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Breast Cancer - Overview

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

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 made up of different tissue, ranging from very fatty tissue to very dense 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 healthy 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 grow and spread to other parts of the body. A benign tumor means the tumor can grow but 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. If cancer comes back after initial treatment, it can recur locally, meaning in the breast and/or regional lymph nodes. It can also recur elsewhere in the body, called distant metastases.

Types of breast cancer

Most breast cancers start in the ducts or lobes and are called ductal carcinomas or lobular carcinomas:

  • Ductal carcinoma. These cancers starts in the cells lining the milk ducts and make up the majority of breast cancers.

    • Ductal carcinoma in situ (DCIS). This is cancer that is located only in the duct.

    • Invasive or infiltrating ductal carcinoma. This is cancer that has spread outside of the duct.

  • Lobular carcinoma. This is cancer that starts in the lobules.

    • Lobular carcinoma in situ (LCIS). LCIS is located only in the lobules. LCIS is not considered cancer. However, LCIS in one breast is a risk factor for developing invasive breast cancer in both breasts (see the Risk Factors section for more information.)

Normal Breast Tissue

Normal Breast Tissue
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Ductal Carcinoma

Ductal Carcinoma
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Lobular Carcinoma

Lobular Carcinoma
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These images used with permission by the College of American Pathologists.

Other, less common types of breast cancer include:

  • Medullary

  • Mucinous

  • Tubular

  • Metaplastic

  • Papillary breast cancer

  • Inflammatory breast cancer is a faster-growing type of cancer that accounts for about 1% to 5% of all breast cancers.

  • Paget’s disease is a type of cancer that begins in the ducts of the nipple. Although it is usually in situ, it can also be an invasive cancer.

Breast cancer subtypes

Breast cancer is not all one disease, even among the same type of breast cancer. Often, the disease is made up of three main subtypes. Special receptors on the outside of the cancer cell help determine the subtype of breast cancer:

  • Hormone receptor positive. Breast cancers expressing estrogen receptors (ER) and progesterone receptors (PR) are called hormone receptor positive. These cancers may depend on the hormones estrogen and/or progesterone to grow. Hormone receptor positive cancers can occur at any age, but may be more frequent in women who are postmenopausal. About 60% to 75% of breast cancers have estrogen and/or progesterone receptors.

  • HER2 positive. About 20% to 25% of breast cancers depend on the gene called human epidermal growth factor receptor 2 (HER2) to grow. These cancers are called HER2 positive and have excessive numbers of HER2 receptors or copies of the HER2 gene. The HER2 gene makes a protein that is found on the cancer cell and is important for tumor cell growth. This type of cancer may grow more quickly.

  • Triple negative. If a person’s tumor does not express 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 of breast cancer diagnosed in women with mutations in a gene called BRCA1. This type of breast cancer may grow more quickly than hormone receptor-positive disease, and may be more sensitive to chemotherapy. Triple-negative breast cancer seems to be more common among younger women, particularly younger black women. Woman with triple-negative breast cancer should be tested for BRCA gene mutations. See the Risk Factors section for more information on BRCA gene mutations.

Looking for More of an Overview?

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

The next section in this guide is Statistics and it helps explain how many people are diagnosed with this disease and general survival rates. Or, use the menu on the side of your screen to choose another section to continue reading this guide. 

Breast Cancer - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will find information about how many people are diagnosed with 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 231,840 women in the United States will be diagnosed with invasive breast cancer, and 60,290 women will be diagnosed with in situ breast cancer. An estimated 2,350 men in the United States will be diagnosed with breast cancer. It is estimated that 40,730 people (40,290 women, 440 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 found. 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 85%. If the cancer has spread to a distant part of the body, the five-year survival rate is 25%. For all stages combined, the five-year survival rate for breast cancer is 89%, the 10-year rate is 83%, and the 15-year rate is 78%.

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 3.2% per year from 2007 to 2011 in white women and a decrease of 2.4% per year in black women. In women age 50 and older, the decrease has been 1.8% per year for white women and 1.1% per year for black women. Currently, there are more than 2.8 million women living in the United States as breast cancer survivors, 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, so the actual risk for a particular individual may be different. 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 multi-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 2015, and the National Cancer Institute Surveillance Epidemiology and End Results (SEER) database.

The next section in this guide is Medical Illustrations and it offers drawings of body parts often affected by this disease. Or, use the menu on the side of your screen to choose another section to continue reading this guide.    

Breast Cancer - Medical Illustrations

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

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.

The next section in this guide is Risk Factors and it explains what factors may increase the chance of developing this disease. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Breast Cancer - Risk Factors

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

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.

Generally, most breast cancers are sporadic, meaning they develop from damage to a person’s genes that occurs by chance after they are born. 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 are x-rays 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 your family has one or more of the following characteristics:

    • First-degree relatives, such as mothers, sisters, brothers, and children who have been diagnosed with breast cancer or ovarian cancer, especially before age 50. If two first-degree relatives developed breast cancer, the risk is five times the average risk.

    • Many close relatives who have been diagnosed with breast cancer or ovarian cancer, especially before age 50. Close relatives include grandparents, aunts and uncles, nieces and nephews, grandchildren, and cousins.

    • A family member who developed breast cancer in both breasts.

    • A male relative who developed breast cancer. 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 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 known gene mutations are breast cancer genes 1 and 2. These are commonly called 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 in a one-page fact sheet (available as a PDF) or in a more detailed guide.

    Other gene mutations or hereditary conditions that can increase a person’s risk of breast cancer include Lynch syndrome, Cowden syndrome (CS), Li-Fraumeni syndrome (LFS), Peutz-Jeghers syndrome (PJS), and ataxia telangiectasia (A-T).

    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. For example, a person can inherit a gene mutation but not develop breast cancer. Research is also ongoing to find other genes that may affect breast cancer risk.

    Genetic testing through blood tests is available to test for known mutations in BRCA1 and BRCA2 genes and other hereditary syndromes. However, 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 may be 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. Women with breast cancer who did not inherit a BRCA1 or BRCA2 mutation are generally not at increased risk of ovarian cancer.

  • 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 progestin 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 substantially as fewer women have been taking postmenopausal hormone therapy. However, women who have taken estrogen alone, without previously receiving progestin, 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 45, the disease is more common in black women than in 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 may be more likely to have inherited a BRCA gene mutation. 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 health care and a range of treatment options playing an additional role.

  • Radiation. Exposure to ionizing radiation at a young age, for example, from therapeutic radiation to the chest for Hodgkin lymphoma, may increase a woman’s 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 a tumor on standard imaging tests, such as 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, which is available 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.

Prevention

Different factors cause different types of cancer. Researchers continue to look into what factors cause this type of cancer. Although there is no proven way to completely prevent this disease, you may be able to lower your risk. Talk with your doctor for more information about your personal risk of 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 possible physical and emotional side effects when considering having these procedures.

  • Chemoprevention. Women who have a higher 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) and are not chemotherapy. 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 hormone blocking 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.

The next section in this guide is Screening and it explains how tests may find breast cancer before signs or symptoms appear. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Breast Cancer - Screening

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will find out more about how people may be screened for this type of cancer, including risks and benefits of screening. To see other pages, use the menu on the side of your screen.

Scientists have developed, and continue to develop, tests that can be used to screen a person for specific types of cancer before signs or symptoms appear. The overall goals of cancer screening are to:

  • Lower the number of people who develop the disease

  • Lower the number of people who die from the disease, or eliminate deaths from cancer altogether

  • Identify people with a higher risk of a specific type of cancer who may need screening more often

Learn more about the basics of cancer screening.

Screening Information for Breast Cancer

Mammography

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. Tomosynthesis is not currently a standard screening option or widely available. Research on this method is ongoing.

Other breast cancer screening methods

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 very high risk of breast cancer, those with extremely dense breast tissue, or when a lump or mass is found during a breast examination.

According to the American Cancer Society, women with BRCA gene mutations, prior radiation therapy to the chest, or a very strong family history for breast cancer should consider alternating mammography and MRI.

Women at moderate risk of breast cancer, for example, those with precancerous changes on a biopsy, can talk with the doctor about whether MRI screening should be considered.

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 a mammogram. Calcifications can be 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 may be 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.

Screening recommendations

Different organizations have looked at the evidence, risks, and benefits of mammography and have developed different screening recommendations. Decisions about screening for breast cancer are becoming increasingly individual. It’s important for each woman to talk with her doctor about how often she should receive screening and which tests are most appropriate.

  • 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.

  • ACS recommends that women age 40 to 44 have the choice to start yearly mammography. They recommend that women age 45 to 54 receive mammography every year and that women 55 and older can switch to having a mammogram every 2 years or continue yearly screening, if they choose.

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. Learn more about recommendations for breast cancer screening with mammography.

The USPSTF and ACS also differ on their recommendations for clinical breast examinations. A clinical breast examination is when a doctor or other health care professional performs a physical examination of your breasts to check for abnormalities or lumps. The USPSTF recommends a clinical breast examination along with mammography. The ACS does not recommend a clinical breast examination.

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 through breast examinations between regular mammograms.

The next section in this guide is Symptoms and Signs and it explains what body changes or medical problems this disease can cause. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Breast Cancer - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

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:

  • A lump that feels like a hard knot or a thickening in the breast or under the arm. It is important to feel the same area in the other breast to make sure the change is not a part of healthy breast tissue in that area.

  • 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 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 with dimpling 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 in this guide is Diagnosis and it explains what tests may be needed to learn more about the cause of the symptoms. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Breast Cancer - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

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 or cells 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

The following imaging tests may be done to learn more about a suspicious area found in the breast during screening.

  • 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 a new lump or nipple discharge. 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.

  • 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, along with mammography, for some women with a very high risk of developing breast cancer (see Prevention).

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. A pathologist then analyzes the sample(s). A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. 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, which is medication to block pain, is used to lessen a patient’s discomfort during the procedure.

  • 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.

  • 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.

  • Sentinel lymph node biopsy is a way to find out if there is cancer in the lymph nodes near the breast. Learn more about sentinel lymph node biopsy in the Treatment Options section.

Analyzing the biopsy sample

Analyzing the sample(s) removed during the biopsy can help your doctor learn about specific features of a cancer that help determine treatment options.

  • Tumor features. Examination of the tumor under the microscope is used to determine if it is invasive or in situ, ductal or lobular, 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.

  • ER and PR. Testing for ER and PR (see Overview) helps determine both the patient’s risk of recurrence and the type of treatment that is most likely to lower the risk of recurrence. ER and PR are often measured for DCIS as well. Generally, hormonal therapy (see Treatment Options) works well for ER-positive and/or PR-positive cancers. Learn about ER and PR testing recommendations from ASCO and the College of American Pathologists (CAP).

  • HER2. The HER2 status (see Overview) helps determine whether drugs that target the HER2 receptor, for example the antibody treatment trastuzumab (Herceptin), might help treat the cancer. In addition, about 50% of HER2-positive tumors also have hormone receptors and can benefit from both hormone and HER2 directed therapy. Read ASCO’s and CAP's recommendations for HER2 testing for breast cancer

  • Grade. The tumor grade is also determined from a biopsy. Grade refers to how different the cancer cells look from healthy cells, and whether they appear slower growing or faster growing. There are three grades: grade 1 (well differentiated), grade 2 (moderately differentiated), and grade 3 (poorly differentiated).

Your doctor may recommend additional laboratory tests on your tumor sample to identify specific genes, proteins, and other factors unique to the tumor. This helps your doctor find out the subtype of cancer.

Genomic tests to predict recurrence risk

Tests that take an even closer look at the biology of the tumor are commonly used to understand more about a woman’s breast cancer, particularly for a cancer that has not spread to other organs. These tests can help estimate the risk of cancer recurrence in the years after diagnosis. They can also predict whether a treatment will be helpful to reduce the risk of cancer recurrence. This helps some patients avoid the possible side effects of a treatment that is not likely to work well.

The tests described below are typically done on tissue removed during surgery. Most patients will not need an extra biopsy or more surgery. For more information about genomic tests, what they mean, and how the results might affect your treatment plan, talk with your doctor.

  • Oncotype Dx™. This test evaluates 16 cancer-related genes and 5 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) 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. Although this test is typically used for patients with breast cancer that has not spread to the lymph nodes, recent research suggests that this test may be useful for some patients with cancer that has spread to the lymph nodes.

  • Mammaprint™. This test uses information from 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. This test is more common in Europe than in the United States.

  • Additional tests. Other tests are being researched and may become additional tools to guide treatment options in the future. These tests include the following, among others:

    • Breast cancer index (BCI)

    • Prosigna™ (PAM50)

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 well.

  • 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 tumor proteins in a person's blood. Higher 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 such testing 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. Most patients with early-stage breast cancer do not need additional imaging tests.

  • X-ray. 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.

  • Bone scan. 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.

  • Computed tomography (CT or CAT) scan. A CT 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.

  • Positron emission tomography (PET) scan. A 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 determine the location of the bright spots more accurately. 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 amount of cancer in the body; this is called staging. If there are suspicious areas found outside of the breast, at least one area may be biopsied if possible to confirm the diagnosis of cancer.

The next section in this guide is Stages, and it explains the system doctors use to describe the extent of the disease. Or, use the menu on the side of your screen to choose another section to continue reading this guide. 

Breast Cancer - Stages

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

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.

TNM staging system

The most commonly used tool that doctors use to describe the stage is the TNM system. Doctors use the results from diagnostic tests and scans to answer these questions:

  • Tumor (T): How large is the primary tumor? Where is it located?

  • Node (N): Has the tumor spread to the lymph nodes? If so, where and how many?  

  • Metastasis (M): Has the cancer metastasized to other parts of the body? If so, where and how much?

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, which may include physical examination, mammogram, ultrasound, 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 (T)

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 develop into an invasive breast cancer later. 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 5 mm 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 (N)

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 microscope. This is often called a micrometastasis.

N1: The cancer has spread to one to three axillary lymph nodes under the arm, and is at least 2 mm in size. This is called a macrometastasis. 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 4 to 9 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.

Metastasis (M)

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 5 to 7 days after surgery. When systemic or whole body treatment is given before surgery, called neoadjuvant therapy, the stage of the cancer is primarily determined clinically. Doctors may refer to stage I to stage IIA cancer as early stage, and stage IIB to stage III as locally advanced.

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 4 to 9 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).

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 found when the cancer is first diagnosed occurs about 5% to 6% of the time. This may be called de novo metastatic breast cancer. Most commonly, metastatic breast cancer is found after a previous diagnosis of early 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 the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

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 published by Springer-Verlag New York, www.cancerstaging.net.

Information about the cancer’s stage will help the doctor recommend a specific treatment plan. The next section in this guide is Treatment Options. Or, use the menu on the side of your screen to choose another section to continue reading this guide. 

Breast Cancer - Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

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 known 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 About Clinical Trials and Latest Research sections.

Treatment overview

In cancer care, doctors specializing in different areas of cancer treatment—such as surgery, radiation oncology, and medical oncology—work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. Cancer care teams also include a variety of other health care professionals, including physician assistants, oncology nurses, social workers, pharmacists, counselors, nutritionists, and others.

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

  • The stage of the tumor

  • The tumor’s subtype, including hormone receptor status (ER, PR) and HER2 status (see Overview)

  • Genomic markers, such as Oncotype DX™ and Mammaprint™ (if appropriate) (See Diagnosis)

  • 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 the breast cancer 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 healthy 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 systemic treatment with chemotherapy or hormonal therapy before surgery, called neoadjuvant therapy. There may be several benefits to having other treatments before surgery:

  • Women who may have needed a mastectomy could have breast conserving surgery (lumpectomy) if the tumor shrinks before surgery

  • Surgery may be easier to perform

  • Your doctor may find out if certain treatments work well for the cancer

  • Women may also be able to try a new treatment through a clinical trial

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 undetectable but are believed to be responsible for both local and distant recurrence of cancer. Treatment given after surgery is called adjuvant therapy. Adjuvant therapies may include radiation therapy, chemotherapy, targeted therapy, and/or hormonal therapy (see below for more information on each of 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, available at another, independent website called www.adjuvantonline.com, is a tool that your doctor can use 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™) may be also used to better understand the risks from the cancer and whether chemotherapy will help reduce those risks.

When surgery to remove the cancer is not possible, it is called inoperable. The doctor will then recommend treating the cancer in other ways. Chemotherapy, targeted therapy, radiation therapy, and/or hormonal therapy may be given to shrink the cancer.

For recurrent cancer and metastatic cancer, treatment options depend 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 during and after treatment. Learn more about making treatment decisions.

Surgery

Surgery is the removal of the tumor and some surrounding healthy 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. Learn more about the basics of cancer 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 healthy 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 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. It is important to find out whether any of the lymph nodes near the breast contain cancer. This information is used to determine treatment and prognosis.

  • 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 lower the risk of several possible side effects, including swelling of the arm called lymphedema, 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. If only one or two sentinel lymph nodes have cancer and you plan to have a lumpectomy and radiation therapy to the entire breast, an axillary lymph node dissection is not needed. 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 containing 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 form 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.

The techniques discussed below are typically used to shape a new breast.

  • Implants. A breast implant uses saline-filled or silicone gel-filled forms to reshape the breast. The outside of a saline-filled implant is made up of silicone, and it is filled with sterile saline, which is salt water. Silicone gel-filled implants are filled with silicone instead of saline. They were thought to cause connective tissue disorders, but clear evidence of this has not been found. Before having permanent implants, a woman may temporarily have a tissue expander placed that will create the correct sized pocked for the implant. Talk with your doctor about the benefits and risks of silicone versus saline implants. Other important factors to consider when choosing implants include:

    • Saline implants sometimes "crinkle" at the top or shift with time, but many women don't find it bothersome enough to replace.

    • Saline implants tend to feel different than silicone implants.  They are often firmer to the touch than silicone implants.

    • There can be problems with breast implants. The implants can rupture or break, cause pain and scar tissue around the implant, or get infected. Some women may also have problems with the shape or appearance. Although these problems are very unusual, talk with your doctor about the risks.

  • Tissue flap procedures. These techniques use muscle and tissue from elsewhere in the body to reshape the breast. There are several flap procedures:

    • Transverse rectus abdominis muscle (TRAM) flap. This method uses muscle and tissue from the lower stomach wall.

    • Latissimus dorsi flap, which uses muscle and tissue from the upper back.

    • Deep inferior epigastric artery perforator (DIEP) flap. The DIEP flap takes tissue from the abdomen and the surgeon attaches the blood vessels to the chest wall. 

    • Gluteal free flap. The gluteal free flap uses tissue and muscle from the buttocks to create the breast, and the surgeon also attaches the blood vessels.  

    Because blood vessels are involved with flap procedures, they are usually not recommended for a woman with a history of diabetes or connective tissue or vascular disease, or for a woman who smokes, as the risk of problems during and after surgery is much higher.

    The DIEP and gluteal free flap procedures are longer procedures and the recovery time is longer, but the appearance of the breast may be preferred, especially when radiation therapy is part of the treatment plan.

Talk with your doctor for more information about reconstruction options. When considering a plastic surgeon, choose a doctor who has experience with a variety of reconstructive surgeries, including implants and flap procedures, and can discuss the pros and cons of each procedure.

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. These can be made of silicone or soft material, and fit into a mastectomy bra. 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 the surrounding area.

The long-term survival of women who choose lumpectomy is exactly the same as those who have a mastectomy. Even with a mastectomy, not all breast tissue can be removed and there is still a chance of recurrence.  

Women with a very high risk of developing a new cancer in the other breast may consider a bilateral mastectomy, meaning both breasts are removed. This includes women with BRCA1 or BRCA2 gene mutations and women with cancer in both breasts. Having a healthy breast removed in a bilateral mastectomy neither prevents cancer recurrence nor improves a woman’s survival. In addition, it may be linked with a greater risk of complications.

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 typically reserved for a small cancer with no evidence that it has spread to the lymph nodes. Learn more about the basics of radiation therapy.

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 less than 5% in the 10 years after treatment, and survival is the same with lumpectomy or mastectomy.

Adjuvant radiation therapy may 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 healthy 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. This approach is quite uncommon and is only considered when a tumor cannot be removed by surgery.

Radiation therapy can cause 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, and this tends to heal with time. 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 5 to 6 weeks. This often includes radiation therapy to the whole breast the first 4 to 5 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 a patient with a larger tumor, 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 5 days a week for 5 to 6 weeks.

There has been growing interest in the use of newer regimens that shorten the length of radiation treatment from 5 to 6 weeks to 3 to 4 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 3 to 4 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 5 days, and others are researching a 3-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 when lymph nodes are not involved, called 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).

These shorter schedules may not be options for women who need radiation therapy after a mastectomy or radiation therapy to their lymph nodes. Also, longer schedules of radiation therapy may be needed for some women with very large breast size. More research is being done to find out whether younger patients or those who need radiation therapy after chemotherapy may also be eligible for these shorter radiation schedules.

  • 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 includes the use of plastic catheters or a metal wand placed temporarily in the breast. Breast brachytherapy can involve short treatment times, ranging from 1 dose to 1 week, or it can be given as 1 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 may decrease possible damage to nearby organs, such as the heart and lung, and 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.

    IMRT is not recommended for everyone. Talk with your radiation oncology doctor to learn more. Special insurance approval may also be needed for coverage for IMRT, so 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 a small tumor

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 radiation does not lengthen women’s 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 a low-risk tumor could reasonably choose not to have radiation therapy and use only systemic 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.

Systemic therapy

Systemic therapy is treatment taken by mouth or through a vein that gets into the bloodstream to reach cancer cells throughout the body. There are three general categories of systemic therapy used for breast cancer: chemotherapy, hormonal therapy, and targeted therapy. Each treatment is described below in more detail. Treatment options are based on information about the cancer and your overall health and treatment preferences.

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. 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 make surgery easier, called neoadjuvant chemotherapy. It may also be given after surgery to reduce the risk of recurrence, called adjuvant chemotherapy. Chemotherapy may also be 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 (epirubicin, cyclophosphamide)

  • TAC (docetaxel, doxorubicin, and cyclophosphamide)

  • TC (docetaxel and cyclophosphamide)

Therapies that target the HER2 receptor may be given with chemotherapy for HER2-positive breast cancer (see Targeted therapy, below). One example is the antibody trastuzumab. Combination regimens for HER2-positive breast cancer may include:

  • ACTH (doxorubicin, cyclophosphamide, paclitaxel, trastuzumab)

  • TCH (docetaxel, carboplatin, trastuzumab)

  • THP (paclitaxel or docetaxel, trastuzumab, pertuzumab)

  • TCHP (docetaxel, carboplatin, trastuzumab, pertuzumab)

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 very successfully prevented or managed during treatment with supportive medications, 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. Many patients feel well during chemotherapy treatment and are active taking care of their families, working, and exercising during treatment, although each person’s experience can be different. Talk with your health care team about the possible side effects of your specific chemotherapy plan.

Learn more about the basics of 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 (called ER-positive or PR-positive; see Overview), in both early-stage and metastatic breast 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. 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. Common side effects of tamoxifen include hot flashes; vaginal dryness, discharge or bleeding; very rare risks include a cancer of the lining of the uterus; cataracts; and 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). 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 (Aromasin). 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 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 undesirable 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 prescribed hormonal therapy have several options: start therapy with an AI for up to 5 years, begin treatment with tamoxifen for 2 to 3 years and then switch to an AI for 2 to 3 years, or take tamoxifen for 5 years then switch to an AI for up to 5 years, in what is called extended hormonal therapy. Recent research has shown that taking tamoxifen for up to 10 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.

Hormonal therapy for premenopausal women

As noted above, premenopausal women should not take AIs, as they are not effective. Options for adjuvant hormonal therapy for premenopausal women include the following:

  • Five or more years of tamoxifen, with switching to an AI after menopause begins

  • Either tamoxifen or an AI 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.

Hormonal therapy for metastatic breast cancer

Hormonal therapies are also commonly used to treat metastatic breast cancer. Options include:

  • Tamoxifen

  • Ovarian suppression

  • AIs

  • Fulvestrant (Faslodex) 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 2 weeks for 3 doses and continued monthly. 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 (see below) 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. These treatments are very focused, and work differently than chemotherapy. 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 the basics of targeted treatments.

The first approved targeted therapies for breast cancer were hormonal therapies. Then, HER2 targeted therapies were approved to treat HER2-positive breast cancer. Newer medications, including palbociclib (Ibrance) and Everolimus (Afinitor), are targeted therapies approved for metastatic ER-positive HER2-negative 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 HER2-positive breast cancer and as an adjuvant therapy for non-metastatic HER2-positive breast cancer. Currently, patients with stage I to stage III breast cancer receive a trastuzumab-based regimen often including a combination of trastuzumab with chemotherapy, followed by completion of one year of adjuvant trastuzumab. For metastatic cancer, trastuzumab can be 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 may go away and can be treatable with medication.

  • Pertuzumab (Perjeta) 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 chemotherapy 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 chemotherapy 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 chemotherapy.

  • Ado-trastuzumab emtansine or T-DM1(Kadcyla) 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 one medication that is a combination of trastuzumab linked to a type of chemotherapy. This allows the drug to deliver chemotherapy into the cancer cell while lessening the chemotherapy received by healthy cells. T-DM1 is given by vein every 3 weeks. Studies are now testing T-DM1 as a treatment for early-stage breast cancer.

  • Lapatinib (Tykerb) is available 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 cancer is growing while on trastuzumab. Lapatinib is considered following treatment with T-DM1. Lapatinib may also have some ability to penetrate into the brain, and may be considered when treating HER2 positive breast cancer that has spread to the brain.

Targeted therapy for metastatic hormone receptor-positive breast cancer

  • Palbociclib is a targeted therapy approved as an initial treatment by the FDA in combination with the AI letrozole. Palbociclib targets a protein in breast cancer cells called CDK4/6, which may stimulate cancer cell growth. This treatment combination is an option for women who have been through menopause and have ER-positive, HER2-negative metastatic breast cancer. Palbociclib generally has few side effects, but can cause fewer numbers of infection-fighting cells in the body.

  • Everolimus is a targeted therapy approved in combination with the AI exemestane in ER-positive, HER2-negative breast cancer that has grown despite treatment with another AI. Everolimus targets a protein called mTOR that is thought to be important in cancer cells’ resistance to hormonal therapies. Side effects of everolimus can include mouth sores and, rarely, an inflammation of the lungs called interstitial pneumonitis.

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.

Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process. 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, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, or 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 palliative 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 can be addressed as quickly as possible. Learn more about palliative care

Recurrent breast cancer

If the cancer does return after treatment for early-stage disease, it is called recurrent cancer. When breast cancer recurs, it may come back in the following parts of the body:

  • The same place as the original cancer, which is called a local recurrence.

  • The chest wall or lymph nodes under the arm or in the chest. This is called a regional recurrence.

  • Another place, including distant organs such as the bones, lungs, liver, and brain. This is called a distant recurrence or a metastatic recurrence. For more information on a metastatic recurrence, see the Metastatic breast cancer section below.

When breast cancer recurs, a cycle of testing will begin again to learn as much as possible about the recurrence. Testing may include imaging tests, such as those discussed in the Diagnosis section. In addition, another biopsy may be needed to confirm the breast cancer recurrence and learn about the features of the cancer.

After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the treatments 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. The treatment options for recurrent breast cancer depend on the following factors:

  • Previous treatment(s) for the original cancer

  • Time since the original diagnosis

  • Location of the recurrence

  • Characteristics of the tumor, such as ER, PR, and HER2 status

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.

Treatment options for a local or regional breast cancer recurrence

A local or regional recurrence is often manageable and may be curable. The treatment options are explained below:

  • For women with a local recurrence in 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. However, if radiation therapy has already been given for the initial cancer, this may not be an option. 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 therapy, chemotherapy, hormonal therapy, and targeted therapy. These are used depending on the tumor and the type of treatment previously received.

Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.

Metastatic breast cancer

If cancer has spread to another location in the body or comes back in a distant location, it is called metastatic breast cancer. In general, metastatic breast cancer is incurable, although it is generally treatable and controlled for some time. Some patients live years after a metastatic recurrence of breast cancer, depending on a number of factors.

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 getting 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. Palliative 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 introductory information on coping with the diagnosis.

If treatment fails

Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal. At some point, options for treatment become very limited and the cancer will become difficult to control.

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

Patients who have advanced cancer and who are expected to live less than six months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in 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 in this guide is About Clinical Trials and it offers more information about research studies that are focused on finding better ways to care for people with cancer. Or, use the menu on the side of your screen to choose 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, 08/2015

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.

What are clinical trials?

Doctors and scientists are always looking for better ways to care for patients with breast cancer. To make scientific advances, doctors create research studies involving volunteers, called clinical trials. In fact, every drug that is now approved by the U.S. Food and Drug Administration (FDA) was previously tested in 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.

Deciding to join a clinical trial

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, in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” However, placebos are usually combined with standard treatment in most cancer clinical trials. 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.

Patient safety and informed consent

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.

Insurance coverage of clinical trial costs differs by location and by study. 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.

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.

Finding a clinical trial

Research through clinical trials is ongoing for all types of cancer. For specific topics being studied for breast cancer, learn more in the Latest Research section.

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.

In addition, this website offers free access to a video-based educational program about cancer clinical trials, located outside of this guide.

The next section in this guide is Latest Research and it explains areas of scientific research currently going on for this type of cancer. Or, use the menu on the side of your screen to choose another section to continue reading this guide.   

Breast Cancer - Latest Research

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

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, diet, and lifestyle choices, to find other ways to help prevent the disease

  • New ways to prevent breast cancer and 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 in this guide is Coping with Side Effects and it offers some guidance in how to cope with the physical, emotional, and social changes that cancer and its treatment can bring. Or, use the menu on the side of your screen to choose 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, 08/2015

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 in addition to treatment to slow, stop, or eliminate the cancer, preventing and controlling side effects is a major focus of your health care team. This is called palliative care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

There are possible side effects for every cancer treatment, but patients don’t experience the same side effects when given the same treatments for many reasons. That can make it hard to predict exactly how you will feel during treatment. 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.

Talking with your health care team about side effects

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 Follow-up Care and Monitoring section of this guide or talking with your doctor.

The next section in this guide is Follow-up Care and Monitoring and it explains the importance of check-ups after cancer treatment is finished. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Breast Cancer - Follow-Up Care and Monitoring

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

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

Care for people diagnosed with cancer doesn’t end when active treatment has finished. Your health care team will continue to check to make sure the cancer has not returned, manage any side effects, and monitor your overall health. This is called follow-up care.

This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. In some instances, patients may be able to visit survivorship clinics that specialize in the post-treatment needs of people diagnosed with breast cancer.

Learn more about the importance of follow-up care.

Watching for recurrence

One goal of follow-up care is to check for a recurrence. Cancer recurs because small areas of cancer cells may remain undetected in the body. Over time, these cells may increase in number until they show up on test results or cause signs or symptoms.

During follow-up care, a doctor familiar with your medical history can give you personalized information about your risk of recurrence. Understanding your 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.

Breast cancer can come back in the breast or other areas of the body. Generally, a recurrence is found when a person has symptoms or an abnormal finding on physical examination. The 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

  • Changes in vision

  • Changes in energy levels, such as feeling ill or extremely tired

  • Having a low appetite and/or weight loss

Your doctor will also ask specific questions about your health. Some people may have blood tests or imaging tests as part of regular follow-up care, but testing recommendations depend on several factors including the type and stage of cancer originally diagnosed and the types of treatment given.

Managing long-term and late side effects

Most people expect to experience side effects when receiving treatment. However, it is often surprising to survivors that some side effects may linger beyond the treatment period. These are called long-term side effects. In addition, other side effects called late effects may develop months or even years afterwards. Long-term and late effects can include both physical and emotional changes.

Talk with your doctor about your risk of developing such side effects based on the type of cancer, your individual treatment plan, and your overall health. If you had a treatment known to cause specific late effects, you may also have certain physical examinations, scans, or blood tests to help find and manage them.

  • Long-term effects of surgery. 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 survivors.

  • Long-term effects of radiation therapy. 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 may seem similar to the symptoms of pneumonia but do not go away with antibiotics. The symptoms can be treated with medications called steroids. Most patients fully recover with treatment. Talk with your doctor if you develop any new symptoms after radiation therapy or if the side effects are not going away.

  • Long-term effects of trastuzumab and/or chemotherapy. 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.

  • Long-term effects of hormonal therapy. 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 periodically during treatment, 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 with medications or other options. Women recovering from breast cancer may also experience the following long-term effects:

  • Neuropathy

  • Menopausal symptoms

  • Joint pain

  • Fatigue

  • Mood changes

  • 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.

Keeping personal health records

You and your doctor should work together to develop a personalized follow-up care plan. Be sure to ask about any concerns you have about your future physical or emotional health. ASCO offers forms to help create a treatment summary to keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed.

This is also a good time to decide who will lead your follow-up care. Some survivors continue to see their oncologist, while others transition back to the general care of their family doctor or another health care professional. This decision depends on several factors, including the type and stage of cancer, side effects, health insurance rules, and your personal preferences.

If a doctor who was not directly involved in your cancer care will lead your follow-up care, be sure to share your cancer treatment summary and survivorship care plan forms with him or her, as well as all future health care providers. Details about your cancer treatment are very valuable to the health care professionals who will care for you throughout your lifetime.

The next section in this guide is Survivorship and it describes how to cope with challenges in everyday life after a cancer diagnosis. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Breast Cancer - Survivorship

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will read about how to cope with challenges in everyday life after a breast cancer diagnosis. To see other pages, use the menu on the side of your screen.

What is survivorship?

The word survivorship means different things to different people. Two common definitions include:

  • Having no signs of cancer after finishing treatment.

  • The process of living with, through, and beyond cancer. According to this definition, cancer survivorship begins at diagnosis and includes people who continue to have treatment over the long term, to either reduce the risk of recurrence or to manage chronic disease.

In some ways, survivorship is one of the most complex aspects of the cancer experience because it is different for every person.

Survivors may experience a mixture of strong feelings, including joy, concern, relief, guilt, and fear. Some people say they appreciate life more after a cancer diagnosis and have gained a greater acceptance of themselves. Others become very anxious about their health and uncertain of how to cope with everyday life. Some people may even prefer to put the experience behind them and feel that their lives have not changed in a major way.

Survivors may feel some stress when frequent visits to the health care team end following treatment. Often, relationships built with the cancer care team provide a sense of security during treatment, and people miss this source of support. This may be especially true as new worries and challenges surface over time, such as any late effects of treatment, emotional challenges including fear of recurrence, sexuality and fertility concerns, and financial and workplace issues.

Every survivor has individual concerns and challenges. With any challenge, a good first step is being able to recognize your fears and talk about them. Effective coping requires:

  • Understanding the challenge you are facing,

  • Thinking through solutions,

  • Asking for and allowing the support of others, and

  • Feeling comfortable with the course of action you choose.

Many survivors find it helpful to join an in-person support group or an online community of survivors. This allows you to talk with people who have had similar first-hand experiences. Other options for finding support include talking with a friend or member of your health care team, individual counseling, or asking for assistance at the learning resource center of the center where you received treatment.

Changing role of caregivers

Family members and friends may also go through periods of transition. A caregiver plays a very important role in supporting a person diagnosed with cancer, providing physical, emotional, and practical care on a daily or as-needed basis. Many caregivers become focused on providing this support, especially if the treatment period lasts for many months or longer.

However, as treatment is completed, the caregiver's role often changes. Eventually, the need for caregiving related to the cancer diagnosis will become much less or come to an end. Caregivers can learn more about adjusting to life after caregiving in this article.

A new perspective on your health

For many people, survivorship serves as a strong motivator to make positive lifestyle changes.

People recovering from breast cancer are encouraged to follow established guidelines for good health, such as not smoking, limiting alcohol, eating well, and managing stress. Regular physical activity can help rebuild your strength and energy level. Your health care team can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Many people find it easier to stick with an exercise program with a partner. Consider asking your spouse/partner or a friend to join you. Learn more about making healthy lifestyle choices.

In addition, it is important to have recommended medical check-ups and tests (see Follow-up Care and Monitoring) to take care of your health. Cancer rehabilitation may also be recommended, and this could mean any of a wide range of services such as physical therapy, career counseling, pain management, nutritional planning, and/or emotional counseling. The goal of rehabilitation is to help people regain control over many aspects of their lives and remain as independent and productive as possible.

Talk with your doctor to develop a survivorship care plan that is best for your needs.

Looking for More Survivorship Resources?

For more information about cancer survivorship, explore these related items. Please note these links will take you to other sections of Cancer.Net:

  • ASCO Answers Cancer Survivorship Guide: This 44-page booklet (available as a PDF) helps people transition into life after treatment. It includes blank treatment summary and survivorship care plan forms.

  • Cancer.Net Patient Education Video: View a short video led by an ASCO expert that provides information about what comes next after finishing treatment. 

  • Survivorship Resources: Cancer.Net offers an entire area of this website with resources to help survivors, including for survivors in different age groups.

The next section offers Questions to Ask the Doctor to help start conversations with your cancer care team. Or, use the menu on the side of your screen to choose 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, 08/2015

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 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 after getting a diagnosis

  • 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?

  • 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?

  • I 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?

  • Do you have a social worker I can speak with?

  • What should I tell my employer, if anything, and what laws protect my rights as an employee?

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? Is reconstruction (plastic surgery) an option for me? What are the advantages and disadvantages to this? Is it possible to avoid removing my nipple and areola?

  • 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?

  • Will I need radiation therapy after surgery? Does this affect my reconstruction options?

  • 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 are my biomarkers? What do these 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 avoid?

  • 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 genomic testing of the tumor?

  • Do you share electronic records with my surgeon?

  • 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 genetic 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 additional treatment?

  • 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?

  • If I have a strong family history of cancer, what is my chance of getting another cancer?

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 clinical trial options are available?

  • What are the new research advances for this type of cancer?

  • What will happen if this treatment stops working?

  • What 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?

  • What should I consider before deciding to have breast reconstruction?

  • What types of breast reconstruction options are available to me?

  • 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? Does it matter if I sleep on my stomach? Will it be uncomfortable?

  • 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? How well do these options work?

  • 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.

Questions to ask about planning follow-up care

  • What is the risk of the cancer returning? Are there signs and symptoms I should watch for?

  • What long-term side effects or late effects are possible based on the cancer treatment I received?

    • 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?

  • After my treatment has ended, what will my follow-up care plan be?

  • How do I get a treatment summary and survivorship care plan to keep in my personal records?

  • Who will be coordinating my follow-up care?

  • What survivorship support services are available to me? To my family?

The next section in this guide is Additional Resources, and it offers some more resources on this website beyond this guide that may be helpful to you. Or, use the menu on the side of your screen to choose another section to continue reading this guide. 

Breast Cancer - Additional Resources

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

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.

Beyond this guide, here are a few links to help you explore other parts of Cancer.Net:

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.