Breast Cancer Treatment
MD Anderson’s Nellie B. Connally Breast Center provides patients with truly multidisciplinary care. That means your medical oncologist, radiation oncologist, surgical oncologist, and reconstructive surgeon work together as a team to achieve the best possible outcome. They coordinate care and develop a comprehensive treatment plan that’s unique to each patient’s disease and needs.
Surgery
Many patients undergo some form of surgery as part of their breast cancer treatment.
Some will receive chemotherapy or targeted therapy before surgery. The goal of these treatments is to shrink the tumor and affected lymph nodes to make the procedure and recovery easier on the patient. This also allows the treating team to assess how cancer has responded to treatment, which can be important for some breast cancer subtypes.
There are two categories of breast cancer surgery:
- Lumpectomy: In a typical lumpectomy surgery, the tumor and a small amount of surrounding normal tissue are removed. This procedure may be appropriate for early breast cancer cases where the tumor is still small. Lumpectomies are generally outpatient procedures and have shorter recovery times. These procedures are usually followed by radiation therapy.
- Mastectomy: In a typical mastectomy surgery, the tumor and the entire breast are removed. There are several different types of mastectomies, including procedures that spare the breast’s skin and nipple/areola. Often a mastectomy and breast reconstruction can be performed in the same procedure.
In some cases, both breasts are removed (double mastectomy). This can help prevent the development of new breast cancer. It is typically done for patients who have an elevated risk of developing breast cancer due to family history or their own genetic profile, such as a BRCA mutation.
In both lumpectomies and mastectomies, surgeons may also remove nearby lymph nodes. Breast cancer can spread through nearby lymph nodes. Doctors will study the ones that are removed to determine if there are cancer cells within the nodes. This information can help determine the risk of the disease spreading to distant organs, as well as the need for chemotherapy and radiation therapy.
Like all surgeries, breast cancer surgery is most successful when performed by a specialist with a great deal of experience in a particular procedure. MD Anderson’s breast cancer surgeons are among the most skilled and renowned in the world. They perform a large number of surgeries for breast cancer each year, using the least-invasive and most-effective techniques. At the start of treatment, care teams assess if the patient needs reconstructive surgery. If so, our breast cancer surgeons and reconstructive surgeons work together to plan procedures that minimize incision and possible scarring. Their goal is to achieve the most effective surgery and the best possible cosmetic outcome and symmetry.
Radiation therapy
Radiation therapy uses powerful beams of energy carefully designed to kill breast cancer cells.
For breast cancer patients, radiation therapy can be used before surgery to shrink large tumors and make the surgery easier on the patient. Radiation therapy can also be used after surgery to kill any remaining breast cancer cells that can’t be seen by the naked eye. After a lumpectomy, patients often receive three to four weeks of daily radiation therapy. In some cases, one to two weeks may be appropriate. When the lymph nodes are involved or a mastectomy was needed, patients usually need six weeks of daily radiation therapy.
In metastatic breast cancer cases, radiation therapy can also be used as a palliative treatment to reduce symptoms caused by cancer spreading to other parts of the body and improve the patient’s quality of life.
There are different techniques used in radiation therapy. Your doctors and radiation oncologist will collaborate to make sure you receive the most effective and precise dose of treatment. Radiation therapy treatments for breast cancer patients include:
- 3D conformal radiation therapy: This technique uses radiation beams that are shaped to the tumor’s dimension.
- Intensity-modulated radiation therapy: IMRT uses multiple beams of radiation with different intensities to deliver a precise, high dose of radiation to the tumor.
- Volumetric arc therapy: In this special type of IMRT, in VMAT therapy, the section of the machine that shoots out the beam of radiation rotates around the patient in an arc. This can irradiate the tumor more precisely and shorten procedure times.
- Accelerated partial breast irradiation: A form of brachytherapy, APBI uses radioactive pellets or seeds to kill cancer cells that may remain after a lumpectomy.
- Stereotactic body radiation therapy: Sterotactic body radiation therapy administers very high doses of radiation, using several beams of various intensities aimed at different angles to precisely target the tumor.
- Stereotactic radiosurgery: Stereotactic radiosurgery is most commonly used to treat breast cancer that has spread to the brain. Stereotactic radiosurgery uses dozens of tiny radiation beams to target tumors with a precise, high dose of radiation.
At most hospitals, the radiation oncologist developing these treatments works on several different types of cancer. At MD Anderson's Breast Center, radiation oncologists are dedicated exclusively to caring for patients with breast cancer. This gives them the incredibly deep experience to draw from when designing treatment plans. Each breast cancer radiation treatment plan is also reviewed by every breast radiation oncology faculty member, ensuring that patients receive the best possible treatment.
Our physicians are recognized as world leaders in their field. MD Anderson radiation oncologists have developed radiation therapy treatments shown to deliver the most effective radiation courses in the shortest amount of time and with the fewest side effects.
Proton therapy
Proton therapy is similar to the radiation therapies described above, but it uses a different type of energy and is much more accurate at targeting tumors. It delivers high radiation doses directly into the tumor, sparing nearby healthy tissue and vital organs. For many patients, this results in better cancer control with fewer side effects.
Targeted therapy
Cancer cells rely on specific molecules (often in the form of proteins) to survive, multiply and spread. Targeted therapies stop or slow the growth of cancer by interfering with, or targeting, these molecules or the genes that produce them.
In recent years, targeted therapy has become a major weapon in the fight against breast cancer. Breast cancer subtypes that once had poor prognoses are now highly treatable.
One type of targeted therapy is endocrine therapy (also known as hormone therapy), which is given to patients with hormone receptor-positive breast cancer. This can be given before surgery to shrink the tumor. It is also given after surgery for five to 10 years to prevent a recurrence. Patients with the metastatic form of this disease are also given endocrine therapy to prevent disease progression.
Patients with HER2-positive breast cancer also receive targeted therapies. These patients may receive a different set of targeted therapy drugs both before and after surgery. Since about half of patients with HER2-positive breast cancer also have hormone receptor-positive tumors, they are also given endocrine therapy.
While there are no targeted therapies for triple-negative breast cancer, researchers are studying the disease to identify possible drug targets.
Chemotherapy
Chemotherapy uses powerful drugs to directly kill cancer cells, control their growth or relieve pain. It is often given to patients before surgery to shrink the tumor and simplify the procedure. Breast cancer patients can receive chemotherapy either orally or intravenously.
Angiogenesis inhibitors
Angiogenesis is the process of creating new blood vessels. Vascular endothelial growth factor (VEGF) is one of the main molecules that control the process. Some cancerous tumors are very efficient at using these molecules to create new blood vessels, which increases blood supply to the tumor and allows it to grow rapidly.
Researchers developed drugs called angiogenesis inhibitors, or anti-angiogenic therapy, to disrupt the growth process. These drugs search out and bind themselves to VEGF molecules, These drugs search out and bind themselves to VEGF molecules or receptor proteins, prohibiting them from activating angiogenesis.
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When cancer is found in both breasts or there’s a high risk of developing breast cancer, a double mastectomy may be an option to treat or prevent breast cancer.
This surgery removes all breast tissue. It can be performed with or without breast reconstruction surgery, either at the same time or as a separate procedure.
We spoke to surgical oncologist Rosa Hwang, M.D., to learn more about this procedure and what patients can expect before, during and after a double mastectomy.
Who needs a double mastectomy?
Very few patients need a double mastectomy, but there are some cases where patients and their care teams may decide to seek this treatment option, if they meet certain requirements.
The National Comprehensive Cancer Network’s guidelines outline which patients may benefit from double mastectomy. These include patients who have:
certain genetic mutations, like BRCA1 and BRCA2, that put them at increased risk for developing breast cancer,
cancer in both breasts,
several close family members who’ve been diagnosed with breast cancer at a young age, and/or
a history of radiation therapy to the chest.
Patients with a tumor in one breast may consider a double mastectomy, also called a bilateral mastectomy, for cosmetic reasons to achieve symmetry in the other breast.
What are the alternatives to double mastectomy?
When you have breast cancer, your first instinct may be to remove all potential for it to grow or spread. But surgery isn’t the only option for many patients. Even if you’re at high risk for developing breast cancer, there are non-surgical treatment options that don’t require a double mastectomy. These include more frequent screenings and surveillance.
MD Anderson patients can seek care from our High-Risk Screening and Genetics Clinic, where they’ll receive frequent mammograms and/or breast MRIs to detect cancer early, when it’s easiest to treat.
Talk to your care team to see if you’re eligible for more frequent screenings instead of surgery.
What are the different types of double mastectomy?
There are several different surgical techniques that can be used during a double mastectomy. These include:
Total mastectomy: This surgery removes all the breast tissue, including the skin and nipple.
Skin-sparing mastectomy: Breast tissue is removed along with the nipple and areola, but the skin around the breast is saved. This leaves a “skin envelope,” which allows for breast reconstruction surgery at the same time, either with implants or your own tissue. This approach offers a more natural appearance after patients recover.
Nipple-sparing mastectomy: This technique is the most complex option for mastectomy; it saves the skin as well as the nipple-areolar complex. Nipple-sparing mastectomy is performed with reconstruction at the same time, similar to a skin-sparing mastectomy. Surgeons remove tissue inside the breast but save the skin, nipple and areola.
Your recovery time will depend on which surgical approach you receive and whether you undergo breast reconstruction. This can range from two weeks for total mastectomy with no reconstruction to 4 to 8 weeks after mastectomy with reconstruction using your own tissue.
What are the risks associated with double mastectomy?
As with any surgery, there are risks associated with double mastectomy. And, because the treatment involves two different spots on the body, that risk is doubled.
With skin-sparing and nipple-sparing mastectomy, there’s risk that the skin and nipple will lose blood supply and die or lose sensation. Bleeding and infection are also possible side effects of surgery. That’s why it’s so important to seek care from a surgeon with experience performing this specialized surgery to get the best result and minimize risks.
Anything else patients should know about double mastectomy?
A double mastectomy can be beneficial for some patients, but it’s not right for everyone. Having both breasts removed is a big decision, and you want to make sure that it’s the right one for you based on your quality of life and personal treatment goals.
Talk to your care team to see if a double mastectomy makes sense for you and your breast cancer treatment goals.
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
Hormones control nearly all of our bodily functions, from growth and development to emotions, sexual function and even sleep. But hormones, which occur naturally in our bodies, can also fuel the growth of certain breast cancers. We talked with breast medical oncologist Rachel Layman, M.D., to learn about hormone therapy for breast cancer, which can stop or slow the cancer-fueling action of hormones.
What is hormone therapy for breast cancer?
Hormone therapy is a form of treatment that deprives breast cancer of estrogen and progesterone, the two main female hormones that it needs to survive and grow.
Estrogen and progesterone are carried along in the bloodstream. When they encounter a breast cancer cell, they stick to proteins called hormone receptors on the cell’s surface. This connection acts as an “on switch” and triggers the cancer cell to grow. The goal of hormone therapy is to prevent hormones from attaching to cancer cells, which deprives the cancer cells of the fuel they need to grow.
Are all breast cancers fueled by hormones?
No, but most are. About 70% of all breast cancers depend on estrogen or progesterone for growth.
These hormone-dependent breast cancers are called “hormone-sensitive.” This means they’re either estrogen receptor positive or progesterone receptor positive, depending on which hormone they connect with. Some cancer cells have receptors for estrogen, some have receptors for progesterone, and some have receptors for both. 30% of breast cancers have no hormone receptors and don’t benefit from hormone therapy.
How do hormone therapies for breast cancer work?
Hormone therapies reduce or eliminate contact between hormones and breast cancer cells in several different ways:
- One approach is to block hormones from attaching to the receptors on cancer cells. When the hormones can’t access the cancer cells, tumor growth slows and the cancer cells may die. Medications that block hormones include tamoxifen, toremifene and fulvestrant.
- Another approach stops hormone production in younger women who have not yet been through menopause. This can be done with medications such as goserelin or leuprolide, with surgery to remove the ovaries where most hormones are made, or, less commonly, with radiation therapy aimed at the ovaries.
- Yet another approach stops hormone production in women who have already experienced menopause. Estrogen and progesterone levels plummet after menopause, but the body continues to make small amounts. Medications called aromatase inhibitors to reduce the level of these post-menopausal hormones, which starves the cancer cells of the fuel they need. Aromatase inhibitors are used only in post-menopausal women and include the drugs anastrozole, exemestane and letrozole.
How and when are hormone therapy medications delivered?
Most hormone therapy drugs are taken as a daily oral pill, though a few are given as injections in the clinic.
Women usually begin hormone therapy after undergoing surgery for the removal of a breast tumor. They typically take hormone therapy drugs for at least five years and sometimes as long as 10 years after surgery, depending on how likely the cancer is to return. In some instances, hormone therapy is given before breast cancer surgery to shrink the tumor, which makes it easier to remove.
Women who aren’t healthy enough to withstand an operation may take hormone therapy drugs until they’re well enough to undergo surgery. The treatment won’t get rid of cancer, but it can stop it from growing or shrink it until surgery can be performed.
Can hormone therapy prevent breast cancer, in addition to treating it?
Yes, women who have completed breast cancer treatment often use hormone therapy to help prevent the disease from coming back. Hormone therapy also helps lower the odds of getting cancer in the other breast.
Doctors may also recommend hormone therapy for healthy women who have a family history of breast cancer, or genetic mutations that raise their risk for the disease.
How effective is hormone therapy for breast cancer?
Clinical trials of breast cancer patients show that overall, hormone therapy cuts the risk of cancer developing or coming back in half.
What are the side effects of hormone therapy?
The potential side effects of hormone therapy depend largely on the specific drug or type of treatment. Common side effects of all hormone therapies include:
- hot flashes
- night sweats
- vaginal dryness
Less common, more serious side effects of some hormone therapy drugs may include:
- blood clots
- stroke
- heart disease
- osteoporosis
Is hormone therapy the same as hormone replacement therapy?
No, the two are opposites. Hormone therapy blocks or removes hormones to treat breast cancer, while hormone replacement therapy adds hormones to the body to counter the effects of menopause. Hormone therapy for breast cancer is actually “anti-hormone therapy” or “hormone-blocking therapy.”
What’s your advice for people considering hormone therapy for breast cancer treatment?
Deciding on hormone therapy for breast cancer can be a complex decision. The type of therapy you receive may depend on the stage of your disease, whether you’ve gone through menopause, and whether you want to have children. Talk with your doctor about your options to help make the best decision for you.
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
Last updated March 22, 2022.
Can immunotherapy treat breast cancer? For certain patients, the answer is yes.
Pembrolizumab is approved by the Food and Drug Administration (FDA) for some patients with metastatic and early-stage triple-negative breast cancer. It’s an immune checkpoint inhibitor, the most common type of immunotherapy.
To understand how the drug works, which breast cancer patients are benefiting and what’s ahead with research, we spoke with Clinton Yam, M.D.
How does immunotherapy work to treat triple-negative breast cancer?
Immunotherapy treats cancers by waking the immune system’s natural ability to defend the body from infection and disease, including cancer. T cells are a type of immune cell that help lead the immune system’s response to an illness.
PD-L1 is a protein that can be found on the surface of cancer cells and/or immune cells. It binds with a partner protein called PD-1 that’s on the surface of a T cell. But this bond turns off the T cell and allows the cancer cell to hide from the T cell. Immune checkpoint inhibitors take off this brake, which increases the likelihood that the T cells will attack and destroy the cancer cells.
Is immunotherapy an option for all patients with triple-negative breast cancer?
Pembrolizumab is currently approved to treat some patients with early-stage or metastatic triple-negative breast cancer.
For patients with metastatic triple-negative breast cancer, immunotherapy in combination with chemotherapy is an option if the PD-L1 protein is detected on the cancer and/or immune cells within the tumor. We determine if a patient has a high expression of PD-L1 through an immunohistochemistry test. This is performed on tissue that’s removed during a biopsy or a previous surgery. If the PD-L1 protein is not found on the cancer cells and/or immune cells within the tumor in patients with metastatic triple-negative breast cancer, a PD-1 immune checkpoint inhibitor won’t be effective.
Patients with high-risk, early-stage disease will be eligible to receive a combination of pembrolizumab and chemotherapy before surgery. After surgery, patients will continue receiving pembrolizumab alone. While “high risk” isn’t defined by the FDA, most providers rely on the definition used in the clinical trial that led to the approval of pembrolizumab. Specifically, this includes patients with breast tumors larger than 2 cm. Patients with smaller breast tumors may be eligible to receive immunotherapy if there is evidence of cancer in the lymph nodes.
Importantly, immunotherapy may worsen symptoms of autoimmune disorders like lupus and rheumatoid arthritis, so these drugs aren’t typically used in women with these chronic illnesses.
What are the side effects of immunotherapy in patients with breast cancer?
Immunotherapy side effects are the same, regardless of the type of cancer being treated.
Immunotherapy increases the ability of the immune system to attack cancer cells, but it also increases the chances that the immune system will affect normal cells. This can cause inflammation throughout the body, which can lead to side effects, such as skin changes, cough, chest pain and diarrhea. In some cases, these side effects can be debilitating, depending on the organ(s) involved.
For example, if the thyroid gland is affected, the patient may develop a condition called hypothyroidism (low thyroid hormone) and may need thyroid hormone replacement in the future. In rare but extreme cases, liver or kidney failure can develop.
When treating breast cancer, is immunotherapy used alone or in combination with other therapies?
Right now, pembrolizumab is used in combination with chemotherapy to treat metastatic triple-negative breast cancer.
However, there are ongoing clinical trials studying other combinations. For example, researchers are trying to find out if immunotherapy is more effective when combined with targeted therapies, such as PARP inhibitors. One challenge with treating breast cancer with immunotherapy is that immune cells have a harder time infiltrating the tumors. By combing immune checkpoint inhibitors with targeted therapies, we hope to help the immune cells better enter the tumor and, therefore, make these drugs an effective treatment option for more patients.
There is also hope that we may be able to use therapeutic vaccines to train the immune system to fight cancer.
Lastly, we know that radiation therapy helps jump-start the immune system. Through clinical trials, researchers are exploring how we might optimize immunotherapy by combining it with radiation therapy.
What are the immunotherapy options for patients with other breast cancer subtypes?
Clinical trials are working to expand the use of immunotherapy to more patients, including those with other stages of triple-negative breast cancer, as well as other breast cancer subtypes.
If you’re interested in immunotherapy options for breast cancer treatment, I encourage you to talk with your care team about clinical trial options. You may find a clinical trial opportunity that can give you access to immunotherapy and also enable you to pay it forward for future cancer patients.
Request an appointment at MD Anderson online or by calling 1-877-632-6789.