Breast Cancer Treatment Options by Stage

Overview

A variety of treatments for breast cancer exist, and treatment is available at every stage of cancer. Most people need a combination of two or more treatments.

After diagnosis, your doctor will determine the stage of your cancer. They will then decide on the best treatment options based on your stage and other factors, such as age, family history, genetic mutation status, and personal medical history.

Treatments for early stage breast cancer may not be effective for advanced stage breast cancer. Breast cancer stages range from 0 to 4. Different factors determine your stage, including:

• the size of the tumor
• the number of lymph nodes affected
• whether the cancer has spread to other parts of your body

Doctors use different tests to stage breast cancer. Imaging tests include CT scan, MRI, ultrasound, X-ray, and PET scan.

These can help the doctor narrow down the location of the cancer, calculate tumor size, and determine whether the cancer has spread to other parts of the body.

If an imaging test shows a mass in another part of the body, your doctor can perform a biopsy to see whether the mass is malignant or benign. A physical exam and blood test can also help with staging.

Stage 0 (DCIS)

If precancerous or cancer cells are confined to the milk ducts, it’s called noninvasive breast cancer or ductal carcinoma in situ (DCIS).

Stage 0 breast cancer can become invasive and spread beyond the ducts. Early treatment can stop you from developing invasive breast cancer.

Surgery

In a lumpectomy, the surgeon removes the cancerous cells and spares the rest of the breast. It’s a viable option when DCIS is confined to one area of the breast.

A lumpectomy may be performed as an outpatient procedure. This means you can go home shortly after the surgery and won’t need to stay in a hospital overnight.

A mastectomy is the surgical removal of the breast. It’s recommended when DCIS is found throughout the breast. Surgery to reconstruct the breast can begin at the time of the mastectomy or at a later date.

Radiation therapy

Radiation is a type of targeted therapy. It’s usually recommended after lumpectomy for stage 0 breast cancers. High-energy X-rays are used to destroy cancer cells and prevent them from spreading.

This treatment can lower the risk of recurrence. Radiation therapy is typically administered five days per week over the course of five to seven weeks.

Hormone treatment or targeted therapy

Your doctor may recommend a hormone treatment if you’ve had a lumpectomy or single mastectomy for estrogen receptor-positive or progesterone receptor-positive breast cancer.

Oral hormone treatments, such as tamoxifen, are generally prescribed to lower your risk of developing invasive breast cancer. Hormone treatment may not be prescribed for women who have had a double mastectomy for stage 0 breast cancer.

Your doctor may also recommend trastuzumab (Herceptin), a targeted therapy, if your breast cancer tests positive for excessive HER2 proteins.

Stage 1

Stage 1A breast cancer means the primary tumor is 2 centimeters or less and the axillary lymph nodes aren’t affected. In stage 1B, cancer is found in lymph nodes and there’s no tumor in the breast or the tumor is smaller than 2 centimeters.

Both 1A and 1B are considered early stage invasive breast cancers. Surgery and one or more other therapies may be recommended.

Surgery

Lumpectomy and mastectomy are both options for stage 1 breast cancer. The decision is based on:

• the size and location of the primary tumor
• personal preference
• other factors such as genetic predisposition

Biopsy of the lymph nodes will probably be performed at the same time.

For mastectomy, reconstruction of the breast can begin at the same time if wanted, or after additional treatment is completed.

Radiation therapy

Radiation therapy is often recommended after surgery for stage 1 breast cancer. It may not be necessary for women older than 70 years, especially if hormone therapy is possible.

Chemotherapy and targeted therapy

Breast cancer that’s negative for estrogen, progesterone, and HER2 is called triple negative breast cancer (TNBC). Chemotherapy is almost always needed for these cases because there’s no targeted treatment for TNBC.

Chemotherapy be also be given for hormone-positive breast cancers. Herceptin, a targeted therapy, is given along with chemotherapy for HER2-positive breast cancers. Your doctor may also recommend other HER2-targeted therapies, such as Perjeta or Nerlynx.

However, chemotherapy isn’t always needed for early stage breast cancer, especially if it can be treated with hormone therapy.

Hormone therapy

Doctors may recommend hormone therapy for hormone receptor-positive breast cancers, regardless of tumor size.

Stage 2

In stage 2A, the tumor is smaller than 2 centimeters and has spread to between one and three nearby lymph nodes. Or, it’s between 2 and 5 centimeters and hasn’t spread to lymph nodes.

Stage 2B means the tumor is between 2 and 5 centimeters and has spread to between one and three nearby lymph nodes. Or it’s larger than 5 centimeters and hasn’t spread to any lymph nodes.

You’ll probably need a combination of surgery, chemotherapy, and one or more of the following: targeted therapy, radiation, and hormone treatment.

Surgery

Lumpectomy and mastectomy may both be options depending on the size and location of the tumor.

A modified radical mastectomy is a removal of the breast, including chest muscles. If you choose reconstruction, the process may begin at the same time or after cancer treatment is complete.

Radiation therapy

Radiation therapy targets any remaining cancer cells in the chest and lymph nodes. It’s often recommended after surgery.

Chemotherapy

Chemotherapy is a systemic therapy to kill cancer cells throughout the body. These powerful drugs are delivered intravenously (into a vein) over the course of many weeks or months.

There are a variety of chemotherapy drugs used to treat breast cancer, including:

• docetaxel (Taxotere)
• doxorubicin (Adriamycin)
• cyclophosphamide (Cytoxan)

You may receive a combination of several chemotherapy drugs. Chemotherapy is particularly important for TNBC. Herceptin is given along with chemotherapy for HER2-positive breast cancers.

Your doctor may also recommend other HER2-targeted therapies, such as Perjeta or Nerlynx.

Hormone treatment

After all other treatment is complete, you may benefit from continued treatment for hormone-positive breast cancers.

Oral medications such as tamoxifen or aromatase inhibitors may be prescribed for five or more years.

Stage 3

Stage 3A breast cancer means that the cancer has spread to four to nine axillary (armpit) lymph nodes or has enlarged the internal mammary lymph nodes. The primary tumor may be any size.

It can also mean the tumor is bigger than 5 centimeters and small groups of cancer cells are found in the lymph nodes. Finally, stage 3A can also include tumors greater than 5 centimeters with involvement of one to three axillary lymph nodes or any breastbone nodes.

Stage 3B means a breast tumor has invaded the chest wall or skin and may or may not have invaded up to nine lymph nodes.

Stage 3C means cancer is found in 10 or more axillary lymph nodes, lymph nodes near the collarbone, or internal mammary nodes.

Symptoms of inflammatory breast cancer (IBC) are different from other types of breast cancer. Diagnosis may be delayed since there’s usually no breast lump. By definition, IBC is diagnosed at stage 3B or above.

Treatment

Treatments for stage 3 breast cancers are similar to those for stage 2.

Stage 4

Stage 4 indicates that breast cancer has metastasized (spread to a distant part of the body).

Breast cancer most often spreads to the lungs, brain, liver, or bones. Metastatic breast cancer can’t be cured, but it can be treated with aggressive systemic therapy.

Because the cancer involves different parts of the body, you may need multiple therapies to stop tumor growth and ease symptoms.

Treatment

Depending on how advanced your breast cancer is, you’ll probably have chemotherapy, radiation therapy, and hormone therapy (if you have a hormone receptor-positive cancer).

Another option is targeted therapy, which targets the protein that allows cancer cells to grow. For HER2-positive cancers, HER2-targeted therapies may include Herceptin, Perjeta, Nerlynx, Tykerb, or Kadcyla.

If the cancer spreads to the lymph nodes, you may notice swelling or enlargement of your nodes. Surgery, chemotherapy, and radiation can be used to treat cancer that spreads to the lymph nodes.

The number and location of tumors determines your surgical options.

Surgery isn’t the first line of defense with advanced breast cancer, but your doctor may recommend surgery to treat spinal cord compression, broken bones, and single masses caused by metastasis. This helps relieve pain and other symptoms.

Other drugs used to treat advanced stage breast cancer include:

• antidepressants
• anticonvulsants
• steroids
• local anesthetics

Immunotherapy as an emerging treatment

Immunotherapy is a relatively new treatment option, and while it hasn’t been FDA approved for breast cancer yet, it’s a promising area.

There are several preclinical and clinical studies that suggest that it can improve clinical outcomes for people with breast cancer.

Immunotherapy has fewer side effects than chemotherapy and is less likely to cause resistance. Immunotherapy works by raising the body’s natural defenses to fight off the cancer.

Pembrolizumab is an immune checkpoint inhibitor. It’s a type of immunotherapy that has shown particular promise in the treatment of metastatic breast cancer.

It works by blocking specific antibodies that make it harder for the immune system to fight the cancer, allowing the body to fight back more efficiently. One study found that 37.5 percent of patients with triple-negative breast cancer saw a benefit from the therapy.

Because immunotherapy isn’t FDA approved yet, treatment is mostly available through clinical trials at this time.

Pain management

Breast cancer that spreads to other parts of the body can cause pain, such as bone pain, muscle pain, headaches, and discomfort around the liver. Talk to your doctor about pain management.

Options for mild to moderate pain include acetaminophen and NSAIDs, such as ibuprofen.

For severe pain in a later stage, your doctor may recommend an opioid such as morphine, oxycodone, hydromorphone, or fentanyl.

Factors impacting breast cancer treatment

While breast cancer stage has a lot to do with treatment options, other factors can impact your treatment options as well.

Age

The prognosis for breast cancer is usually worse in women younger than 40 because breast cancer tends to be more aggressive in younger women.

Balancing body image with perceived risk reduction may play a role in the decision between lumpectomy and mastectomy.

In addition to surgery, chemotherapy, and radiation, several years of hormonal therapy for hormone-positive breast cancers is often recommended for young women. This can help prevent a recurrence or spread of breast cancer.

For premenopausal women, ovarian suppression may be recommended in addition to hormone therapy.

Pregnancy

Being pregnant also impacts breast cancer treatment. Breast cancer surgery is usually safe for pregnant women, but doctors may discourage chemotherapy until the second or third trimester.

Hormone therapy and radiation therapy can harm an unborn baby and aren’t recommended during pregnancy.

Tumor growth

Treatment also depends on how fast the cancer grows and spreads.

If you have an aggressive form of breast cancer, your doctor may recommend a more aggressive approach, such as surgery and a combination of other therapies.

Genetic mutation status and family history

Treatment for breast cancer may depend partly on having a close relative with a history of breast cancer or testing positive for a gene that increases the risk of developing breast cancer.

Women with these factors may choose a preventive surgical option, such as a bilateral mastectomy.

Outlook

The prognosis for breast cancer depends, in large part, on the stage at the time of diagnosis. The earlier you’re diagnosed, the better the outcome.

This is why it’s important to conduct monthly breast exams on yourself and to schedule regular annual mammograms beginning at age 40, or younger in some cases.

There are standard treatments for the different types and stages of breast cancer, but your treatment will be tailored to your individual needs.

In addition to the stage at diagnosis, your doctors will consider the type of breast cancer you have and other health factors. Your treatment plan is adjusted according to how well you respond to it.

Clinical trials are research studies that use people to test new treatments. If you’re interested, ask your oncologist for information about available trials.

You can also look into complementary therapies at any stage of breast cancer. These are therapies used in conjunction with standard medical treatments. Many women benefit from therapies like massage, acupuncture, and yoga.

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