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Breast Cancer - Overview

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Breast Cancer. To see other pages, use the menu on the side of your screen. Think of that menu as a roadmap to this full guide.

In the United States, breast cancer is the most common cancer in women (excluding skin cancer). Men can also develop breast cancer, but breast cancer in men is rare, accounting for less than 1% of all breast cancers.

About the breast

The breast is mostly made up of fatty tissue. Within this tissue is a network of lobes, which are made up of tiny, tube-like structures called lobules that contain milk glands. Tiny ducts connect the glands, lobules, and lobes, carrying the milk from the lobes to the nipple, located in the middle of the areola, which is the darker area that surrounds the nipple. Blood and lymph vessels also run throughout the breast; blood nourishes the cells, and the lymph system drains bodily waste products. The lymph vessels connect to lymph nodes, the tiny, bean-shaped organs that help fight infection.

About breast cancer

Cancer begins when normal cells in the breast change and grow uncontrollably, forming a mass or sheet of cells called a tumor. A tumor can be cancerous or benign. A cancerous tumor is malignant, meaning it can spread to other parts of the body. A benign tumor means the tumor will not spread.

Breast cancer spreads when the cancer grows into other parts of the body or when breast cancer cells move to other parts of the body through the blood vessels and/or lymph vessels. This is called metastasis. Breast cancer most commonly spreads to the regional lymph nodes. The regional lymph nodes are located under the arm, in the neck, under the chest bone, or just above the collarbone. When the cancer spreads further through the body, it most commonly spreads to the bones, lungs, and liver. Less often, breast cancer may spread to the brain. The cancer can come back after treatment, or recur, locally in the breast, skin, other tissues of the chest, or elsewhere in the body.

Types of breast cancer

Most breast cancers start in the ducts or lobes. Almost 75% of all breast cancers begin in the cells lining the milk ducts and are called ductal carcinomas. Cancer that begins in the lobules is called lobular carcinoma. The diagnosis of ductal or lobular cancer is determined by a pathologist who examines the tumor sample removed during a biopsy (see Diagnosis). A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease.

If the disease has spread outside of the duct or lobule and into the surrounding tissue, it is called invasive or infiltrating ductal or lobular carcinoma. Cancer that is located only in the duct or lobule is called in situ, meaning “in place.” How in situ disease grows and spreads, as well as how it is treated, depends on whether it is ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS).

Most in situ breast cancers are DCIS. Currently, oncologists recommend surgery to remove DCIS to help prevent the development of invasive breast cancer that can then spread to other parts of the breast or the body. Radiation therapy and hormonal therapy may also be recommended for DCIS (see Treatment Options for more information).

LCIS is not considered cancer and is usually monitored with regular examinations and imaging tests. LCIS in one breast is a risk factor for developing invasive breast cancer in both breasts (see the Risk Factors section for more information). To reduce this risk, LCIS is sometimes treated with hormonal therapy (see Treatment Options).

Other, less common types of breast cancer include medullary, mucinous, tubular, metaplastic, and papillary breast cancer, as well as other even less common types. Inflammatory breast cancer is a faster-growing type of cancer that accounts for about 1% to 5% of all breast cancers. It may be misdiagnosed as a breast infection at first because there is often swelling of the breast and redness of the breast skin that begins suddenly, and there is no breast mass or nodule. Paget’s disease is a type of cancer that begins in the ducts of the nipple. The skin often appears scaly and may be itchy. Although it is usually in situ, it can also be an invasive cancer.

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If you would like additional introductory information, explore these related items. Please note these links take you to other sections on Cancer.Net:

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Breast Cancer - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will find information about how many people develop this type of cancer each year and some general survival information. Remember, survival rates depend on many factors. To see other pages, use the menu on the side of your screen.

This year, an estimated 232,670 women in the United States will be diagnosed with invasive breast cancer, and 62,570 women will be diagnosed with in situ breast cancer. An estimated 2,360 men in the United States will be diagnosed with breast cancer. It is estimated that 40,430 people (40,000 women, 430 men) will die from breast cancer this year.

The five-year survival rate is the percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases. If the cancer is located only in the breast, the five-year relative survival rate of people with breast cancer is 99%. If the cancer has spread to the regional lymph nodes, the five-year survival rate is 84%. If the cancer has spread to a distant part of the body, the five-year survival rate is 24%. About 5% of women have metastatic cancer when they are first diagnosed with breast cancer. Even if the cancer is found at a more advanced stage, new treatments help many people with breast cancer maintain a good quality of life, at least for some period of time.

It is important to note that these statistics are averages, and each person’s risk depends on many factors, including the size of the tumor, the number of lymph nodes that contain cancer, and other features of the tumor that affect how quickly a tumor will grow and how well treatment works.

Breast cancer is the second most common cause of death from cancer in women in the United States, after lung cancer. However, since 1989, the number of women who have died of breast cancer has steadily decreased. In women younger than 50, there has been a decrease of around 3% per year from 2006 to 2010. In women age 50 and older, the decrease has been 1.8% per year. Currently, there are more than 2.8 million women living in the United States who have been diagnosed with and treated for breast cancer.

Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of people with this type of cancer in the United States, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with breast cancer. Because the survival statistics are measured in five-year intervals, they may not represent advances made in the treatment or diagnosis of this cancer. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2014, and the National Cancer Institute Surveillance Epidemiology and End Results (SEER) database.

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Breast Cancer - Medical Illustrations

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will find a basic drawing about the main body parts affected by this disease. To see other pages, use the menu on the side of your screen.

Breast Anatomy

Larger image

For medical illustrations showing the different stages of breast cancer, please visit the Stages section.

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Breast Cancer - Risk Factors

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will find out more about the factors that increase the chance of developing this type of cancer. To see other pages, use the menu on the side of your screen.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the risk of developing of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

A woman with an average risk of breast cancer has about a 12% chance of developing breast cancer within her lifetime. Generally, most breast cancers are sporadic, meaning they develop from damage to a person’s genes that occurs by chance after they are born, and there is no risk of passing this gene on to a person's children. Inherited breast cancers are less common, making up 5% to 10% of cancers, and occur when gene changes called mutations are passed down within a family from one generation to the next (see below).

When considering your breast cancer risk, it is important to remember that most women who develop breast cancer have no obvious risk factors and no family history of breast cancer. Multiple risk factors influence the development of breast cancer. This means that all women need to be aware of changes in their breasts and talk with their doctors about receiving regular breast examinations by a doctor and mammograms, which is an x-ray of the breast that can often detect a tumor that is too small to be felt.

The following factors may raise a woman’s risk of developing breast cancer:

Age. The risk of developing breast cancer increases as a woman ages, with most cancers developing in women older than 50.

Personal history of breast cancer. A woman who has had breast cancer in one breast has a 1% to 2% chance per year of developing a second breast cancer in her opposite breast, if she has no other risk factors. This risk may be reduced by treatment such as hormonal therapy for some women (see Treatment Options).

Family history of breast cancer. Breast cancer may run in the family if first-degree relatives, such as mothers, sisters, brothers, and children, or many close relatives (including grandparents, aunts and uncles, nieces and nephews, grandchildren, and cousins) have been diagnosed with breast cancer or ovarian cancer, especially before age 50. Breast cancer may also be likely to run in the family if the relative who developed breast cancer is a man, because this may be a sign that inherited genetic changes contributed to the risk of developing cancer (see below). Women with a first-degree relative who developed breast cancer have a risk that is about double an average woman's risk. If two first-degree relatives developed breast cancer, the risk is five times the average risk. It is uncertain how much a woman's risk of breast cancer is increased when a man in the family has breast cancer, unless this is due to an inherited mutation. If a man within your family has developed breast cancer or a woman has developed breast cancer at an early age or has as developed ovarian cancer, it is important to talk with your doctor, as this could be a sign that your family carries an inherited breast cancer gene, such as BRCA1 or BRCA2 (see below).

When looking at family history, it’s also important to consider your father’s side of the family as this is equally important as your mother’s side in determining your personal risk for developing breast cancer.

Inherited risk/Genetic predisposition. There are several inherited genes linked with an increased risk of breast cancer, as well as other types of cancer. The most common are breast cancer genes 1 or 2. These are commonly shortened to BRCA1 or BRCA2. Mutations on these genes are linked to an increased risk of breast and ovarian cancer, as well as other types of cancer. A man’s risk of breast cancer, as well as the risk for prostate cancer, is also increased if he has mutations on these genes. Learn more about hereditary breast and ovarian cancer.

Other gene mutations or hereditary conditions that can increase a person’s risk of breast cancer, including ataxia telangiectasia (A-T), Li-Fraumeni syndrome (LFS)Cowden syndrome (CS), Peutz-Jeghers syndrome (PJS), and Lynch syndrome. There are also other genes that may cause an increased risk of breast cancer. However, more research is needed to understand how they increase a person’s risk and to find other genes that affect breast cancer risk.

Genetic testing through blood tests is available to test for known mutations in BRCA 1 and BRCA 2 genes and other hereditary syndromes, but these tests are not recommended for everyone and are recommended only after a person has received appropriate genetic counseling. If a woman learns she has one of these genetic mutations, there are steps she can take to lower her risk of breast and ovarian cancers, and she may need a different breast cancer screening schedule than the general population, such as having tests more often or starting screening at a younger age.

Personal history of ovarian cancer. A history of ovarian cancer can increase a woman’s risk of breast cancer, if the ovarian cancer was because of an inherited mutation. Breast cancer gene mutations, such as BRCA1 or BRCA2, greatly increase the risk of both ovarian and breast cancers.

Estrogen and progesterone exposure. Estrogen and progesterone are hormones in women that control the development of secondary sex characteristics, such as breast development, and pregnancy. A woman’s production of estrogen and progesterone decreases with age, with a steep decrease around menopause. Long-term exposure to these hormones increases breast cancer risk.

  • Women who began menstruating before ages 11 or 12 or went through menopause after age 55 have a somewhat higher risk of breast cancer because their breast cells have been exposed to estrogen and progesterone for a longer time.
  • Women who had their first pregnancy after age 35 or who have never had a full-term pregnancy have a higher risk of breast cancer. Pregnancy may help protect against breast cancer because it pushes breast cells into their final phase of maturation.

Hormone replacement therapy after menopause. Using hormone therapy with both estrogen and progesterone after menopause, often called postmenopausal hormone therapy or replacement, within the past five years or for several years increases a woman’s risk of breast cancer. In fact, the number of new breast cancers diagnosed has dropped as fewer women have been taking postmenopausal hormone therapy. However, women who have taken estrogen alone, without previously receiving progesterone, for up to five years because they have had their uterus removed for other reasons appear to have a slightly lower risk of breast cancer.

Oral contraceptives or birth control pills. Some studies suggest that oral contraceptives slightly increase the risk of breast cancer, while others have shown no link between the use of oral contraceptives to prevent pregnancy and development of breast cancer. Research on this topic is ongoing.

Race and ethnicity. Breast cancer is the most common cancer diagnosis in women, other than skin cancer, regardless of race. White women are more likely to develop breast cancer than black women, but among women younger than 44, the disease is more common in black women than in young white women. Black women are also more likely to die from the disease. Reasons for survival differences include differences in biology, other health conditions, and socioeconomic factors affecting access to medical care. Women of Ashkenazi Jewish heritage also have an increased risk of breast cancer because they are more likely to have BRCA gene mutations. Breast cancer is least commonly diagnosed in Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women. Both black and Hispanic women are more likely to be diagnosed with larger tumors and later-stage cancer than white women. However, Hispanic women generally have better survival rates than white women. Breast cancer diagnoses have been increasing in second generation Asian/Pacific islander and Hispanic women for unclear reasons, but likely related to changes in diet and lifestyle associated with living in the United States.

Atypical hyperplasia of the breast. This diagnosis increases the risk of developing breast cancer in the future and is characterized by abnormal, but not cancerous, cells found in a biopsy of the breast.

LCIS. As explained in the Overview section, this diagnosis refers to abnormal cells found in the lobules or glands of the breast. LCIS in one breast increases the risk of developing invasive breast cancer in either breast in the future. Invasive cancer is cancer that spreads into surrounding tissues. If LCIS is found during a biopsy (see Diagnosis), it may be removed to check for other changes, and additional treatment may be recommended. Talk with your doctor about the best way to monitor this condition.

Lifestyle factors. As with other types of cancer, studies continue to show that various lifestyle factors may contribute to the development of breast cancer.

  • Weight. Recent studies have shown that postmenopausal women who are overweight or obese have an increased risk of breast cancer, and they have a higher risk of having the cancer come back after treatment.
  • Physical activity. Increased physical activity is associated with a decreased risk of developing breast cancer and a lower risk of having the cancer come back after treatment. Regular physical activity may protect against breast cancer by helping women maintain a healthy body weight, lowering hormone levels, or causing changes in a women’s metabolism or immune factors.
  • Alcohol. Current research suggests that having more than one to two alcoholic drinks, including beer, wine, and spirits, per day raises the risk of breast cancer, as well as the risk of having the cancer come back after treatment.
  • Food. There is no reliable research that confirms that eating or avoiding specific foods reduces the risk of developing breast cancer or having the cancer come back after treatment. However, eating more fruits and vegetables and fewer animal fats is linked with many health benefits.

Socioeconomic factors. More affluent women in all race and ethnic groups have a higher risk of developing breast cancer than less-affluent women in the same groups. Although the reasons for this difference are not known, it is thought to be due to variations in diet, environmental exposures, and other risk factors such as breast density. In contrast, women living in poverty are more likely to be diagnosed at an advanced stage and are less likely to survive their disease than more affluent women. This is likely due multiple factors, including lifestyle factors, other health conditions such as obesity, and tumor biology, with access to healthcare playing an additional role.

Radiation. High doses of ionizing radiation, such as from tanning booths and x-rays, may increase a woman’s risk of breast cancer. Radiation to the chest given at a young age, such as that given for treatment for a childhood cancer, also increases the risk of breast cancer. However, the very small amount of radiation a woman receives during a yearly mammogram has not been linked to an increased risk of breast cancer.

Breast density. Dense breast tissue may make it more difficult to find tumors on standard imaging tests, such as a mammography (see Diagnosis). Breast density may be a result of higher levels of estrogen, rather than a separate risk factor, and usually decreases with age. Some states are beginning to require that results from mammograms include information about breast density, if the results show a woman has dense breast tissue. Researchers are looking at whether lowering breast density might also decrease the risk of breast cancer.

Understanding your risk of breast cancer

Several breast cancer risk assessment tools have been developed to help a woman estimate her chance of developing breast cancer. The best studied is the Gail model (found on the National Cancer Institute’s website at www.cancer.gov/bcrisktool). After you enter some personal and family information, including race/ethnicity, the tool provides you with a five-year and lifetime estimate of the risk of developing invasive breast cancer. Because it only asks for information about breast cancer in first-degree family members and doesn’t include their age at diagnosis, the tool works best at estimating risk in women without a strong inherited breast cancer risk. For some women, other ways of determining the risk of breast cancer may work better. It’s important to talk with your doctor about how to find out your personal risk of breast cancer.

Lowering your risk of breast cancer

Researchers continue to look into what factors cause breast cancer and what people can do to lower their personal risk. There is no proven way to completely prevent this disease, but there may be steps you can take to lower your risk. Talk with your doctor if you have concerns about your personal risk of developing breast cancer.

Mastectomy. For women with BRCA1 or BRCA2 mutations, the preventive removal of the breasts through a procedure called a prophylactic mastectomy may be considered. This appears to reduce the risk of developing breast cancer by at least 95%. Women with these mutations may also consider the preventive removal of the ovaries and fallopian tubes, called a prophylactic salpingo-oophorectomy. This procedure can reduce the risk of developing ovarian cancer, as well as breast cancer by stopping the ovaries from making estrogen. Talk with your doctor about potential side effects when considering having these procedures.

Chemoprevention. Women who have a higher than normal risk of developing breast cancer may consider chemoprevention. Chemoprevention is the use of drugs to reduce cancer risk. Two drugs, tamoxifen (Nolvadex, Soltamox) and raloxifene (Evista), are approved to lower breast cancer risk. These drugs are called selective estrogen receptor modulators (SERMs). A SERM is a medication that blocks estrogen receptors in some tissues and not others. Postmenopausal women and premenopausal women may take tamoxifen, whereas raloxifene is only approved for postmenopausal women. Each drug also has different side effects. Talk with your doctor about whether you may benefit from chemoprevention for breast cancer. Aromatase inhibitors (AIs) are also being looked at to reduce breast cancer risk. AIs are a type of hormonal treatment that reduces the amount of estrogen in a woman's body by stopping tissues and organs other than the ovaries from producing estrogen. One AI called exemestane (Aromasin) has shown promise in reducing breast cancer risk. However, AIs can only be used in women who have gone through menopause, and exemestane is not yet approved by the U.S. Food and Drug Administration (FDA) for lowering breast cancer risk in women who do not have the disease. Read more about drugs to reduce breast cancer risk.

Other drugs being looked at to reduce breast cancer risk include statins and metformin (multiple brand names), a drug commonly used for diabetes.

Lifestyle choices. Other ways to lower your risk of breast cancer include getting regular physical activity, staying at a healthy weight, limiting the amount of alcohol you drink, and limiting the use of post-menopausal hormone therapy. Learn about more lifestyle choices that may help lower your risk of breast cancer.

Screening guidelines

Mammography is the best tool doctors have to screen healthy women for breast cancer, as it has been shown to lower deaths from breast cancer. Like any medical test, mammography involves risks, such as additional testing and anxiety if the test falsely shows a suspicious finding; this is called a false-positive. Up to 10% to 15% of the time, mammography will not see an existing cancer, called a false-negative result. Digital mammography may be better able to find cancers, particularly in women with dense breasts. A new type of mammogram, called tomosynthesis or 3D mammography, when combined with standard mammograms may improve the ability to find small cancers and reduce the need to repeat tests due to false positives.

Different organizations have looked at the evidence, risks, and benefits of mammography and have developed different screening recommendations:

  • The U.S. Preventive Services Task Force (USPSTF) recommends that women ages 50 to 74 have mammography every two years. They recommend that mammography be considered in women ages 40 to 49 after evaluating the risks and benefits of this test with a doctor.
  • The American Cancer Society (ACS) recommends yearly mammography beginning at age 40.

The controversy about screening mammography is related to the ability of early detection to lower the number of deaths from breast cancer. Breast cancers detected by mammography are often small, with a low risk of recurrence. In contrast, rapidly growing, aggressive cancers are more commonly found in between screening mammograms, are associated with worse chance of recovery, and are more frequently found in young women.

All women should talk with their doctors about mammography and decide on an appropriate screening schedule. For women at high risk for developing breast cancer, screening is recommended at an earlier age and more often than the schedules listed above.

The USPSTF and ACS also differ on their recommendations for clinical breast examinations. The USPSTF recommends a clinical breast examination along with mammography. The ACS recommends a clinical breast examination every one to three years until age 40, then annually.

Finally, although breast self-examination has not been shown to lower deaths from breast cancer, it is important for women to become familiar with their breasts so that they can be aware of any changes and report these to their doctor. Cancers that are growing more quickly are often found by breast examination between regular mammograms.

Other ways to examine the breasts, such as ultrasound and magnetic resonance imaging (MRI), are not regularly used to screen for breast cancer. These tests may be helpful for women with a higher risk of breast cancer or when a lump or mass is found during a breast examination. According to the ACS, women with BRCA gene mutations, a strong family history of breast cancer, or precancerous changes on a biopsy have a higher risk of developing breast cancer and should receive regular MRI screening and mammography, usually in an alternating schedule. MRI may be better than mammography and ultrasound at finding a small mass in a woman’s breast, especially for women with very dense breast tissue. However, an MRI has a higher rate of false-positive test results, which may mean more biopsies, surgeries, and other tests. In addition, an MRI does not show tiny spots of calcium called calcifications that can be found on an x-ray. Calcifications are a sign of in situ breast cancer (DCIS).

Ultrasound or MRI may also be used for women with a suspicious breast finding on physical examination or mammography. If a lump or mass is found during a physical examination, further testing is needed, even if the mammogram is reported to be normal. Women are encouraged to talk with their doctor about the method of screening recommended for them and how often screening is needed.

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Breast Cancer - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. To see other pages, use the menu on the side of your screen.

Women with breast cancer may experience breast changes or symptoms, but many women do not show any of these signs or symptoms when diagnosed. Many times, breast signs or symptoms can be caused by a medical condition that is not cancer.

The signs and symptoms that should be discussed with a doctor include:

  • Lumps that feel like a hard knot or a thickening in the breast or under the arm.
  • Change in the size or shape of the breast
  • Nipple discharge that occurs suddenly, is bloody, or occurs in only one breast.
  • Physical changes, such as a nipple turned inward or a persistent sore in the nipple area
  • Skin irritation or changes, such as puckering, dimpling, scaliness, or new creases
  • Warm, red, swollen breasts with or without a rash resembling the skin of an orange, called peau d'orange
  • Pain in the breast, particularly breast pain that doesn’t go away. Pain is not usually a symptom of breast cancer, but it should be reported to a doctor.

If you are concerned about one or more symptoms or signs on this list, please talk with your doctor. You doctor will ask how long and how often you’ve been experiencing the symptom(s), in addition to other questions. This is to help find out the cause of the problem, called a diagnosis.

If cancer is diagnosed, relieving symptoms is an important part of cancer care and treatment. This may also be called symptom management, supportive care, or palliative care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

The next section helps explain what tests and scans may be needed to learn more about the cause of the symptoms. Use the menu on the side of your screen to select Diagnosis, or you can select another section, to continue reading this guide.

Breast Cancer - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will find a list of the common tests, procedures, and scans that doctors can use to find out what’s wrong and identify the cause of the problem. To see other pages, use the menu on the side of your screen.

Doctors use many tests to diagnose cancer and find out if the cancer has spread or metastasized to other parts of the body beyond the breast and the lymph nodes under the arm. Some tests may also help the doctor decide which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. A biopsy is the removal of a small amount of tissue for examination under a microscope. See below for more information about the types of biopsies that can be performed. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has spread. This list describes options for diagnosing this type of cancer, and not all tests listed will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

  • Age and medical condition
  • Type of cancer suspected
  • Signs and symptoms
  • Previous test results

The series of tests needed to evaluate a possible breast cancer usually begins when a woman or her doctor discover a mass or abnormal calcifications on a screening mammogram, or a lump or nodule in the woman’s breast during a clinical or self-examination. Less commonly, a woman might notice a red or swollen breast or a mass or nodule under the arm.

The following tests may be used to diagnose breast cancer or for follow-up testing after the cancer has been diagnosed. Not every person will need all of these tests.

Imaging tests

Diagnostic mammography. Diagnostic mammography is similar to screening mammography except that more pictures of the breast are taken, and it is often used when a woman is experiencing signs, such as nipple discharge or a new lump. Diagnostic mammography may also be used if something suspicious is found on a screening mammogram.

Ultrasound. An ultrasound uses high-frequency sound waves to create an image of the breast tissue. An ultrasound can distinguish between a solid mass, which may be cancer, and a fluid-filled cyst, which is usually not cancer. Ultrasounds are not used for screening.

MRI. An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. An MRI can also be used to measure the tumor’s size. A special dye called a contrast medium is given into the patient’s vein before the scan to help create a clear picture of the possible cancer. A breast MRI may be used after a woman has been diagnosed with cancer to check the other breast for cancer or to find out how much the disease has grown throughout the breast. It may also be used for screening, particularly along with mammography for some women with a high risk of developing breast cancer.

Surgical tests

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed during the biopsy is analyzed by a pathologist. There are different types of biopsies, classified by the technique and/or size of needle used to collect the tissue sample.

  • A fine needle aspiration biopsy uses a thin needle to remove a small sample of cells.
  • A core needle biopsy uses a wider needle to remove a larger sample of tissue. This is usually the preferred biopsy technique for finding out whether an abnormality on a physical examination or an imaging test is cancer. A vacuum-assisted biopsy removes several large cores of tissue. Local anesthesia, medication to block pain, is used to lessen a patient’s discomfort during the procedure.
  • Image-guided biopsy is used when a distinct lump cannot be felt, but an abnormality is seen with an imaging test, such as a mammogram. During this procedure, a needle is guided to the location with the help of an imaging technique, such as mammography, ultrasound, or MRI. A stereotactic biopsy is done using mammography to help guide the needle. A small metal clip may be put into the breast to mark where the biopsy sample was taken, in case the tissue is cancerous and more surgery is needed. This clip is usually titanium so it will not cause problems with future imaging tests, but check with your doctor before you have additional imaging tests. An image-guided biopsy can be done using a fine needle, core, or vacuum-assisted biopsy (see above), depending on the amount of tissue being removed. Imaging tests may also be used to help do a biopsy on a lump that can be felt, in order to help find the best location.
  • A surgical biopsy removes the largest amount of tissue. This biopsy may be incisional, which is the removal of part of the lump, or excisional, which is the removal of the entire lump. Because surgery is best done after a cancer diagnosis has been made, a surgical biopsy is usually not the recommended way to diagnose breast cancer. Most often, non-surgical core needle biopsies are recommended to diagnose breast cancer. This means that only one surgical procedure is needed to remove the tumor and to take samples of the lymph nodes.

If cancer is diagnosed, surgery is needed to remove the cancer in the breast. It is also needed to evaluate the lymph nodes for cancer in a procedure called a sentinel lymph node biopsy. Sometimes, treatment may be given before surgery, called neoadjuvant therapy, to shrink the cancer; see Treatment Options. The goal of surgery is to achieve clear surgical margins, which means that there are no cancer cells at the edge of the tissue removed during surgery. If there is cancer in the lymph nodes, the cancer is called lymph node-positive breast cancer or node-positive; if there is no cancer in the lymph nodes, the cancer is called lymph node-negative breast cancer or node-negative. More information about lymph node evaluation can be found in Stages.

Tumor features. Examination of the tumor under the microscope is used to determine if it is invasive or in situ; ductal or lobular; how different the cancer cells look from healthy cells, called the grade; and whether the cancer has spread to the lymph nodes. The margins or edges of the tumor are also examined and their distance from the tumor is measured, which is called margin width.

Molecular testing of the tumor

The standard tests to further evaluate an invasive breast cancer include estrogen receptor (ER), progesterone receptor (PR), HER2, and Ki67 tests. ER is often measured for DCIS as well. These tests are used to determine the appropriate treatment plan to lower the chance that the cancer will return. Your doctor may recommend additional laboratory tests on your tumor sample to identify specific genes, proteins, and other factors unique to the tumor.

ER and PR. Breast cancer cells with these receptors depend on the hormones estrogen and/or progesterone to grow. The presence of these receptors helps determine both the patient’s risk of recurrence and the type of treatment that is most likely to lower the risk of recurrence. Generally, hormonal therapy (see Treatment Options) works well for ER-positive and/or PR-positive cancers, also called hormone receptor-positive cancers. About 75% to 80% of breast cancers have estrogen and/or progesterone receptors. Learn about ER and PR testing recommendations from ASCO and the College of American Pathologists (CAP).

HER2. About 20% to 25% of breast cancers have an increase in the number of copies of a gene called the human epidermal growth factor receptor 2 (HER2). This is called HER2-positive cancer. The gene makes a protein that is found on the cancer cell and is important for tumor cell growth; these types of cancers usually grow more quickly. The HER2 status helps determine whether a certain type of drug, such as trastuzumab (Herceptin), lapatinib (Tykerb), pertuzumab (Perjeta), or ado-trastuzumab emtansine (Kadcyla, also known as T-DM1), might help treat the cancer. In addition, about 50% of HER2-positive tumors also have hormone receptors and can benefit from both types of therapy. Several tests are available to test for HER2. Read ASCO’s and CAP's recommendations for HER2 testing for breast cancer.

If a person’s tumor does not have ER, PR, and/or HER2, the tumor is called triple-negative. Triple-negative breast cancers make up about 15% of invasive breast cancers and are the most common type diagnosed in women with BRCA1 mutations. This type of breast cancer usually grows and spreads more quickly than hormone receptor-positive disease. Triple-negative breast cancer seems to be more common among younger women, particularly younger black women.

Ki67. How quickly a cell divides into two cells, called tumor proliferation, can be measured in a tumor sample and is referred to as Ki67 or MIB1. How well chemotherapy works to treat a tumor has been linked with how quickly tumor cells grow and divide. Hormone receptor-positive cancers are most commonly slow growing with a low risk of recurrence if they are treated with hormonal therapy, but some are more rapidly growing with a higher risk of recurrence. In these cancers, chemotherapy may play an important role in reducing the risk of recurrence. In contrast, most HER2-positive and triple-negative cancers are fast growing and are treated with chemotherapy, with HER2 targeted therapy for a cancer that is also HER2-positive. In some situations, Ki67 may be used to help to plan treatment or to help estimate a patient’s chance of recovery, but it is not used in many hospitals because the results are highly variable. Ki67 results depend on the laboratory doing the testing, the method of testing, and what part of the tumor is tested. Standardization of the testing methods and training appear to improve the results, so there is increasing interest in measuring tumor proliferation more routinely. In addition, molecular testing may be a more accurate measure of proliferation (see below).

Genetic testing of the tumor. Tests that look at the biology of the tumor are commonly used to understand more about a woman’s breast cancer, particularly for cancers that have not spread to other organs. The tests below look at the genes in the tumor cells, not the genes a person inherits, to help predict the risk of cancer recurrence and to help choose the type of treatment, such as hormonal therapy or hormonal therapy plus chemotherapy. They can also help determine if radiation therapy would be helpful. Tests are used to look at several genetic measures, such as ER, PR, HER2, and tumor proliferation. These tests are usually performed after surgery, on a sample of the tumor that was removed (see Treatment Options). A person with a higher risk of recurrence will likely need chemotherapy, while a person with a lower risk of recurrence can possibly avoid chemotherapy and its potential side effects. For more information about genetic tests, what they mean, and how the results might affect your treatment plan, talk with your doctor.

  • Oncotype Dx™ is a test that evaluates 16 cancer-related genes and five reference genes to estimate the risk of the cancer coming back in a place other than the breast and nearby lymph nodes, within 10 years after diagnosis for women with stage I or stage II (see Stages), node-negative, ER-positive breast cancer treated with hormonal therapy alone. Results are mainly used to help make decisions about whether chemotherapy should be added to a person’s treatment with hormonal therapy. Recent research suggests that this test may be useful to decide about use of chemotherapy in addition to hormonal therapy in node-positive disease in some situations.
  • Mammaprint™ is a similar test that uses information about 70 genes to predict the risk of the cancer coming back for early-stage, low-risk breast cancer. It is approved by the FDA for estimating the risk of recurrence in early-stage breast cancer, but it is not yet known if this test can predict whether chemotherapy will work.
  • Additional tests are widely available with unknown impact on treatment choice and are being studied. Talk with your doctor about any test you are considering.

Blood tests

The doctor may also need to do several types of blood tests to learn more about the cancer:

Complete blood count. A complete blood count (CBC) is used to measure the number of different types of cells, such as red blood cells and white blood cells, in a sample of a person’s blood. It is done to make sure that your bone marrow is functioning normally.

Serum chemistry. These tests are often done to look at minerals in your blood, such as potassium and calcium, called electrolytes and specialized proteins called enzymes that can be abnormal if cancer has spread. However, many noncancerous conditions can cause changes in these tests, and they are not specific to cancer.

  • Alkaline phosphatase is an enzyme that can be associated with disease that has spread to the liver, bone, or bile ducts.
  • Blood calcium levels can be high if cancer has spread to the bone.
  • Total bilirubin count and the enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) evaluate liver function. High levels of any of these substances can indicate liver damage, a sign that the cancer may have spread to that organ.

Hepatitis tests. These may be used to check for evidence of prior exposure to hepatitis B and/or hepatitis C. If you have evidence of an active hepatitis B infection, you may need to take a special medication to suppress the virus before you receive chemotherapy. Without this medication, the chemotherapy can help the virus to grow and cause damage to the liver.

Blood tumor marker tests. Serum tumor markers are proteins found in a person's blood that can be associated with cancer. High levels of a serum tumor marker may be due to cancer or a noncancerous condition. Tumor marker testing is not recommended for early-stage breast cancer because the markers are not usually high, but they may be useful to monitor the growth of recurrent or metastatic disease along with symptoms and imaging tests. Tumor markers should not be used to monitor for a recurrence, as it does not appear to improve a patient’s chance of recovery. Learn more about tumor markers for breast cancer.

Additional tests

The tests your doctor recommends to evaluate whether the cancer has spread and its stage depends on your medical history, symptoms, how much the disease has grown in the breast and lymph nodes, and the results of your physical examination. Read Stages for more information. Many of these tests may not be done until after surgery. These tests are generally only recommended for patients with later-stage disease.

  • An x-ray is a way to create a picture of the structures inside of the body, using a small amount of radiation. A chest x-ray may be used to look for cancer that has spread from the breast to the lungs.
  • A bone scan may be used to look for spread of cancer to the bones. A radioactive dye or tracer is injected into a patient’s vein, and then the scan is performed several hours later using a special camera. The tracer collects in areas of the bone that are healing, which occurs in response to damage from the cancer cells. The areas where the tracer collects appear dark, compared to healthy bone, which appears gray. Some cancers do not cause the same healing response and will not show up on the bone scan. Areas of advanced arthritis or healing after a fracture will also appear dark.
  • A computed tomography (CT or CAT) scan may be used to look for tumors in organs outside of the breast, such as the lung, liver, bone, and lymph nodes. A CT scan creates a three-dimensional picture of the inside of the body with a special x-ray machine. A computer combines these images into a detailed, cross-sectional view that shows abnormalities including most tumors. A CT scan can also be used to measure the tumor’s size and if it is shrinking with treatment. A contrast dye may be injected into a patient’s vein before the scan to provide better detail.
  • A positron emission tomography (PET) scan may also be used to find out whether the cancer has spread to organs outside of the breast. Similar to a CT scan, a PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into a patient’s vein. This sugar substance is then taken up by cells that use the most energy because they are actively dividing. Because cancer cells tend to use energy actively, they absorb more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. Areas that are most active appear as bright spots, and the intensity of the brightness can be measured to better describe these areas. A combination PET/CT scan may also be used to measure the size of tumors and to more accurately determine the location of the bright spots. A PET/CT scan will also show any abnormalities in the bone, similar to the bone scan.

After diagnostic tests are completed, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging. If there are suspicious areas found outside of the breast, at least one area will be biopsied if possible to confirm the diagnosis of cancer.

The next section helps explain the different stages for this type of cancer. Use the menu on the side of your screen to select Stages, or you can select another section, to continue reading this guide.

Breast Cancer - Stages

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread. This is called the stage. To see other pages, use the menu on the side of your screen.

Staging is a way of describing where the cancer is located, how much the cancer has grown, and if or where it has spread. Doctors use diagnostic tests to find out the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

The most commonly used tool that doctors use to describe the stage is the TNM system. TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

  • How large is the primary tumor and where is it located? (Tumor, T)
  • Has the tumor spread to the lymph nodes, and if so, how many nodes are involved? (Node, N)
  • Has the cancer metastasized to other parts of the body? (Metastasis, M)

The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero), which is noninvasive ductal carcinoma in situ (DCIS), and stages I through IV (one through four), which are used for invasive breast cancer. The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

There are two types of TNM staging for breast cancer. First, the clinical stage is based on the results of tests done before surgery, such as a physical examination, x-rays, and CT and MRI scans. Then, the pathologic stage is assigned based on the pathology results from the breast tissue and any lymph nodes removed during surgery. It is usually determined several days after surgery. In general, more importance is placed on the pathologic stage than the clinical stage.

Here are more details on each part of the TNM system for breast cancer:

Tumor. Using the TNM system, the “T” plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are divided into smaller groups that help describe the tumor in even more detail.

TX: The primary tumor cannot be evaluated.

T0: There is no evidence of cancer in the breast.

Tis: Refers to carcinoma in situ. The cancer is confined within the ducts or lobules of the breast tissue and has not spread into the surrounding tissue of the breast. There are three types of breast carcinoma in situ:

Tis (DCIS): DCIS is a noninvasive cancer, but if not removed it can later develop into an invasive breast cancer. DCIS means that cancer cells have been found in breast ducts and have not spread past the layer of tissue where they began.

Tis (LCIS): Lobular carcinoma in situ (LCIS) describes abnormal cells found in the lobules or glands of the breast. LCIS is not cancer, but it increases the risk of developing invasive breast cancer.

Tis (Paget’s): Paget’s disease of the nipple is a rare form of early, noninvasive cancer that is only in the skin cells of the nipple. Sometimes Paget’s disease is associated with another invasive breast cancer. If there is also an invasive breast cancer present, it is classified according to the stage of the invasive tumor.

T1: The invasive part of the tumor in the breast is 20 millimeters (mm) or smaller in size at its widest area. This is a little less than an inch. This stage is then broken into three substages depending on the size of the tumor:

  • T1a is a tumor that is larger than 1 mm, but 5mm or smaller
  • T1b is a tumor that is larger than 5 mm, but 10 mm or smaller
  • T1c is a tumor that is larger than 10 mm, but 20 mm or smaller.

T2: The invasive part of the tumor is larger than 20 mm but not larger than 50 mm.

T3: The invasive part of the tumor is larger than 50 mm.

T4: The tumor falls into one of the following groups:

  • T4a means the tumor has grown into the chest wall.
  • T4b is when the tumor has grown into the skin.
  • T4c is cancer that has grown into the chest wall and the skin.
  • T4d is inflammatory breast cancer.

Node. The “N” in the TNM staging system stands for lymph nodes. Lymph nodes located under the arm, above and below the collarbone, and under the breastbone are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes. As explained above, if the doctor evaluates the lymph nodes before surgery, based on other tests and/or a physical examination, a letter “c” for “clinical” staging is placed in front of the “N.” If the doctor evaluates the lymph nodes after surgery, which is a more accurate assessment, a letter “p” for “pathologic” staging is placed in front of the “N.” The information below describes the pathologic staging.

NX: The lymph nodes cannot be evaluated.

N0: No cancer was found in the lymph nodes.

N0(i+): When very small areas of “isolated” tumor cells are found in a lymph node under the arm, called the axillary lymph nodes. This is usually less than 0.2 mm or less than 200 cells. In this stage, the nodes are still called N0, but an “i+” is also listed.

N1mic: Cancer in the axillary lymph nodes is larger than 0.2 mm but less than 2 mm in size and can only be seen through a microscopic.

N1: The cancer has spread to one to three axillary lymph nodes under the arm. This category can include positive internal mammary lymph nodes if they are found during a sentinel lymph node procedure and not otherwise clinically detected. The internal mammary lymph nodes are located under the sternum or breastbone.

N2: The cancer within the lymph nodes falls into one of the following groups:

  • N2a is when the cancer has spread to four to nine axillary, or underarm, lymph nodes.
  • N2b is when the cancer has spread to or to internal mammary lymph nodes without spread to the axillary nodes.

N3: The cancer falls within one of the following groups:

  • N3a is when the cancer has spread to 10 or more lymph nodes under the arm or to those located under the clavicle, or collarbone.
  • N3b is when the cancer has spread to the internal mammary nodes and the axillary nodes.
  • N3c is when the cancer has spread to the lymph nodes located above the clavicle, called the supraclavicular lymph nodes.

If there is cancer in the lymph nodes, knowing how many lymph nodes are involved, and where they are helps doctors to plan treatment. The pathologist can find out the number of axillary lymph nodes that contain cancer after they are removed during surgery. It is not common to remove the supraclavicular or internal mammary lymph nodes during surgery. If there is cancer in these lymph nodes, treatment other than surgery, such as radiation therapy, chemotherapy, and hormonal therapy, is used to control the disease.

Distant metastasis. The “M” in the TNM system indicates whether the cancer has spread to other parts of the body.

MX: Distant spread cannot be evaluated.

M0: The disease has not metastasized.

M0 (i+): There is no clinical or radiographic evidence of distant metastases, but microscopic evidence of tumor cells is found in the blood, bone marrow, or other lymph nodes that are no larger than 0.2 mm in a patient without other evidence of metastases.

M1: There is evidence of metastasis to another part of the body, meaning there are breast cancer cells growing in other organs.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications. Most patients are anxious to learn the exact stage of the cancer. However, it is important to keep in mind that tumor biology, including the diagnostic markers outlined above, has a significant impact on the type of treatment that is recommended, as well as on the prognosis. Your doctor will generally confirm the stage of the cancer when the testing after surgery is finalized, usually about five to seven days after surgery. When treatment is given before surgery, called neoadjuvant therapy, the stage of the cancer will be determined from other tests.

Stage 0: Stage zero (0) describes disease that is only in the ducts and lobules of the breast tissue and has not spread to the surrounding tissue of the breast. It is also called noninvasive cancer (Tis, N0, M0).

Stage 0 Breast Cancer

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Stage IA: The tumor is small, invasive, and has not spread to the lymph nodes (T1, N0, M0).

Stage IA Breast Cancer

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Stage IB: Cancer has spread only to the lymph nodes, and is larger than 0.2 mm but less than 2 mm in size. There is either no evidence of a tumor in the breast or the tumor in the breast is 20 mm or smaller (T0 or T1, N1mic, M0).

Stage IB Breast Cancer

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Stage IB Breast Cancer

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Stage IIA: Any one of these conditions:

  • There is no evidence of a tumor in the breast, but the cancer has spread to the axillary lymph nodes but not to distant parts of the body. (T0, N1, M0).
  • The tumor is 20 mm or smaller and has spread to the axillary lymph nodes (T1, N1, M0).
  • The tumor is larger than 20 mm but not larger than 50 mm and has not spread to the axillary lymph nodes (T2, N0, M0).

Stage IIA Breast Cancer

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Stage IIA Breast Cancer

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Stage IIA Breast Cancer

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Stage IIB: Either of these conditions:

  • The tumor is larger than 20 mm but not larger than 50 mm and has spread to one to three axillary lymph nodes (T2, N1, M0).
  • The tumor is larger than 50 mm but has not spread to the axillary lymph nodes (T3, N0, M0).

Stage IIB Breast Cancer

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Stage IIB Breast Cancer

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Stage IIIA: The cancer of any size has spread to four to nine axillary lymph nodes, but not to other parts of the body (T0, T1, T2 or T3, N2, M0). Stage IIIA may also be a tumor larger than 50 mm that has spread to one to three lymph nodes (T3, N1, M0). 

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Stage IIIA Breast Cancer

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Stage IIIA Breast Cancer

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Stage IIIA Breast Cancer

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Stage IIIA Breast Cancer

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Stage IIIA Breast Cancer

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Stage IIIB: The tumor has spread to the chest wall or caused swelling or ulceration of the breast or is diagnosed as inflammatory breast cancer. It may or may not have spread to the lymph nodes under the arm, but it has not spread to other parts of the body (T4; N0, N1 or N2; M0). 

Stage IIIB Breast Cancer

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Stage IIIB Breast Cancer

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Stage IIIB Breast Cancer

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Stage IIIC: A tumor of any size that has not spread to distant parts of the body but has spread to 10 or more axillary lymph nodes or the lymph nodes in the N3 group (any T, N3, M0). 

Stage IIIC Breast Cancer

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Stage IV (metastatic): The tumor can be any size and has spread to other organs, such as the bones, lungs, brain, liver, distant lymph nodes, or chest wall (any T, any N, M1). Metastatic cancer spread is found when the cancer is first diagnosed about 5% to 6% of the time. Most commonly, metastatic breast cancer is found after a previous diagnosis of early-stage breast cancer. 

Stage IV Breast Cancer

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Recurrent: Recurrent cancer is cancer that has come back after treatment, and can be either local or distant or both. If there is a local recurrence, the cancer may need to be staged again (called re-staging) using the system above.

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual Seventh Edition (2010) published by Springer-Verlag New York, www.cancerstaging.net.

Information about the cancer’s stage will help the doctor recommend a treatment plan.  The next section helps explain the treatment options for this type of cancer. Use the menu on the side of your screen to select Treatment Options, or you can select another section, to continue reading this guide. 

Breast Cancer - Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will learn about the different ways doctors use to treat people with 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. 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 approaches such 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, doctors specializing in different areas of cancer treatment work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team and includes surgeons, medical oncologists, radiation oncologists, plastic surgeons, and others as needed.

The biology and behavior of a breast cancer affects the treatment. Some tumors are small but grow fast, while others are large and grow slowly. Treatment options and recommendations depend on several factors, including:

  • The stage of the tumor
  • The tumor’s hormone receptor status (ER, PR) and HER2 status (see Diagnosis)
  • Other markers, such as Ki67, Oncotype DX™, Mammaprint™ (if appropriate)
  • The patient’s age, general health, and preferences
  • The patient’s menopausal status
  • The presence of known mutations in inherited breast cancer genes, such as BRCA1 or BRCA2

Even though your health care team will specifically tailor the treatment for each patient and the breast cancer, there are some general steps for treating breast cancer.

For both DCIS and early-stage invasive breast cancer, doctors generally recommend surgery to remove the tumor. To make sure that the entire tumor is removed, the surgeon will also remove a small area of normal tissue around the tumor. Although the goal of surgery is to remove all of the visible cancer, microscopic cells can be left behind, either in the breast or elsewhere. In some situations, this means that another surgery could be needed to remove remaining cancer cells. For larger cancers, or those that are growing more quickly, doctors may recommend treatment with chemotherapy before surgery, called neoadjuvant therapy. Neoadjuvant hormonal therapy may also be recommended in specific situations.

After surgery, the next step in managing early-stage breast cancer is to lower the risk of recurrence and to get rid of any remaining cancer cells. These cancer cells are invisible, but are believed to be responsible for both local and distant recurrence of cancer. Treatment given after surgery is called adjuvant therapy. Adjuvant therapies include radiation therapy, chemotherapy, targeted therapy, and/or hormonal therapy (see below for more information on these treatments). Whether adjuvant therapy is needed depends on the chance that any cancer cells remain in the breast or the body and the chance that a specific treatment will work to treat the cancer. Although adjuvant therapy lowers the risk of recurrence, it does not completely get rid of the risk.

Along with staging, other tools can help estimate prognosis and help you and your doctor make decisions about adjuvant therapy. The website Adjuvant! Online (found at another, independent website called www.adjuvantonline.com) is a tool that your doctor can access to interpret a variety of prognostic factors. This website should only be used with the interpretation of your doctor. In addition, other tests that can predict the risk of recurrence for your specific tumor by testing your tumor tissue (such as Oncotype Dx™ and Mammaprint™; see Diagnosis) may be also used to better understand whether chemotherapy may work.

When surgery to remove the cancer is not possible, it is called inoperable. Chemotherapy, targeted therapy, radiation therapy, and/or hormonal therapy may be given to shrink the cancer.

The treatment of recurrent cancer and metastatic cancer depends on how the cancer was first treated and the characteristics of the cancer mentioned above, such as ER, PR, and HER2.

Descriptions of the most common treatment options for breast cancer are listed below. Your care plan should 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, and after the treatment is completed. Learn more about making treatment decisions.

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. Surgery is also used to examine the nearby underarm or axillary lymph nodes. A surgical oncologist is a doctor who specializes in treating cancer with surgery. Generally, the smaller the tumor, the more surgical options a patient has. The types of surgery include the following:

  • A lumpectomy is the removal of the tumor and a small, cancer-free margin of normal tissue around the tumor. Most of the breast remains. For both DCIS and invasive cancer, radiation therapy to the remaining breast tissue is generally recommended after surgery. A lumpectomy may also be called breast-conserving surgery, a partial mastectomy, quadrantectomy, or a segmental mastectomy.
  • A mastectomy is the surgical removal of the entire breast. There are several types of mastectomies. Talk with your doctor about whether the skin can be preserved, called a skin-sparing mastectomy, or the skin and the nipple, called a total skin-sparing mastectomy.

Lymph node removal and analysis

Cancer cells can be found in the axillary lymph nodes in some cancers; this information is used to determine treatment and prognosis. It is important to find out whether any of the lymph nodes near the breast contain cancer.

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) procedure for patients whose sentinel lymph nodes are free of cancer. The smaller lymph node procedure helps patients lower 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 varies depending on the specific 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 may 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. Normally, the lymph nodes are not evaluated when the cancer is DCIS, since the risk of spread is very low. However, the surgeon may consider a sentinel lymph node biopsy for patients diagnosed with DCIS who choose to have or need a mastectomy. If some invasive cancer is found with DCIS at the time of the mastectomy, which happens occasionally, the lymph nodes will then need to be evaluated. Once the breast tissue has been removed with a mastectomy, it is more difficult to find the sentinel lymph nodes since it is not as obvious where to inject the dye.

Reconstructive (plastic) surgery

Women who have a mastectomy may want to consider breast reconstruction, which is surgery to create a breast using either tissue taken from another part of the body or synthetic implants. Reconstruction is usually performed by a plastic surgeon. A woman may be able to have reconstruction at the same time as the mastectomy, called immediate reconstruction, or at some point in the future, called delayed reconstruction. In addition, reconstruction may be done at the same time as a lumpectomy to improve the look of the breast and to match the breasts, this is called oncoplastic surgery, and many breast surgeons can do this without the help of a plastic surgeon. Surgery on the healthy breast is also often done so both breasts have a similar appearance. Talk with your doctor for more information.

External breast forms (prostheses)

An external breast prosthesis or artificial breast form provides an option for women who plan to delay or not have reconstructive surgery. Breast prostheses can be made to provide a good fit and natural appearance for each woman. 

Summary of surgical options

To summarize, surgical treatment options include the following:

  • Removal of cancer in the breast: Lumpectomy or partial mastectomy almost always followed by radiation therapy or mastectomy, with or without immediate reconstruction
  • Lymph node evaluation: Sentinel lymph node biopsy and/or axillary lymph node dissection

Women are encouraged to talk with their doctors about which surgical option is right for them. More aggressive surgery, such as a mastectomy, is not always better and may cause more complications. The combination of lumpectomy and radiation therapy has a slightly higher risk of the cancer coming back in the same breast or near the breast and new cancers in the breast, but the long-term survival of women who choose lumpectomy is the same as those who have a mastectomy. Learn more about cancer surgery.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill 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 a probe in the operating room, it is called intra-operative radiation. When radiation is given by placing radioactive sources into the tumor, it is called brachytherapy. Although the research results are encouraging, intra-operative radiation and brachytherapy are not widely used, and treatment is reserved for a small cancer with no evidence that it has spread to the lymph nodes.

A radiation therapy regimen (schedule; see below) usually consists of a specific number of treatments given over a set period of time. Most commonly, radiation therapy is given after a lumpectomy, and following adjuvant chemotherapy if recommended. Radiation therapy is usually given daily for a set number of weeks to get rid of any remaining cancer cells near the tumor site or elsewhere in the breast. This helps lower the risk of recurrence in the breast. In fact, with modern surgery and radiation therapy, recurrence rates in the breast are now be less than 5% in the 10 years after treatment, and survival is often the same with lumpectomy or mastectomy.

Adjuvant radiation therapy is also recommended for some women after a mastectomy, depending on the age of the patient, the size of their tumor, the number of lymph nodes under the arm that contain cancer, the width of normal tissue around the tumor removed by the surgeon, the ER, PR, and HER2 status, and other factors.

Neoadjuvant radiation therapy is radiation therapy given before surgery to shrink a large tumor, which makes it easier to remove, although this approach is not common and is only used when a tumor cannot be removed by surgery.

Radiation therapy causes side effects, including fatigue, swelling of the breast, redness and/or skin discoloration/hyperpigmentation and pain/burning in the skin where the radiation was directed, sometimes with blistering or peeling. Very rarely, a small amount of the lung can be affected by the radiation, causing pneumonitis, a radiation-related swelling of the lung tissue. This risk depends on the size of the area that received radiation therapy. In the past, with older equipment and radiation therapy techniques, women who received treatment for breast cancer on the left side of the body had a small increase in the long-term risk of heart disease. Modern techniques are now able to spare most of the heart from the effects of radiation.

Many types of radiation therapy may be available to you with different schedules (see below). Talk with your doctor about the advantages and disadvantages of each option.

Radiation therapy schedule

Standard radiation therapy after a lumpectomy is external-beam radiation therapy given Monday through Friday for five to six weeks. This often includes radiation therapy to the whole breast the first four to five weeks, followed by a more focused treatment to 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. Women with DCIS may also receive the boost. For women with a low risk of recurrence, the boost may be optional. It is important to discuss this treatment approach with your doctor.

If there is cancer in the lymph nodes under the arm, radiation therapy may also be given to the same side of the neck or underarm near the breast or chest wall. Patients who have a mastectomy may not need radiation therapy, depending on the features of the tumor. Radiation may be recommended after mastectomy for patients with tumors larger than 5 cm, for those with cancer in many lymph nodes, for those with cancer cells outside of the capsule of the lymph node, and for those whose cancer has grown into the skin or chest wall, as well as other reasons. Radiation therapy following a mastectomy can be given after reconstruction, and is usually given five days a week for five to six weeks.

There has been growing interest in the use of newer regimens that shorten the length of radiation treatment from six to seven weeks to three to four weeks. In one method called hypo-fractionated radiation therapy, a higher daily dose is given to the whole breast so that the overall length of treatment is shortened to three to four weeks. This approach can also be combined with a boost to the tumor site either during or after the whole breast radiation treatments. Even shorter schedules have been studied and are in use in some centers, including accelerated partial breast radiation for five days, and others are researching a three-week schedule.

Research studies have shown that these shorter schedules are similarly safe and control the cancer as well as longer radiation treatment schedules in patients with node-negative breast cancer. These shorter schedules are becoming more accepted in the United States for cancers that have a lower risk of recurrence, and are one way to improve the convenience and reduce the time needed to complete radiation therapy (see also partial breast irradiation below). Information about the long-term effectiveness of these very short courses of radiation is not yet available.

Partial breast irradiation

Partial breast irradiation (PBI) is radiation therapy that is given directly to the tumor area, usually after a lumpectomy, instead of the entire breast, as is usually done with standard radiation therapy. Targeting radiation directly to the tumor area more directly usually shortens the amount of time that patients need to receive radiation therapy. However, only some patients may be able to have PBI. Although early results have been promising, PBI is still being studied. It is the subject of a large, nationwide clinical trial, and the results on the safety and effectiveness compared with standard radiation therapy are not yet ready. This study will help find out which patients are the most likely to benefit from PBI.

PBI can be done with standard external-beam radiation therapy that is focused on the area where tumor was removed and not on the entire breast. PBI may also be performed using brachytherapy. Brachytherapy is the use of plastic catheters or a metal wand placed temporarily in the breast. Breast brachytherapy can involve short treatment times, ranging from one dose to one week, or it can be given as one dose in the operating room immediately after the tumor is removed. These forms of focused radiation are currently used only for patients with a smaller, less-aggressive, and node-negative tumor.

Intensity-modulated radiation therapy

Intensity-modulated radiation therapy (IMRT) is a more advanced way to give external-beam radiation therapy to the breast. The intensity of the radiation directed at the breast is varied to better target the tumor, spreading the radiation more evenly throughout the breast. The use of IMRT lessens the radiation dose and the possible damage to nearby organs, such as the heart and lung, and lower the risks of some immediate side effects, such as peeling of the skin during treatment. This can be especially important for women with medium to large breasts who have a higher risk of side effects, such as peeling and burns, compared with women with smaller breasts. IMRT may also help to lessen the long-term effects on the breast tissue that were common with older radiation techniques such as hardness, swelling, or discoloration.

Even though IMRT has fewer short-term side effects, many insurance providers may not cover IMRT. It is important to check with your health insurance company before any treatment begins to make sure it is covered.

Adjuvant radiation therapy concerns for older patients and/or those with small tumors

Recent research studies have looked at the possibility of avoiding radiation therapy for women age 70 or older or for those women with a small tumor. Overall, these studies show that radiation therapy reduces the risk of breast cancer recurrence in the same breast, compared with no radiation therapy, but does not lengthen lives. Guidelines from the National Comprehensive Cancer Network (NCCN) continue to recommend radiation therapy as the standard option after lumpectomy. However, they note that women with special situations or low-risk tumors could reasonably choose not to have radiation therapy and use only hormonal therapy (see below) after lumpectomy, if they are willing to accept a modest increase in the risk that the cancer will come back in the breast. This includes women age 70 or older or those with other medical conditions that could limit life expectancy within five years.

Learn more about radiation therapy.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, which work by stopping the cancer cells’ ability to grow and divide. Chemotherapy is prescribed 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).

Chemotherapy may be given before surgery to shrink a large tumor and reduce the risk of recurrence, called neoadjuvant chemotherapy. It may also be given after surgery to reduce the risk of recurrence, called adjuvant chemotherapy. Chemotherapy is also commonly given if a patient has a metastatic breast cancer recurrence.

A chemotherapy regimen (schedule) consists of a specific treatment schedule of drugs given at repeating intervals for a set period of time. Chemotherapy may be given on many different schedules depending on what worked best in clinical trials for that specific type of regimen. It may be given once a week, once every two weeks (also called dose-dense), once every three weeks, or even once every four weeks. Common drugs for breast cancer include:

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

A patient may receive one drug at a time or combinations of different drugs at the same time. Research has shown that combinations of certain drugs are sometimes more effective than single drugs for adjuvant treatment. The following drugs or combinations of drugs may be used as adjuvant therapy to treat breast cancer:

  • AC (doxorubicin and cyclophosphamide)
  • AC or EC (epirubicin and cyclophosphamide) followed by T (doxorubicin and cyclophosphamide, followed by paclitaxel or docetaxel, or the reverse)
  • CAF (cyclophosphamide, doxorubicin, and 5-FU)
  • CEF (cyclophosphamide, epirubicin, and 5-FU)
  • CMF (cyclophosphamide, methotrexate, and 5-FU)
  • EC
  • TAC (docetaxel, doxorubicin, and cyclophosphamide)
  • TC (docetaxel and cyclophosphamide)

Trastuzumab, lapatinib, and pertuzumab are HER2-targeted therapies that may be given with chemotherapy for HER2-positive breast cancer (see Targeted therapy, below). Bevacizumab (Avastin) is another targeted therapy that has been used in combination with chemotherapy for the treatment of metastatic breast cancer, but is no longer approved for the treatment of breast cancer.

The side effects of chemotherapy depend on the individual, the drug(s) used, and the schedule and dose used. These side effects can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects can often be prevented or managed during treatment, and they usually go away once treatment is finished. Rarely, long-term side effects may occur, such as heart damage, nerve damage, or secondary cancers.

Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor, oncology nurse, or pharmacist 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.

Hormonal therapy

Hormonal therapy, also called endocrine therapy, is an effective treatment for most tumors that test positive for either estrogen or progesterone receptors (ER-positive or PR-positive; see Diagnosis), in both early-stage and metastatic cancer. This type of tumor uses hormones to fuel its growth. Blocking the hormones can help prevent a cancer recurrence and death from breast cancer when used for early-stage disease either by itself or after adjuvant or neoadjuvant chemotherapy. Hormonal therapy is also effective as treatment for metastatic breast cancer, shrinking the cancer and improving cancer-related symptoms.

Tamoxifen is a drug that blocks estrogen from binding to breast cancer cells. It is effective for lowering the risk of recurrence in the breast that had cancer, the risk of developing cancer in the other breast, and the risk of distant recurrence. It is also approved to reduce the risk of breast cancer in women at high risk for developing breast cancer and for lowering the risk of a local recurrence for women with DCIS who have had a lumpectomy. Tamoxifen is also an effective treatment for metastatic hormone receptor-positive breast cancer.

Tamoxifen is a pill that is taken daily by mouth. It is important to discuss any other medications or supplements you take with your doctor, as there are some that can interfere with tamoxifen. The side effects of tamoxifen include hot flashes; vaginal dryness, discharge or bleeding; a small increased risk of cancer in the uterus including uterine sarcoma; cataracts; and an increase in the risk of blood clots. However, tamoxifen may improve bone health and cholesterol levels and is effective for the treatment of breast cancer in both premenopausal and postmenopausal women.

Aromatase inhibitors (AIs) decrease the amount of estrogen made by tissues other than the ovaries in postmenopausal women by blocking the aromatase enzyme, which changes weak male hormones called androgens into estrogen when the ovaries have stopped making estrogen during menopause. These drugs include anastrozole (Arimidex), letrozole (Femara), and exemestane. All of the AIs are pills taken daily by mouth. Treatment with AIs, either alone or following tamoxifen, is more effective than tamoxifen alone at reducing the risk of recurrence from early-stage breast cancer in post-menopausal women. AIs are also an effective treatment for metastatic hormone receptor positive breast cancer.

The side effects of AIs may include muscle and joint pain, hot flashes, vaginal dryness, an increased risk of osteoporosis and broken bones, and increased cholesterol levels. Research shows that all three AI drugs work equally well and have similar side effects. However, women who have severe side effects while taking one AI may have fewer side effects with another AI for unclear reasons. Women who have not gone through menopause should not take AIs, as they do not block the effects of estrogen made by the ovaries. Often, doctors will monitor blood estrogen levels in women whose periods have recently stopped, or those whose periods stop with chemotherapy to be sure that the ovaries are no longer producing estrogen.

Women who have gone through menopause and are given hormonal therapy have several options: take tamoxifen or an AI for five years, begin treatment with tamoxifen for two to three years and then switch to an AI for the rest of the five-year period, or take tamoxifen for five years then switch to an AI for what is called extended hormonal therapy. Recent research has shown that taking tamoxifen for longer than five years can further reduce the risk of recurrence following a diagnosis of early-stage breast cancer, although side effects are also increased with longer duration of therapy. Learn more about ASCO's recommendations for hormonal therapy for hormone receptor-positive breast cancer.

As noted above, premenopausal women should not take AIs, as they are not effective. Options for adjuvant hormonal therapy for premenopausal women include five or more years of tamoxifen, switching to an AI after menopause begins, or either drug combined with suppression of ovarian function. One of the oldest hormone treatments for hormone receptor-positive breast cancer is to stop the ovaries from making estrogen, called ovarian suppression. Medications called gonadotropin or luteinizing releasing hormone (GnRH or LHRH) analogues stop the ovaries from making estrogen, causing temporary menopause. Goserelin (Zoladex) and leuprolide (Lupron) are drugs given by injection under the skin that can stop the ovaries from making estrogen for one to three months. Most commonly, these are given with tamoxifen or AIs as part of adjuvant therapy for breast cancer. Less commonly, these drugs may be given alone. Surgical removal of the ovaries, which is a permanent way to stop the ovaries from working, may also be considered in certain situations. Ovarian suppression or ablation is also used for premenopausal women with metastatic breast cancer, in combination with tamoxifen or an AI. Learn more about recommendations for ovarian ablation.

Tamoxifen, ovarian suppression and AIs are also commonly used to treat metastatic breast cancer. Fulvestrant (Faslodex) is an additional hormonal therapy approved for patients with metastatic breast cancer. Fulvestrant is a selective estrogen receptor downregulator (SERD). Unlike the other oral hormonal therapies used to treat breast cancer, fulvestrant is given monthly by an injection into a muscle. Most commonly, two injections are given every two weeks for three doses, then continued monthly. Side effects from fulvestrant include menopausal symptoms, such as hot flashes and vaginal dryness. The combination of fulvestrant and an AI has been tested as treatment for metastatic breast cancer that has not yet been treated with hormonal therapy. The combination was more effective than an AI alone in one study, but similar to the AI in a second study. Additional clinical trials are testing this combination, so more data should be available in the near future.

Other hormonal therapies used to treat metastatic breast cancer after AIs, fulvestrant, tamoxifen, and targeted therapy include megestrol acetate (Megace) and high-dose estradiol, which is an estrogen replacement.

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, although this is considered experimental. 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.

The first approved targeted therapies for breast cancer were hormonal therapies. Then, HER2 targeted therapies were been approved to treat HER2-positive breast cancer. Most recently, a drug that targets a protein called mTOR, which contributes to cancer growth, was approved in combination with hormonal therapy for the treatment of metastatic breast cancer. Targeted therapy is also used to prevent growth of cancer that has spread to the bone and to maintain bone health. Talk with your doctor about possible side effects of specific medications and how they can be managed.

HER2 targeted therapy

  • Trastuzumab is approved for both the treatment of advanced breast cancer and as an adjuvant therapy for early-stage HER2-positive breast cancer. Currently, one year of trastuzumab is recommended for the treatment of early-stage breast cancer. For metastatic cancer, trastuzumab is given in combination with different types of chemotherapy. Patients receiving trastuzumab have a small (2% to 5%) risk of heart problems. This risk is increased if a patient has other risk factors for heart disease or receives chemotherapy that also increases the risk of heart problems at the same time. These heart problems do not always go away, but they are usually treatable with medication.
  • Pertuzumab is approved for the treatment of advanced breast cancer, and is being studied as a treatment for early-stage disease. Research shows that adding pertuzumab to trastuzumab and the chemotherapy drug docetaxel for advanced breast cancer not yet treated with either chemotherapy or trastuzumab increases the effectiveness of treatment and lengthens lives with few additional side effects. Based on this data, the combination of trastuzumab, pertuzumab, and either docetaxel or paclitaxel has become the standard of care for the treatment of untreated advanced breast cancer. Pertuzumab is also approved as neoadjuvant treatment for breast cancer in the United States, in combination with trastuzumab and docetaxel or paclitaxel.
  • Lapatinib is commonly used for women with HER2-positive metastatic breast cancer when trastuzumab and pertuzumab in combination with docetaxel are no longer effective at controlling the cancer’s growth. The combination of lapatinib and the chemotherapy capecitabine is approved to treat advanced or metastatic HER2-positive breast cancer when a patient has already received chemotherapy and trastuzumab. The combination of lapatinib and letrozole is also approved for metastatic HER2-positive and ER-positive cancer. Lapatinib is also used in combination with trastuzumab for patients whose cancers were growing on trastuzumab. Lapatinib is being studied for early-stage breast cancer in combination with trastuzumab. The recent approval of ado-trastuzumab emtansine (see below) has changed the use of lapatinib, as this drug was shown to be more effective than the combination of lapatinib and capecitabine. Lapatinib is now more commonly used following treatment with T-DM1.
  • Ado-trastuzumab emtansine or T-DM1 is approved for the treatment of metastatic breast cancer for patients who have previously received trastuzumab and chemotherapy with either paclitaxel or docetaxel. T-DM1 is made up of trastuzumab linked to a type of chemotherapy. Research shows that treatment with this drug caused fewer side effects and controlled tumor growth better than the combination of lapatinib and the capecitabine. T-DM1 is given by vein every three weeks. Studies are now testing T-DM1 as a treatment for early-stage breast cancer

mTOR inhibitor therapy

Everolimus (Afinitor) is approved in combination with exemestane (see above) for the treatment of metastatic hormone receptor-positive breast cancer that has grown while receiving hormonal therapy with letrozole or anastrozole. In clinical trials, the combination controlled cancer for longer than exemestane alone, although it also resulted in more side effects including mouth sores and rarely an inflammation of the lungs called interstitial pneumonitis. Everolimus and similar drugs are being researched in combination with hormonal therapy for metastatic and early-stage breast cancer.

Osteoclast targeted therapy (drugs that block bone destruction)

  • Bisphosphonates are drugs that block the cells that destroy bone, called osteoclasts. Bisphosphonates are commonly used in low doses to prevent and treat osteoporosis. Osteoporosis is the thinning of the bones. In women with breast cancer that has spread to bone, higher doses of bisphosphonates have been shown to reduce the side effects of cancer in the bone, including broken bones and pain. Pamidronate (Aredia) and zoledronic acid (Zometa) are two intravenous bisphosphonates used to treat breast cancer bone metastasis. These drugs may also be able to reduce breast cancer recurrences, particularly in bone, when given after treatment in postmenopausal women, although the research on this effect is conflicting.
  • Denosumab (Xgeva) is another osteoclast-targeted therapy called a RANK ligand inhibitor. Recent studies have shown that denosumab works well to treat breast cancer bone metastases, and may be better than bisphosphonates at controlling the symptoms of bone metastases. Denosumab is also effective at treating osteoporosis and is being studied as a cancer treatment in early-stage breast cancer.

Learn more about drugs that block bone destruction.

Getting care for symptoms and side effects

Cancer and its treatment cause symptoms and 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 supportive or palliative care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Supportive or 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 medications, nutritional support, 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 option in your treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment and supportive care options. 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 breast cancer

If cancer has spread to another location in the body or come back in a distant location, it is called metastatic breast cancer. Patients with diagnosed with metastatic breast cancer 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 studying new treatments.

Your health care team may recommend a treatment plan that includes a combination of systemic therapies, such as chemotherapy, hormonal therapy, and targeted therapies. Radiation therapy and surgery may be used in certain situations for women with metastatic breast cancer. Supportive care is also important to help relieve symptoms and side effects. For instance, radiation therapy is often used to treat painful bone metastases.

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.

For an overview of metastatic breast cancer, read a one-page fact sheet (available as a PDF) that offers information on coping the diagnosis.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body by physical examination or imaging tests 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 following treatment of early-stage breast cancer 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, and will help you make decisions about your treatment. Learn more about coping with the fear of recurrence.

If the cancer does return after treatment for early-stage disease, it is called recurrent cancer. It may come back in the same place (called a local recurrence), in the chest wall or lymph nodes under the arm or in the chest (regional recurrence), or in another place, including distant organs such as the bones, lungs, liver, and brain (distant recurrence). A local or regional recurrence is often managed with further treatment. A metastatic (distant) recurrence is generally incurable, but treatable. Some patients live years after a metastatic recurrence of breast cancer, depending on a number of factors.

Other than mammograms and MRI scans of the breast, routine scans and blood tests after a diagnosis of early-stage breast cancer are not a good way to screen for recurrent cancer, and they can expose a patient to risk from unnecessary additional testing. Generally, a recurrence is detected when a person has symptoms or an abnormal finding on physical examination. These symptoms depend on where the cancer has recurred and may include:

  • A lump under the arm or along the chest wall
  • Pain that is constant, worsening, and not relieved by over-the-counter medication
  • Bone pain or fractures, a possible sign of bone metastases
  • Headaches or seizures, a possible sign of brain metastases
  • Chronic coughing or trouble breathing, possible symptoms of lung metastases
  • Abdominal pain or yellow skin and eyes from a condition called jaundice, which may be associated with liver metastases

Other symptoms may be related to the location of metastasis and may include changes in vision, changes in energy levels, feeling ill, low appetite and/or weight loss, or extreme fatigue.

If a woman has a recurrence, a cycle of testing will begin to learn as much as possible about the recurrence, including whether the cancer’s stage has changed. A biopsy of the recurrent tumor is recommended confirm the diagnosis and to check for ER, PR, and HER2 status, because this may have changed since the original diagnosis. 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, radiation therapy, chemotherapy, targeted therapy, and hormonal therapy, but they may be used in a different combination or at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.

The treatment of recurrent breast cancer depends on the previous treatment(s), the time since the original diagnosis, the location of the recurrence, and the characteristics of the tumor, such as ER, PR, and HER2 status.

  • For women with a local recurrence within the breast after initial treatment with lumpectomy and adjuvant radiation therapy, the recommended treatment is mastectomy. Usually the cancer is completely removed with this treatment.
  • For women with a local or regional recurrence in the chest wall after an initial mastectomy, surgical removal of the recurrence followed by radiation therapy to the chest wall and lymph nodes is the recommended treatment, unless radiation therapy has already been given because radiation therapy cannot usually be given at full dose to the same area more than once.
  • Other treatments used to reduce the chance of a future distant recurrence include radiation, chemotherapy, hormonal therapy, and targeted therapy and are used depending on the tumor and the type of treatment previously used.

Women with recurrent breast 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 cancer is not always possible. In general, metastatic breast cancer is incurable, although it can be treated and controlled for some time. However, at some point, options for treatment become very limited and the cancer will become difficult to control.

This diagnosis is stressful, and this is difficult to discuss for many people. However, it is essential to have open and honest conversations with your doctor and health care team, as well as your family, 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 an inpatient hospice environment. Nursing care and special equipment can make staying at home a workable and preferable 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.

Breast Cancer - About Clinical Trials

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will learn more about clinical trials, which are the main way that new medical approaches are tested to see how well they work. To see other pages, use the menu on the side of your screen.

Doctors and scientists are always looking for better ways to treat patients with breast cancer. To make scientific advances, doctors create research studies involving volunteers, called clinical trials.

Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating breast cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with breast cancer. For example, the benefits of using of dose-dense chemotherapy, which is giving the drugs more frequently than the traditional three-week intervals, and adding trastuzumab for early-stage breast cancer were tested and confirmed in clinical trials.

Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare, and for breast cancer research, placebos are most commonly given along with standard therapy. For example, one group of patients receives the standard treatment plus the placebo, and another group receives standard treatment plus the treatment being researched. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.

To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient's options, so that the person understands the standard treatment, and how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. The coverage of clinical trial costs differs by location. In some programs, expenses associated with participating in the research, such as transportation, childcare, meals, and accommodations are reimbursed. It’s important to talk with the research team and your insurance company to learn about how the treatment in a clinical trial will be covered.

For specific topics being studied for breast cancer, learn more in the Latest Research section.

Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason, including if the new treatment is not working or if there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends.

Cancer.Net offers a lot of information about cancer clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of cancer.

The next section helps explain the areas of research going on today about this type of cancer. Use the menu on the side of your screen to select Latest Research, or you can select another section, to continue reading this guide.

Breast Cancer - Latest Research

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will read about the scientific research being done now to learn more about this type of cancer and how to treat it. To see other pages, use the menu on the side of your screen.

Doctors are working to learn more about breast cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

  • Research on the causes of breast cancer, such as endocrine (hormone) disrupters, environment causes, and lifestyle choices, to find other ways to help prevent the disease
  • New ways to help find breast cancer early
  • Developing ways to best evaluate the genes and proteins at work in each patient and each breast cancer, to determine the best treatment options for each patient
  • Evaluating the need for axillary node dissection after a positive sentinel node biopsy or if non-surgical treatment has helped to remove cancer in a lymph node
  • Testing shorter radiation schedules and more targeted radiation approaches
  • Testing new drug therapies and combinations of therapies, such as new chemotherapy and hormonal treatments, and targeted therapies including those that target HER2 either during or after treatment with trastuzumab, and those that are aimed at improving the effectiveness of hormonal therapy.
  • Determining what early-stage cancers may not need chemotherapy
  • Determining the best ways to give hormonal therapy
  • Finding new reconstructive surgery approaches
  • Finding better ways of reducing symptoms and side effects of current breast cancer treatments in order to improve patients’ comfort and quality of life
  • Learning more about the social and emotional factors that may affect patients’ treatment plans and quality of life

Looking for More About the Latest Research?

If you would like additional information about the latest areas of research regarding breast cancer, explore these related items that take you outside of this guide:

The next section addresses how to cope with the symptoms of the disease or the side effects of its treatment. Use the menu on the side of your screen to select Coping with Side Effects, or you can select another section, to continue reading this guide. 

Breast Cancer - Coping with Side Effects

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will find out more about steps to take to help cope with physical, social, and emotional side effects. This page includes several links outside of this guide to other sections of this website. To see other pages, use the menu on the side of your screen.

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for breast cancer are described in detail within the Treatment Options section. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with breast cancer. Learn more about caregiving.

In addition to physical side effects, there may be emotional and social effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies, including concerns about managing the cost of your cancer care.

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. Learn more by reading the After Treatment section or talking with your doctor.

The next section helps explain medical tests and check-ups needed after finishing cancer treatment. Use the menu on the side of your screen to select After Treatment, or you can select another section, to continue reading this guide.

Breast Cancer - After Treatment

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will read about your medical care after cancer treatment is finished and why this follow-up care is important. To see other pages, use the menu on the side of your screen.

After treatment for breast cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. ASCO’s recommendations for breast cancer follow-up care include regular physical examinations and mammograms, as well as other recommendations. In addition, ASCO offers cancer treatment summaries and a survivorship care plan to help keep track of the breast cancer treatment you received and develop a follow-up care plan once treatment ends. In some instances, patients may be able to visit survivorship clinics that specialize in the post-treatment needs of people diagnosed with breast cancer.

As explained in Treatment Options, breast cancer can come back in the breast or other areas of the body. The symptoms of a cancer recurrence include a new lump in the breast, under the arm, or along the chest wall; bone pain or fractures; headaches or seizures; chronic coughing or trouble breathing; extreme fatigue; and/or feeling ill. Talk with your doctor if you have any of these or other symptoms. The possibility of recurrence is a common concern among cancer survivors; learn more about coping with fear of recurrence and the tests that are not helpful to watch for a recurrence.

After a mastectomy or lumpectomy to treat breast cancer, the breast may be scarred and may have a different shape or size than before surgery. Or, the area around the surgical site may become hardened. If lymph nodes were removed as part of the surgery or affected during treatment, lymphedema may occur, even many years after treatment, and this is a life-long risk for patients.

Some patients experience breathlessness, a dry cough, and/or chest pain two to three months after finishing radiation therapy because the treatment can cause swelling and a hardening or thickening of the lungs called fibrosis. These symptoms usually go away. Talk with your doctor if you develop any new symptoms after radiation therapy or if the side effects are not going away.

Patients who received trastuzumab or certain types of chemotherapy called anthracyclines may be at risk of heart problems. Talk with your doctor about the best ways to check for heart problems.

Women taking tamoxifen should have yearly pelvic exams, because this drug can increase the risk of uterine cancer. Tell your doctor or nurse if you notice any abnormal vaginal bleeding or other new symptoms. Women who are taking an AI, such as anastrozole, exemestane, or letrozole, should have a bone density test before they start treatment and as recommended by their doctor, as these drugs may cause some bone weakness or bone loss.

In addition, women recovering from breast cancer have other side effects that may continue after treatment. However, these can often be managed. For example, medications can help manage neuropathy, menopausal symptoms, and joint pain. Vaginal dryness and a lowered sex drive are common side effects during or after treatment for breast cancer; treatment is individualized for the patient and the type of cancer and may be best managed by a gynecologist working with your oncologist. Learn about ways of coping with cancer-related fatigue and other late effects of cancer treatment.

Women recovering from breast cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, limiting alcohol, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level and may lower the risk of cancer recurrence. Your doctor can help you create a safe exercise plan based upon your needs, physical abilities, and fitness level.

Many breast cancer survivors need time to adapt to the “new normal.” Treatment for breast cancer may cause physical or emotional changes that affect how you view yourself. Learn more about self-image and breast cancer and the next steps to take in survivorship.

The next section offers a list of questions you may want to ask. Use the menu on the side of your screen to select Questions to Ask the Doctor, or you can select another section, to continue reading this guide.

Breast Cancer - Questions to Ask the Doctor

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will find some questions to ask your doctor or other members of your health care team, to help you better understand your diagnosis, treatment plan, and overall care. To see other pages, use the menu on the side of your screen.

Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your child’s next appointment, or download Cancer.Net’s free mobile app for an e-list and other interactive tools to manage your care. 

Questions to ask your entire health care team

  • Is there enough information to recommend a treatment plan for me? If not, which tests or procedures will be needed?
  • Who would you recommend for a second opinion?
  • When do I need to make a treatment decision?
  • Who will be part of my health care team, and what does each member do?
  • Who will be coordinating my overall treatment and follow-up care?
  • What is the goal of each treatment? Is it to eliminate the cancer, help me feel better, or both?
  • What can I do to get ready for treatment?
  • If I’m worried about managing the costs related to my cancer care, who can help me with these concerns? Who can help me understand what aspects of my care are covered by my insurance?
  • Whom can I call if I have a problem or question about my treatment? Whom do I call if I experience side effects?
  • Do you communicate with your patients by email or with an electronic health record system?
  • Who can I contact for supportive and emotional help for me? For my family?
  • If have a strong family history of cancer, what is my chance of getting another cancer? How does that change my treatment options? Should I see a genetic counselor?

Questions to ask your breast surgeon, before your first surgery

  • Are you board-certified?
  • Do you specialize in this type of surgery?
  • How many operations like the one I am considering have you performed?
  • Do I need any other tests before this surgery?
  • Am I a candidate for a lumpectomy?
  • Do I need a mastectomy? If so, would you recommend an immediate breast reconstruction (plastic surgery)? What are the advantages and disadvantages to this?
  • Do the lymph nodes in my underarm need to be removed?
  • What is a sentinel lymph node biopsy? What are the benefits and risks? Would you recommend it for me?
  • What is the risk of lymphedema with a sentinel lymph node biopsy? With axillary lymph node dissection?
  • Should I consider chemotherapy before surgery?
  • When do I need to make a decision about surgery?
  • What should I do to get ready for the operation? Do you have recommendations on how to help me relax before surgery?
  • What medications and supplements should I stop taking? Should I stop taking hormone replacement therapy? What about birth control pills?
  • Will you describe exactly what you will be doing during this operation, and why?
  • Will my tumor be saved? Where will it be stored? For how long? How can it be accessed in the future?
  • What are the potential risks and side effects of this operation? What can be done to ease side effects following surgery?
  • Does the hospital offer programs that help aid healing?
  • What can I expect regarding the operation?
    • Will I need to be admitted to a hospital for this operation? If so, how long will I stay in the hospital?
    • How long will my surgery take?
    • What type of anesthesia will I need for this operation?
    • How long do I have to wait for my preoperative test results? Do I call you, or does your office call me?
    • Will a pathologist examine the tissue and write a report? Who will explain that report to me?
    • What are the possible complications for this type of surgery? How would I know if there is a problem?
    • How long will it take me to recover after the surgery?
    • When can I return to work and other daily activities?
    • Will I have stitches, staples, and/or bandages?
    • Will there be permanent effects from the surgery?
    • Where will the scar be, and what will it look like?
    • What type of clothes should I bring to go home it? Will I need a special type of bra?
    • Are there instructions or post-operative care pamphlets I can take home with me? When can I shower or bathe?
    • Will I need to have surgical drains? What does this mean? How long will the surgical drains be in?
    • Do I need a nurse to visit my home after surgery? How is this arranged?
    • When will I need to return for a follow-up appointment?
    • Will I need help at home after the surgery?
    • What kind of pain will I be in afterwards? Can you help me manage my pain?
    • When should I call your office if I experience any side effects?

Questions to ask your breast surgeon, after your first surgery

  • What type of breast cancer do I have?
  • What is the size of the tumor?
  • What is the grade and stage of this disease? What does this mean?
  • What are the chances that the breast cancer will return?
  • Can you explain my pathology report (laboratory test results) to me?
  • Can I get a copy of my pathology report? How and when can I get these results?
  • Was all of the cancer removed during the surgery?
  • How many lymph nodes were removed?
  • Has the cancer spread to any of the lymph nodes? If so, how many? Has the cancer spread to anywhere else in my body?
  • Do I need additional surgery?
  • If I have a mastectomy without reconstruction, where can I get a prosthesis? Is this covered through my insurance?
  • Will my arm be affected by surgery? For how long? Will I need physical therapy for my arm?
  • When will I be able to work and/or return to my normal routine? Are there any activities I should refrain from?
  • Will my surgeon communicate with my medical oncologist?
  • Do you recommend any genetic testing of the tumor?

Questions to ask your medical oncologist

  • What type of breast cancer do I have?
  • What is the size of my tumor?
  • What is the grade and stage of this disease? What does this mean?
  • What is the hormone status of my tumor? What does this mean?
  • What is my HER2 status? What does this mean?
  • Do you recommend any genetic testing of the tumor?
  • Do I need more tests to find out if there is cancer anywhere else in my body?
  • Do you recommend genetic testing and seeing a genetics counselor?
  • Do I need other treatment, such as chemotherapy or hormonal therapy?
  • What is chemotherapy? What is hormonal (endocrine) therapy? What is targeted therapy?
  • What are my options for treatment?
  • What clinical trials are available to me? Where are they located, and how do I find out more about them?
  • How will each treatment option benefit me? What are the risks?
  • What is the expected timeline for each treatment option?
  • What treatment plan do you recommend for me? Why?
  • When do I need to make a decision about starting additional treatment?
  • Should I consider my family’s history of breast cancer in making my decision about treatment?
  • How does having reached (or not reached) menopause affect my treatment options?
  • What is my prognosis?
  • What can I do to get ready for this treatment?
  • Should I bring someone with me to my chemotherapy treatment?
  • What are the potential side effects of each treatment?
  • Will I lose my hair, and can I do anything to prevent hair loss?
  • What can be done to ease side effects?
  • How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
  • Will this treatment affect my sex life? If so, how and for how long? Is there anything I can do to prevent or treat these effects?
  • Will this treatment affect my ability to have children (fertility)? Should I talk with a fertility specialist before treatment begins? Are there other treatments available that do not pose as high a risk to my fertility but are equally effective?
  • How much time do I have before I have to start my cancer therapy?
  • Can I become pregnant while receiving chemotherapy or radiation therapy? What happens if I become pregnant during treatment? Is there a risk of birth defects and/or harm to the fetus and/or to me?
  • How long should I wait after cancer treatment before trying to have a child?
  • What lifestyle changes should I consider making during my treatment?
  • Do you recommend any nutritional supplements or changes to my diet?
  • Can I take herbal supplements during my treatment? Is there any risk?
  • How will you determine if the cancer has come back after treatment?
  • If have a strong family history of cancer, what is my chance of getting another cancer?
  • After my treatment has ended, what will my follow-up care plan be?
  • How often will I need to see a doctor?
  • What tests will I need?
  • How often will I need those tests?
  • Can I get copies of my laboratory test results?

Questions to ask your radiation oncologist

  • What is the goal of this treatment? Is it to eliminate the cancer?
  • What are the chances that this treatment will prevent the cancer from coming back?
  • If the cancer comes back, can I get radiation therapy again?
  • How often will I receive radiation therapy?
  • Are there alternatives to the recommended treatment?
  • How much time will each treatment take?
  • Can I bring someone with me to treatment?
  • Will each treatment be the same? Does the radiation dose or area treated change throughout the period of treatment?
  • What can I do to get ready for this treatment? Are there recommendations on what clothes to wear or leave behind?
  • How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
  • Will you describe what I will experience when I receive radiation therapy? Will it hurt or cause me discomfort during the treatment?
  • What are the potential side effects of this treatment? How can I ease side effects?
  • How will my skin be affected during radiation therapy? What skin products can I use each day?
  • Do I need to be concerned about sun exposure?
  • Should I avoid certain foods, vitamins, or supplements?
  • Should I avoid using deodorant or antiperspirant during treatment?
  • What are the possible long-term effects of this treatment?
  • If I decide to have reconstructive surgery, how would that affect my treatment plan?
  • Will this treatment affect my fertility?
  • Are there special services for patients receiving radiation therapy, such as certain parking spaces or parking rates?

Questions to ask if you have metastatic breast cancer

  • Where else in my body has the cancer spread?
  • What treatment plan do you recommend? What is the goal of each treatment?
  • What will happen if this treatment stops working?
  • What supportive care will be given to help control my symptoms and side effects?
  • What will happen if I choose to stop treatment?
  • What level of caregiving will I need at this time?
  • What support services are available specifically for people with metastatic breast cancer?

Questions to ask your plastic surgeon

  • Are you board-certified? Is breast reconstruction your specialty?
  • How many breast reconstruction surgeries do you perform in a year?
  • Now that you have examined me, am I a candidate for reconstruction?
  • What types of breast reconstruction options do I have?
  • What are the advantages and disadvantages of each type?
  • When can I have my reconstruction?
  • Will I need surgery to the non-reconstructed breast to make the breasts match?
  • Will I need to coordinate this with my breast surgeon?
  • If I have radiation therapy, does that change my options for reconstruction?
  • What are tissue expanders, and will I need them?
  • What are the advantages and disadvantages of each?
  • Which type of implants do you recommend (saline or silicone), and why? What size?
  • If you use tissue from another part of my body to rebuild my breast(s), where do you recommend it be taken from, and why?
  • If I have a mastectomy with implant reconstruction, can I also have a nipple reconstruction? If so, when?
  • What are the costs involved with breast reconstruction? What is covered by my insurance? Is surgery on the non-reconstructed breast covered by insurance?
  • How long will the surgery take?
  • What do I need to do to prepare for the surgery?
  • What type of anesthesia will I need for this operation?
  • What can I expect after the operation?
    • How long will I stay in the hospital?
    • What are the possible complications for this type of surgery?
    • How long will it take me to recover?
    • When can I resume my normal activities, including exercise?
    • Will I need to have surgical drains? What does this mean?
    • Will I have stitches, staples, and/or bandages?
    • Will there be a scar or other permanent effects from the surgery?
    • Are there instructions or post-operative care pamphlets I can take home with me?
    • When will I need to return for a follow-up appointment?
    • What type of results can I expect?
  • Are there photographs of reconstructed breasts that I can view?
  • How will the reconstructed breast feel to the touch?
  • What type of sensation (feeling) will the reconstructed breast have?
  • What changes to the reconstructed breast can I expect over time?
  • Will I need to have surgery again in the future (for example, to replace implants over time)?
  • Do I need mammograms or MRI tests after a breast reconstruction?
  • What can I expect if my weight changes?
  • What if I become pregnant in the future?

Questions to ask your fertility specialist

If you are a young women with breast cancer and you are concerned about your ability to have children in the future, you are encouraged to talk with a fertility specialist (in addition to the doctors listed above) as early as possible after your diagnosis and before cancer treatment begins. Recommendations from the fertility specialist should always be discussed with your oncologist as well, before starting any fertility-related efforts.

  • How often do you advise people with cancer?
  • What are my options to preserve my fertility?
  • What are the costs involved with my options to preserve fertility? What is covered by my insurance?

Learn more about preserving fertility before cancer treatment.

The next section offers some more resources that may be helpful to you. Use the menu on the side of your screen to select Additional Resources, or you can select another section, to continue reading this guide.

Breast Cancer - Additional Resources

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2014

ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about cancer care and treatment. This is the final page of Cancer.Net’s Guide to Breast Cancer. To go back and review other pages, use the menu on the side of your screen.

Cancer.Net includes many other sections about the medical and emotional aspects of cancer, both for the person diagnosed and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond. Here are a few sections that may get you started in exploring the rest of Cancer.Net:

- Search for a cancer specialist in your local area using this free database of doctors from the American Society of Clinical Oncology.

- Review dictionary articles to help understand medical phrases and terms used in cancer care and treatment.

- Read more about the first steps to take when newly diagnosed with cancer.

- Find out more about clinical trials as a treatment option.

- Learn more about coping with the emotions that cancer can bring, including those within a family or a relationship.

- Find a national, not-for-profit advocacy organization that may offer additional information, services, and support for people with this type of cancer.

- Explore next steps a person can take after active treatment is complete.

This is the end of Cancer.Net’s Guide to Breast Cancer. Use the menu on the side of your screen to select another section, to continue reading this guide.