Breast Cancer - Inflammatory: Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2014

ON THIS PAGE: You will learn about the different ways doctors use to treat this type of cancer. To see other pages, use the menu on the side of your screen.

This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new approach to treatment to evaluate whether it is safe, effective, and possibly better than the standard treatment. Clinical trials may test such approaches as a new drug, a new combination of standard treatments, or new doses of current therapies. Your doctor can help you review all treatment options. For more information, see the Clinical Trials and Latest Research sections.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team.

Inflammatory breast cancer is typically considered a locally-advanced breast cancer and is treated aggressively with surgery, radiation therapy, chemotherapy, hormone therapy, and/or HER2 targeted therapy as appropriate. Chemotherapy is usually the first type of treatment for inflammatory breast cancer. After chemotherapy, patients with inflammatory breast cancer usually receive surgery and radiation therapy to the breast or chest wall.

Descriptions of the most common treatment options for inflammatory breast cancer are listed below. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. Learn more about making treatment decisions.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication.

Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally). A chemotherapy regimen consists of a specific treatment schedule of drugs given at repeating intervals for a set number of times. Chemotherapy for inflammatory breast cancer is usually given before surgery, called preoperative or neoadjuvant chemotherapy. Chemotherapy is also commonly given if there is a breast cancer recurrence (see below.)

A patient may receive one drug at a time or combinations of different drugs at the same time. Chemotherapy for inflammatory breast cancer that has not spread outside of the breast and regional lymph nodes is usually a combination of drugs.

Common drugs for inflammatory breast cancer include:

  • Capecitabine (Xeloda)
  • Carboplatin (Paraplatin)
  • Cisplatin (Platinol)
  • Cyclophosphamide (Neosar)
  • Docetaxel (Docefrez, Taxotere)
  • Doxorubicin (Adriamycin)
  • Pegylated liposomal doxorubicin (Doxil)
  • Epirubicin (Ellence)
  • Eribulin (Halaven)
  • Fluorouracil (5-FU, Adrucil)
  • Gemcitabine (Gemzar)
  • Ixabepilone (Ixempra)
  • Methotrexate (multiple brand names)
  • Paclitaxel (Taxol)
  • Protein bound paclitaxel (Abraxane)
  • Vinorelbine (Navelbine)

Common drug combinations for inflammatory breast cancer include:

  • Doxorubicin/cyclophosphamide (AC) followed by paclitaxel or docetaxel
  • Docetaxel/cyclophosphamide (TC)
  • Docetaxel/doxorubicin/cyclophosphamide (TAC)

For HER2 positive cancers, chemotherapy is combined with HER2 targeted therapy (see Targeted therapy below).

The side effects of chemotherapy depend on the individual and the drug and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. Rarely, long-term side effects may occur, such as heart damage, nerve damage, or secondary cancers, but studies have shown that these side effects do not shorten a patient’s survival time.

Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. It is also used to examine the surrounding axillary or underarm lymph nodes. A surgical oncologist is a doctor who specializes in treating cancer using surgery.

Because inflammatory breast cancer is usually located throughout the breast and the lymphatic vessels in the skin, it is difficult to remove the entire tumor with negative margins, meaning no cancer is left at the edges of the tissue removed during surgery, if surgery is the first step in treatment. Any cancer left behind during surgery increases the chances of recurrence in the breast and affects wound healing. So, chemotherapy is usually given first in inflammatory breast cancer to shrink and kill the cancer in the breast, improving the chance that surgery will be successful.

The usual surgical treatment for inflammatory breast cancer is the removal of the entire breast, a procedure called a mastectomy. Sometimes, the removal of the tumor and a small, cancer-free margin of tissue around it is possible. This is called a lumpectomy, breast-conserving surgery, a partial mastectomy, or a segmental mastectomy. Talk with your doctor about which surgery is recommended for you, the possible side effects, and how side effects will be relieved. Reconstructive surgery of the breast after mastectomy is discussed below.

Lymph node removal and analysis

Cancer cells are sometimes found in the axillary lymph nodes in some patients. It is important to find out whether any of the lymph nodes near the breast contain cancer as part of the treatment planning.

Sentinel lymph node biopsy. The sentinel lymph node biopsy procedure allows for the removal of one to a few lymph nodes, avoiding the removal of multiple lymph nodes in an axillary lymph node dissection (see below) for patients whose sentinel lymph nodes are free of cancer. The smaller lymph node procedure lowers the risk of swelling of the arm called lymphedema and decreases the risk of numbness, as well as arm movement and range-of-motion problems, which are long-lasting issues that can severely affect a person’s quality of life.

In a sentinel lymph node biopsy, the surgeon finds and removes about one to three sentinel lymph nodes from under the arm that receive lymph drainage from the breast. The pathologist then examines these lymph nodes for cancer cells. To find the sentinel lymph node, the surgeon injects a dye and/or a radioactive tracer into the area of the cancer and/or around the nipple. The dye or tracer travels to the lymph nodes, arriving at the sentinel node first. The surgeon can find the node when it turns color if the dye is used or gives off radiation if the tracer is used.

If the sentinel lymph node is cancer-free, research has shown that it is likely that the remaining lymph nodes will also be free of cancer and no further surgery is needed. If the sentinel lymph node shows that there is cancer, then the surgeon may perform an axillary lymph node dissection to remove more lymph nodes to look for cancer, depending on the stage of the cancer, the features of the tumor, and the amount of cancer in the sentinel lymph nodes. It is recommended that patients with signs of cancer in the axillary lymph nodes receive an axillary lymph node dissection, regardless of whether a sentinel lymph node biopsy is done. Find out more about ASCO's recommendations for sentinel lymph node biopsy.

Axillary lymph node dissection. In an axillary lymph node dissection, the surgeon removes many lymph nodes from under the arm, which are then examined by a pathologist for cancer cells. The actual number of lymph nodes removed varies from person to person. Recent research has shown that an axillary lymph node dissection may not be needed for all women with early-stage breast cancer with small amounts of cancer in the sentinel lymph nodes. Women having a lumpectomy and radiation therapy who have a smaller tumor and no more than two sentinel lymph nodes involved with cancer may avoid a full axillary lymph node dissection, which helps reduce the risk of side effects and does not decrease survival. If cancer is found in the sentinel lymph node, whether more surgery is needed to remove additional lymph nodes depends on each person’s situation.

Most patients with invasive cancer will have either a sentinel lymph node biopsy or an axillary lymph node dissection. A sentinel lymph node biopsy alone should not be done if there is obvious evidence of cancer in the lymph nodes before any surgery. In this situation, a full axillary lymph node dissection is preferred.

Reconstructive or plastic surgery

Women who receive a mastectomy may wish to consider breast reconstruction, which is surgery to rebuild the breast. Reconstruction may be done with tissue from another part of the body, or with synthetic or artificial implants. In inflammatory breast cancer, the reconstruction is usually not done at the same time as mastectomy, called immediate reconstruction, due to the need for radiation therapy. However, many women may consider future or delayed reconstruction. Talk with your doctor for more information.

Learn more about cancer surgery.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy.

A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. Standard radiation therapy after a mastectomy is given to the chest wall for five days (Monday through Friday) for five to six weeks. Standard radiation therapy after a lumpectomy is external-beam radiation therapy given daily for five days per week (Monday through Friday) for six to seven weeks. This usually includes radiation therapy to the whole breast first for four-and-a-half to five weeks, followed by a more focused treatment to the area where the tumor was located in the breast for the remaining treatments. This focused part of the treatment, called a boost, is standard for women with invasive breast cancer to reduce the risk of a recurrence in the breast. If there is evidence of cancer in the underarm lymph nodes, radiation therapy may also be given to the lymph node areas in the neck or underarm near the breast or chest wall. There has been growing interest in newer radiation regimens to shorten the length of treatment from six to seven weeks to periods of three to four weeks. However, these regimens have not been studied in patients with inflammatory breast cancer. As always, patients should talk with their doctors about available options for radiation therapy, as well as the advantages, and disadvantages of these options.

Adjuvant radiation therapy is radiation treatment after surgery. It is effective in reducing the chance of breast cancer returning in both the breast and the chest wall. Adjuvant radiation therapy is nearly always recommended for patients with inflammatory breast cancer after mastectomy, because of the high risk of cancer cells being left behind on the chest wall. Neoadjuvant radiation therapy is radiation therapy given before surgery to shrink a large tumor, which makes it easier to remove, although this approach is rare.

Radiation therapy can cause side effects, including fatigue, swelling of the breast, and skin changes. Other side effects may include upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished. A small amount of the lung can be affected by the radiation, although the risk of pneumonitis, or a radiation-related inflammation of the lung tissue, is low. In the past, with older equipment and techniques of radiation therapy, women treated for left-sided breast cancers had a small increase in the long-term risk of heart disease. Modern techniques are now able to spare most of the heart from radiation damage. Talk with your doctor about the possible side effects of your radiation therapy plan and how they will be managed.

Learn more about radiation therapy.

Targeted therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.

Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. As a result, doctors can better match each patient with the most effective treatment whenever possible. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them. Learn more about targeted treatments.

HER2 is a specialized protein found on breast cancer cells that controls cancer growth and spread. As explained in Diagnosis, if an inflammatory breast cancer tests positive for HER2, targeted therapy may be an option for treatment. HER2-positive inflammatory breast cancer may be treated with the drugs trastuzumab, pertuzumab, lapatinib, and/or ado-trastuzumab emtansine. HER2-targeted therapy is usually given in combination with chemotherapy, and then after the completion of chemotherapy. Patients receiving HER2-targeted therapies have a small risk of heart problems, and this risk is increased if a patient has other risk factors for heart disease. These heart problems do not always go away, but they are usually treatable with medication. Talk with your doctor about possible side effects for a specific medication and how they can be managed. Other targeted treatments are being tested in clinical trials; see the Latest Research section for more information.

Hormone therapy

Hormone therapy helps manage a tumor that tests positive for either estrogen (ER) or progesterone receptors (PR; See Diagnosis) in all stages of breast cancer. A small percentage of inflammatory breast cancers have these receptors and might benefit from the use of hormone therapy following chemotherapy and radiation, or as treatment for metastatic disease. Find additional information about hormone therapy in the breast cancer treatment section.

Getting care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, and radiation therapy. Talk with your doctor about the goals of each treatment in the treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it is addressed as quickly as possible. Learn more about palliative care.

Metastatic inflammatory breast cancer

If cancer has spread to another location in the body, it is called metastatic cancer. Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. Learn more about seeking a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials.

Your health care team may recommend a treatment plan that includes a combination of the treatments discussed above. Supportive care will also be important to help relieve symptoms and side effects.

For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED.

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence, including whether the cancer’s stage has changed. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above such as surgery, chemotherapy, and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence.

If treatment fails

Recovery from inflammatory breast cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.

This diagnosis is stressful, and it may be difficult to discuss. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Patients who have advanced cancer and who are expected to live less than six months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

The next section helps explain clinical trials, which are research studies. Use the menu on the side of your screen to select About Clinical Trials, or you can select another section, to continue reading this guide.