Breast Cancer

Table of Contents

Breast cancer affects 1 in 8 women in their lifetime. The exact cause of why women can have breast cancer is unknown, but there are many risk factors. The possible risk factors for breast cancer in women may include: 

  • Age factor – the risk for breast cancer increases with age
  • Genes – two genes, BRCA1 and BRCA2 – may greatly increase the risk. Women who have family members with a history of breast or ovarian cancer may need to be tested for the gene.
  • Personal factors – menstruation that starts before the age of 12 or going through menopause after the age of 55

Facts about Breast Cancer 

Other risk factors for breast cancer include being obese, using hormone replacement therapy (also called menopausal hormone therapy), taking birth control pills, drinking alcohol, not having children or giving birth for the first time after the age of 35, and having dense breasts.

Symptoms of breast cancer may include a breast lump, change in breast size or shape, and nipple discharge. Breast examinations and breast mammography may help detect breast cancer early – when it is most treatable. A surgical procedure can be the first treatment option –  it may be either a lumpectomy or a mastectomy. Other treatments include radiation therapy, chemotherapy, hormone therapy, and targeted therapy. Targeted therapy uses substances that attack cancer cells without damaging normal cells.

Breast cancer does not only affect women. In very rare cases, men can get breast cancer as well. 

Overview of Breast Cancer

Breast cancer is a disease in which malignant (cancer) cells form in the breast tissue.

The breast is made up of lobes and ducts. Each breast has 15 to 20 sections called lobes. Each lobe has many smaller sections called lobules. The lobules end in dozens of alveoli which are the site of milk production. The lobes, lobules, and alveoli are connected by very small ducts.

The nipple and areola are visible outside the breast.

Each breast also has blood vessels and lymph vessels. Lymph vessels carry a nearly colorless fluid called lymph. Lymph vessels carry lymph to lymph nodes. Lymph nodes are small, bean-shaped structures that are widely distributed throughout the body. These small glands filter substances in the lymph and help fight infection and disease. Groups of lymph nodes are found near the breast in the axilla (in the armpit), above the collarbone, and in the chest.

The most common type of breast cancer is ductal carcinoma – which starts in the duct cells. Cancer that starts in a lobe or lobule is called lobular carcinoma and is found more often in both breasts. Inflammatory breast cancer is a rare type of breast cancer, in which the breasts may feel warm and look red and swollen.

Risk Factors

Anything that increases your chances of getting a disease is called a risk factor. Having a risk factor does not mean you will get cancer; not having risk factors does not mean you will not get cancer. Talk with your doctor if you think you may be at risk for breast cancer.

Risk factors for breast cancer include the following:

  • Personal history of invasive breast cancer, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ (LCIS).
  • Personal history of benign (non-cancerous) breast disease.
  • Family history of breast cancer in a first-degree female relative (mother, daughter, or sister).
  • Inherited mutation in the BRCA1 or BRCA2 genes or other genes that increase the risk of breast cancer.
  • Dense breast tissue on a mammogram.
  • Exposure of breast tissue to estrogen made by the body. This may be caused by:
    • Menstrual periods at a young age.
    • Advanced maternal age or never been pregnant
    • Late-onset menopause
    • Treating menopausal symptoms with hormones such as estrogen combined with progestins.
  • Treatment with radiation therapy to the breast / chest.
  • Alcohol consumption
  • Obesity.

Advancing age is a major risk factor for most cancers. The chance of getting cancer increases with age.

In some cases, breast cancer may be caused by an inherited gene mutation

Genes carry the information that determine your characteristics that are inherited from your parents. About 5% to 10% of breast cancer cases are thought to be hereditary. Certain mutated genes linked to breast cancer are more common in certain ethnic groups.

Women with certain gene mutations, such as the BRCA1 or BRCA2 gene, run a higher risk to develop breast cancer. These women also have an increased risk of ovarian cancer, and may have an increased risk of other cancers. Men who may have inherited a mutation in genes linked to breast cancer can also have an increased risk for breast cancer.

Use of certain drugs and other factors reduces the risk of breast cancer.

Anything that decreases your chances of getting a disease is called a protective factor.

Protective factors for breast cancer include the following:

  • Use one of the following:
    • Estrogen-only hormone therapy after hysterectomy.
    • Selective estrogen receptor modulators (SERMs).
    • Aromatase inhibitors.
  • Reduced exposure of breast tissue to estrogen. This could be the result of:  
    • Early pregnancy.
    • Breastfeeding.
  • Get enough exercise
  • Undergo one of the following procedures:
    • Mastectomy to reduce the risk of cancer.
    • Oophorectomy to reduce the risk of cancer.
    • Ovarian ablation.

Symptoms of Breast Cancer

These and other signs may be caused by breast cancer or by other conditions. Check with your doctor if you experience any of the following:

  • Breast lump or thickening in the armpit area.
  • Change in breast size or shape.
  • Dimpled breast skin.
  • Inverted nipple (the nipple is pulled inward into the breast)
  • Unusual nipple discharge — bloody discharge
  • Scaly, red, or swollen rash on the skin on the nipple, or areola (the area of darker ​​skin surrounding the nipple).
  • Dimpled breast texture resembling an orange peel (peau d’orange)

Prevention of Breast Cancer

Diagnosis and Prognosis of Breast Cancer

Diagnosis

Check with your doctor if you notice any changes in your breasts. The following tests and procedures can be used:

  • Physical exam and health history: An exam of the body to check for general signs of health, including checking for signs of disease, such as lumps or anything else that looks unusual. A history of the patient’s medical habits and illnesses and previous care will also be taken.
  • Clinical breast examination (Sadanis): Examination of the breast by a doctor or other health professionals. The doctor will carefully feel the breasts and under the armpits to check for lumps or anything else that seems unusual.
  • Mammogram: An X-ray of the breast.
  • Ultrasound: A procedure in which high-energy sound waves (ultrasound) are reflected from internal tissues or organs and make echoes. The echoes form an image of body tissue called a sonogram. Images can be printed for later viewing.
  • MRI (magnetic resonance imaging): A procedure that uses magnets, radio waves, and a computer to create a series of detailed images of both breasts. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • Blood chemistry study: A procedure in which a blood sample is checked to measure the amount of certain substances released into the blood by organs and tissues in the body. An unusual amount of a substance (higher or lower than normal) may be a sign of disease.
  • Biopsy: The removal of cells or tissue to be viewed under a microscope by a pathologist to check for signs of cancer. A biopsy may be performed if a breast lump is found

There are four types of biopsy performed to check for breast cancer:

  • Excisional biopsy: The removal of the entire lump of tissue.
  • Incisional biopsy: The removal of partial lump or tissue samples.
  • Core needle biopsy: The removal of tissue using a large needle.
  • Fine-needle aspiration (FNA) biopsy: The removal of tissue or fluid, using a fine needle.

Tests will be performed to study the cancer cells – if cancer is detected.

The decision to determine the right treatment is based on the results of this test. The test provides information about:

  • How fast the cancer can grow.
  • How likely for the cancer to spread throughout the body.
  • How effective certain treatments can be
  • How likely for the cancer to recur (come back).

The test includes the following:

  • Estrogen and progesterone receptor test: A test to measure the number of estrogen and progesterone (hormones) receptors in cancerous tissue. If estrogen and progesterone receptors are more than normal, the cancer is called estrogen and / or progesterone receptor positive. This type of breast cancer may grow faster. The test results show whether treatment to block estrogen and progesterone be effective to stop cancer growth. 
  • Human epidermal growth factor/receptor type 2 test (HER2 / neu) test: A laboratory tests to measure how many HER2 / neu genes are present and how much HER2 / neu protein is made in tissue samples. If there are more HER2 / neu genes or greater than normal levels of the HER2 / neu protein, the cancer is called HER2 / neu positive. This type of breast cancer may grow faster and spread to other parts of the body. The cancer may be treated with drugs that target the HER2 / neu protein – such as trastuzumab and pertuzumab.
  • Multigene test: A laboratory test in which many genes are studied in a sample of tissue. This test can help predict if the cancer may spread to other parts of the body or recur (come back).

There are many types of multigene tests. The following multigene tests have been studied in clinical trials:

  • Oncotype DX: This test helps predict whether stage I or stage II breast cancer – which is estrogen receptor positive and node negative – will spread to other parts of the body. If there is a high risk of cancer to spread, chemotherapy may be given to reduce the risk.
  • MammaPrint: This test helps predict whether stage I or stage II breast cancer – which is node negative – will spread to other parts of the body. If there is a high risk of cancer to spread, chemotherapy may be given to reduce the risk.

Based on these tests, breast cancer is described as one of the following types:

  • Hormone receptor positive (estrogen and / or progesterone receptor positive) or hormone receptor negative (estrogen and / or progesterone receptor negative).
  • HER2 / neu positive or HER2 / neu negative.
  • Triple negative (estrogen receptor, progesterone receptor, and HER2 / neu negative).

This information helps the doctor decide the most suitable treatment for you.

Prognosis of Breast Cancer

Prognosis (chance of recovery) and treatment options depend on the following:

  • Stage of cancer (tumor size and whether it is only in the breast or has spread to lymph nodes or elsewhere in the body).
  • Types of breast cancer.
  • Estrogen receptor and progesterone receptor levels in tumor tissue.
  • Levels of human epidermal growth factor receptor type 2 (HER2 / neu) in tumor tissue.
  • Triple negative tumor tissue (cells lacking estrogen receptors, progesterone receptors, or high levels of HER2 / neu).
  • How fast the tumor grows.
  • How likely the tumor will recur (come back).
  • The woman’s age, general health, and menopausal status
  • Whether the cancer has recently been diagnosed or has recurred (came back).

Stages of Breast Cancer

Cancer staging is to find out if cancer has spread within the breast or to another part of the body. Staging determines the severity of the disease as well as suggests the treatment option. The results from these tests are used to diagnose breast cancer and to determine the stage the disease.

The following tests and procedures may also be used in the staging process:

  • Sentinel lymph node biopsy: The surgical removal of the sentinel lymph node. The sentinel lymph nodes are the first lymph nodes to receive lymphatic drainage from the tumor. It is the first lymph node cancer likely to spread from the tumor. A radioactive substance and / or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph nodes to receive the substance or dye are removed. A pathologist will view the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may be unnecessary to remove more lymph nodes.
  • Chest x-ray: An X-ray of the organs and bones inside the chest. X-rays are a type of energy beam that can pass through the body and onto film – creating images of parts inside your body.
  • CT scan (CAT scan): A procedure that makes a series of detailed images of internal body parts taken from multiple angles. The images are created by a computer connected to an x-ray machine. The dye can be injected into a vein or swallowed to help an organ or tissue appear more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography
  • Bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. It is detected by a scanner. 
  • Positron emission tomography scan (PET scan): A PET scan is a procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and creates images of where glucose is being used in the body. Malignant tumor cells appear brighter in the image because they are more active and take up more glucose than normal cells.

There are three ways cancer spreads in the body.

Cancer can spread through the tissues, lymph system, and blood:

  • Tissues. Cancer spreads from where it started by spreading to nearby areas. 
  • Lymph system. The cancer spreads from where it started by getting into the lymph system. Cancer spreads through lymph vessels to other parts of the body.
  • Blood. The cancer spreads from where it started by getting into the blood. Cancer spreads through the blood vessels to other body parts

When cancer spreads to other parts of the body, it is called metastasis. Cancer cells break away from where they started (the main tumor) and spread through the lymph or blood systems.

  • Lymph system. Cancer gets into the lymph system, spreads through the lymph vessels, and forms tumors (metastatic tumors) in other body parts
  • Blood. Cancer enters the blood, spreads through the blood vessels, and forms tumors (metastatic tumors) in other parts of the body..

Metastatic tumors are the same type of cancer as primary tumors. For example, if breast cancer spreads to the bone, the cancer cells in the bone are actually breast cancer cells.  The disease is metastatic breast cancer, not bone cancer.

The following are stages to determine breast cancer:

This section describes the stages of breast cancer. Breast cancer staging is based on the results of tests performed on the tumor and lymph nodes removed during surgery and other tests.

Stage 0 (carcinoma in situ)

There are 3 types of breast carcinoma in situ:

  • Ductal carcinoma in situ (DCIS) is a non-invasive condition in which abnormal cells are found in the lining of the breast ducts. The abnormal cells have not spread outside the ducts to other tissues in the breast. In some cases, DCIS can become invasive cancer and spread to other tissues. At this time, it is unknown which lesions could become invasive.
  • Lobular carcinoma in situ (LCIS-lobular carcinoma in situ) is a condition in which abnormal cells are found in the lobules of the breast. This condition is rarely an invasive cancer. 
  • Paget’s Disease of The Nipple is a condition in which abnormal cells are solely found in the nipple.

Stage 1

In stage IA, the tumor is 2 cm or smaller and has not spread beyond the breast. In stage IB, there is no tumor in the breast or tumors 2 cm or smaller. Small clusters of cancer cells (larger than 0.2 millimeters but not more than 2 millimeters) are found in the lymph nodes.

In stage 1, cancer has formed. Stage I is divided into stage I A and IB.

  • In stage IA, the tumor is 2 cm or smaller. Cancer has not spread outside the breast.
  • In stage IB, small clusters of breast cancer cells (larger than 0.2 millimeters but no more than 2 millimeters) are found in the lymph nodes and:
    • No tumor is found in the breast; or
    • The tumor is 2 cm or smaller.

Stage II

Stage II is divided into Stage IIA and IIB.

  • In Stage IIA:
    • No tumor is found in the breast or the tumor is 2 cm or smaller. Cancer (more than 2 millimeters) is found in 1 to 3 axillary lymph nodes or in lymph nodes near the breastbone (may be found during a sentinel lymph node biopsy); or
    • The tumor is larger than 2 cm, but not more than 5 cm. The cancer has not spread to the lymph nodes.
  • In Stage IIB:
    • Larger than 2 cm, but not more than 5 cm. Small clusters of breast cancer cells (larger than 0.2 millimeters, but not larger than 2 millimeters) are found in the lymph nodes; or
    • Larger than 2 cm, but not more than 5 cm. Cancer has spread to 1 to 3 axillary lymph nodes or to lymph nodes near the sternum (found during sentinel lymph node biopsy); or
    • More than 5 cm. The cancer has not spread to the lymph nodes

Stage IIIA

In Stage IIIA:

  • No tumor is found in the breast or the tumor may be of any size. Cancer is found in 4 to 9 axillary lymph nodes or in the lymph nodes near the breastbone (may be found during imaging tests or physical exam); or
  • The tumor is bigger than 5 cm. Small clusters of breast cancer cells (larger than 0.2 millimeters but not larger than 2 millimeters) are found in the lymph nodes; or
  • The tumor is more than 5 cm. Cancer has spread to 1 to 3 axillary lymph nodes or to lymph nodes near the sternum (may be found during sentinel lymph node biopsy).

Stage IIIB

In Stage IIIB, the tumor can be any size and the cancer has spread to the chest wall and / or to the skin of the breast and causes swelling or ulcers. Also, cancer may have spread to:

  • Up to 9 axillary lymph nodes; or
  • Lymph nodes near the sternum.

Cancer that has spread to the breast may also become inflammatory breast cancer.

Stage IIIC

In Stage IIIC, the tumor is not found in the breast or the tumor may be of any size. Cancer may have spread to the skin of the breast and cause swelling or ulcers and / or spread to the chest wall. Cancer has also spread to:

  • 10 or more axillary lymph nodes; or
  • Lymph nodes above or below the collarbone; or
  • Axillary lymph nodes and lymph nodes near the sternum.

Cancer that has spread to the breast may also become inflammatory breast cancer. 

Stage IV

In Stage IV, cancer has spread to other organs of the body —  usually,  the bones, lungs, liver, or brain.

Treatment for Breast Cancer 

Various types of treatment are available to treat patients with breast cancer. Some are standard treatments, and some are still in clinical trials. A clinical trial is research intended to help improve current treatments or gather information about new treatments for cancer patients. When clinical trials show that the new treatment is better than standard treatment, the new treatment can become standard treatment. The patients may want to take part in clinical trials. Certain clinical trials are only open to patients who have not undergone any treatment. 

Five types of standard treatment are used:

Surgery

Most patients with breast cancer undergo surgery to remove the cancer.

The types of surgery include the following

  • Breast-conserving surgery is done to remove the tumor and surrounding healthy tissue — but not the breast. Part of the chest wall lining may also be removed if cancer is near it. This type of surgery may also be called a lumpectomy, partial mastectomy, segmental mastectomy, quadrantectomy, or breast reduction surgery. 
  • Total mastectomy: A surgical procedure to treat breast cancer by removing the entire breast. This procedure is also called a simple mastectomy. Some of the lymph nodes in the armpit may be removed and examined.  This procedure can be done during breast surgery or afterward. Furthermore, it is done through a separate incision.
  • Modified radical mastectomy: Surgery to remove the entire breast that is affected by cancer, the lymph nodes in the armpit, the layer over the chest muscle, and sometimes, part of the chest wall muscle.

Chemotherapy may be given before surgery to remove the tumor. When given before surgery, chemotherapy will shrink the tumor and reduce the amount of tissue that needs to be removed during surgery. The treatment given pre-surgery is called preoperative therapy or neoadjuvant therapy.

After the doctor removes all of a cancerous tumor, some patients may be given radiation therapy, chemotherapy, targeted therapy, or hormone therapy after surgery. This is done to kill any remaining cancer cells. The treatment given after surgery that helps lower the risk of recurrent cancer is called postoperative therapy or adjuvant therapy.

If a patient is going to have a mastectomy, breast reconstruction (surgery to rebuild a breast’s shape after a mastectomy) may be an option to consider. Breast reconstruction may be done at the time of the mastectomy or afterwards. Reconstructed breasts can be done using implants filled with saline or silicone gel.

Radiation Therapy

Radiation therapy is a cancer treatment that uses high-energy X-rays or other types of radiation to kill cancer cells or prevent them from growing. There are two types of radiation therapy:

  • External radiation therapy uses a machine outside the body to send radiation towards the cancer.
  • Internal radiation therapy uses a radioactive substance that is sealed in a needle, granule, cable, or catheter that is placed directly into or near the cancer.

The way radiation therapy is given depends on the type and stage of cancer being treated. External radiation therapy is used to treat breast cancer. Internal radiation therapy with strontium-89 (radionuclide) is used to relieve bone pain caused by breast cancer that has spread to the bones. Strontium-89 is injected into a vein and travels to the surface of the bone. Radiation is released and kills cancer cells in the bones.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is given by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, organs, or body cavities such as the stomach, the drugs mainly affect cancer cells in those areas (regional chemotherapy).

The way chemotherapy is given depends on the type and stage of cancer being treated. Systemic chemotherapy is used in the treatment of breast cancer.

Hormone Therapy

Hormone therapy is a cancer treatment that removes or blocks hormones to stop the growth of cancer cells. Hormones are produced by glands in your body and circulated in the bloodstream. Several hormones may support certain tumors’ growth. If a test shows that cancer cells have sites where hormones can attach to (receptors) – medications, surgery, or radiation therapy are used to reduce or block the hormone production. The estrogen hormone, which causes the growth of several breast cancers, is mainly produced by the ovaries. Ovarian ablation is a treatment that can be done to stop the ovaries from making estrogen hormones. 

Hormone therapy with tamoxifen can often be given to patients with localized early stage breast cancer that can be removed surgically and patients with metastatic breast cancer (cancer that has spread to other parts of the body). Hormone therapy with tamoxifen or estrogen can work on cells throughout the body and increase the chance of developing endometrial cancer. Women taking tamoxifen should have a pelvic exam every year to look for signs of cancer. Any vaginal bleeding, other than menstrual bleeding, should be reported to the doctor right away.

Hormone therapy with luteinizing hormone-releasing hormone (LHRH) is given to selected premenopausal women who have recently been diagnosed with hormone receptor positive breast cancer. LHRH agonists decrease the body’s estrogen and progesterone.

Hormone therapy with aromatase inhibitors is given to selected postmenopausal women who have hormone receptor positive breast cancer. Aromatase inhibitors lower the body’s estrogen by blocking an enzyme called aromatase from converting androgens to estrogen. Anastrozole, letrozole, and exemestane are types of aromatase inhibitors.

In treatment for localized early stage breast cancer — which can be removed surgically — certain aromatase inhibitors can be used as adjuvant therapy instead of tamoxifen or after 2 to 3 years of tamoxifen use. As for the treatment of metastatic breast cancer, aromatase inhibitors are being tested in clinical trials to compare them to hormone therapy with tamoxifen.

In women with hormone receptor positive breast cancer, at least 5 years of adjuvant hormone therapy may help reduce the chance of cancer to recur (come back).

Other types of hormone therapy include megestrol acetate or anti-estrogen therapy such as fulvestrant.

Targeted Therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without damaging normal cells. Monoclonal antibodies, tyrosine kinase inhibitors, cyclin-dependent kinase inhibitors, mammalian target of rapamycin (mTOR) inhibitors, and PARP inhibitors are types of targeted therapies used in the treatment of breast cancer.

Monoclonal antibody therapy uses antibodies made in the laboratory from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that can stimulate the growth of cancer cells. Antibodies attach to the substance and kill cancer cells, block their growth, or prevent them from spreading. Monoclonal antibodies are given through intravenous infusion. Monoclonal antibodies can be used independently or are delivered directly to the cancer cells through medications, toxins, or radioactive materials. Monoclonal antibodies can also be used in combination with chemotherapy as adjuvant therapy.

Types of monoclonal antibody therapy include the following:

  • Trastuzumab is a monoclonal antibody that blocks the effects of the growth factor protein HER2, which sends growth signals to breast cancer cells. It can be used with other therapies to treat HER2 positive breast cancer.
  • Pertuzumab is a monoclonal antibody that can be combined with trastuzumab and chemotherapy to treat breast cancer. It can be used to treat certain patients with HER2 positive breast cancer that has metastasized (spread to other parts of the body). It can also be used as neoadjuvant therapy in selected patients with early Stage HER2 positive breast cancer.
  • Ado-trastuzumab emtansine is a monoclonal antibody associated with anticancer drugs. This is called an antibody-drug conjugate. It is used to treat HER2 positive breast cancer that has spread to other parts of the body or has recurred (come back).

Tyrosine kinase inhibitors are targeted therapy drugs that block the signals needed for tumor growth. Tyrosine kinase inhibitors can be used with other anticancer drugs as adjuvant therapy. Tyrosine kinase inhibitors include the following:

  • Lapatinib is a tyrosine kinase inhibitor that blocks the effects of the HER2 protein and other proteins in tumor cells. It can be used with other medicines to treat patients with HER2 positive breast cancer that has developed after treatment with trastuzumab.
  • Neratinib is a tyrosine kinase inhibitor that blocks the effects of the HER2 protein and other proteins in tumor cells. It can be used to treat patients with HER2 positive Early Stage breast cancer after treatment with trastuzumab.

Cyclin-dependent kinase inhibitors are targeted therapy drugs that block proteins called cyclin-dependent kinases — which cause cancer cell growth. Cyclin-dependent kinase inhibitors include the following:

  • Palbociclib is a cyclin-dependent kinase inhibitor used along with  the drug letrozole to treat breast cancer with estrogen receptor positive and HER2 negative and has spread to other parts of the body. It is used in postmenopausal women whose cancer has not been treated with hormone therapy. Palbociclib can also be used fulvestrant in women whose cancer has worsened after treatment with hormone therapy.
  • Ribociclib is a cyclin-dependent kinase inhibitor used with letrozole to treat breast cancer that is hormone receptor positive and HER2 negative and has recurred or spread to other parts of the body. It is used in postmenopausal women whose cancer has not been treated with hormone therapy.
  • Abemaciclib is a cyclin-dependent kinase inhibitor used to treat hormone receptor positive and HER2 negative breast cancer that has developed or has spread to other parts of the body. It can be used alone or with other medications to treat breast cancer that gets worse after other treatments.

Mammalian target of rapamycin (mTOR) blocks a protein called mTOR, which can prevent cancer cells from growing and prevent the growth of new blood vessels that tumors need to grow. MTOR inhibitors include the following:

  • Everolimus is an mTOR inhibitor used in postmenopausal women with advanced stage positive hormone receptor positive breast cancer who is also HER2 negative and has not improved with other treatments.

PARP inhibitors are a type of targeted therapy that block DNA repair and can cause cancer cells to die. PARP inhibitor therapy is being studied for the treatment of patients with triple negative breast cancer or tumors with BRCA1 or BRCA2 mutations.

Stage-Based Treatment for Breast Cancer

Early, Localized, or Operable Breast Cancer

Early, localized, or operable breast cancer treatment may include the following:

Surgery 

  • Breast conserving surgery and sentinel lymph node biopsy. If cancer is found in the lymph nodes, a lymph node dissection may be performed.
  • Modified radical mastectomy. Breast reconstruction surgery may also be performed.

Postoperative radiation therapy

For women who undergo breast conserving surgery, radiation therapy is given to the entire breast to reduce the chance for cancer to recur. Radiation therapy may also be given to lymph nodes in the area.

For women who have had a modified radical mastectomy, radiation therapy may be given to reduce the chance of the cancer recurring if one of the following applies:

  • Cancer is found in 4 or more lymph nodes.
  • Cancer has spread to the tissues around the lymph nodes.
  • Tumor is large-sized
  • A tumor found near or remained in the tissue near the edge where the tumor was removed.

Postoperative systemic therapy

Systemic therapy is the use of drugs that enter the bloodstream and reach cancer cells throughout the body. Postoperative systemic therapy is given to reduce your risk of cancer recurrence after surgery to remove the tumor.

Postoperative systemic therapy is given depending on whether: 

  • The tumor is hormone receptor negative or positive.
  • The tumor is HER2 / neu negative or positive.
  • The tumor is hormone receptor negative and HER2 / neu negative (triple negative).
  • The size of the tumor.

In premenopausal women with hormone receptor positive tumors, no further treatment is required or postoperative therapy may include:

  • Tamoxifen therapy with or without chemotherapy.
  • Tamoxifen therapy and medication to stop or reduce how much estrogen the ovaries make. Drug therapy, surgery to remove the ovaries, or radiation therapy to the ovaries can be used.
  • Aromatase inhibitor therapy and treatment to stop or reduce how much estrogen the ovaries make. Drug therapy, surgery to remove the ovaries, or radiation therapy to the ovaries can be used.

In postmenopausal women with hormone receptor positive tumors, no further treatment is required or postoperative therapy may include:

  • Aromatase inhibitor therapy with or without chemotherapy.
  • Tamoxifen is followed by aromatase inhibitor therapy, with or without chemotherapy.

In women with hormone receptor negative tumors, no further treatment is required or postoperative therapy may include:

  • Chemotherapy.

In women with negative HER2 / neu tumors, postoperative therapy may include:

  • Chemotherapy

In women with small tumors, HER2 / neu positive, and without cancer in the lymph nodes — no further treatment is required. If there is cancer in the lymph nodes, or a large tumor, postoperative therapy may include:

  • Chemotherapy and targeted therapy (trastuzumab).
  • Hormone therapy, such as tamoxifen therapy or aromatase inhibitors, for tumors that are also hormone receptor positive.

In women with small tumors, hormone receptors, negative and HER2 / neu negative tumors (triple negative) and no cancer found in the lymph nodes — no further treatment is required. If there is cancer in the lymph nodes or a large tumor, postoperative therapy may include:

  • Chemotherapy.
  • Radiation therapy.
  • A clinical trial of a new chemotherapy regimen.
  • A clinical trial of PARP inhibitor therapy.

Preoperative systemic therapy

Systemic therapy is the use of drugs that can enter the bloodstream and reach cancer cells throughout the body. Preoperative systemic therapy is given to shrink the tumor before surgery.

In postmenopausal women with hormone receptor positive tumors, preoperative therapy may be include: 

  • Chemotherapy.
  • Hormone therapy, such as tamoxifen or aromatase inhibitor therapy, for women who cannot undergo chemotherapy.

In premenopausal women with hormone receptor positive tumors, preoperative therapy may include:

  • Clinical trials of hormone therapy, such as tamoxifen or aromatase inhibitor therapy.

In women with positive HER2 / neu tumors, preoperative therapy may include:

  • Chemotherapy and targeted therapy (trastuzumab).
  • Targeted therapy (pertuzumab).

In women with HER2 / neu negative or triple negative tumors, preoperative therapy may include:

  • Chemotherapy.
  • Clinical trial of new chemotherapy regimen.
  • Clinical trials of monoclonal antibody therapy.

Advanced or inflammatory localized breast cancer

Treatment of localized advanced or inflammatory breast cancer is a combination of therapies that may include the following:

  • Surgery (breast-conserving surgery or total mastectomy) with lymph node dissection.
  • Chemotherapy before and / or after surgery.
  • Radiation therapy after surgery.
  • Hormone therapy after surgery for tumors that are estrogen receptor positive or estrogen receptor unknown.
  • Clinical trials test new anticancer drugs, new drug combinations, and new ways of delivering treatment.

Locoregional Breast Cancer Recurrence

Treatment for locoregional breast cancer recurrence (cancer that has returned after treatment in the breast, on the chest wall, or in nearby lymph nodes), may include the following:

  • Chemotherapy.
  • Hormone therapy for tumors that are hormone receptor positive.
  • Radiation therapy.
  • Operation.
  • Targeted therapy (trastuzumab).
  • Clinical trials of new treatments.

Metastatic Breast Cancer

Treatment options for metastatic breast cancer (cancer that has spread to distant parts of the body) may include the following:

Hormone therapy

In postmenopausal women who have recently been diagnosed with metastatic breast cancer that is hormone receptor positive or if the hormone receptor status is unknown, treatment may include:

  • Tamoxifen therapy.
  • Aromatase inhibitor therapy (anastrozole, letrozole, or exemestane). In some cases,  cyclin-dependent kinase inhibitor therapy (palbociclib, ribociclib, or abemaciclib) is also given.

In premenopausal women who have recently been diagnosed with metastatic breast cancer that is hormone receptor positive, treatment may include:

  • Tamoxifen, LHRH agonist, or both.

In women whose tumors are hormone receptor positive or unknown hormone receptor, with spread to bone or soft tissue only and who have been treated with tamoxifen — treatment may include:

  • Aromatase inhibitor therapy.
  • Other hormone therapy such as megestrol acetate, estrogen or androgen therapy, or anti-estrogen therapy such as fulvestrant.

Targeted therapy

In women with metastatic breast cancer that is hormone receptor positive and has not responded to other treatments, options may include targeted therapies such as:

  • Trastuzumab, lapatinib, pertuzumab, or mTOR inhibitors.
  • Antibody-drug conjugate therapy with ado-trastuzumab emtansine.
  • Cyclin-dependent kinase inhibitor therapy (palbociclib, ribociclib, or abemaciclib) may be combined with hormone therapy.

In women with metastatic breast cancer that is HER2 / neu positive, treatment may include:

  • Targeted therapy such as trastuzumab, pertuzumab, ado-trastuzumab emtansine, or lapatinib.

Chemotherapy

In women with metastatic breast cancer that is hormone receptor negative, has not responded to hormone therapy, has spread to other organs or has caused symptoms, treatment may include:

  • Chemotherapy with one or more drugs.

Surgery

  • Total mastectomy for women with open or painful breast lesions. Radiation therapy may be given after surgery.
  • Surgery to remove cancer that has spread to the brain or spine. Radiation therapy treatments be given after surgery.
  • Surgery to remove cancer that has spread to the lungs.
  • Surgery to repair or help support weak or broken bones. Radiation therapy treatments be given after surgery.
  • Surgery to remove fluid that has accumulated around the lungs or heart.

Radiation therapy

  • Radiation therapy to the bones, brain, spinal cord, breast, or chest wall to relieve symptoms and improve quality of life.
  • Strontium-89 (radionuclide) for pain relief from cancer that has spread to bones throughout the body.

Other treatment options

Other treatment options for metastatic breast cancer include:

  • Drug therapy with bisphosphonates or denosumab to reduce bone disease and pain when cancer has spread to the bones.
  • Cinical trial of high-dose chemotherapy with stem cell transplant.
  • Clinical trials testing new anticancer drugs, new drug combinations, and new ways of delivering treatment.

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