The first set of decisions involves what to do about the breast itself. Today, 80 percent of patients with early stage cancer are candidates for a breast-sparing operation called a "lumpectomy," followed by radiation therapy. But if the tumor is large or there are multiple tumors, it may make sense to have a "modified radical mastectomy," in which the surgeon removes all the breast tissue but spares underlying muscle.
Paradoxically, many women with in situ cancers opt for the more extensive surgery because their doctors have given them a choice of a lumpectomy with radiation (to reduce the odds of recurrence) or a mastectomy without. Even if your doctor is willing to spend a lot of time with you discussing all your options, this is another good time to get a second opinion. This is because the views of doctors about different treatment choices can vary.
As part of your surgery, the doctor will likely want to remove a few lymph nodes in your armpit to see if the cancer has spread. (The first stop outside the breast for invasive cancer is the underarm lymph nodes.) This is called a “sentinel node biopsy” and is done while you are still under anesthetic. If no cancer is found, the other nodes are left in place.
If you choose mastectomy, you’ll then have to decide whether to have reconstructive surgery, at the same time, or later on. Women who choose reconstruction often are given a choice of a saline or silicone implant, or one of several procedures that build a new breastlike mound from tissue from your belly or elsewhere in your body. Each comes with its own benefits and risks. Implants can become hard, leak or burst; transplants of your own tissue are lengthy and difficult operations. Hearing from women who have had the different surgeries — whether in person at a support group or online at a discussion board — may help you figure out which option will best suit you.
If you choose lumpectomy, you’ll most likely need radiation treatments to eradicate any errant cancer cells in the breast. (Some mastectomy patients whose cancer has spread also receive radiation to the chest.) While the standard course of radiation requires daily treatments for five or six weeks, recent studies have shown that early stage breast cancer patients may benefit from a new treatment course in which doctors irradiate just the area surrounding the tumor, not the whole breast. After the tumor has been removed, the doctor inserts a small balloon into the cavity. For five days, high doses of radiation are delivered via a catheter attached to the balloon. After the treatment has been completed, the balloon is removed.
If the cancer is found to have spread beyond the breast, you’ll have to make a decision about "systemic" treatments, called as such because they course throughout your whole body, or system. Your systemic-therapy options — including hormone therapy, immune therapy and chemotherapy — depend on the type of cancer you have and whether the cancer has been found in your lymph nodes, among other factors. There are downsides to all these treatments, however, so it’s important to weigh the risks of your particular type of cancer against the risks of different systemic therapies.
If you are among the 70 percent of patients with "estrogen receptor-positive" tumors (meaning that the cancer cells respond to the hormone estrogen), hormone therapy can help fend off a recurrence. These medications block estrogen from entering cancer cells and spurring their growth. The two most commonly used hormonal therapies are "selective estrogen-receptor modulators," such as tamoxifen, and "aromatase inhibitors," such as anastrozole, exemestane and letrozole.
Although tamoxifen used to be first-line therapy for postmenopausal women, recent studies have found that aromatase inhibitors do a slightly better job. "It probably does not make a major difference whether the aromatase inhibitors are started as the initial treatment or whether they are given after a course of tamoxifen," says Dr. Eric Winer, director of the Breast Oncology Center at the Dana-Farber Cancer Institute in Boston. And for women who are premenopausal at the time of diagnosis, initial treatment with tamoxifen remains the gold standard, Winer adds.