Cancer therapies can be highly individualized – your treatment may differ from what is described below.
Breast cancers are treated by surgery, radiation, chemotherapy or hormonal therapy. Almost always it’s a combination of these that is offered, depending on the individual situation. The choice of treatment depends on: type, size and location of the breast cancer; age and health of patient; known or possible spread to the lymph nodes in the underarm or elsewhere in the body; tumour receptor status for estrogen, HER2 and progesterone; and patient and physician preference of treatment.
For early breast cancer that is contained to the breast and/or underarm lymph nodes, surgery is the most important component and is usually the first treatment.
The need for radiation, chemotherapy and/or hormone therapy is generally decided based on the information found under the microscope, after examining the removed cancer.
For breast cancers that have already spread to distant parts of the body, surgery may not always be part of the treatment.
Getting Ready for Breast Surgery - This booklet helps prepare patients for breast surgery at BC Cancer or Vancouver Hospital / UBC. Although most of the information is similar to breast surgery at other B.C. hospitals, please check with your surgeon or hospital for their information about getting ready for surgery.
Surgery for invasive breast cancer includes removing the tumor from the breast and examining some of the lymph nodes from under the arm to determine if the cancer has spread.
Surgery of the breast can be either a lumpectomy or mastectomy.
Optimal surgery for ‘in situ’ breast cancer does not require sampling of the underarm lymph nodes, as this type of disease rarely spreads outside the breast.
Surgery for the underarm nodes can be a ‘sentinel node biopsy’ or an ‘axillary dissection’, and sometimes both are needed.
This is also called Segmental or Partial Mastectomy. This surgery removes the tumour and a small margin of the surrounding normal tissue. Because of this, it saves or ‘conserves’ most of the breast. Currently, approximately 1/2 - 3/4 of all breast cancers can be treated with this breast conserving surgery.
Sometimes a surgical margin may be too close to the cancer cells, and a further surgery is recommended to remove additional tissue in this area (a “re-excision”). Occasionally a mastectomy (removal of all the breast tissue) will be recommended after a lumpectomy, if more cancer is found than was expected.
Lumpectomy is followed by radiation therapy to the breast to reduce the chance of the cancer coming back within the remaining breast tissue. Anyone who cannot have radiation, or does not want radiation, should have a mastectomy instead.
This refers to a surgery where one whole breast is removed. There are several types of mastectomy described below. A lumpectomy is not always the safest or best surgery for breast cancer. Whether a mastectomy or lumpectomy is recommended depends on many factors, which are described in more detail below.
Simple Mastectomy: In this procedure, all the breast tissue is removed, but no underarm lymph nodes are removed. This type of mastectomy may be used in the treatment of in situ disease.
Modified Radical Mastectomy: In this procedure, all the breast tissue is removed, and lymph nodes under the arm are removed at the same time.
Radical Mastectomy: In this procedure, all the breast tissue and underarm lymph nodes are removed, and the muscles of the chest wall underneath the breast are removed. Although this was the standard operation for breast cancer until 1970, it is rarely performed now, as this extensive surgery has not been shown to improve survival and is more disfiguring.
Immediate or delayed breast reconstruction is frequently an option for patients following a mastectomy. With immediate reconstruction, a general surgeon performs the mastectomy and a plastic surgeon performs the first part of reconstruction during the same anaesthetic. Depending on what type of reconstruction is performed, further surgery may still be necessary later. With delayed reconstruction, all cosmetic reconstructive surgery is performed much later, after all cancer treatment is completed. For more information, see Breast Reconstruction and Prosthesis or Vancouver Coastal Health.
Lymph nodes are part of the lymphatic system, which is part of the immune system. The most common place for breast cancer to move (metastasize) to is to the lymph nodes under the arm.
When breast cancer spreads only to the underarm lymph nodes, it is still a curable cancer.
Because in situ cancer so rarely spreads outside the breast, underam lymph nodes are not usually removed when breast surgery is done for in situ cancer.
During the surgery for invasive breast cancer, the surgeon usually takes out some underarm lymph nodes. A pathologist then separates out the lymph nodes from the remaining tissue and examines them under the microscope to see if there are any cancers cells inside any of them. There are two types of lymph node removal.
Examining lymph nodes under the microscope provides important information about the chance (risk) of a cancer coming back, and helps guide recommendations for treatment after surgery.
Complications of lymph node removal from the underarm.
The risk of these complications is lower with a sentinel node biopsy than with axillary dissection, which is why the sentinel node biopsy is preferred for most patients.
When the normal drainage of lymph fluid from the arm and breast are disturbed by a sentinel node biopsy or axillary dissection, there is a risk of
lymphedema, or swelling of the hand or arm.
Difficulty raising the arm: Following underarm surgery, scarring occurs as part of the body’s natural healing process. This can create a pulling or sore sensation under the arm when trying to raise one’s hand above one’s head. It is important to practice this kind of arm movement early and regularly after surgery to minimize this problem.
Numbness under the arm: Surgery to the underam often results in an unavoidable injury to a nerve that provides sensation to the skin under the upper arm. This usually leads to numbness in this area, which may be permanent or very slowly improve.
Pain in the upper arm: This occasionally happens just below where the surgery was done, and improves with time.
Exercise after surgery is very important to return the full use and range of motion of the arm and shoulder.
The choice of lumpectomy or mastectomy, and of sentinel node biopsy or axillary dissection, depends on many factors. These include:
the size and location of the tumour relative to the size of the breast
medical fitness of the patient
the patient's own preference
In general, patients who are suitable for lumpectomy would have:
a solitary breast cancer less than 4 cm in diameter
a large enough breast that removal of sufficient tissue would not leave a poor cosmetic result
a preference to preserve the breast
no reasons that make radiation after breast conserving surgery dangerous, impossible or impractical
In general, regardless of the breast surgery performed, the patient suitable for sentinel node biopsy has:
A solitary cancer less than 2 cm in diameter
No previous breast reduction surgery
No previous surgery to the lymph nodes under the arm
No obvious spread of cancer to underam lymph nodes prior to surgery
Has not already had a mastectomy
Prophylactic (preventive) mastectomy is the removal of one or both breasts (bilateral mastectomies) when there is no evidence of cancer in that breast. These are done very rarely.
Surgery for existing breast cancers is more important than surgery to prevent possible future cancers. Sometimes a patient with breast cancer will ask for, or be recommended to have, a prophylactic mastectomy. Usually the prophylactic mastectomy will be done during breast cancer surgery on the affected breast.
Some patients without breast cancer who are considered to be at very high lifetime risk of developing breast cancer (for example, a 50% or higher risk) may choose to have both breasts removed even though no cancer has yet been diagnosed.
A doctor may recommend that a patient have a prophylactic mastectomy if there is a strong suspicion of cancer developing in the opposite (contralateral) breast because of:
a strong family history of breast or ovarian cancer or the patient has the BRCA gene.
pre-invasive (in situ) or invasive lobular cancer in the opposite breast.
The decision to have a prophylactic mastectomy should be made only after a thorough discussion between the patient and their doctor(s).
There are two kinds of prophylactic mastectomies. Immediate or delayed reconstruction should be discussed with patients undergoing prophylactic mastectomy.
In a total prophylactic mastectomy, the breast and nipples are removed, but not the lymph nodes.
A subcutaneous prophylactic mastectomy preserves the nipple but leaves behind more breast tissue than a total mastectomy. Subcutaneous mastectomy is discouraged.
100% of the breast tissue is not removed during a total prophylactic mastectomy; a small amount of breast glandular tissue probably remains against the chest muscles or attached to the skin, even after bilateral mastectomy.
Every patient at high risk for breast cancer should be offered psychological and genetic counselling. The risk of developing breast cancer can be estimated, fully discussed and understood. Information about reconstruction alternatives should be provided. Patients with a very strong family history of breast cancer who are considering prophylactic mastectomy can be referred to the Hereditary Cancer Program for counselling and referral for testing, if testing criteria are met.
Radiation therapy can also be called radiotherapy, irradiation or just radiation. The health care providers may also say that they are going to radiate the tumour.
This treatment is designed to stop the growth of cancer cells while trying to preserve the normal tissue.
The most common kind of radiotherapy in B.C. is called external beam radiotherapy and it uses a large machine, like an x-ray machine, to deliver radiation into specific areas of the body at a specific angle and depth.
It is painless, much like having a chest x-ray. The patient lies flat on a table and the machine is lined up to treat the part of the body that the doctor feels is necessary.
Since these machines are large, expensive and highly specialized, the only place in British Columbia where radiation treatment can be obtained is at BC Cancer clinics.
Also used in B.C. (in clinical trials only) is partial breast radiotherapy. This is available at all BCCA Centres.
Radiation treats the breast and sometimes the nodal areas (the lymph nodes nearest to the tumour).
Radiation therapy is used in several different circumstances:
After a lumpectomy (segmental mastectomy), radiation to the breast greatly reduces the risk of cancer re-growing in that breast. In order to minimize side effects, the treatments are usually given over a series of treatments on weekdays for 3.5 - 6 weeks.
It is used after a total mastectomy if the doctors think that there is a high risk of cancer regrowth on the chest wall. This happens when there are large cancers, or if there are many positive lymph nodes found during the surgery.
Sometimes radiation is used before surgery, if the doctors feel that the cancer cannot be safely removed. Often it can shrink the cancer so that surgery can happen after the radiation.
If the cancer comes back, radiation is often useful to relieve pain, bleeding or certain other problems.
Side effects of radiation therapy can be very different depending upon which part of the body is treated, and by the patient’s response to the dose they are given. When treating the breast area the usual side effects are:
Some redness, discomfort and dryness of the skin.
Possibly a sore throat.
After treatment, protect the radiated area from the sun, especially in the first year.
Instructions as to what side effects to expect and how to minimize them are given to each patient before they start treatment.
Available treatments for any possible side effects will also be discussed.
Chemotherapy is the use of drugs to kill cancer cells.
Chemotherapy can be given as tablets or injections.
Chemotherapy is used in both pre- and post-menopausal patients.
Many drugs have been shown to be effective in the treatment of breast cancer.
In general, chemotherapy is used in two situations:
To kill cancer cells that might still remain after the surgery and/or radiation, when the cancer seems to be confined to the breast and/or lymph nodes under the arm. This is called adjuvant therapy.
If cancer shows up elsewhere in the body, or comes back after treatment is over (recurs), then a treatment which can go throughout the whole body (systemic) is needed. Recurrent breast cancer at this time is treatable, but not curable. Each patient’s situation is different. The choice of when to start chemotherapy, what drugs to use and what side effects to expect, needs to be discussed between the patient and her doctor.
There are many different types of drugs, each with its own actions and side effects. Not everyone gets all these side effects. The usual side effects are:
occasional vomiting. The majority of patients do not vomit when given newer anti-nausea medications.
immune system and infections. Drugs can affect the blood producing bone marrow, which lowers "white blood cell" counts. Patients with low white blood cell counts have an increased risk of infection.
hair loss does not always happen, and depends on the drug and the amount of the dose
some patients' periods may stop temporarily or permanently (menopause)
occasionally, people get mouth sores. Talk to your oncologist about any mouth sores. There is a
prescription mouthwash available that will help
Like normal breast tissue, some breast cancers can be stimulated to grow by hormones (estrogen and progesterone). These are called estrogen receptor positive (ER+) or progesterone receptor positive (PR+). If the tumour cells do not respond to the hormones, they are referred to as estrogen receptor negative (ER-) and progesterone receptor negative (PR-).
It has been found that the growth of ER+ and PR+ breast cancers can be stopped in:
post-menopausal patients by interfering with the low levels of estrogen that exist.
pre-menopausal patients by stopping the ovaries from working, or by the use of anti-estrogen drugs.
Hormone therapies are almost always used once the initial treatments are over.
Currently at BC Cancer, we recommend the use of tamoxifen
for premenopausal patients, and tamoxifen followed by an aromatase inhibitor (AI) for postmenopausal patients. The length of time the patient will spend first on tamoxifen and then the AI is dependent on their individual circumstances, such as menopausal status.
More information about specific drugs used for hormonal cancer treatment can be found in our Cancer Drug Manual ©
In premenopausal patients whose ovaries are still working, tamoxifen is the preferred option, but sometimes ovarian ablation is used. Permanent and temporary options include:
removing the ovaries surgically.
giving a one-week course of radiation, which destroys the ability of the ovaries to function.
Medications that can cause temporary menopause have been shown to be effective.
Guidelines for follow-up after treatment are covered on our website.
Follow-up Program after Breast Cancer Treatments pamphlet is available here as a PDF file for reading or printing:
You will be returned to the care of your family doctor or specialist for regular follow-up. If you do not have a family physician, please discuss this with your BC Cancer oncologist or nurse.
Follow-up testing is based on your type of cancer and your individual circumstances.
Life after Cancer focuses on the issues that cancer survivors can face.