Understanding my treatment options

Surgery for early-stage breast cancer:

For most breast cancers stage 0 to 3 the primary form of treatment is breast surgery. There are two main surgical options:

• Mastectomy: the surgical removal of the breast and surrounding tissue (surgical margin)
• Lumpectomy (also known as breast-conserving surgery): the surgical removal of the lump/tumour and a small amount of surrounding tissue (surgical margin)

Regardless of the surgery you choose, your surgeon will also likely choose to remove some lymph nodes under your arm for further biopsy. The purpose of removing lymph nodes helps to ensure that your cancer has been staged accurately. For instance, if you were diagnosed with stage I breast cancer, had lymph nodes removed and the presence of cancer was found, your stage will be reclassified after your surgery.

There are two methods of lymph node removal:

• Sentinel lymph node biopsy (SLNB): This biopsy focuses on the sentinel lymph node – generally the first node(s) that the cancer cell would spread to from the main tumour. The surgeon injects a small amount of radioactive substance or dye under the skin of your breast to trace the pathway of the lymphatic system. This helps to identify the sentinel node. The node(s) is removed through a small incision and sent to be examined under a microscope by a pathologist.
  This is the least invasive form of lymph node removal. SLNB causes less pain and less difficulty moving the arm. It allows more movement and less risk of swelling in the arm (known as lymphedema).
  
   
• Axillary lymph node dissection (ALND): The surgeon may remove tissue containing up to 40 lymph nodes in the armpit and send the sample to a pathologist to be examined for the presence of cancer. After the surgery, preventative measures such as draining tubes, antibiotics, pain relievers and instructions on how to manage the wound will be discussed, along with your level of physical activity, how to position the arm, lymphedema, and how to assess for symptoms/side effects.

Finally, your surgeon may give you options for reconstructive surgery. This is surgery to help rebuild the breast.

Visit our digital decision aid, SurgeryGuide to learn more about the various surgical options.

Surgery for metastatic breast cancer:

For metastatic breast cancer, the purpose of surgery is often different from that of early-stage breast cancer. Surgery becomes a supportive method added to treatment if needed and systemic therapy becomes the primary form of treatment. If your cancer is causing additional side effects, surgery can be used to help relieve those side effects or reduce pain.

If you have oligometastatic breast cancer, meaning breast cancer that has only spread to a few areas or the tumours are small, you may benefit from surgery. Surgery in these instances can be used to remove the cancer completely.

Radiation therapy has been used to treat cancer for at least a century. Radiation is given either as a primary therapy or in combination with a primary therapy (like surgery). Radiation given after surgery is called adjuvant therapy.

The main type of radiation treatment works by using high-energy rays to damage the DNA of cancer cells in the part of the body that is exposed to radiation. Radiation can also affect normal cells, but usually, these cells can quickly repair itself. Cancer cells, however, cannot repair their damaged DNA because they divide more rapidly and therefore, are more sensitive to radiation damage.

To limit damage to normal tissue, the breast is not given more than one series of radiation treatments, even if cancer recurs in the same breast. Other parts of the body, including the other breast, may receive radiation if it is ever needed in the future.

Adjuvant radiation therapy is administered after breast cancer surgery is healed (usually about 3 to 4 weeks with no complications). The purpose of adjuvant radiation is to kill any cancer cells potentially remaining after your surgery and to help further reduce your risk of a recurrence (cancer coming back).  If chemotherapy is required after your surgery, radiation is given after the chemotherapy is completed. Some treatments like hormone therapy and HER2 targeted therapy can be given along with radiation.

Radiation for metastatic breast cancer has a slightly different purpose. Because you are likely not receiving primary surgery, radiation can be used to treat the metastases in other areas of your body. It is a common treatment option for people with breast cancer metastases in the brain. Radiation for brain metastases can use a specialized form of therapy called stereotactic radiation therapy.  Radiation for mBC is also used to help relieve any side effects caused by the cancer.

There are two common types of radiation therapy used in breast cancer:

• External beam radiation: Breast cancer is usually treated with external beam radiation. A radiation machine, called a linear accelerator, directs the beam of radiation onto the surgical site and surrounding tissue. You may receive small marks or tattoos on your body to ensure the radiation beam is targeting the same area at each session.
  
  The total dose of radiation you receive is divided into daily doses, called fractions. For each session, time is spent to help you get into position on the table and to check/position the machines. The actual radiation only takes a few minutes each time and is painless. It is important to know that you will not be radioactive after an external beam of radiation and that it is safe for others to be around you immediately afterward.
   
• Internal radiation (brachytherapy): This form of radiation involves using a device, which contains radioactive seeds, or pellets that are internally placed into the breast where the cancer was originally growing and removed. Brachytherapy is dependent on the size and location of the cancer and is ideally for people aged 45 years and older with a diagnosis of early-stage invasive breast cancer who have had breast-conserving surgery.
  
  Depending on the type of internal radiation, it may take up to one treatment or more in an outpatient radiation clinic, taking precautions for you and the people around you to minimize radiation exposure.

For more information on radiation therapy for breast cancer, visit www.cbcn.ca/radiation.

Systemic therapies focus on drugs that are taken by mouth in the form of a pill or through the bloodstream which respond to cancer cells throughout the body giving a systematic response. Systemic treatments include:

• Chemotherapy
• Hormonal therapy (also known as endocrine therapy)
• Targeted therapy
• Immunotherapy

You may be offered a combination of the above systemic therapies depending on your stage and sub-type.

The purpose and timing of systemic therapy for early-stage breast cancer include:

• Neoadjuvant therapy: Systemic therapy given before the primary treatment (surgery) is called neoadjuvant therapy. Receiving neoadjuvant therapy can help shrink the tumour before it is removed. In the case of large tumours, it may also provide the surgeon with clear margins in the tissue surrounding the tumour, increasing the chances that all cancer cells are removed during the surgery. In some cases, it can also allow patients who were not eligible for a lumpectomy to have that option. Neoadjuvant therapy is routinely offered for stage II and III breast cancers that are either triple negative or HER2+.
• Adjuvant therapy: Systemic therapy given after the primary treatment (surgery) is called adjuvant therapy. The purpose of adjuvant therapy is to destroy any microscopic cancer cells left behind after surgery, with the hope of reducing the risk of recurrence.

When systemic therapy is used for metastatic breast cancer, the purpose and timing is different than in early-stage breast cancers. Typically, systemic therapy becomes the primary treatment, while surgery becomes a supportive treatment option to relieve pain and side effects. You will likely not hear the terms neoadjuvant or adjuvant therapy when referring to systemic therapy for mBC.

Chemotherapy:

Chemotherapy is the most well-known form of systemic therapy. It can slow the growth or destroy cancer cells. Cancer cells and most normal cells multiply by repeatedly dividing themselves according to a complex process. There are many chemotherapies used in cancer treatment that interfere in one or more steps in the complex process of cell division. The goal is to stop the cancer cells from dividing so that it soon dies. Cancer cells divide rapidly, and therefore they are most liable to be killed by chemo.

Chemotherapy can be used in combination with other forms of systemic therapy and can be used for all sub-types of breast cancer.

Hormonal therapy:

Hormonal therapy slows the growth and spread of cancer cells either by changing the hormone levels (estrogen or progesterone) in your body or by blocking the effects of the hormones on the breast cancer cells.

Hormonal therapy is only effective for breast cancers that are HR positive. They can be used as adjuvant therapy to help reduce the risk of cancer coming back or as a neoadjuvant therapy to help reduce the size of the tumour before surgery.

There are 4 types of hormonal therapy:

• Estrogen blockers: blocks estrogen from fueling the growth of the tumour
  Can be used in the premenopausal or postmenopausal setting
• Aromatase Inhibitors (AIs): prevent estrogen from being made by non-ovarian tissue
  Can only be used in the postmenopausal setting unless in combination with a LHRH agonist
• Luteinizing hormone-releasing hormone (LHRH) agonists: prevents estrogen from being made by the ovaries
  Can only be used in the premenopausal setting
• Ovarian ablation: removal of ovaries to reduce the levels of ovarian hormones
  Can only be used in the premenopausal setting

Targeted therapy:

Targeted therapy is a form of systemic therapy that blocks or targets certain parts of the cancer cells (specific proteins or genes) that make the cancer grow and spread. There are different types of targeted therapies depending on what part of the cell is being targeted. Targeted therapies are available for HER2 positive and HR positive sub-types, along with breast cancers that have a BRCA gene mutation.

Targeted therapy is different from chemotherapy because the treatment specifically targets abnormal cells while leaving most normal cells alone. Chemotherapy can inevitably damage normal cells in the process of destroying cancer cells. Side effects from targeted therapy tend to be less severe because they leave most normal cells alone.

Immunotherapy:

This newer form of systemic therapy is a treatment that stimulates and engages your immune system to defend against cancer. Currently, immunotherapy in breast cancer treatment is only used for advanced or metastatic triple-negative breast cancer.