Which treatment for breast cancer?

• A quick guide to what's on this page
• How treatment is planned
• Stage and grade of your cancer
• Tests on your cancer cells
• Switching off the ovaries
• Surgery and radiotherapy

• Breast reconstruction
• Chemotherapy and hormone therapy
• Biological therapy for breast cancer
• Predicting how well treatment may work
• Taking notes
• Second opinions

The treatments used for breast cancer include

• Surgery
• Radiotherapy
• Hormone therapy
• Chemotherapy
• Biological treatments

You may have any of these treatments, or all of them, depending on your situation. It is impossible to generalise about breast cancer treatment because there are so many different sets of circumstances. Your doctor will take many different factors into account when deciding how to treat you. Some of the factors they consider are

• Whether you have had your menopause
• The type of breast cancer you have
• The size of your breast tumour
• The stage of your breast cancer
• The grade of your cancer cells
• Whether your cancer cells have particular receptors
• Your general health

If you feel strongly about having or not having any particular treatment, do tell your doctor. There may be other options for you. And if you would prefer a particular treatment, but your specialist hasn't suggested it, do ask them why. They almost certainly have very good reasons and can explain them to you.

Specialised computer programmes are available for doctors that can help them, and you, to decide which treatment may be best in your particular case. The programmes contain all the details of trial results for treatments after surgery for early stage breast cancer. Doctors can type in the details of your cancer and then add in different types of treatment, such as chemotherapy or hormonal therapy. The computer tells your doctor how much each treatment reduces the chance of the cancer coming back and gives the risk of side effects. One commonly used programme is called adjuvant! online.

Both the stage and grade are important for helping to decide which treatments you need. The stage of your breast cancer means how far it has grown and whether it has spread. Grade means what the cancer cells look like under the microscope. Breast cancers can be

• Low grade - grade 1 (slow growing)
• Intermediate grade - grade 2
• High grade - grade 3 (faster growing)

Low grade cancers tend to grow more slowly than high grade. High grade cancers are more likely to come back after they have first been treated. But these are both rules of thumb, and can only give a guideline about how any individual cancer will behave. Having said that, doctors will look at grade, as well as stage, when deciding which treatments to offer you.

If you have a high grade cancer, your doctor will probably advise you to have chemotherapy after surgery, even if there is no sign that the cancer has spread. This reduces the chance of the cancer coming back. Your doctor will also take into account the stage of the cancer and your age and general health when deciding about chemotherapy.

If your cancer has spread beyond the breast and lymph nodes in the armpit when it is diagnosed, your specialist may advise that instead of surgery you have radiotherapy and chemotherapy combined with other treatments.

Your breast cancer cells will be tested to see if they have 'hormone receptors' or biological therapy receptors. You may hear your doctor talk about 'your oestrogen receptor status' or 'ER status'. Oestrogen is a female sex hormone. Many breast cancers are stimulated to grow by oestrogen. Tests can show whether the surface of your breast cancer cells have receptors that oestrogen attaches to. A hormone receptor is like a lock on the surface of the cell. The hormone acts like the key. When it fits into its receptor, it stimulates the cancer cell to divide and grow.

If your breast cancer cells have oestrogen receptors, the cancer is said to be 'ER positive'. Hormone therapy that blocks oestrogen is likely to work well for you. Your doctor may recommend hormone therapy to shrink a tumour before surgery. More often they will recommend hormone therapy after surgery, to reduce the chance of the cancer coming back.

Current national guidelines for early breast cancer treatment recommend that you should have hormone therapy after surgery if

• You have had your menopause, and
• Your breast cancer is ER positive, and
• Your doctors think there is more than a low risk that your cancer will come back after surgery

If your cancer does not have oestrogen receptors (is ER negative) you will usually be advised to have chemotherapy. Younger women who are ER positive may have chemotherapy as well as hormone therapy. They will get benefit from both. The chemotherapy directly kills cancer cells but can also stop the ovaries from working and so lowers the oestrogen supply to the cancer.

Older women who have a small, ER negative cancer with a low risk of it coming back might not always have chemotherapy. It depends on how much the doctor thinks chemotherapy would help and the person's general health. There is more information about chemotherapy and hormone therapy further down the page.

You may have heard of another test for a protein called Her2. This test is to see if the biological therapy called trastuzumab (Herceptin) may work as a treatment for your breast cancer. Herceptin is only likely to work if your breast cancer cells have a lot of Her2 protein. You may see this written as HER2neu or erbB2. Her2 protein is on the cell surface of up to 1 in 4 breast cancers. Herceptin attaches to this protein. If your breast cancer cells don't have this protein, Herceptin won't be a helpful treatment for you. There is more about Her2 testing in the breast cancer questions section.

Women who haven't had their menopause before being diagnosed with breast cancer are still producing oestrogen. Oestrogen can stimulate some breast cancer cells to grow. So some treatments are aimed at stopping the ovaries making oestrogen. For some women, chemotherapy treatment will cause a menopause. But there are other ways of stopping the ovaries working. This is called ovarian ablation. To stop your ovaries working, you may have

• Surgery to remove your ovaries
• Drug treatment

Surgery stops the ovaries working permanently. If you do not want your ovaries to stop working permanently you may be offered drugs called 'LHRH analogues' or 'pituitary downregulators' for 2 to 3 years. These drugs stop the ovaries producing oestrogen. When you stop having the drug, your ovaries should start to work again. But the nearer you are to the age at which you would naturally have the menopause, the more likely it is that these drugs will switch off your ovaries permanently. There is more about pituitary downregulators in the hormone therapy for breast cancer section.

Ovarian ablation can cause quite intense menopausal symptoms because the oestrogen levels in the body drop very quickly.

Researchers are looking into the role of ovarian ablation compared to chemotherapy for premenopausal women. In May 2007, the journal 'The Lancet' published a review of the research into LHRH analogues. The reviewers found that switching off the ovaries with an LHRH analogue works as well as chemotherapy for women under 40, with ER positive breast cancer. In most women, periods come back 6 to 12 months after finishing treatment and they will become fertile again. And any menopausal symptoms usually stop soon after the treatment ends.

There are ongoing trials to find out more about the role of ovarian ablation in treating breast cancer. Some trials are combining ovarian ablation with hormone therapy. There is more information about all these trials in our research page in this section.

Most people begin their breast cancer treatment with surgery. There are different types of surgery for breast cancer. You may be offered some choice about your treatment. Depending on the size and position of the tumour, you may be able to have just the cancerous lump removed with a border of normal breast tissue (lumpectomy) plus several weeks of radiotherapy to the rest of the breast. Or you may prefer to have the whole breast removed (mastectomy) and perhaps have a breast reconstruction. To help you decide, you may want to consider

• How you feel about having the whole breast removed
• How you feel about having only part of the breast removed
• How you feel about having radiotherapy
• How quickly you want the treatment to be finished
• How you would cope with travelling to hospital daily for radiotherapy
• Whether you want to have a breast reconstruction straight away or some months after surgery

There are no right and wrong answers to most treatment decisions. Women each feel very differently. Some women want to keep their breast if at all possible, so they choose a lumpectomy (wide local excision) and radiotherapy. Other women feel that once they have breast cancer they would rather have the whole breast removed and they may then have a new breast made.

Some women feel strongly that they do not want radiotherapy. Others welcome it if it means keeping their breast. The most important thing is to take time to find out how you feel and make the right decision for you.

For some women the position of the cancer within the breast or its size may mean that they do not have a choice of treatment. If the cancer is quite big, or right in the centre of the breast, the only option may be to remove the whole breast. But reconstruction is usually possible. The type and timing of reconstruction may depend on the need for further treatment such as chemotherapy or radiotherapy.

Remember that you don't have to make an ‘on the spot’ decision about treatment. You can say that you need some time to think over your options. Use the time to discuss the issues with family or friends, find out more about the treatments, or just to quietly reflect on your own about how you really feel.

There is more information about these treatments in the CancerHelp UK sections about surgery for breast cancer and radiotherapy for breast cancer.

Breast reconstruction is an operation to make a new breast shape after having a breast removed. Or it can be an operation to fill in an area where a large lump was removed from the breast. If you have a mastectomy, you can usually choose whether you would like breast reconstruction at the time of the mastectomy or during a later operation. Sometimes there are medical reasons that make it difficult to do a breast reconstruction. There is detailed information about breast reconstruction in the surgery for breast cancer section of CancerHelp UK.

You may have chemotherapy or hormone therapy before or after your surgery and radiotherapy.

Doctors call cancer treatment before surgery 'neo-adjuvant treatment', or sometimes 'primary treatment'. You may have chemotherapy or hormone therapy before surgery for large tumours or locally advanced breast cancer to try to make the cancer smaller and easier to remove. These drugs can often help to shrink the cancer in the breast. Hormone therapy is only used if you have oestrogen receptor positive breast cancer. It will usually be obvious how well the treatment is going to work within 6 to 12 weeks of starting it.

Chemotherapy or hormone therapy after surgery is called adjuvant treatment. Your doctor will suggest this because it helps to lower the chance of the cancer coming back. Which treatment you have depends on

• Whether you have had your menopause
• Tests on your cancer cells that help to show whether hormone therapy or chemotherapy will work for you
• The grade of your cancer cells
• The size of the cancer in the breast and whether it has spread to your lymph nodes

Biological therapy uses chemicals that are naturally made in the body to treat cancer. Trastuzumab (Herceptin) is a type of biological therapy that can be used for breast cancer. It only works for women who have receptors for Her2 protein on their cancer cells (known as Her2 positive). If you have early breast cancer, there is now evidence that Herceptin may help to stop your Her2 positive breast cancer from coming back. If you have advanced breast cancer, it may help to keep it under control for longer.

In 2002 NICE approved Herceptin to treat advanced breast cancer. And in August 2006, they approved it for women with early breast cancer. There is more information about biological therapies for breast cancer in this section. And also information about the NICE guidance on Herceptin in early breast cancer. Herceptin is not suitable for everyone. You may not be able to have it if you have certain heart problems. The links above take you to more information about who can have treatment with Herceptin.

Some doctors in the UK use a formula called The Nottingham Prognostic Indicator (NPI) to give them some idea of how well treatment may work for a person with breast cancer and how long the person may live. It is not possible to predict exactly what will happen to each individual person but the index can give a general idea. The NPI is a useful guide but not a guarantee of what will happen.

The Index looks at 3 factors

• The size of the cancer
• Whether the cancer has spread to the lymph nodes (lymph glands) under the arm (and if so, how many nodes are affected)
• The grade of the cancer

The formula is:

NPI = (0.2 x tumour diameter in cms) + lymph node stage + tumour grade, where

• The lymph node stage can be 1 (if there are no nodes affected), 2 (if up to 3 glands are affected) or 3 (if more than 3 glands are affected)
• The tumour grade is scored as either 1, 2, or 3

The formula gives scores which fall into three bands

• A score of less than 4 - this suggests a good outcome with a high chance of a cure
• A score of between 4.01 to 5.4 - this suggests an intermediate level with a moderate chance of cure
• A score of more than 5.4 - this suggests a lower chance of cure

The NPI is based on information from a group of patients treated some time ago. Treatment results have improved since then. So it may not give as good an outlook (prognosis) as you actually have, if you are being treated now.

When you are first diagnosed, cancer treatment can sometimes seem very complicated. As you can see there are quite a few different ways of treating breast cancer. And it can seem even more confusing if other people you meet are having different treatments. Do remember that other people will have different circumstances to you. They may

• Be older or younger
• Have a different type of breast cancer
• Have a different stage of breast cancer
• Have a cancer with different hormone receptor status

Don’t be afraid to ask your doctor or nurse if something is puzzling you. This is a complicated area of medicine, even for doctors. It can help to take notes when you talk to people about your treatment. Or you can ask to record the conversation so that you don't forget what they say. If you still don't understand, do ask again. No one will think it strange that you want to ask a lot of questions about your treatment.

If you don't feel you are getting the treatment you want or need, you can ask for a second opinion. This means going to see another specialist and asking them what treatment they think you should have. They will need to see all your test results and X-rays. Having a second opinion doesn't usually mean that the new doctor takes over your treatment and care. They just discuss with your current doctor which is the best treatment approach to take. Most doctors are quite happy to arrange this for you. It takes time to arrange a second opinion and may mean that your treatment is delayed for a while.

It is worth discussing your current specialists' approach with them first. Once you have heard why they are suggesting particular treatments for you, you may feel that you don't need a second opinion.  It is always a good idea to jot down a few questions before you go to the hospital for an appointment with your specialist.  It is difficult to remember everything you want to ask once you get there.  Your doctor won’t think this strange. These days many patients write their questions down.

There is more detailed information about breast surgery, radiotherapy, chemotherapy, hormone therapy, biological therapy and breast reconstruction in this section of CancerHelp UK.