In general, the following treatments are used for breast cancer:
- Surgery
- Drug therapies, including chemotherapy, targeted therapy, immunotherapy, etc.
- Radiation therapy
- Hormone therapy
Surgery
Surgery is the main treatment for breast cancer and is required in almost all cases, except in certain advanced stages where the disease has spread throughout the body. In many cases, surgery is performed as the first treatment, but in some situations, it may be done after chemotherapy or hormone therapy or rarely after radiotherapy.
Breast cancer surgery includes:
- Breast surgery: This can involve either removing the entire breast (mastectomy) or preserving the breast (breast-conserving surgery).
- Axillary surgery (underarm lymph node surgery): This may involve removing only the sentinel lymph nodes (the first lymph nodes to which cancer is likely to spread) or removing all lymph nodes in the underarm area.
Nowadays, the most common approach is sentinel lymph node removal, while complete lymph node removal is reserved for rare cases.
Chemotherapy
Chemotherapy is one of the most commonly used treatments for many types of cancer, including breast cancer. This treatment affects all cells in the body, especially fast-growing ones, including cancer cells. However, it can also impact normal fast-growing cells, leading to side effects.
Many patients find chemotherapy to be the most challenging phase of treatment due to its long duration (typically 4–6 months) and side effects, which can include fatigue, nausea, hair loss, and changes in skin and nails. However, not all patients experience the same side effects. Chemotherapy is usually given through an intravenous (IV) infusion, though in some situations, based on the characteristics of the tumor, an oncologist may prescribe oral chemotherapy.
Targeted Therapy
Cancer cells grow and multiply faster than normal cells. Chemotherapy works by stopping the growth of these rapidly dividing cells, but it can also affect other rapidly growing healthy cells, leading to side effects such as hair loss.
Targeted therapy focuses specifically on cancer cells that have certain proteins or receptors on their surface. For example, patients whose cancer cells have the HER-2 protein may receive targeted drugs such as Herceptin (trastuzumab) or Pertuzumab. Another example is the inhibitors of CDK4/6, Such as Abemaciclib or Ribociclib, which are effective mostly in more advanced hormone-positive, HER-2-negative breast cancers.
Immunotherapy
Immunotherapy helps the body’s immune system recognize and attack cancer cells. Research has shown that this treatment is effective for some types of breast cancer, particularly triple-negative breast cancer (a subtype that lacks estrogen, progesterone, and HER-2 receptors on its surface). Studies are ongoing to determine its effectiveness for other breast cancer types. Pembrolizumab is a good example of this category of treatment.
Radiation Therapy
Radiation therapy uses X-rays to treat the affected area, such as the breast or, in cases of bone metastasis, the specific bone affected.
- It is usually given 5 days a week for 3–5 weeks.
- Each session lasts about 5–10 minutes.
- Side effects are usually mild and may include skin irritation (similar to a sunburn) and fatigue, which typically subside over time.
- Modern radiation techniques have improved, making treatment shorter and more effective, and in some cases, radiation is even applied during surgery.
Hormone Therapy
Hormone therapy is usually the final step of breast cancer treatment, given after radiation therapy. However, not all patients need it—only those whose cancer cells have hormone receptors (estrogen or progesterone receptors).
- If hormone therapy is needed, patients take a pill daily for at least 5 years.
- In some cases, treatment may continue for a longer period.
- The type of hormone therapy differs for pre-menopausal and post-menopausal women.
Which Treatment Is Needed for Each Patient?
Not all patients require every type of treatment. The treatment plan depends on several factors, including:
- Hormone receptor status (ER, PR) and HER-2 status:
- If HER-2 is positive, or all three important markers are negative (Triple Negative), chemotherapy is often needed even for small tumors (as small as 5 mm).
- If ER and PR are positive but HER-2 is negative, chemotherapy is less likely to be needed, especially in postmenopausal women.
- If ER and PR are present, hormone therapy is necessary.
- Age and menopausal status:
- Younger women (under 50 or premenopausal) are more likely to need chemotherapy.
- Type of surgery performed:
- If part of the breast is preserved or if lymph nodes are involved, radiation therapy is required.
- Cancer cell characteristics (pathology report):
- Some features, like tumor grade or lymphovascular invasion (LVI), indicate a more aggressive cancer and may increase the need for chemotherapy.
- Cancer stage (how advanced it is):
- The more advanced the cancer, the more treatments may be needed.
Treatment Sequence
In most cases, treatment follows this order:
- Surgery
- Chemotherapy (if needed)
- Radiation therapy (if needed)
- Hormone therapy (if needed)
For example:
- If chemotherapy is not required, the patient moves directly to radiation therapy (if needed), and if neither chemotherapy nor radiation therapy is needed, hormone therapy begins.
Every patient’s treatment plan is made based on their type and stage of cancer. Sometimes, treatment starts with chemotherapy before surgery. For most people with HER2-positive or triple-negative (a subtype that lacks estrogen, progesterone, and HER-2 receptors on its surface) breast cancer who have a lump or affected lymph nodes, treatment begins with chemotherapy—this is called neoadjuvant chemotherapy.
If everything goes as planned, the time interval between surgery, chemotherapy, and radiotherapy wil