Treating breast cancer

Content provided by the Faculty of the Harvard Medical School

Treating breast cancer

More than many other illnesses, breast cancer demands that you take an active role in your care. That's because there are many treatment options you will need to consider. Two different treatments may offer the same chance for controlling the cancer but may affect your daily life in different ways. The difference comes down to quality and quantity of life and personal preferences. Before making a decision, you owe it to yourself to learn about all of your treatment options and how they are likely to affect the way you will look and feel.

Today, the optimal management includes a committed team of health care specialists from different disciplines — surgery, reconstructive surgery, medical and radiation oncology, radiology, pathology, nursing and social services. While each person of this team has his or her own area of specialization, the best care comes from a coordinated effort that considers all of the differing aspects of the medical and pathological aspects of the cancer that has been diagnosed.

For example, you may need to decide, with your surgeon's help, whether breast-conserving surgery (lumpectomy) or full breast removal (mastectomy) is the best choice, weighing both recurrence rates and cosmetic and lifestyle considerations. Likewise, you'll need to determine whether you want breast reconstruction and, if so, which of several procedures to select. Ask whether it's possible to have the reconstruction performed at the same time the cancer is removed.

Local and systemic treatments

Most breast cancers are treated with a combination of local therapies, designed to eliminate cancer cells in the breast, and systemic treatments, designed to destroy cancer cells that may have spread beyond the breast to other parts of the body. Surgery and radiation are local treatments. Chemotherapy (treatment with anticancer medications) is a systemic treatment, as is the use of hormonal drugs and Herceptin to target specific types of cancer cells. It is the spread of cancer cells to other parts of the body that is life-threatening, so systemic treatment, in combination with local treatment, often is necessary.

Local treatments. The purpose of these therapies is to remove cancer cells in the breast to prevent a local recurrence, or the return of the cancer to the primary (original) site, a so called local recurrence. Breast surgery (either lumpectomy or mastectomy) and radiation therapy (generally given after lumpectomy) are the most common treatments for the local control of breast cancer. Local treatment involves a collaborative effort between the surgeon, radiologist, pathologist, radiation oncologist, and, in some cases, a medical oncologist and a reconstructive plastic surgeon.

Systemic treatments. These treatments send drugs through the bloodstream to reach and destroy cancer cells that have migrated beyond the breast. Examples are chemotherapy, hormonal therapy with drugs such as oral tamoxifen, and immunotherapy with Herceptin, a monoclonal antibody designed to target specific cells.

Chemotherapy is able to destroy or eliminate cancer cells, regardless of any individual specific characteristics of the cancer cell. In contrast, hormonal treatments are often used based upon specific characteristics of the cancer that are determined once a biopsy or lumpectomy has been performed. For example, analysis of the removed cancer cells can help physicians identify whether treatment with hormones is likely to be beneficial based upon specialized study of the individual patient's breast cancer. In the case of Herceptin, a new drug, analysis of the cancer cells can predict which patients will benefit from this treatment.

Originally, doctors believed that cancer simply grew larger and outward. However, research and experience have demonstrated that even in the early stages of the disease, cancer cells can separate from the primary tumor and spread through the bloodstream and lymphatic system to start new tumors in other organs or bones.

Systemic therapy is designed to kill these microscopic deposits of metastatic cancer cells. It can be used after surgery (adjuvant therapy) to prevent recurrence, or before surgery (neoadjuvant therapy) to shrink a large tumor.

There are many factors that go into making a decision about whether adjuvant or neoadjuvant treatments are necessary. For example, if there are cancer cells that have spread to the axillary lymph nodes, often adjuvant treatments are used. If the primary breast cancer is large or has other characteristics, such as being inflamed or involving the skin, systemic therapy (neoadjuvant) treatments may be used before breast surgery is undertaken.

Comprehensive breast centers

Women with breast cancer increasingly are choosing to be treated at comprehensive breast centers that offer up-to-date treatments and the specialists who can provide them. Such centers feature close cooperation among medical oncologists, surgeons, pathologists, mammographers, radiation oncologists, plastic surgeons, radiation therapists, psychiatrists or psychologists, social workers, physical therapists, and nutritionists. Because they treat so many cancer patients, their staff members can maintain a high level of skill. Their goal is to provide rapid and accurate diagnosis and a broad range of state-of-the-art treatment options. A woman who is concerned that a large institution will be too impersonal can be assured that she will be matched with one surgeon, one medical and radiation oncologist, and probably one nurse practitioner, and that she will see the same health care team for each visit.

Should you join a clinical trial?

Many clinical trials are under way to test new treatments for breast cancer. If your doctor asks you to participate in a clinical trial, you will receive either the treatment that is considered to be the most effective today for your type of breast cancer or a modified treatment that is being tested to see if it offers advantages over the current standard of care, such as improved survival or fewer side effects. Many women find it comforting to know that something good can come out of having breast cancer — that their participation in a clinical trial will provide improved treatments for their own sisters, friends, and daughters in years to come. The National Cancer Institute lists the following benefits and drawbacks of joining a clinical trial.

Possible benefits

Clinical trials offer high-quality cancer care. If you are in a study and do not receive the new treatment being tested, you will still receive the best standard treatment. This may be as good as, or better than, the new approach.
If a new treatment approach is proved to work and you are taking it, you may be among the first to benefit.
You have the chance to help others and improve cancer treatment.
Participation in most clinical studies does not result in extra charges to the participating patient. Oftentimes, patients will be provided with expense reimbursement, especially if additional visits or tests are performed as part of the clinical study.

Possible drawbacks

New treatments under study are not always better than, or even as good as, standard care. They may have side effects that doctors do not expect or that are worse than those of standard treatment.
Even if a new treatment has benefits, it may not work for you. Even standard treatments, proven effective for many people, do not help everyone.
Health insurance and managed care providers may not cover all patient care costs in a study. However, most studies will be structured to make sure that participating patients don't incur extra costs.

Your rights and protections

You have certain rights before and during your participation in a cancer treatment study. Knowing these can help protect you from harm.

Taking part in a treatment study is up to you. It may be only one of your treatment choices.
If you do enter a study, doctors and nurses will follow your response to treatment carefully throughout the research.
If researchers learn that a treatment harms you, you will be taken off the study right away. You may then receive other treatment from your own doctor.
You have the right to leave a study at any time.
You have the right to informed consent. That means you must be given all the facts about a study before you decide whether to take part.

Created by the Faculty of the Harvard Medical School

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Last updated:	April 23, 2007

Medical content reviewed by the Faculty of the Harvard Medical School. Harvard Health Publications, Copyright © 2007 by President and Fellows of Harvard College. All rights reserved. Used with permission of StayWell.

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