Treatments for breast cancer

The first treatment for breast cancer is usually surgery. The aim of surgery is to remove all the cancer. The type of surgery depends on factors such as the size of your cancer, the size of your breast, the position of the cancer in your breast and what you want.

Surgery may involve removing the cancer and a rim of breast tissue around it (wide local excision) or removing the whole breast (mastectomy).

At the same time, some of the lymph glands in your armpit (the axillary lymph nodes) are removed. A pathologist will examine these lymph glands to see whether you need further treatment after your surgery.

Mastectomy

Mastectomy is the removal of your whole breast, including some of the skin and the nipple. Your chest muscles are not removed. 

Usually, the lymph nodes in your armpit are removed through the same cut (incision) during this operation (called axillary node clearance or dissection).

Mastectomy performed today is less disfiguring than the radical mastectomy of the past. It is carried out in a way that makes it easier for your breast to be reconstructed. After a mastectomy, most women will have a horizontal scar across their chest. 

Breast reconstruction can be performed at the same time as a mastectomy (immediate reconstruction) or after all your treatments for cancer are completed, as a separate operation (delayed reconstruction). 

Breast-conserving treatment

For many women, it is now possible to have a smaller operation, such as a partial mastectomy (or wide local excision). A breast-conserving operation involves removing the breast lump with some surrounding normal breast tissue to ensure a good clearance.

Surgery is then followed by radiation treatment to the remaining part of the breast. This usually happens 6–8 weeks after surgery. This makes sure any cancer cells that are still present in your breast are treated, and significantly reduces the risk of cancer recurring in the remaining breast tissue.

Lymph glands are also removed for examination in these smaller operations. This is often done through a separate incision (cut) in your armpit.

Breast-conserving operations have been routinely performed for many years. Studies show that both mastectomy and breast-conserving operations with radiation treatment are equally effective in the treatment of early breast cancer. 

However, breast-conserving surgery is not suitable for every woman with breast cancer.

Advantages and disadvantages of surgical methods

While many women may want a breast-conserving operation, whether this is possible depends on the size of the breast cancer and the size of your breast. 

It is helpful to weigh up the advantages and disadvantages of each method for yourself.

Side effects of breast surgery

You may experience some of the following:

• Wound infection where the wound may feel tender, swollen and warm to touch. There may be redness in the area and/or discharge from the wound. You may feel unwell with fever. If this happens, you need to see your healthcare provider as soon as possible.
• Bruising and haematoma is when blood collects within the tissues surrounding the wound causing swelling, discomfort and hardness. Your body will reabsorb the blood within a few weeks.
• Pain in your armpit or down your arm is more likely if you have lymph glands removed. You will get advice about exercises to reduce the pain and improve your arm movement after surgery.
• Cording is a pain like a tight cord running from your armpit, down your upper arm and through to the back of your hand. Cording is thought to be due to hardening of your lymph vessels. Cording may restrict movement and continue for many months. Physiotherapy and exercise may help.
• Reduced sensitivity of the inner side of your upper arm may occur. It may be a sign of nerve damage which would have been discussed with you before your surgery. It's usually temporary and improves or disappears about 3 months after surgery.
• Swelling caused by fluid build-up (seroma) which may need to be drained for days, and in some cases, several weeks. A nurse will tend to your drain and bandages.
• Swelling of your arm (lymphoedema) may occur after lymph glands have been removed from your armpit. On rare occasions, this swelling can extend into the chest wall.
• Reduced range of movement in your shoulder may happen. You'll be given an exercise programme to improve this after surgery, and sometimes a physiotherapist will help you.

It’s a good idea to discuss possible side effects with your doctor before your operation. Tell your breast care nurse or doctor if you have any of these side effects after your surgery.

After your operation, your surgeon will discuss your tumour with other specialists to decide what further treatment, if any, will be recommended to you. This might include radiation treatment, chemotherapy and/or hormone treatment.

After surgery care

Arm care

Following your surgery, it may take some time to regain the full use of your arm. Your physiotherapist or breast care nurse will give you instructions for exercises.

You may be concerned that your arm will swell after your lymph glands have been removed. This is much less common today because of the better methods of surgery and radiation treatment. However, a few people still develop problems with arm swelling (called lymphoedema). To reduce the risk of this happening, you should avoid injury or infection to your arm or hand by doing the following:

• Wear gardening gloves when gardening, use an oven glove when handling hot dishes and use a thimble for sewing.
• If you're out in the sun, protect your arm from sunburn by wearing a long-sleeved shirt, and use a good sunscreen (SPF 30+) on uncovered areas.
• Get help with heavy jobs like moving furniture or carrying heavy luggage, and avoid using heavy backpacks for any length of time.
• It may help to wear a support sleeve when flying.
• If it can be avoided, remind health professionals not to take your blood pressure or have blood tests taken from the affected arm. 
• Avoid having an intravenous drip in that arm and ask that any injections, including acupuncture or anaesthetics, be given elsewhere.
• If you have a cut, clean it well and use an antiseptic dressing. See your healthcare provider quickly if you think it is infected.
• Be aware of swelling in your arm at any point in the future. Contact your doctor if this occurs.

Lymphoedema therapists and physiotherapists can also advise you about the need to wear a support sleeve if your arm does swell up. Read more about lymphoedema.

Breast forms (prostheses)

If you have had a mastectomy, you may want to consider using a breast form (prosthesis). A breast form can give a good cosmetic appearance as well as helping your balance and posture. Many people choose to use a breast form although some prefer not to.

Breast forms are also available for people who have had lesser surgery (partial mastectomy). 

Immediately after surgery, temporary prostheses are available from your local Cancer Society or breast care nurse. About 6 weeks after your operation, you may choose to wear a permanent prosthesis.

You are entitled to a benefit for a permanent breast form. Ask your surgeon or breast care nurse for a medical certificate of entitlement.

Reconstruction of your breast

After a mastectomy, your breast can be reconstructed either straight away or later. A surgeon's decision about which method of reconstruction to recommend is based on many factors.

You should discuss reconstruction fully with your specialist and ask any questions you have before the operation. You may be referred to a plastic (or reconstructive) surgeon.

Many people don't want to have a reconstruction. Speaking with a breast care nurse or with other people who have had breast cancer may be helpful.

Radiation treatment is the use of radiation (rays of energy called photons or little particles called electrons) to destroy cancer cells. You will see a radiation oncologist who will discuss your treatment with you. 

Treatment is carefully planned to reduce any effect on normal cells. Treatment is given 4–5 days a week, over about 4–5 weeks. It is painless and only takes a few minutes for each treatment. 

An extra radiation boost dose may be given to the area where your breast cancer was located, taking the overall treatment time up to 5–6 weeks. Partial breast irradiation is being investigated as an alternative to whole breast irradiation for some patients.

Sometimes radiation is given after mastectomy and axillary (armpit) surgery to reduce the likelihood of developing recurrence in/over the chest wall or in the axillary (armpit) or supraclavicular (above the collarbone) lymph nodes. This decision is usually made once the results of the surgery are available and the risks of the cancer coming back in these sites assessed.

Radiation may also be used for the treatment of recurrence or cancers that cannot be removed, either directly where it is situated or in other parts of the breast. The aim is to try to control the disease or reduce your symptoms. This usually requires fewer visits. 

If you live a long way from the nearest oncology (cancer) centre, you will need to stay nearby during your radiation treatment. Oncology centres have special accommodation close by. 

Find out more about radiation treatment.

Side effects of radiation treatment

You may experience the following side effects:

• general tiredness
• some reddening or sunburning of your skin – follow the advice of your radiation therapists about skin care and underarm hygiene
• your breast may feel firmer.

Late side effects, which develop many months or years later, may include skin changes and changes in the size, shape, colour or feel of your breast. Radiation to your lymph nodes can increase the risk of developing lymphoedema (swelling of your arm).

If you're having radiation treatment you should get both extra rest and regular exercise to help you cope with the tiredness. Try to wear loose cotton clothing whenever possible to reduce any irritation to the area having the radiation.

Before you start having the radiation treatment, talk with your healthcare provider or the radiation therapy staff about any possible side effects and how to manage them.

Find out more about radiation treatment side effects. 

Chemotherapy is the treatment of cancer by drugs. The aim is to destroy cancer cells while having the least possible effect on normal cells. The drugs are usually injected into a vein via a drip so they can be circulated around your body.

• Chemotherapy treats your whole body (systemic therapy) compared with surgery and radiation treatment, which are local treatments to a specific area in your body (such as your breast, chest wall or armpit).
• Treatment is often in cycles at 3-weekly intervals, and may last for 6 cycles (which means it takes nearly 6 months). A doctor who specialises in cancer (an oncologist) will discuss all aspects of the treatment with you.
• Chemotherapy is offered to some people with early breast cancer as an additional treatment to surgery, radiation treatment or both. This is called adjuvant chemotherapy.
• Adjuvant chemotherapy aims to destroy cancer cells that remain in your body but that can't be detected. The purpose of this treatment is to reduce the chance of the breast cancer coming back (known as a recurrence).
• If you're are also having radiation treatment, that will happen after your chemotherapy, and will start about 4 weeks after your last cycle of chemotherapy. If you have been recommended hormone therapy, that will start after your radiation treatment.
• You're most likely to benefit from chemotherapy when there are cancer cells in the lymph glands in your armpit. There is also a benefit from chemotherapy if you have a more aggressive cancer (Grade 3 and oestrogen receptor negative). Women who are HER2 positive will benefit greatly from chemotherapy.
• People with large tumours or a type of cancer called inflammatory breast cancer may be offered chemotherapy pre-surgery. This is called neo-adjuvant chemotherapy.

Find out more about chemotherapy.

Side effects of chemotherapy

Chemotherapy side effects vary according to the particular drugs used. They may include the following:

• infections – the chemotherapy medicines can lower your ability to fight infections
• sore mouth
• nausea and vomiting
• loss of appetite or taste changes
• feeling off-colour and tired
• thinning or loss of hair
• if you are still having periods, your periods may become irregular or stop while you are having treatment
• if you are approaching menopause, your periods may not return once your treatment has stopped
• your ability to become pregnant, but this is not always the case – you and your partner should use a reliable contraceptive, such as a condom, during treatment because the drugs can cause birth defects or miscarriage
• infertility – some women may be permanently infertile after chemotherapy
• hot flushes, vaginal dryness, mood swings or other symptoms of menopause
• individual chemotherapy drugs may have particular side effects, and your healthcare provider will discuss this with you.

When to see your doctor

During treatment, if you develop a fever (your temperature is 38° C or more), or if you feel unwell in any way – take action quickly. Your body won’t be able to fight infection as well as it normally does. Contact your cancer doctor or nurse and follow their advice.

Discuss any side effects you experience with your doctor. Side effects are usually temporary and there are ways of reducing the impact of any unpleasant symptoms. For example, if you have temporary hair loss you are entitled to a benefit to buy a wig.

See also chemotherapy side effects.

Monoclonal antibodies are drugs that recognise and bind to specific proteins (receptors) that are found in particular cancer cells or in your bloodstream.

One of these is Trastuzumab (Herceptin or biosimilar Herzuma). It's given intravenously once every week or 3 weeks, and is usually well tolerated. It may cause some impairment of your heart’s pumping function, especially when used with a chemotherapy drug that affects your heart. A heart echo test will be done every 12 weeks to check this.

Many breast cancers appear to be influenced by the female hormones, oestrogen and progesterone.

If you are pre-menopausal (you are still having periods) you may be offered tamoxifen, a hormone treatment taken as a tablet. You may also have menopause induced to stop your own production of hormones. This can be done by 4-weekly injections with goserelin (Zoladex) or by surgical removal of your ovaries (laparoscopic oophorectomy). Once you stop taking goserelin, your periods will usually return.

If you are post-menopausal (no longer have periods) you may be offered oral hormone treatments, either tamoxifen or an aromatase inhibitor anastrozole (Arimidex) or letrozole (Femara). These medicines reduce the production of hormones in your body (other than from the ovaries).

Side effects of hormone treatments

These may include:

• menopausal symptoms such as hot flushes, vaginal dryness or mood swings
• effects on fertility – if you have not reached menopause it may still be possible to become pregnant while you are taking hormone therapies, so if you are sexually active with a male partner, it's recommended you use reliable contraception, such as a condom.
• permanent menopause.

Specific hormone drugs may cause additional side effects. Discuss these with your doctor before you start treatment and if you notice any symptoms once you start. 

Aromatase inhibitors can cause a loss of minerals from your bones (osteoporosis). You may be asked to have a bone density study before starting or sometime during treatment.

Treatment may be given for several years. Osteoporosis can be treated with oral bisphosphonates (bone-hardening drugs).

Research into the causes of breast cancer and into ways to prevent, detect and treat it, is continuing. Your doctor may suggest you consider taking part in a clinical trial. It is always your decision whether or not to take part in a clinical trial. If you do not wish to take part, your doctor will discuss the best current treatment option for you.

Current clinical trials can be found on the NZ Breast Cancer Foundation(external link) website. 

Find out more about cancer and clinical trials.