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Treatment for breast cancer usually involves a combination of surgery, chemotherapy, radiotherapy and, in some cases, hormone or biological therapies. The amount and type of treatment you receive will depend on the type of breast cancer you have, its stage and grade, and your overall health.

You will receive treatment from a team of healthcare professionals led by an oncologist (a specialist in cancer). Discuss any fears and concerns that you have with your oncologist as they will be able to explain each phase of your treatment.

Surgery

Most women who have breast cancer will need surgery. This is often the first form of treatment you will receive. There are two types of surgery for breast cancer. These are surgery to remove just the cancerous lump (tumour), which is known as breast-conserving surgery, and surgery to remove the whole breast, which is called a mastectomy. In many cases, a mastectomy can be followed by reconstructive surgery to recreate the removed breast.

In some cases, particularly if the cancer is detected in its early stages, you may be able to choose which type of surgery you would prefer. This is a big decision, so discuss your options fully with your surgeon and oncologist (specialist in cancer). Some women decide that they want to keep their breast if possible while others feel more comfortable having their breast removed.

The two different types of surgery are described in more detail below.

Breast-conserving surgery

The aim of breast-conserving surgery is to save as much of your breast as possible while removing as much of the cancer as possible to prevent it from recurring. You may be able to have breast-conserving surgery if the cancer is in its early stages or has not spread beyond your breast.

Breast-conserving surgery ranges from a lumpectomy or wide local excision, in which just the tumour and a little surrounding breast tissue is removed, to a partial mastectomy or quadrantectomy, in which up to a quarter of your breast is removed.

If you have breast-conserving surgery, the amount of breast tissue you have removed will depend on:

• the type of cancer you have,
• the size of the tumour and where it is in your breast,
• the amount of surrounding tissue which needs to be removed, and
• the size of your breasts.

Your surgeon will always remove an area of healthy breast tissue around the cancer, which will be tested for traces of cancer. If there is no cancer present in the healthy tissue, there is less chance that the cancer will recur. If cancer cells are found in the surrounding tissue, you may need to have more tissue surgically removed from your breast.

After breast-conserving surgery, you will need to have radiotherapy to destroy any remaining cancer cells.

Mastectomy

A mastectomy removes all your breast tissue, including your nipple. You may need to have a mastectomy if the tumour is large or very central in your breast, or if the cancer has spread beyond your breast to other parts of your body.

The type of mastectomy that you have will depend on whether or not the cancer has spread to your lymph nodes (small glands under your breast and in your armpit that filter bacteria from the body), or to your chest wall muscles.

If the cancer has not spread to your lymph nodes, you may have a simple mastectomy in which only your breast is removed. If the cancer has spread to your lymph nodes, you may need a modified or radical mastectomy, in which your breast will be removed along with lymph nodes under your arm or your chest wall muscles.

If you have lymph nodes removed from your armpit during a mastectomy, the scarring can sometimes block the filtering action of the lymph nodes. This is known as lymphoedema and can cause excess fluid to build up in your arm. Lymphoedema can also be caused by radiotherapy.

Lymphoedema can be treated through exercise, massage and using compression sleeves (tightly fitting bandages that push excess fluid out of your arm), but it is a long-term (chronic) condition. Lymphoedema can develop months or sometimes years after surgery. See your breast care nurse or GP if you notice any swelling in your arm or hand on the side of your operation.

Breast reconstruction and prostheses

If you have a mastectomy, you may be able to have reconstructive surgery at the same time or later to recreate your breast. This can be done either by inserting a breast implant or by using tissue from another part of your body to create a new breast.

You decide whether to have reconstructive surgery following a mastectomy and when to have it, as long as there is no medical reason for delaying the surgery. Discuss your options fully with your surgeon and breast nurse before making a decision.

Women who decide against breast reconstruction can wear a false breast or breast prosthesis, which are available free on the NHS. After having a mastectomy, you may have a temporary fibre-filled prosthesis and a permanent prosthesis made from silicone, which can be replaced every two years.

Chemotherapy

Chemotherapy is a specialist treatment for cancer which uses medicines to stop the growth of cancer cells. These medicines are known as cytotoxic, which means that they target rapidly growing cancer cells, stopping them from dividing and multiplying.

Chemotherapy is usually used before radiotherapy to destroy any cancer cells that cannot be removed by surgery, although you may have it before surgery to shrink a large tumour. It can also be used to treat breast cancer that has recurred (come back).

If you need to have chemotherapy, you will probably be given the medicine intravenously (by injection through a vein, directly into your bloodstream). In some cases, you may need to take tablets. There are many different cytotoxic medicines for breast cancer and you will probably be given a combination of three at the same time. As it circulates through your blood, the medicine targets cancer cells in your breast, as well as any that may have spread elsewhere in your body.

If you have not yet been through the menopause, chemotherapy can stop the production of oestrogen in your body (which can encourage the growth of some breast cancers). Your ovaries should start producing oestrogen again once your chemotherapy is over. In a small number of cases, this does not happen and chemotherapy can cause you to enter early menopause.

It is not possible to predict whether or not this will happen, but it is more likely to occur in women over the age of 40 as they are closer to menopausal age. If you do enter menopause as a result of chemotherapy, you will no longer be able to conceive.

You may receive chemotherapy sessions three or four times a week, over a period of four to eight months. Your sessions will be three to four weeks apart to give your body a rest between treatments. The medicine is usually injected over a period of three hours, although in some cases this may be extended to 24 hours. If this is the case, you will need to stay in hospital overnight.

Side effects of chemotherapy

Chemotherapy works by preventing cells, such as those that are cancerous, from growing rapidly. However, there are other cells in your body that divide and multiply rapidly, including hair follicles and red and white blood cells. Chemotherapy also destroys these non-cancerous cells, which can cause many side effects, including:

• hair loss,
• nausea and vomiting,
• diarrhoea or constipation,
• rashes on the skin of your hands and feet,
• loss of appetite,
• sores around your mouth,
• anaemia (tiredness and breathlessness brought on by a lack of red blood cells), and
• leukopenia (infection brought on by a lack of white blood cells).

If you need chemotherapy, the side effects you experience will depend on the type of cytotoxic medicine that you take, the number of treatment sessions you have and your individual reaction to treatment.

If you experience nausea and vomiting as a result of chemotherapy, you may be able to take anti-sickness medication to help it. This may be given intravenously (by injection directly into your bloodstream) at the same time as your chemotherapy.

The side effects of chemotherapy only last as long as your course of treatment. Once your treatment is over, the rapidly growing cells that occur naturally in your body will repair themselves. This means that your hair will grow back, although it may look or feel different to how it did before. For example, it may be a slightly different colour, or softer or curlier than before.

Radiotherapy

Radiotherapy uses high-energy X-rays. Like chemotherapy, it targets rapidly growing cancer cells. Radiotherapy is usually given after chemotherapy to minimise the risk of the cancer recurring following breast-conserving surgery, or to destroy any remaining cancer cells in your lymph nodes under your arm after a mastectomy. It may also be given without chemotherapy if the cancer is detected in its early stages.

If you have radiotherapy, your treatment will begin about a month after your surgery or chemotherapy to give your body a chance to recover. It is a painless procedure in which you lie under a radiotherapy machine while it directs radiation at your affected breast. You will be positioned by your radiographer (a specialist in radiotherapy) so that the machine targets only the cancer cells and avoids as much of your healthy tissue as possible.

You will probably have radiotherapy sessions five days a week for three to six weeks. Each session will only last a few minutes. The radiation does not stay in your system afterwards and it is perfectly safe to be around others between treatments.

Side effects of radiotherapy

As radiotherapy targets rapidly growing cancer cells, like chemotherapy it can have several side effects. Other rapidly growing cells, such as skin cells and the cells that line your digestive system, are also damaged by radiotherapy. The side effects of radiotherapy include:

• irritation and darkening of the skin on your breast,
• fatigue (extreme tiredness), and
• lymphoedema (excess fluid build-up in your arm caused by blockage of the lymph nodes under your arm).

Lymphoedema can develop months or years after radiotherapy. See your breast care nurse or GP if you notice any swelling in your arm or hand on the side of your treatment.

Hormone therapy

If your breast cancer was found to be hormone-receptor positive when it was diagnosed, you may be able to have hormone therapy to further minimise the risk of your breast cancer recurring. For more information about hormone receptor testing, see Diagnosis, above.

Breast cancers that are hormone-receptor positive are stimulated to grow by the hormones oestrogen or progesterone, which are found naturally in your body. Hormone therapy works by lowering the levels of hormones in your body or by stopping their effects. It may be used as the only treatment for breast cancer if your general health prevents you from having surgery, chemotherapy or radiotherapy.

If hormone therapy is suitable for you, your treatment will probably be given after surgery or chemotherapy. In some cases, it may be given before surgery to shrink a large tumour. There are several different hormone therapy medicines, including tamoxifen, aromatase inhibitors and pituitary downregulators. In most cases, you will need to take hormone therapy for up to five years after your breast cancer surgery.

Tamoxifen

Tamoxifen is the most common type of hormone therapy. It is most effective for treating cancers that are oestrogen-receptor positive, although you may be prescribed tamoxifen if your cancer is progesterone-receptor positive. If you are prescribed taxmoxifen, you will need to take it every day by mouth (orally) as either a tablet or a liquid. Tamoxifen can cause several side effects, including:

• tiredness,
• changes to your periods,
• nausea and vomiting,
• hot flushes,
• aching joints,
• headaches, and
• weight gain.

Aromatase inhibitors

Aromatase inhibitors come in brands called Arimidex, Aromasin and Femara. They are only suitable for women who have been through the menopause because they block the oestrogen that is made after the menopause by the adrenal glands. Aromatase inhibitors are taken as a tablet once a day. Aromatase inhibitors can cause side effects, including:

• hot flushes and sweats,
• loss of interest in sex,
• nausea and vomiting,
• tiredness,
• aching joints,
• headaches, and
• skin rashes.

Pituitary downregulators

The most commonly used pituitary downregulator in the treatment of breast cancer is goserelin (Zoladex). It is prescribed to women who are still having periods as it stops the ovaries from producing hormones.

If you are prescribed a pituitary downregulator, your periods will stop while you are taking it. They should start again once your treatment is complete. However, if you are approaching menopause (around the age of 50), you may find that your periods do not start again once you stop taking the pituitary downregulator.

This type of hormone therapy is taken as an injection once a month and can cause menopausal side effects, including:

• hot flushes and sweats,
• mood swings, and
• trouble sleeping.

Biological therapy

If your breast cancer was found to be HER2 positive at the time of diagnosis, you may be able to have biological therapy to further minimise the risk of your breast cancer recurring. Biological therapy can also increase the effects of chemotherapy on breast cancer cells. For more information about HER2 testing, see Diagnosis, above.

Breast cancers that are HER2 positive are stimulated to grow by the protein HER2. Biological therapy works by stopping the effects of HER2 and by helping your immune system to fight off cancer cells.

Trastuzumab (Herceptin)

If you are able to have biological therapy, you will probably be prescribed a medicine called trastuzumab (Herceptin). Trastuzumab is usually used after chemotherapy.

Trastuzumab is a type of biological therapy known as a monoclonal antibody. Antibodies occur naturally in your body and are made by your immune system to destroy harmful cells, such as viruses and bacteria. Trastuzumab targets and destroys cancer cells that are HER2 positive.

If you are prescribed trastuzumab, you will need to have your treatment in hospital as it is given intravenously (an injection directly into your vein). Each treatment session takes up to one hour and the number of sessions you need will depend on whether you have early breast cancer or cancer that is more advanced. On average, you will need one session every three weeks for early breast cancer and weekly sessions if your cancer is more advanced.

Trastuzumab can cause side effects, including heart problems. This means that it is not suitable if you have existing heart problems, such as angina, uncontrolled high blood pressure (hypertension) or heart valve disease. If you need to take trastuzumab, you will have regular tests on your heart to make sure the medication is not causing any problems. Other side effects of trastuzumab include:

• an initial allergic reaction that can cause nausea, wheezing, chills and fever,
• diarrhoea,
• tiredness, and
• aches and pains.

view information about Cancer of the breast female on www.nhs.co.uk »