Treatments for Breast Cancer

Different treatments for breast cancer have different goals. For example, some treatments are used to reduce the chance the cancer will come back, and other treatments attempt to reduce the growth of the cancer. Treatment recommendations are based on the specific type, extent, and characteristics of the cancer. Every treatment comes with potential risks and harms. Each person should have the opportunity to fully understand both the possible benefits and harms of a particular treatment in order to make their own treatment decisions, based on their values, priorities, and life circumstances. We encourage each person to take the time and seek the resources they need to make the choices that feel best for them.

One tool used to evaluate the benefits of treatment options is risk, measured in both relative risk and absolute risk. Relative risk, often expressed as a percentage increase or decrease, is the number that tells you how much something you do can change your risk. In comparison, absolute risk is your own overall risk. For example, when we say that a treatment will reduce the risk of recurrence by 50%, it does not mean you have a 50% chance of recurrence. It means if the original risk was 10%, it now goes down to 5%. The relative risk was reduced by 50%, and the absolute risk is now 5%. Proponents of various medical interventions sometimes use both relative and absolute risk to describe benefits or harms to either maximize the maximize benefits or minimize the apparent harms.

Note that treatment recommendations will likely be different for patients who have a deleterious BRCA mutation that is known to increase the risk of breast cancer, including the risk that a person who has already had breast cancer will develop a second breast cancer. When this happens, the new cancer is known as a second primary cancer which is different from recurrent cancer.

For hundreds of years, surgery has been the primary way to treat breast cancer. Most people whose breast cancer has not spread to other parts of the body will have surgery to remove the cancer. Today, with improvements in both radiation and systemic treatments (like chemotherapy and targeted therapies), surgery is playing a smaller role in treatment to improve the chances of survival.

There are two basic surgical options: mastectomy to remove the entire breast or lumpectomy to remove only the tumor and a small amount of healthy tissue. Most people who have a lumpectomy also have radiation treatment. Survival rates for both a lumpectomy and a mastectomy are nearly identical—in fact lumpectomy is slightly better for most women! Removing the entire breast does not improve survival rates for women at average risk of breast cancer. Similarly, removing the healthy breast that is not affected by cancer also does not improve survival rates for people at average risk.

Surgery is a major decision and different people will make different choices. The recovery and risks are different for these two surgical options. Mastectomy is a much bigger surgery, and as journalist Peggy Orenstein wrote, “Breasts don’t just screw off, like jar lids.” Our hope is that everyone has the information and support needed to make the decision that feels right to them.

Some people decide to have a breast reconstruction after a mastectomy, to create an artificial breast mound. There are several surgical techniques to do this, including implants under the skin and muscle, and using a flap of tissue from another part of the body.

After decades of concern about the risks of breast implants, the FDA has acknowledged a range of risks associated with the procedure, including a rare lymphoma and autoimmune-related symptoms known as Breast Implant Illness. Because breast implants have been around for decades, there is now more information about the risks and harms, but it’s important to remember that every surgery and reconstruction technique carries specific risks and limitations. The decision whether and how to reconstruct a breast mound is extremely personal, and there are many resources to learn about reconstruction options.

Whatever the choice, for nearly all people who undergo mastectomy, there is little to no sensation on the chest after surgery. This means when anyone says that a reconstructed breast “feels normal” they are referring how it feels to the hand that is touching the breast, not the sensation of the breast itself.

Around a third of those who have a mastectomy go flat, or do not have reconstruction. A recent swell in activism around destigmatizing this choice has had a powerful impact on the lives of people who consider themselves part of the flat community. Advocates for going flat have helped change the culture around not reconstructing, showing that however you are most comfortable in your body is the most beautiful choice. This culture shift pushes back on the stigma associated with foregoing breast reconstruction. For many patients, the medical decision to get reconstruction has been complicated by societal pressures and norms. Living without breast is neither unfeminine nor misguided, and individuals considering whether or not to reconstruct should be make decisions based on individual needs, wants, and values, as well as the harms and risks associated with the medical procedure.

Additionally with mastectomy, the surgeon will want to remove and examine some lymph nodes as an indicator of the chance of cancer being in other organs, even if microscopic. Removing cancerous lymph nodes does not help patients live longer and comes with a significant risk of lymphedema, a painful and sometimes disabling condition. In the past, it was common for surgeons to remove all lymph nodes (called full axillary node dissection) at the time of breast surgery. However, clinical trial data has convinced most surgeons to instead perform a sentinel node biopsy. This procedure allows doctors to identify, remove, and examine only the lymph node (or nodes) closest to the tumor, where any cancer cells are most likely to spread. It is important for people considering this procedure to discuss and agree in advance whether the surgeon will plan to remove more lymph nodes if the sentinel node comes back positive, a procedure that will be performed when the patient is unconscious on the surgery table.

Ionizing radiation damages living tissue. Radiation can cause cancer, but it can also be used therapeutically to damage cancer cells, leading to cellular death to stop the cancer from continuing to divide and grow. Some people find it confounding that the same thing that can damage DNA and cause cancer is also used to treat cancer. Some surgeons believe that the harms of radiation can be limited by the dose of the radiation or the way it is delivered. There is a small risk of secondary cancer from radiation therapy, but improvements in radiation oncology over the last decade have significantly reduced the harms and risks so that for many breast cancer patients, the benefits outweighs the harms of radiation treatment.

Most women who undergo lumpectomy will also receive radiation therapy, or radiotherapy, after surgery to reduce the risk of recurrence. Additionally, some women who have a mastectomy may also have radiation therapy to reduce the chance the cancer will come back. In metastatic breast cancer, breast cancer that spread to other areas of the body, radiation therapy is used to control the cancer’s growth or relieve pain. For example, targeted radiation may be used to treat the spread of breast cancer to the brain or bones.

Because of the risks of radiation therapy (including heart damage, lung damage, and secondary cancers), it is important to identify who might be able to avoid radiation treatment without compromising survival rates. In some cases, older women with early-stage, non-aggressive breast cancer can avoid radiation treatment.

For people who do receive radiation treatment, one way to reduce the toxicity of radiation without compromising efficacy is to have a shorter duration at a higher dose, reducing the standard treatment from 5 weeks to 3. This is called hypofractionated radiation. It should be noted that there are financial disincentives for radiation oncologists to make this transition.Additionally, a drug-free way to reduce heart damage, especially for radiation treatment to the left breast, is to coordinate with the radiation team to do deep inspiration breath hold, holding your breath for brief periods so that the air in the lung creates a space to protect the heart.

Chemotherapy drugs are frequently used in addition to other breast cancer treatments, to try to stop cancer cells from dividing and growing. There are many different chemotherapy drugs and they may be given intravenously or by pill.

For people whose breast cancer has not spread, chemotherapy may be used to reduce the risk of the cancer coming back as a recurrence. Recurrence is when a cancer comes back after a time of not being detected. Local recurrence is when the cancer has come back at the same place or near where the first tumor was found. Distant recurrence is when the cancer has spread to another organ within the body.

For people with metastatic disease, chemotherapy may be used to stop the cancer from growing or spreading further, improve quality of life, and help patients live longer.

Chemotherapy can be given before or after surgery for people whose breast cancer has not spread. In the case of metastatic disease chemotherapy is usually used instead of surgery. Chemotherapy given before surgery is called neoadjuvant therapy.

Some of the reasons to do this are to try to prevent the spread of the most aggressive cancers, to shrink larger tumors making surgery easier, and to evaluate the tumor response to therapy. For people with metastatic disease, chemotherapy is one of many systemic (whole-body) treatments available to manage the disease, and may be the first treatment given or may be given after other treatments stop working.

Side effects from chemotherapy include everything from temporary and mild symptoms to serious, permanent, or even life-threatening harms. As with all health decisions, it is important to weigh the benefits and the risks so that each person can make the decision that is best for them.

Most breast cancers are hormone-driven, meaning and the presence of estrogen and/or progesterone can promote the growth of these breast cancers. Hormone therapy works in different ways to try to stop or slow the growth of hormone-sensitive cancers. Which treatment is used may depend on whether the person is in menopause or not.

The most common hormone therapy is tamoxifen, which has been used for more than 30 years to treat hormone positive breast cancers. Tamoxifen is in a category of drugs called selective estrogen receptor modulators (SERMs) which bind to estrogen receptors throughout the body. When SERMs bind to estrogen receptors of some tissues (for example breast tissue) they block estrogen. But tamoxifen can mimic estrogen effects in other tissue, such as the uterus and bone. In fact, tamoxifen has been labeled a carcinogen by some agencies because it increases the risk of endometrial cancer.

Aromatase inhibitors (AIs) are another category of hormone treatments. They are mostly used to treat hormone-sensitive breast cancer in women who have reached menopause. These drugs (including anastrozole, letrozole, and exemestane) block an enzyme called aromatase from making estrogen for the body after the ovaries stop producing it through menopause.

Typically premenopausal women are not offered AIs if their ovaries are not producing estrogen. A woman’s ovaries can be forced to stop working through ovarian suppression, a medical process that permanently or temporarily blocks the ovaries from functioning. This can be done through three types of ovarian ablation: surgery called oophorectomy, radiation, or ovarian suppression drugs (such as Lupron or Zoladex).

Because hormone therapy can impact quality of life and may also come with health harms for some women, it is important for each person to weigh harms and benefits.

Arguably the one true breakthrough in breast cancer treatment in the last 25 years was the development of the targeted treatment trastuzumab (brand name Herceptin). The introduction of trastuzumab as the standard of care for Her2 positive breast cancers has reduced deaths from this aggressive type of breast cancer.

Unfortunately, trastuzumab does not work for everyone, and tumors can develop resistance to treatment. New therapies are being developed that work in different ways to target Her2 positive breast cancer including pertuzumab (Perjeta), lapatinib (Tykerb), and ado-trastuzumab emtansine (Kadcyla).

A fascinating history which offers insights into the inherent challenges of drug development in the U.S. and includes the role of Breast Cancer Action’s early members is Robert Bazell’s book on the subject, "Her-2: The Making of Herceptin, a Revolutionary Treatment for Breast Cancer."

Targeted cancer therapies have proven to be elusive but remain one of the main areas of cancer research. The hope is that treatments that target specific characteristics of cancer cells will be both more effective than existing treatments and less harmful to normal, healthy cells.

Recent success with immunotherapy for other kinds of cancer has sparked a resurgence in interest in immunotherapy research for breast cancer, particularly for those with triple negative breast cancer. Immunotherapy is different from chemotherapy in that it utilizes the body’s own immune system to attack the cancer cells. Recent evidence shows improved progression free survival, the length of time during and after treatment that the individual lives with breast cancer without it getting worse. Breast Cancer Action believes treatments should be approved on the basis of overall survival benefit. As of 2020, overall survival benefit has also been demonstrated by some immunotherapy treatments, which means these drugs are no longer considered to experimental. Despite clinical outcomes, there is still concern about expense of immunotherapies.

Chemoprevention is the use of cancer treatments by healthy people to lower the risk of cancer. Breast Cancer Action has long questioned any large-scale strategy of “pills for prevention” and instead urges research and resources to go toward true primary prevention. Too often, efforts that promote chemoprevention define “high risk” as any woman age 60 or older. This implicitly defines older women as “sick” and in need of treatment — in effect pathologizing the normal process of aging for women.

However, some people whose risk of breast cancer is significantly higher than average may want to consider various ways of reducing their individual risk. An inherited BRCA1 or BRCA2 mutation is the most well-understood risk factor and people with these mutations should weigh the risk and potential benefit of several risk-reduction and surveillance strategies to decide what is right for them.

Studies of chemoprevention have shown that the vast majority of people who take the drugs will not benefit, most often because they would never have developed cancer anyway, but also because the risk-reducing drug does not always prevent someone from getting cancer. Defining “high risk” too broadly means that a lot of people are unnecessarily exposed to the harmful effects of powerful anti-cancer drugs.

The “number needed to treat” (NNT), which is the average number of patients who will be treated for every one person who will avoid a bad outcome compared to a control arm in a clinical trial, is an important way to assess studies when considering chemoprevention: How many people do not benefit for every one person who does benefit?

Promoting large-scale chemoprevention is not a good public health strategy even though it expands the potential market, thus generating more profits for Pharma and biotech. In addition to exposing a lot of people to the harmful side effects of powerful cancer drugs, it also diverts focus and resources away from finding and eradicating environmental causes of, as well as more effective treatments for, breast cancer.

Despite the billions of dollars spent on awareness, breast cancer treatments remain largely the same as they were decades ago. Activists and health providers alike worry that the basic treatments for breast cancer continue to be “slash, burn, poison”—more commonly referred to in medical offices as surgery, radiation, chemotherapy—with too few advances benefitting too few women.

From a patient perspective, treatments work if they (1) help people live longer (improve overall survival), (2) help people live better (improve quality of life), or (3) cost less (so that more people have access and aren’t bankrupted by treatment). If a treatment doesn’t do one of these three things, the companies who sell it may benefit, but breast cancer patients do not. Until a new treatment has been shown to do one of these three things, we believe it should not be approved by the Food and Drug Administration (FDA).

In the face of slow medical advances, with true breakthroughs few and far between, the FDA too often gives into pressure to approve new cancer drugs for the sake of saying they’ve approved new treatments. But fast approvals don’t help patients if the drugs in question are ineffective or unsafe. And granting FDA approval of essentially experimental drugs drives up medical costs without advancing health and wellbeing.

We believe that the best way to incentivize the development of desperately needed safe and effective new treatments is for the FDA to uphold high drug approval standards. The real barrier to breast cancer patients receiving more effective, less toxic treatments is scientific, not regulatory. Lowering standards for safety and efficacy will not speed up innovation but instead threatens to lower the quality of treatments that come to market.

Of course, there are times when available treatments don’t work and someone may want to try an experimental treatment. The main way is through participation in a clinical trial. But not everyone qualifies for or has access to a clinical trial. When someone cannot participate in a clinical trial, and available treatments are ineffective, patients may be provided access to promising experimental treatments through the FDA’s compassionate access programs. Additionally, with the passage of the federal Right to Try law in 2018, physicians may directly request access to experimental therapies from companies, without the oversight of the FDA. While this may seem appealing to some, the FDA’s compassionate use program has several advantages compared to Right to Try, including important patient protections.