is recommended for patients with breast tumors larger than 3 centimeters or with lymph node tumors larger than 2 centimeters. It may also be recommended for high-risk cases with smaller breast tumors (1.9-2.9 centimeters)

Stage III (Advanced Breast Cancer)

In stage IIIA breast cancer, breast tumors are larger than 5 centimeters in diameter and cancerous growth has been detected in the lymph nodes. Tumors in this stage have not reached the breast skin or chest wall. In stage IIIB breast cancer, tumors have spread to involve the breast skin and/or chest wall. In stage IIIC breast cancer, the cancer has spread deep into the lymph nodes and throughout the breast.

Because stage III breast cancers are more severe than DCIS or stages I & II, the treatment is often more aggressive. Treatment for stage III breast cancers includes:

• Chemotherapy. For stage III breast cancers, chemotherapy is often given as neoadjuvant therapy, meaning it is given before surgical intervention in order to shrink tumors and slow the growth of cancerous cells.
• Surgery. If cancer responds well to neoadjuvant treatment, it may still be possible to conduct a partial mastectomy at this stage. Full mastectomies are most often the chosen surgical method for late stage III cases and those cases that do not respond to neoadjuvant therapy. In stage III cancers, surgical procedures will most likely involve the removal of lymph nodes.
• Radiation therapy may be used after a mastectomy, lumpectomy, or round of chemotherapy. For stage IIIA cancers, radiation is given to the whole breast and possibly nearby lymph nodes. For stages IIIB & IIIC, radiation is given to the breast, chest wall, and lymph nodes.
• Hormone therapy may be prescribed to slow the growth of cancerous cells in patients that have received chemotherapy, radiation, or surgical treatments. Premenopausal women most commonly prescribed a 5-year treatment with tamoxifen, which blocks the production of estrogen. Post-menopausal women may consider tamoxifen or an aromatase inhibitor, which lowers the bodily level of estrogen.

Stage IV (Metastatic Breast Cancer)

Stage IV breast cancers have spread beyond the local area of the breast to different parts of the body such as the bones, liver, lungs, or brain. Cancerous sites in a stage IV breast cancer patient that are not in the local area of the breast are known as metasteses.

Since most cases of stage IV breast cases are widespread, surgical options are less likely to be considered given that they may not eliminate the majority of the cancer cells and may put further stress on a patient. Treatment for stage IV cancers is mainly focused on the systemic slow of cancer growth. These include:

• Hormone therapy including antiestrogens, which stop the production of estrogen, aromatase inhibitors, which lower the level of estrogen in the body but do not stop its production, and other hormones such as megestrol acetate and fluoxymesterone. Hormone therapy may be accompanied by the removal of the ovaries (oophorectomy), radiation therapy directed at the ovaries, or ovarian suppression using lutenizing hormone-releasing hormone in order to slow the rate of estrogen production by the ovaries.
• Chemotherapy using one of four types of chemotherapy agents: alkylating agents, anthracyclines, antimetabolites, and microtubule inhibitors.
• Targeted therapy, which work to stop particular cellular functions that lead to the reproduction of cancer cells. Targeted therapy drugs used to treat stage IV breast cancers include:
• • Trastuzumab
  • Pertuzumab
  • Ado-trastuzumab emtansine
  • Lapatinib
  • Bevacizumab
  • Everolimus

Since the task of completely eliminating or curing stage IV breast cancer can be a daunting one, many patients and doctors choose a palliative approach to treatment. In palliative treatment, doctors and patients focus on physical and emotional comfort during treatment rather than aggressive elimination of the disease. This can help a patient relieve stress, anxiety, and pain while they live with their disease.

Palliative care for stage IV breast cancer may include:

• Prescription or over the counter pain medications
• Chemotherapy or targeted therapies to slow overall cancer growth and prolong life expectancy
• Working with a social worker to help a patient adjust to changes advanced stage breast cancer brings to daily life
• Alternative treatments such as acupuncture and massage
• Joining a support group online or in your community
• Psychological therapy sessions
• Working with a dietitian or nutritionist to outline a diet and exercise plan
• Meditation, prayer, or spiritual counseling

For more information on palliative care, visit the thirdAGE palliative care condition center.

Surgery

Many patients with breast cancer will need surgery either to remove a cancerous tumor from the breast (breast-conserving surgery) or to remove the entire breast (mastectomy).

Breast-Conserving Surgery. In breast-conserving surgery, a cancerous tumor or small portion of the breast is removed while preserving the rest of the breast tissue. Breast-conserving surgery can also be called a lumpectomy, partial mastectomy, or quadrantectomy. Because these procedures do not involve the full removal of the breast, radiation treatment and/or chemotherapy is often given after the surgery to ensure the death of as many cancerous cells as possible. This mode of treatment works best for those with stage I or II cancer, when it is not yet widespread. If the surgeon is unable to remove all of the cancerous tissue with a lumpectomy/partial mastectomy, he or she may recommend a full mastectomy for the patient.

Depending on the size and location of the tumor, there may still be significant deformation of the breast. Reconstructive surgical options are available to help restore the breast to its original form.

Mastectomy. In a mastectomy, the entire breast (and possibly surrounding tissues) is removed. There are several different types of mastectomies:

• Simple/total mastectomy, in which the entire breast and nipple are removed. This may be a single mastectomy (one breast is removed) or a double mastectomy (both are removed).
• Skin-sparing mastectomy, in which the entire breast is removed but the breast skin (minus the nipple and areola) is left intact.
• Nipple-sparing mastectomy, in which the entire breast is removed but the breast skin and nipple is left intact. This is a good option for those who have early stage cancers or those whose cancer is at the periphery of the breast.
• Modified radical mastectomy, in which the entire breast is removed in addition to the axilliary lymph nodes and muscles of the chest wall that underlay the breast.

Reconstructive Surgery

If surgery has caused significant changes to the appearance of the breast, a woman may opt for reconstructive surgery to help restore the breast to a more normal appearance. Reconstructive surgeries can either be immediate (done in the same procedure as the mastectomy) or delayed (done during a later surgery). To determine which reconstructive and surgical options are best for you, consult with your doctor.

Radiation Therapy

Radiation therapy bombards the site of the cancer with high energy particles that kill the cancerous cells. There are two major types of radiation therapy:

• External beam radiation. In this form of radiation therapy, a machine is used to direct radiation beams at specific points on the body. This may include the breast, lymph nodes, or other parts of the body where the cancer has spread. This type of radiation therapy is most often given five days a week for five to six weeks.

• Brachytherapy. In this form of radiation therapy, radiation energy is delivered by radioactive pellets that are left inside the breast or affected area. Brachytherapy may be administered by itself or in combination with other types of surgical and radiation therapies. Types of brachytherapy include:

• Insterstitial brachytherapy, in which catheters (hollow tubes) are inserted into the breast and then filled with radioactive pellets throughout the course of several days.
• Intracavitary brachytherapy, in which a device is placed in a space in the breast created by breast conserving surgery, and then radioactive pellets are inserted and removed from the device over the course of several days. This method is typically done twice a day for five days.

Chemotherapy

Chemotherapy is a form of cancer treatment in which drugs are administered orally (by mouth) or intravenously (by injection) in order to kill cancer cells throughout the body. Because of its harsh side effects, chemo is given in cycles with a recovery period in between each round. Chemotherapy can be given before surgery (neoadjuvant chemotherapy), after surgery (adjuvant chemotherapy), or in cases where breast cancer has spread to many other parts of the body.

According to the American Cancer Society, the following are among the most commonly prescribed chemotherapy drugs:

• Anthracyclines (doxorubicin, epirubicin)
• Taxanes (paclitaxel, docetaxel)
• Fluorouracil
• Cyclophosphamide
• Platinum agents (cisplatin, carboplatin)
• Trastuzumab (best for HER2 positive cancers)
• Pertuzumab (best for HER2 positive cancers)
• Vinorelbine
• Gemcitabine
• Mitoxantrone
• Ixabepilone
• Eribulin

Hormone Therapy

Estrogen can promote the growth of certain breast cancers if the cells have receptors for the either the estrogen or progesterone hormones. Cancers that do have estrogen/progesterone receptors (known as ER-positive cancers) may respond positively to drugs that block the reception of this hormone.

Drugs that help block the reception of these hormones include:

• Estrogen blockers (Tamoxifen, Toremifene, Fulvestrant) which block estrogen reception in breast cancer cells
• Aromatase inhibitors (letrozole, anastrozole, exemstance) which block the production of estrogen in post-menopausal women by inhibiting the functioning of the aromatase enzyme.

There are also drugs that can be given in conjunction with hormone-blocking drugs in order to make hormone therapy more effective. These include:

• Palbociclib, which helps to slow cancer growth through the inhibition of the CDK4 and CDK6 proteins in the cell.
• Everolimus, which works by blocking the mTOR protein which promotes cell divison.

Targeted Therapy

Targeted therapies work on specific genetic mutations that have been shown to influence the development of breast cancer. An example of a targeted therapy would be the use of drugs that target the HER2/neu protein, which promotes growth within cancerous cells. HER2/neu targeting drugs include trastuzumab, pertuzumab, ado-trastuzumab emtansine, and lapatinib.

Because of their specific nature, targeted therapies are only suitable for certain cases of breast cancer. Ask your doctor about whether or not there is a suitable targeted therapy for you.

Pain Management

Treatments for breast cancer may cause considerable pain in some patients. There are many different ways to deal with breast cancer treatment-related pain, including:

• Acetaminophen, available either in prescription or over-the-counter strength
• Non-steroidal anti-inflammatory drugs (NSAIDs), also available in either prescription or over-the-counter strength
• Opioids. Opioid pain-relievers are prescription only and can be much more powerful than acetaminophen or NSAID pain relievers. Popularly prescribed opioids include oxycodone, morphine, hydrocodone, and fentanyl. Opioids are addictive and may cause dependency following treatment. Possible side effects of opioids include nausea, constipation, drowsiness, and fatigue.
• COX-2s. This class of drugs is among the more controversial options for pain management due to recent studies suggesting the link between COX-2s and increased risk of heart attack and stroke. Ask your doctor if COX-2s are right for you.
• Alternative and complimentary therapies including:
• • Acupuncture
  • Yoga
  • Hypnosis
  • Guided imagery
  • Meditation
  • Tai Chi
  • Massage
  • Chiropractic therapy
  • Medical marijuana
  • Prayer/Spiritual therapy
  • Local or online support groups

Remission and Reccurence

Remission is the disappearance of the signs and symptoms of cancer. Remission may last anywhere from several weeks to several years, or in the best cases, a lifetime. Often, only some cancer symptoms disappear. This is known as a partial remission. Even though there is a chance cancer may never come back one in remission, it is said to be in remission rather than “cured” because doctors cannot guarantee that it will not recur at a later point. Whether or not you experience remission depends on how your body responds to treatment.  In addition to the breast cancer treatments that help a patient achieve remission, there are several things your doctor may recommend to help prevent recurrence:

• Hormone therapy, to lessen the presence of hormones that could potentially trigger the growth of cancerous cells.
• Maintain a balanced diet and regular exercise to help the body keep in its best physical condition.
• Return to the doctor for regular checkups. All breast cancer patients should visit their doctor as frequently as he or she recommends, in order to check for signs of recurrence. If the cancer does reappear, it is important to catch it early. Women undergoing hormone therapy should also schedule regular visits to the gynecologist as hormone therapy increases the risk of cervical cancer.

Recurrence is when cancer signs and symptoms reappear after a period of remission. About 20% of breast cancer patients will experience a recurrence within 10 years of initial treatment. The likelihood of recurrence depends on the type of cancer and the body’s response to treatment. The risk of recurrence increases with higher stages of breast cancer. According to the American Cancer Society, a recent study found that the five year recurrence rate for stage I breast cancer is 7% while the rate for stage II is 11% and 13% for stage III. In that same study, the overall recurrence rates for patients who underwent adjuvant therapy were 11% at 5 years after treatment and 20% at 10 years. Treatment for recurring cancers will most likely differ than the initial treatment, given the changes that occur in the body after the first round of treatment.

Clinical Trials

Breast cancer research is ongoing, and many new drugs and treatment technologies are being developed each year. Before a treatment is FDA approved, it must undergo a series of supervised and controlled tests known as clinical trials. Often, researchers draw on the public for eligible participants in the trials. New treatment methods offer an exciting promise for recovery, but they can also have potentially lethal side effects, especially while still in the clinical trial phase. Speak to your doctor before entering into any clinical trial for breast cancer treatment.

For more information on how to find clinical trials, visit www.BreastCancerTrials.org