Treatment for Breast Cancer: A Comprehensive Guide to Your Options

Cancer characteristics

Your healthcare team will consider the size of the tumor, how quickly the cancer is growing, and how it responds to early treatment. Specific features of the type of breast cancer will also guide treatment. 

Individual factors

Some of the personal factors that can help guide treatment include: 

• Age 

• Menopause status

• Other medical conditions 

• Your preferences and priorities for treatment

• Genetic factors that may affect breast cancer risk or treatment options 

• If you’re pregnant or planning to become pregnant

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

1. Surgery

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

Surgery is more often used to treat stage 0 through stage 3 breast cancer, when the cancer is confined to the breast or nearby lymph nodes. This means that the cancer hasn’t metastasized (or spread) to other parts of the body. Surgery is less common for stage 4 (metastatic) cancer, which has spread to other parts of the body. In these cases, surgery may still be used to relieve symptoms, or as part of the treatment plan. 

There are a few different types of surgery for breast cancer, which we go over in more detail below.

Breast-conserving surgery

Also called a lumpectomy or partial mastectomy, this procedure removes the cancer while preserving as much healthy tissue as possible. It’s usually followed by radiation to reduce the risk of the cancer coming back. Whether this is an option depends on the size, type, and location of the tumor. 

Full mastectomy

This surgery removes the entire breast. It may be recommended in these cases: 

• The tumor is large.

• There are multiple tumors in the breast.

• The cancer recurs after breast-conserving therapy.

• Radiation isn’t an option. 

Some people also choose to have both breasts removed (a double mastectomy), particularly if they have a genetic predisposition for breast cancer. Breast-reconstruction surgery can be done at the same time as a mastectomy or at a later date.

In a nipple-sparing mastectomy, the breast tissue is removed, but the nipple and areola are preserved. 

In a skin-sparing mastectomy, the breast tissue is removed while preserving as much of the skin as possible. 

Lymph node surgery

If breast cancer spreads, it usually travels to nearby lymph nodes first. Your surgeon may remove one or a few of the lymph nodes that drain the breast (known as a sentinel lymph node biopsy) to check whether breast cancer has spread. An axillary lymph node dissection (ALND) is a more extensive procedure in which multiple lymph nodes (10 to 20 or more) are removed. It’s usually done when testing suggests that breast cancer has spread to multiple lymph nodes. 

Breast reconstruction

Reconstruction can be done at the same time as a mastectomy (immediate reconstruction) or later (delayed reconstruction). Some people may also have oncoplastic surgery, which combines cancer surgery with plastic surgery techniques to preserve the breast's appearance after breast-conserving surgery.

2. 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 toward a specific area to intentionally damage and kill cells that are multiplying quickly, like cancer cells. Because radiation is targeted to a specific area, it can limit damage to healthy tissue nearby.

Radiation therapy is most helpful for people whose cancer hasn’t spread to distant parts of the body. It targets the breast and surrounding tissues. It’s most often used after surgery — particularly breast-conserving surgery — to destroy any remaining cancer cells. It may also be recommended after a full mastectomy if the original tumor was large or the cancer spread to nearby lymph nodes. 

People with metastatic breast cancer might choose 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.

3. Chemotherapy

Chemotherapy uses medications that kill cancer cells or stop them from growing and dividing. There are many different chemotherapy drugs, but most work by damaging a cancer cell's DNA or preventing it from dividing. Chemotherapy is usually given through an IV infusion, though some medications are available as pills.

Chemotherapy works best against cancer cells that are actively growing and multiplying. Because of this, it’s generally more effective against fast-growing tumors than slow-growing ones. 

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 helps destroy cancer cells that may remain after surgery.

• Neoadjuvant chemotherapy: This refers to chemotherapy given before surgery. It’s a common approach to shrink breast cancer tumors, increase the chance of breast-conserving surgery, and provide valuable information about how well the cancer responds to treatment.

• Chemotherapy for metastatic breast cancer: Chemotherapy may be used to treat breast cancer that has spread to other parts of the body. Because it travels throughout the body, it can reach cancer cells wherever they may be. Unlike adjuvant or neoadjuvant chemotherapy, treatment may continue for as long as it's controlling the cancer and side effects remain manageable.

4. Hormone therapy 

Some breast cancers grow in response to hormones like estrogen or progesterone. After a biopsy, the cancer is tested for hormone receptors. If these receptors are present, hormone therapy can block these signals or lower hormone levels to slow or stop the cancer's growth.

Common hormone therapies include tamoxifen (Nolvadex) and aromatase inhibitors, which lower estrogen levels in the body. Most hormone therapies are taken as pills. However, some — such as fulvestrant (Faslodex) — are given by injection. 

Hormone therapy can be used before surgery, after surgery, or to treat metastatic breast cancer. Even after active treatment ends, some people continue hormone therapy for 5 to 10 years to help lower the risk that the cancer comes back.

5. Targeted therapy

Targeted therapy refers to a group of medications that target specific genes or proteins on cancer cells. Targeted therapy is specific to the cancer cell, so it may have fewer side effects than other types of treatment like chemotherapy. 

There are multiple types of targeted therapy, as follows: 

• HER2-targeted therapies treat HER2-positive breast cancer. About 1 in 5 breast cancers are HER2 positive. Examples of therapies include trastuzumab (Herceptin), pertuzumab (Perjeta), and tucatinib (Tukysa).

• Cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors are often used for hormone receptor-positive, HER2-negative breast cancer. Examples include palbociclib (Ibrance) and ribociclib (Kisqali).

• Poly (ADP-ribose) polymerase inhibitors — or PARP inhibitors — may be used for some people with inherited BRCA (breast cancer) gene mutations. Examples include olaparib (Lynparza) and talazoparib (Talzenna).

• Antibody-drug conjugates (ADCs) combine a targeted therapy with chemotherapy to deliver treatment directly to cancer cells. Examples include trastuzumab deruxtecan (Enhertu) and sacituzumab govitecan (Trodelvy).

• PI3K/AKT pathway inhibitors target specific gene mutations in some hormone receptor-positive breast cancers. An example is alpelisib (Piqray) 

Like other systemic treatments, targeted therapies may be used before surgery, after surgery, or to treat metastatic breast cancer. The timing depends on the type of targeted therapy and the characteristics of the cancer.

6. Immunotherapy

Immunotherapy works by helping the immune system recognize and attack cancer cells. The immune system normally uses “checkpoints” to avoid attacking healthy cells. But some cancer cells can use these checkpoints to hide. Immunotherapy blocks these signals so the immune system can find and destroy cancer cells.

A common immunotherapy medication is pembrolizumab (Keytruda), which is given through an IV infusion. 

Immunotherapy isn’t appropriate for most breast cancers. It’s mainly used for people with triple-negative breast cancer (TNBC), which doesn’t have hormone receptors or excess HER2 protein. It can also be used to treat metastatic cancer in which a certain protein — known as programmed cell death ligand 1 (PD-L1) — is present. 

Surgery side effects

Side effects from breast cancer surgery will vary depending on the type of surgery, but they may include:

• Pain, soreness, or tightness in the breast, chest, or underarm area

• Swelling or fluid buildup near the surgical site

• Changes in the shape or appearance of the breast

• Limited movement or stiffness in the shoulder and arm

• Lymphedema (swelling of the arm or chest area) after lymph node surgery

A full mastectomy may require a longer recovery than breast-conserving surgery because more breast tissue is removed. Recovery time and side effects can also depend on whether someone has lymph node surgery or breast reconstruction.

Chemotherapy side effects

Some of the most common side effects of chemotherapy include:

• Hair loss

• Nausea, vomiting, and diarrhea

• Increased risk of infection

• Tingling or numbness in the arms and legs

• Difficulty concentrating or problems with memory (“chemo brain”)

• Fatigue

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 team knows if fertility is a priority for you.

Radiation side effects

Some of the common side effects of radiation treatment for breast cancer include:

• Skin irritation and rashes (known as radiation dermatitis)

• Fatigue 

• Breast pain

• Increased fluid and swelling of the breast

Hormone therapy side effects

Hormone therapy tends to cause different side effects than chemotherapy, and they may be less severe. Some side effects of hormone therapies are:

• Hot flashes

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

• Bone thinning or weakening

• Muscle and joint pain

Targeted therapy side effects

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

• Diarrhea

• Skin rashes

• Fatigue

• Blurry vision and eye pain

• Damage to the heart, lungs, or liver

Immunotherapy side effects

Because immunotherapy changes how the immune system works, it can sometimes cause the immune system to attack healthy tissues. Common side effects may include: 

• Fatigue

• Skin rashes or changes in color

• Diarrhea

• Decreased appetite

• Muscle and joint pain

• Inflammation of organs, such as the thyroid, lungs, liver, kidneys, or heart (less common but potentially serious)

• Infusion reactions, which can include flushing, fever, chills, rash, itching, or trouble breathing

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