Treatment of Breast Cancer

Treatment Options by Stage of Breast Cancer

Stage 0 Noninvasive, Ductal Carcinoma in situ

  • Definition of DCIS - The cancer is found only in the milk ducts of the breast

  • Treatments for DCIS - Treatment of ductal carcinoma in situ (DCIS) may include the following:

    • Breast-conserving surgery with or without radiation therapy or hormone therapy
    • Total mastectomy with or without hormone therapy

  • Outcome Data for DCIS

    • Two studies found that radiation after breast conserving surgery for DCIS reduced local recurrence and invasive carcinoma compared with no radiation after 4-8 years.

    • One study found that tamoxifen plus radiation following wide excision surgery reduced recurrence in women with estrogen receptor positive tumors.

  • Prognosis for DCIS

DCIS is not regarded as life-threatening, having an overall ten-year survival rate higher than 98% of affected patients.

Stage 0 Lobular Carcinoma in situ

  • Treatments for LCIS - Treatment of lobular carcinoma in situ (LCIS) may include the following:

    • Biopsy to diagnose the LCIS followed by observation (regular examinations and mammograms to find any changes as early as possible)
    • Tamoxifen to reduce the risk of developing breast cancer
    • Bilateral prophylactic mastectomy - This treatment choice is sometimes used in women who have a high risk of getting breast cancer. Most surgeons believe that this is a more aggressive treatment than is needed.

Stage I Breast Cancer

  • Definition - Cancer cells have not spread beyond the breast and the tumor is no more than about 2 centimeters (cm), or about an inch, across.

  • Treatments for Stage I Breast Cancer - Treatment of Stage I breast cancer may include the following:

    • Breast-conserving surgery to remove only the cancer and some surrounding breast tissue, followed by lymph node dissection and radiation therapy.
    • Modified radical mastectomy with or without breast reconstruction surgery

  • Outcome Data for Stage I Breast Cancer

One systematic review found that adjuvant combination chemotherapy reduced recurrence and improved survival at 10 years, compared with no chemotherapy. The benefit seemed to be independent of node or menopause status, although the benefits were greater in women with node positive disease, and probably greater in young women.

  • Prognosis for Stage I Breast Cancer

The 5-tear survival rate for Stage I cancer is nearly 100%

Stage II Breast Cancer

  • Definition of Stage II - This stage is divided into two groups:

    • Stage IIA

      • the tumor in the breast is less than 2 cm across and the cancer has spread to the lymph nodes under the arm but not to other parts of the body; OR
      • the tumor is less than 5 cm but has not spread to the lymph nodes under the arm or to other parts of the body; OR
      • no tumor is visible in the breast, however, cancer cells have been detected in the lymph nodes under the arm but the cancer has not spread to other parts of the body

    • Stage IIB

      • the tumor is less than 5 cm but the cancer has spread to the lymph nodes under the arm but not to other parts of the body; OR
      • the tumor is large (more than 5 cm across), however, cancer cells have not been detected in the lymph nodes under the arm and there is no spread of the cancer to other parts of the body

  • Treatments for Stage II Breast Cancer - Treatment of stage II breast cancer may include the following:

    • Breast-conserving surgery to remove only the cancer and some surrounding breast tissue, followed by lymph node dissection and radiation therapy.
    • Modified radical mastectomy with or without breast reconstruction surgery

  • Outcome Data for Stage II Breast Cancer

One study found that adding chemotherapy to tamoxifen improved survival at 5 years in women with lymph node negative, estrogen receptor positive early breast cancer.

One review found that adjuvant tamoxifen taken for up to 5 years reduced the risk of recurrence and death in women with estrogen receptor positive tumors irrespective of age, menopausal status, node involvement, or the addition of chemotherapy.

  • Prognosis for Stage II Breast Cancer

The 5-year survival rate for Stage II Breast cancer is 81-92%

Stage III Breast Cancer

  • Definition of Stage III - "Locally advanced cancer" - This stage is divided into 3 groups:

    • Stage IIIA

      • no tumor is visible in the breast, however, the cancer has spread to the lymph nodes under the arm (which are stuck together) but the cancer has not spread to other parts of the body; OR
      • the tumor is small (5 cm or less) and the cancer has spread to lymph nodes under the armpit (which are stuck together) but the cancer has not spread to other parts of the body; OR
      • the tumor is large (more than 5 cm) and the cancer has spread to lymph nodes under the armpit (which may or may not stuck together) but the cancer has not spread to other parts of the body

    • Stage IIIB

      • any size tumor that is attached to the skin or to the wall of the chest
      • the cancer may or may not have spread to the lymph nodes under the arm
      • the cancer has not spread to any other part of the body

    • Stage IIIC

      • a tumor of any size that has spread to the lymph nodes under the armpit and under the breast bone OR to lymph nodes either above or below the clavicle (collarbone)
      • the cancer has not spread to other parts of the body

  • Treatments for Stage III Breast Cancer - Treatment of Stage III breast cancer may include the following:

    • Breast-conserving surgery to remove only the cancer and some surrounding breast tissue, followed by lymph node dissection and radiation therapy
    • Modified radical mastectomy with or without breast reconstruction surgery
    • Systemic chemotherapy
    • Systemic chemotherapy followed by surgery (breast-conserving surgery or total mastectomy), with lymph node dissection followed by radiation therapy. Additional systemic therapy (chemotherapy, hormone therapy, or both) may be given.

  • Outcome Data for Stage III Breast Cancer

One study found that hormonal treatments (tamoxifen or ovarian ablation) plus radiation delayed local recurrence and improved survival at 8 years in locally advanced breast cancer compared with radiation therapy alone.

  • Prognosis for Stage III Breast Cancer

Risk of recurrence is highest during the firsts 5 years, but the risk remains even 15-20 years after surgery. Those with node positive disease have a 50-60% chance of recurrence, compared with 30-35% for node negative disease. Recurrence at 10 years, according to one review, is 60-70% compared with 25-30% of node negative women. The prognosis for disease free survival at 5 years is worse for more advanced Stage III B (33%) than for earlier Stage III A (71%). Five year overall survival is 44% for Stage III B and 84% for Stage III A.

Stage IV Breast Cancer

  • Definition of Stage IV - The cancer is metastatic, meaning it has spread from the breast to other parts of body such as the liver, lung, or bones.

  • Treatments for Stage IV Breast Cancer - Treatment of stage IV or metastatic breast cancer may include the following:

    • Hormone therapy and/or systemic chemotherapy with or without trastuzumab (Herceptin)
    • Radiation therapy and/or surgery for relief of pain and other symptoms
    • Bisphosphonate drugs to reduce bone disease and pain when cancer has spread to the bone.

  • Outcome Data for Stage IV Breast Cancer

Two studies found that the aromatase inhibitor anastrozole (Arimidex) as first-line treatment in metastastatic postmenopausal breast cancer was at least as effective as tamoxifen in delaying disease progression and may cause fewer blood clotting events and vaginal bleeding.

Studies have shown that antiestrogens (primarily tamoxifen) resulted in tumor responses in a substantial proportion of women with metastatic breast cancer. The likelihood of benefit with antiestrogen treatment was greatest in postmenopausal women with estrogen-receptor positive tumors.

Studies have found that combination chemotherapy regimens ,such as CAF, containing an anthracycline (e.g.,doxorubicin) [doxorubicin (Adriamycin), cyclophosphamide (Cytoxan), and fluorouracil (Fluorouracil, 5-FU, Adrucil) as first line treatment increased response rates, time to progression, and survival compared with other chemotherapy regimens.

  • Prognosis for Stage IV Breast Cancer

The 5-year survival rate for Stage IV breast cancer is 20%

Breast Cancer Recurrence Following Treatment

Treatment of recurrent breast cancer (cancer that has come back after treatment) in the breast or chest wall may include:

  • Surgery (radical or modified radical mastectomy), radiation therapy, or both.
  • Systemic chemotherapy or hormone therapy.
  • A clinical trial of trastuzumab (Herceptin) combined with systemic chemotherapy.