Overwhelmed by the Choices for Breast Cancer Treatment? This Guide Will Help You Understand Your Options

A breast cancer diagnosis can feel scary and overwhelming. And it doesn’t help that breast cancer treatment is a complicated world with many different options. So we’re here to provide an overview of breast cancer treatment. Our hope is that this will help you understand your options, why certain treatments are recommended, and what to expect as you develop your treatment plan with your cancer specialist. 

What factors determine my treatment options?

There are several factors that determine which treatments are best for someone who has been diagnosed with breast cancer. These are factors specific to the individual as well as features of their particular breast cancer.

Some of the factors of an individual that are taken into account include:

• Their age and, if a women, whether they have gone through menopause

• Other medical conditions 

• Their preferences for the options that align with their values and priorities

• Genes that increase risk for breast cancer

There are also characteristics of the cancer itself that help guide treatment options:

• The size of the tumor  

• If the cancer has spread to nearby lymph nodes or to a distant organ outside of the breast 

• How quickly the cancer is growing 

• If the cancer grows in response to hormones, like estrogen or progesterone

• If there’s a high number of a molecule called HER2 on the surface of the cancer cells

After your cancer specialist gathers this information, you will work together to develop the treatment plan that is best for you. 

As you learn about these options, it helps to understand that treatments for breast cancer fall into two big categories:

• Localized therapy: treatments that work specifically on the breast tumor and surrounding tissues

• Systemic therapy: pills or injected medicines that are intentionally delivered to the entire body

Localized treatments for breast cancer

Localized treatments directly target the breast tumor and surrounding tissue. There are two types of localized treatments: surgery to remove the cancer and radiation therapy to kill any microscopic cancer cells left behind after surgery.

Surgery for breast cancer

The main goal of surgery is to remove all or most of a breast cancer tumor. Surgery can also help determine if the cancer has spread. 

There are a few different types of surgery for breast cancer:

• Breast-conserving surgery: This is the removal of a lump (lumpectomy) or part of the breast (partial mastectomy). This is an option for people whose tumor is well contained in one area of the breast and doesn’t take up most of the breast. This surgical approach is used to save healthy breast tissue. It’s usually followed by radiation treatment to ensure the cancer is fully eliminated. 

• Mastectomy: This involves the removal of the entire breast. This might be a better option if the tumor is large, or if there’s a recurrence of cancer after a breast conserving surgery. Sometimes people elect to have both breasts removed, especially when there’s a genetic predisposition for breast cancer. Many people elect to have breast reconstruction after a mastectomy. 

• Lymph node surgery: If the cancer has spread outside of the breast, it usually first moves to nearby lymph nodes in the armpit. One or multiple lymph nodes are sometimes surgically removed to see if the breast cancer has spread. 

Surgery is more often recommended for people with stage 0-III breast cancer. This means that the cancer has not metastasized (or spread) to other parts of the body. Surgery is only used in stage IV (metastatic) breast cancer if there’s a tumor in a location that’s causing pain or discomfort.

Radiation therapy

The other type of localized treatment for breast cancer is radiation therapy. This is done by a cancer specialist called a radiation oncologist. Radiation directs energy beams towards a specific area to intentionally damage and kill cells that are multiplying quickly, like cancer cells. Because radiation specifically targets replicating DNA, it has less of an effect on healthy non-cancerous cells. 

Radiation therapy is most helpful for people with a tumor that hasn’t spread to distant areas of the body. It’s performed on the breast and surrounding tissues. Most often it’s used after surgery — particularly breast-conserving surgery — to destroy any cancer cells left behind. It’s also helpful for some people who’ve had a full mastectomy. This is especially true if the initial tumor is large or has spread to nearby lymph nodes. 

People with metastatic breast cancer might elect to have radiation to decrease the size of a tumor in the breast or other parts of the body. Similar to surgery, this is mainly done to help improve symptoms like pain or swelling.

The side effects from radiation are usually mild and temporary. Some of the common side effects of radiation include:

• Pain in the area that receives radiation

• Increased fluid and swelling of the breast

• Redness and warmth to the specific area of skin that’s exposed to the radiation

• Weakening of bones that are exposed to the radiation beams

• Infections, given radiation can affect immune system function

Systemic therapies for breast cancer

The goal of systemic therapy is to administer medication to the whole body in order to reach cancer cells that may have spread outside of the breast or the nearby lymph nodes. These wandering cells are called micrometastases. They’re too small for lab or imaging tests to detect.  

Systemic treatments come in the form of oral pills and/or intravenous infusions. There are several categories of systemic therapies. People often receive more than one type.

Chemotherapy

Chemotherapy is a type of medication that interferes with the cancer cells’ ability to grow. There are many different types of chemotherapy. Most of them work by damaging a cancer cell’s DNA so that it can no longer replicate and grow. Chemotherapy works when the cancer cell is actively trying to grow or divide. Because of this, chemotherapy is more effective for cancers that are growing quickly and aggressively. Chemotherapy is less effective in slow-growing cancers.

Chemotherapy can be used at a few different points in the treatment timeline:

• Adjuvant chemotherapy: This refers to chemotherapy that’s given after someone has surgery to remove the primary tumor. It destroys any cancer cells that diagnostic tests may not have detected due to the small number of them.

• Neoadjuvant chemotherapy: This refers to chemotherapy given before planned surgery. It’s only effective and used in specific types of breast cancer. But there are several benefits to this approach. First, it can provide important feedback about which type of systemic therapy is best for people who have “HER2-positive” or “triple-negative” breast cancers. This lets oncologists know which specific chemotherapy drug to use when additional adjuvant systemic therapy is also necessary. Second, if the tumor is fast growing, it can sometimes help shrink the tumor so it’s easier to remove with surgery.

• Ongoing chemotherapy: This may be used for metastatic breast cancer. Chemotherapy is one of the best treatments for metastatic disease because it can treat cancer cells wherever they may be in the body. Ongoing chemotherapy is usually given in lower doses than adjuvant or neoadjuvant therapy. This is so people can tolerate the treatment for a longer period of time.  

Chemotherapy is often an important part of breast cancer treatment. Yet it also comes with many side effects. Some of the most common side effects include:

• Hair loss

• Nausea, vomiting, and diarrhea

• A weakened immune system

• Weakening of the heart muscle (only in select chemotherapies)

• Tingling or numbness in the arms and legs

• Painful skin rashes

• Confusion

• Fatigue

• Low blood counts and easy bruising

• A secondary leukemia can develop after chemotherapy, although this is very rare

Another thing to consider is that if you’re premenopausal, chemotherapy can stop your menstrual cycle, either temporarily or permanently. It can lead to infertility, too. If keeping the option to have children is important to you, that’s an important consideration when developing your treatment plan. Make sure your healthcare providers know if fertility is a priority for you.

Hormone Therapy

Some breast cancers grow in response to hormones like estrogen or progesterone. Most people will get a biopsy of their breast cancer. Then the biopsied cancer cells will be checked for estrogen receptors (ER) or progesterone receptors (PR). If these receptors are present, then estrogen acts like a fuel to help the cancer grow.

Hormone therapy works by blocking estrogen from activating these receptors, or by lowering the amount of hormones in the body. This is an effective way to cut off a cancer’s fuel supply and slow down its growth. Nolvadex (Tamoxifen) is a common hormone therapy for breast cancer. But there are many others, such as aromatase inhibitors. Similar to chemotherapy, hormone therapy can be used as adjuvant treatment, neoadjuvant treatment, or as a metastatic breast cancer treatment. 

For most people, the side effects of hormone therapy are usually less severe than chemotherapy. Some side effects of hormone therapies are:

• Hot flashes

• Vaginal irritation (because estrogen helps to maintain vaginal health)

• Weakening of bones

• Muscle and joint pain

There are also some newer medications called “molecular therapies” that are sometimes combined with hormone therapy. This combination can make the treatment more effective. An example of a molecular therapy is CDK 4/6 inhibitors. 

Targeted therapy

Targeted therapy refers to a group of medications that treat cancers with unique features that specific diagnostic tests may discover. 

The most common type of targeted therapy is for cancer cells with high levels of HER2 receptors. Similar to hormone receptors, this promotes cancer growth. About 1 in 5 people with breast cancer will have HER2-positive cancer. There are available medications that block this molecule to inhibit the cancer from spreading.

A common treatment for HER2-positive breast cancer is trastuzumab (Herceptin), though there are others. Like other systemic treatments, they can be used before and after surgery. They can also be used to treat metastatic breast cancer alongside chemotherapy.

Side effects of target therapies depend on the specific medication, but they can include:

• Diarrhea

• Skin rashes

• Damage to the heart, lungs, or liver

Immunotherapy

Our immune system is constantly scanning the body in search of anything that shouldn’t be there, like bacteria, viruses, and even cancer cells. Then our immune system destroys these invaders once it finds them. Our immune system is able to separate friend from foe because our healthy cells have receptors on them that tell the immune system they aren’t harmful. Think of it like a handshake (or a “checkpoint”) between friendly cells of the body so they don’t attack each other.

Many breast cancer cells take advantage of this checkpoint. They have receptors that trick the immune system into leaving the cancer cells alone instead of attacking them.

Immunotherapy works by blocking the molecules that turn off the immune system. This way it can still identify and kill the cancer cells. These medications are also called checkpoint inhibitors.  A common immunotherapy medication is pembrolizumab (Keytruda), which is given through an intravenous infusion. 

Immunotherapy is mainly used in breast cancer that doesn’t have any hormone receptors and is negative for HER2 (triple-negative breast cancer). In addition to chemotherapy, immunotherapy can be given before or after surgery. Immunotherapy might also be used for metastatic or recurrent breast cancer along with chemotherapy.

Like the other systemic therapies, immunotherapy has many side effects. Immunotherapy affects the way our immune system identifies healthy cells. This means that there can be autoimmune attacks on internal organs such as the lungs and kidneys. These reactions can be serious and lead to organ damage. There can also be reactions to these medications that resemble allergic reactions. This might include rashes, itching, skin flushing, or trouble breathing.

Is breast cancer treatment painful?

Breast cancer tumors usually aren’t painful (but sometimes they can be). It’s more common to experience discomfort from some of the treatments for breast cancer. But there are many ways to treat these symptoms:

• Pain. This may be mild and improve with over-the-counter medications like acetaminophen (Tylenol). It might also be more severe and need prescription pain medications, like hydrocodone or oxycodone.

• Nausea and vomiting. These are common side effects of chemotherapy. Medications to treat nausea like ondansetron (Zofran), metoclopramide (Reglan), or prochlorperazine (Compazine) are often very helpful.

Why trust our experts?

Written by:

Michael Dreis, MD

Dr. Dreis is an emergency medicine physician currently practicing in Milwaukee, Wisconsin. He went to medical school at the University of Wisconsin – Madison and completed his residency at Henry Ford Hospital in Detroit, Michigan.

Edited by:

Katie E. Golden, MD

Katie E. Golden, MD, is a board-certified emergency medicine physician and a medical editor at GoodRx.

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