Breast Cancer

Breast Cancer

 

You are in control of you. Not genes, not your doctor, not fate, you.
-Dr. Kristi Funk, Author
Breasts: The Owner’s Manual – Every Woman’s Guide to Reducing Cancer Risk, Making Treatment Choices, and Optimizing Outcomes.

The following information is provided by the US National Cancer Institute.

Definition of breast cancer:
Cancer that forms in tissues of the breast. The most common type of breast cancer is ductal carcinoma, which begins in the lining of the milk ducts (thin tubes that carry milk from the lobules of the breast to the nipple). Another type of breast cancer is lobular carcinoma, which begins in the lobules (milk glands) of the breast. Invasive breast cancer is breast cancer that has spread from where it began in the breast ducts or lobules to surrounding normal tissue. Breast cancer occurs in both men and women, although male breast cancer is rare.

General Information About Breast Cancer

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

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. Lobules end in dozens of tiny bulbs that can make milk. The lobes, lobules, and bulbs are linked by thin tubes called ducts.

Each breast also has blood vessels and lymph vessels. The lymph vessels carry an almost colorless fluid called lymph. Lymph vessels carry lymph between lymph nodes. Lymph nodes are small bean-shaped structures that are found throughout the body. They filter substances in lymph and help fight infection and disease. Clusters of lymph nodes are found near the breast in the axilla (under the arm), above the collarbone, and in the chest.

The most common type of breast cancer is ductal carcinoma, which begins in the cells of the ducts. Cancer that begins in the lobes or lobules is called lobular carcinoma and is more often found in both breasts than are other types of breast cancer. Inflammatory breast cancer is an uncommon type of breast cancer in which the breast is warm, red, and swollen.

A family history of breast cancer and other factors increase the risk of breast cancer.

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

Risk factors for breast cancer include the following:

  • A personal history of invasive breast cancer, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ (LCIS).
  • A personal history of benign (noncancer) breast disease.
  • A family history of breast cancer in a first-degree relative (mother, daughter, or sister).
  • Inherited changes in the BRCA1 or BRCA2 genes or in other genes that increase the risk of breast cancer.
  • Breast tissue that is dense on a mammogram.
  • Exposure of breast tissue to estrogen made by the body. This may be caused by:
    • Menstruating at an early age.
    • Older age at first birth or never having given birth.
    • Starting menopause at a later age.
  • Taking hormones such as estrogen combined with progestin for symptoms of menopause.
  • Treatment with radiation therapy to the breast/chest.
  • Drinking alcohol.
  • Obesity.

Older age is the main risk factor for most cancers. The chance of getting cancer increases as you get older.

Breast cancer is sometimes caused by inherited gene mutations (changes).

The genes in cells carry the hereditary information that is received from a person’s parents. Hereditary breast cancer makes up about 5% to 10% of all breast cancer. Some mutated genes related to breast cancer are more common in certain ethnic groups.

Women who have certain gene mutations, such as a BRCA1 or BRCA2 mutation, have an increased risk of breast cancer. These women also have an increased risk of ovarian cancer, and may have an increased risk of other cancers. Men who have a mutated gene related to breast cancer also have an increased risk of breast cancer. For more information, see the PDQ summary on Male Breast Cancer Treatment.

There are tests that can detect (find) mutated genes. These genetic tests are sometimes done for members of families with a high risk of cancer. See the PDQ summary on Genetics of Breast and Gynecologic Cancers for more information.

Signs of breast cancer include a lump or change in the breast.

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

  • A lump or thickening in or near the breast or in the underarm area.
  • A change in the size or shape of the breast.
  • A dimple or puckering in the skin of the breast.
  • A nipple turned inward into the breast.
  • Fluid, other than breast milk, from the nipple, especially if it’s bloody.
  • Scaly, red, or swollen skin on the breast, nipple, or areola (the dark area of skin around the nipple).
  • Dimples in the breast that look like the skin of an orange, called peau d’orange.

Tests that examine the breasts are used to detect (find) and diagnose breast cancer.

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

  • Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
  • Clinical breast exam (CBE): An exam of the breast by a doctor or other health professional. The doctor will carefully feel the breasts and under the arms for lumps or anything else that seems unusual.
  • Mammogram: An x-ray of the breast.
  • Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.
  • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of both breasts. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • Blood chemistry studies : A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
  • Biopsy : The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. If a lump in the breast is found, a biopsy may be done.

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

    • Excisional biopsy : The removal of an entire lump of tissue.
    • Incisional biopsy : The removal of part of a lump or a sample of tissue.
    • Core biopsy : The removal of tissue using a wide needle.
    • Fine-needle aspiration (FNA) biopsy : The removal of tissue or fluid, using a thin needle.

If cancer is found, tests are done to study the cancer cells.

Decisions about the best treatment are based on the results of these tests. The tests give information about:

  • how quickly the cancer may grow.
  • how likely it is that the cancer will spread through the body.
  • how well certain treatments might work.
  • how likely the cancer is to recur (come back).

Tests include the following:

  • Estrogen and progesterone receptor test : A test to measure the amount of estrogen and progesterone (hormones) receptors in cancer tissue. If there are more estrogen and progesterone receptors than normal, the cancer is called estrogen and/or progesterone receptor positive. This type of breast cancer may grow more quickly. The test results show whether treatment to block estrogen and progesterone may stop the cancer from growing.
  • Human epidermal growth factor type 2 receptor (HER2/neu) test : A laboratory test to measure how many HER2/neu genes there are and how much HER2/neu protein is made in a sample of tissue. If there are more HER2/neu genes or higher levels of HER2/neu protein than normal, the cancer is called HER2/neu positive. This type of breast cancer may grow more quickly and is more likely to 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 tests: Tests in which samples of tissue are studied to look at the activity of many genes at the same time. These tests may help predict whether cancer will 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 that is estrogen receptor positive and node negative will spread to other parts of the body. If the risk that the cancer will spread is high, chemotherapy may be given to lower the risk.
    • MammaPrint : This test helps predict whether stage I or stage II breast cancer that is node negative will spread to other parts of the body. If the risk that the cancer will spread is high, chemotherapy may be given to lower 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 which treatments will work best for your cancer.

Certain factors affect prognosis (chance of recovery) and treatment options.

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

  • The stage of the cancer (the size of the tumor and whether it is in the breast only or has spread to lymph nodes or other places in the body).
  • The type of breast cancer.
  • Estrogen receptor and progesterone receptor levels in the tumor tissue.
  • Human epidermal growth factor type 2 receptor (HER2/neu) levels in the tumor tissue.
  • Whether the tumor tissue is triple negative (cells that do not have estrogen receptors, progesterone receptors, or high levels of HER2/neu).
  • How fast the tumor is growing.
  • How likely the tumor is to recur (come back).
  • A woman’s age, general health, and menopausal status (whether a woman is still having menstrual periods).
  • Whether the cancer has just been diagnosed or has recurred (come back).

Stages of Breast Cancer

After breast cancer has been diagnosed, tests are done to find out if cancer cells have spread within the breast or to other parts of the body.

The process used to find out whether the cancer has spread within the breast or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The results of some of the tests used to diagnose breast cancer are also used to stage the disease. (See the General Information section.)

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

  • Sentinel lymph node biopsy : The removal of the sentinel lymph node during surgery. The sentinel lymph node is the first lymph node to receive lymphatic drainage from a tumor. It is the first lymph node the cancer is likely to spread to 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 node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes.
  • Chest x-ray : An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up 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. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones with cancer and is detected by a scanner.
  • PET scan (positron emission tomography scan): 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 makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.

There are three ways that cancer spreads in the body.

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

  • Tissue. The cancer spreads from where it began by growing into nearby areas.
  • Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
  • Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

  • Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
  • Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. 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 stages are used for breast cancer:

This section describes the stages of breast cancer. The breast cancer stage is based on the results of tests that are done on the tumor and lymph nodes removed during surgery and on other tests.

Stage 0 (carcinoma in situ)

There are 3 types of breast carcinoma in situ:

  • Ductal carcinoma in situ (DCIS) is a noninvasive condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast. In some cases, DCIS may become invasive cancer and spread to other tissues. At this time, there is no way to know which lesions could become invasive.
  • Lobular carcinoma in situ (LCIS) is a condition in which abnormal cells are found in the lobules of the breast. This condition seldom becomes invasive cancer. Information about LCIS is not included in this summary.
  • Paget disease of the nipple is a condition in which abnormal cells are found in the nipple only.

Stage I

In stage I, cancer has formed. Stage I is divided into stages IA and IB.

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

Stage II

Stage II is divided into stages IIA and IIB.

  • In stage IIA:
    • no tumor is found in the breast or the tumor is 2 centimeters or smaller. Cancer (larger than 2 millimeters) is found in 1 to 3 axillary lymph nodes or in the lymph nodes near the breastbone (found during a sentinel lymph node biopsy); or
    • the tumor is larger than 2 centimeters but not larger than 5 centimeters. Cancer has not spread to the lymph nodes .


    In stage IIB, the tumor is:

    • larger than 2 centimeters but not larger than 5 centimeters. Small clusters of breast cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes; or
    • larger than 2 centimeters but not larger than 5 centimeters. Cancer has spread to 1 to 3 axillary lymph nodes or to the lymph nodes near the breastbone (found during a sentinel lymph node biopsy); or
    • larger than 5 centimeters. 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 any size. Cancer is found in 4 to 9 axillary lymph nodes or in the lymph nodes near the breastbone (found during imaging tests or a physical exam); or
  • the tumor is larger than 5 centimeters. Small clusters of breast cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes; or
  • the tumor is larger than 5 centimeters. Cancer has spread to 1 to 3 axillary lymph nodes or to the lymph nodes near the breastbone (found during a sentinel lymph node biopsy).

Stage IIIB

In stage IIIB, the tumor may be any size and cancer has spread to the chest wall and/or to the skin of the breast and caused swelling or an ulcer. Also, cancer may have spread to:

  • up to 9 axillary lymph nodes; or
  • the lymph nodes near the breastbone.

Cancer that has spread to the skin of the breast may also be inflammatory breast cancer. See the section on Inflammatory Breast Cancer for more information.

Stage IIIC

In stage IIIC, no tumor is found in the breast or the tumor may be any size. Cancer may have spread to the skin of the breast and caused swelling or an ulcer and/or has spread to the chest wall. Also, cancer has 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 breastbone.

Cancer that has spread to the skin of the breast may also be inflammatory breast cancer. See the section on Inflammatory Breast Cancer for more information.

Stage IV
In stage IV, cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain.

Inflammatory Breast Cancer

In inflammatory breast cancer, cancer has spread to the skin of the breast and the breast looks red and swollen and feels warm. The redness and warmth occur because the cancer cells block the lymph vessels in the skin. The skin of the breast may also show the dimpled appearance called peau d’orange (like the skin of an orange). There may not be any lumps in the breast that can be felt. Inflammatory breast cancer may be stage IIIB, stage IIIC, or stage IV.

Recurrent Breast Cancer

Recurrent breast cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the breast, in the skin of the breast, in the chest wall, or in nearby lymph nodes.

Treatment Option Overview

There are different types of treatment for patients with breast cancer.

Different types of treatment are available for patients with breast cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Five types of standard treatment are used:

Surgery

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

Sentinel lymph node biopsy is the removal of the sentinel lymph node during surgery. The sentinel lymph node is the first lymph node to receive lymphatic drainage from a tumor. It is the first lymph node where the cancer is likely to spread. 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 node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. After the sentinel lymph node biopsy, the surgeon removes the tumor using breast-conserving surgery or mastectomy. If cancer cells were not found in the sentinel lymph node, it may not be necessary to remove more lymph nodes. If cancer cells were found, more lymph nodes will be removed through a separate incision. This is called a lymph node dissection.

Types of surgery include the following:

  • Breast-conserving surgery is an operation to remove the cancer and some normal tissue around it, but not the breast itself. Part of the chest wall lining may also be removed if the cancer is near it. This type of surgery may also be called lumpectomy, partial mastectomy, segmental mastectomy, quadrantectomy, or breast-sparing surgery.
  • Total mastectomy: Surgery to remove the whole breast that has cancer. This procedure is also called a simple mastectomy. Some of the lymph nodes under the arm may be removed and checked for cancer. This may be done at the same time as the breast surgery or after. This is done through a separate incision.
  • Modified radical mastectomy: Surgery to remove the whole breast that has cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscles.

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. Treatment given before surgery is called preoperative therapy or neoadjuvant therapy.

After the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given radiation therapy, chemotherapy, targeted therapy, or hormone therapy after surgery, to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, 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 considered. Breast reconstruction may be done at the time of the mastectomy or at some time after. The reconstructed breast may be made with the patient’s own (nonbreast) tissue or by 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 keep them from growing. There are two types of radiation therapy:

  • External radiation therapy uses a machine outside the body to send radiation toward the cancer.
  • Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

The way the radiation therapy is given depends on the type and stage of the cancer being treated. External radiation therapy is used to treat breast cancer. Internal radiation therapy with strontium-89 (a 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 bones. 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 taken 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, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).

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

Hormone therapy

Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances made by glands in the body and circulated in the bloodstream. Some hormones can cause certain cancers to grow. If tests show that the cancer cells have places where hormones can attach (receptors), drugs, surgery, or radiation therapy is used to reduce the production of hormones or block them from working. The hormone estrogen, which makes some breast cancers grow, is made mainly by the ovaries. Treatment to stop the ovaries from making estrogen is called ovarian ablation.

Hormone therapy with tamoxifen is often given to patients with early localized breast cancer that can be removed by surgery and those with metastatic breast cancer (cancer that has spread to other parts of the body). Hormone therapy with tamoxifen or estrogens can act on cells all over the body and may increase the chance of developing endometrial cancer. Women taking tamoxifen should have a pelvic exam every year to look for any signs of cancer. Any vaginal bleeding, other than menstrual bleeding, should be reported to a doctor as soon as possible.

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

Hormone therapy with an aromatase inhibitor is given to some postmenopausal women who have hormone receptor positive breast cancer. Aromatase inhibitors decrease the body’s estrogen by blocking an enzyme called aromatase from turning androgen into estrogen. Anastrozole, letrozole, and exemestane are types of aromatase inhibitors.

For the treatment of early localized breast cancer that can be removed by surgery, certain aromatase inhibitors may be used as adjuvant therapy instead of tamoxifen or after 2 to 3 years of tamoxifen use. 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 reduces the risk that the cancer will 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 harming 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 is a cancer treatment that 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 may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells. Monoclonal antibodies may 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 may be used with other therapies to treat HER2 positive breast cancer.
  • Pertuzumab is a monoclonal antibody that may be combined with trastuzumab and chemotherapy to treat breast cancer. It may be used to treat certain patients with HER2 positive breast cancer that has metastasized (spread to other parts of the body). It may also be used as neoadjuvant therapy in certain patients with early stage HER2 positive breast cancer.
  • Ado-trastuzumab emtansine is a monoclonal antibody linked to an anticancer drug. 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 recurred (come back).

Tyrosine kinase inhibitors are targeted therapy drugs that block signals needed for tumors to grow. Tyrosine kinase inhibitors may 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 inside tumor cells. It may be used with other drugs to treat patients with HER2 positive breast cancer that has progressed after treatment with trastuzumab.
  • Neratinib is a tyrosine kinase inhibitor that blocks the effects of the HER2 protein and other proteins inside tumor cells. It may be used to treat patients with early stage HER2 positive breast cancer after treatment with trastuzumab.

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

  • Palbociclib is a cyclin-dependent kinase inhibitor used with the drug letrozole to treat breast cancer that is 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 may also be used with fulvestrant in women whose disease has gotten worse 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 come back 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 is advanced or has spread to other parts of the body. It may be used alone or with other drugs to treat breast cancer that has gotten worse after other treatment.

Mammalian target of rapamycin (mTOR) inhibitors block a protein called mTOR, which may keep 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 hormone receptor positive breast cancer that is also HER2 negative and has not gotten better with other treatment.

PARP inhibitors are a type of targeted therapy that block DNA repair and may 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.

Treatment for breast cancer may cause side effects.

Some treatments for breast cancer may cause side effects that continue or appear months or years after treatment has ended. These are called late effects.

Late effects of radiation therapy are not common, but may include:

  • Inflammation of the lung after radiation therapy to the breast, especially when chemotherapy is given at the same time.
  • Arm lymphedema, especially when radiation therapy is given after lymph node dissection.
  • In women younger than 45 years who receive radiation therapy to the chest wall after mastectomy, there may be a higher risk of developing breast cancer in the other breast.

Late effects of chemotherapy depend on the drugs used, but may include:

  • Heart failure.
  • Blood clots.
  • Premature menopause.
  • Second cancer, such as leukemia.

Late effects of targeted therapy with trastuzumab, lapatinib, or pertuzumab may include:

  • Heart problems such as heart failure.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today’s standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

Treatment Options for Breast Cancer

Early, Localized, or Operable Breast Cancer

Treatment of early, localized, or operable breast cancer 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 done.
  • Modified radical mastectomy. Breast reconstruction surgery may also be done.

Postoperative radiation therapy

For women who had breast-conserving surgery, radiation therapy is given to the whole breast to lessen the chance the cancer will come back. Radiation therapy may also be given to lymph nodes in the area.

For women who had a modified radical mastectomy, radiation therapy may be given to lessen the chance the cancer will come back if any of the following are true:

  • Cancer was found in 4 or more lymph nodes.
  • Cancer had spread to tissue around the lymph nodes.
  • The tumor was large.
  • There is tumor close to or remaining in the tissue near the edges of where the tumor was removed.

Postoperative systemic therapy

Systemic therapy is the use of drugs that can enter the bloodstream and reach cancer cells throughout the body. Postoperative systemic therapy is given to lessen the chance the cancer will come back 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 more treatment may be needed or postoperative therapy may include:

  • Tamoxifen therapy with or without chemotherapy.
  • Tamoxifen therapy and treatment to stop or lessen how much estrogen is made by the ovaries. Drug therapy, surgery to remove the ovaries, or radiation therapy to the ovaries may be used.
  • Aromatase inhibitor therapy and treatment to stop or lessen how much estrogen is made by the ovaries. Drug therapy, surgery to remove the ovaries, or radiation therapy to the ovaries may be used.

In postmenopausal women with hormone receptor positive tumors, no more treatment may be needed or postoperative therapy may include:

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

In women with hormone receptor negative tumors, no more treatment may be needed or postoperative therapy may include:

  • Chemotherapy.

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

  • Chemotherapy.

In women with small, HER2/neu positive tumors, and no cancer in the lymph nodes, no more treatment may be needed. If there is cancer in the lymph nodes, or the tumor is large, postoperative therapy may include:

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

In women with small, hormone receptor negative and HER2/neu negative tumors (triple negative) and no cancer in the lymph nodes, no more treatment may be needed. If there is cancer in the lymph nodes or the tumor is large, 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 include:

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

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

  • A clinical trial of hormone therapy, such as tamoxifen or aromatase inhibitor therapy.

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

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

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

  • Chemotherapy.
  • A clinical trial of a new chemotherapy regimen.
  • A clinical trial of monoclonal antibody therapy.

Locally Advanced or Inflammatory Breast Cancer

Treatment of locally 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 testing new anticancer drugs, new drug combinations, and new ways of giving treatment.

Locoregional Recurrent Breast Cancer

Treatment of locoregional recurrent breast cancer (cancer that has come back after treatment in the breast, in the chest wall, or in nearby lymph nodes), may include the following:

  • Chemotherapy.
  • Hormone therapy for tumors that are hormone receptor positive.
  • Radiation therapy.
  • Surgery.
  • Targeted therapy (trastuzumab).
  • A clinical trial of a new treatment.

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 just been diagnosed with metastatic breast cancer that is hormone receptor positive or if the hormone receptor status is not known, treatment may include:

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

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

  • Tamoxifen, an LHRH agonist, or both.

In women whose tumors are hormone receptor positive or hormone receptor unknown, with spread to the 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 therapy 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) which 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 may be given after surgery.
  • Surgery to remove cancer that has spread to the lung.
  • Surgery to repair or help support weak or broken bones. Radiation therapy may be given after surgery.
  • Surgery to remove fluid that has collected 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 (a radionuclide) to relieve pain 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 bone.
  • A clinical trial of high-dose chemotherapy with stem cell transplant.
  • Clinical trials testing new anticancer drugs, new drug combinations, and new ways of giving treatment.

Treatment Options for Ductal Carcinoma In Situ (DCIS)

For information about the treatments listed below, see the Treatment Option Overview section.

Treatment of ductal carcinoma in situ may include the following:

  • Breast-conserving surgery and radiation therapy, with or without tamoxifen.
  • Total mastectomy with or without tamoxifen. Radiation therapy may also be given.

Updated: April 12, 2018

Please share this page