03/20/2018

Understanding breast cancer treatment options

One in eight women will be diagnosed with breast cancer in their lifetime

There are several ways to treat breast cancer depending on stage and type. Learn more about treatment options:

Lumpectomy
Mastectomy
Sentinel Node Biopsy
Chemotherapy
Hormone Therapy


Breast cancer is the most commonly diagnosed cancer in women. In fact, one in eight women in the United States will be diagnosed with breast cancer in her lifetime. Chances are you know someone who’s had breast cancer or you’ve had the disease yourself.

However, breast cancer is different for every woman. Just because you heard about Angelina Jolie’s breast cancer in the media doesn’t mean you are going to lose both your breasts. Even your mother or sister can have a different type of breast cancer than you.

Dr. Susan Mahany
Dr. Susan Mahany, breast cancer surgeon and medical director of Telfair Breast Surgery at St. Joseph’s/Candler

“The reason Angelina Jolie had a bi-lateral mastectomy is because she had a genetic mutation,” says Dr. Susan Mahany, breast cancer surgeon and medical director of Telfair Breast Surgery at St. Joseph’s/Candler.  “If you don’t have a genetic mutation and you have breast cancer on one side, the average risk of developing breast cancer on the other side is .5 percent per year. It’s very low.

“We counsel patients that everybody’s cancer is different. Your sister could have breast cancer and it could be different than yours. It could be a different biology; it could be a different stage.”

At the Nancy N. and J.C. Lewis Cancer & Research Pavilion, a multi-disciplinary team of surgeons, oncologists, nurse navigators, genetic counselors and others work on individual patient cases. If you are diagnosed with breast cancer, your surgeon will go over all your options and help you make an educated decision on your course of treatment.

While each case is individualized, it’s good for every woman to have a general understanding of breast cancer treatment options.

There are several ways to treat breast cancer depending on several factors including:

  • The size and location of the breast lump or tumor
  • The type of breast cancer
  • If the cancer has spread within the breast or has spread outside the breast to the lymph nodes or other parts of the body
  • The size of the breast
  • The woman’s preference

Local treatments of breast cancer – meaning they treat the tumor without affecting the rest of the body – include surgery and radiation. Systemic treatments, or therapies that can reach cancer cells almost anywhere in the body, include chemotherapy, hormone therapy and targeted therapy.

The type and stage will help determine if a woman needs surgery, radiation and/or chemotherapy and the order of the treatments.

Let’s look closer at some of the more commonly practiced treatment options for breast cancer.

Lumpectomy

During this surgical procedure, the tumor and cancerous tissue inside the breast is removed, while leaving the rest of the breast attached. The main advantage of a lumpectomy is that it can preserve much of appearance and sensation of the breast. It’s also a less invasive surgery with a shorter recovery time than with a mastectomy, says Dr. Mahany.

Lumpectomy is recommended for smaller cancers because it’s less invasive. Radiation is required after a lumpectomy. If a patient has a very large mass and still prefers a lumpectomy, neoadjuvant chemotherapy, which is chemo prior to surgery, may be necessary to shrink the tumor in order to achieve a good cosmetic result.

Mastectomy

A mastectomy surgical procedure removes the entire breast. Because of the size, type or depth of certain cases, a mastectomy is sometimes the optimal choice to prevent cancer from returning. Radiation is not typically necessary following a mastectomy so this procedure also may be optimal for patients unable to tolerate radiation therapy.

There are exceptions to this. Patients with inflammatory breast cancer, a very large tumor, positive lymph nodes or cancer that is locally advanced still require radiation regardless of their surgical procedure.

A disadvantage to a mastectomy is permanent loss of your breast. Your surgeon will talk about your options including reconstructive surgery and prosthetics, which are available through the Nancy N. and J.C. Lewis Cancer & Research Pavilion’s Transformation Station.

Related Article: Transformation Station at the LCRP helps female cancer patients find their fit

“If you compare a lumpectomy to a mastectomy for survival, in most cases they are essentially the same, stage-for-stage,” Dr. Mahany says. 

A breast surgeon also may recommend a bi-lateral mastectomy, which removes both breasts whether there’s cancer in both or not. This is typically recommended for patients with a genetic mutation because their chance of developing breast cancer can be 65 to 80 percent over their lifetime, Dr. Mahany says. Really young breast cancer patients also may opt for a bi-lateral mastectomy to reduce their chances of recurrence.

“Say someone is 27 or 28, and even if they are a candidate for a lumpectomy, over time they have a higher risk for recurrence of the disease so they may choose to have a mastectomy,” Dr. Mahany says. “In a patient with a genetic mutation, their chance of developing breast cancer can be 65 to 80 percent over their lifestyle so they may choose to have a bi-lateral mastectomy.”

Sentinel Node Biopsy

Sentinel node biopsy is a procedure done prior to surgery to determine if the cancer has spread to the lymph nodes underneath your arm next to the breast. Lymph nodes are filters for harmful substances, such as cancer cells. It is important for your cancer team to determine if there is an absence or presence of cancer in the lymph nodes to set your course of treatment.

In sentinel node dissection, the surgeon will look for the sentinel node or nodes, which is the first lymph node or nodes that filter draining away from the breast. If cancer cells are traveling the lymph system, the sentinel node is more likely than the others to contain them. Due to this, surgeons can remove fewer nodes during a sentinel node biopsy as opposed to its alternative, axillary lymph node dissection.

If the nodes removed during a sentinel node biopsy are negative then there’s an 85 percent chance there’s no disease underneath the arm and fewer lymph nodes need to be removed, Dr. Mahany says. That decreases the risk of a patient developing lymphedema to just three to five percent compared to an axillary dissection which has a 15 to 30 percent chance a patient will get lymphedema.

Related Article: Lymphedema and breast cancer: How occupational therapy helps survivors manage symptoms 

“If there’s a positive sentinel node, and there’s two or less, we can radiate under the arm,” Dr. Mahany says. “We don’t have to do a complete dissection. We are getting further and further away from doing complete axillary dissection.”

Sentinel node biopsies are not necessary for every type of breast cancer. Some examples of when your team would recommend a sentinel node biopsy include invasive cancers, non-invasive high grade tumors associated with a mass, and in all mastectomies for either invasive or non-invasive breast cancer. 

Chemotherapy

A patient’s prognostic panel, which includes information like estrogen receptors and growth hormone receptors, will help determine a patient’s need for chemotherapy.

For example, one possible diagnosis is triple negative breast cancer, which means the three most common types of receptors known to fuel most breast cancer growth (estrogen, progesterone and the HER-2 gene) are not present in the tumor. Because the tumor cells lack these receptors, some treatments, such as hormone therapy or estrogen-targeted drugs, are ineffective. Certain chemotherapy options, however, are effective in destroying cancerous cells.

Chemotherapy may be required before surgery in some cases, known as neoadjuvant chemotherapy, Dr. Mahany explains. Those with a triple negative breast cancer and a tumor larger than two centimeters may get chemotherapy before surgery. If there is no residual tumor found in the surgical specimen, more chemotherapy is usually not required. However, if there’s residual tumor, then further options for chemotherapy will be explored.

“A lot of people think, ‘Just go in and take it out,’ but there’s a lot of thought process that goes into what we do before we do it,” Dr. Mahany says.

Hormone Therapies

Hormone therapies are only used to treat hormone receptor positive breast cancers. This treatment option may be recommended even after successful surgery, radiation and/or chemotherapy.

Hormone therapies slow or stop the growth of hormone receptor positive tumors by preventing the cancer cells from getting the hormones they need to grow. Benefits include a lower risk of breast cancer recurrence, lower risk of breast cancer in the opposite breast and lower risk of death.

One such FDA-approved hormone therapy is Tamoxifen, which may be given to premenopausal patients with certain types of breast cancer, such as estrogen receptor positive, or those at a high risk of recurrence. Tamoxifen is taken daily for five years. Tamoxifen also may be given to someone who’s never had breast cancer but is at a high risk of developing cancer.

Related article: Should I have my genes tested if my mother or grandmother had breast or ovarian cancer?

Qualifying postmenopausal patients may need to take another type of hormone therapy drug called aromatase inhibitor, which slows or stops the growth of hormone receptor positive tumors. It is generally for invasive breast cancers and is taken orally for 10 years.

It’s important for breast cancer patients to weigh all their options with their cancer team and not jump to the worst of conclusions.

“A cancer diagnosis is a scary and emotional time. We do a lot of counseling with our patients, and we design our treatment specifically for the patient we are dealing with,” Dr. Mahany says. “I would advise a patient that is newly diagnosed to feel comfortable with their doctors, to discuss their questions and concerns with their doctors and make an educated decision.”

To learn more about Telfair Breast Surgery, visit our website

  • St. Joseph's Hospital Campus: 11705 Mercy Blvd., Savannah, GA 31419, (p) 912-819-4100
  • Candler Hospital Campus: 5353 Reynolds St., Savannah, GA 31405, (p) 912-819-6000
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St.Joseph's Hospital Campus: 912-819-4100

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