Choosing a Breast Cancer Treatment
There is no single treatment for breast cancer. Treatment depends on the cancer's type, stage, lymph-node involvement, and biological characteristics such as hormone-receptor and HER2 status.
Treatment may include surgery, radiation, hormone therapy, chemotherapy, targeted therapy, or immunotherapy. Not every woman needs all—or even most—of these treatments.
An important trend is treatment de-escalation: avoiding treatments when evidence shows they are unlikely to provide meaningful additional benefit.
The goal is not the most treatment possible, but the best balance of benefit, side effects, and quality of life.
Lumpectomy or Mastectomy?
For many women with early-stage breast cancer, lumpectomy followed by radiation and mastectomy provide similar long-term survival. Removing the entire breast does not necessarily improve the chance of surviving breast cancer.
A lumpectomy removes the cancer and a margin of surrounding tissue while preserving most of the breast. It is usually followed by radiation.
A mastectomy removes most or all of the breast. It may be appropriate when the cancer is large relative to the breast, occurs in several areas, cannot be completely removed by lumpectomy, or radiation is not appropriate. Genetic risk and personal preference may also influence the decision.
A useful question is: “Would mastectomy improve my survival compared with lumpectomy and radiation in my case?”
When Is Radiation Needed?
Radiation is commonly given after lumpectomy to reduce the chance of cancer returning in the breast. It may also be recommended after mastectomy when recurrence risk is higher.
But radiation is not necessary for every woman after lumpectomy.
Two major trials—CALGB 9343 and PRIME II—found that in carefully selected older women with small, hormone-receptor-positive cancers receiving hormone therapy, radiation substantially reduced local recurrence but did not improve overall survival.
This creates an individual choice: How much reduction in local recurrence is worth the inconvenience and possible side effects of radiation?
When Is Chemotherapy Needed?
Chemotherapy is important for some breast cancers, but many women with early breast cancer can avoid it.
The decision depends on the cancer's stage, grade, lymph nodes, hormone-receptor and HER2 status, and the woman's age and overall health.
Chemotherapy is more often used for triple-negative, HER2-positive, higher-risk, or more advanced cancers.
For many women with hormone-receptor-positive, HER2-negative early breast cancer, genomic tests such as Oncotype DX can help determine whether chemotherapy is likely to provide meaningful additional benefit.
Chemotherapy may also be given before surgery to shrink a tumor and see how well the cancer responds.
The important question is: “How much additional benefit is chemotherapy expected to provide in my case?”
Can Some DCIS Be Monitored Instead of Treated?
Ductal carcinoma in situ (DCIS) consists of abnormal cells confined within the breast ducts. Standard treatment has generally involved surgery, sometimes followed by radiation and hormone therapy.
But some DCIS may grow very slowly or never become dangerous. Researchers are therefore studying active monitoring for carefully selected low-risk DCIS.
The COMET randomized trial compared active monitoring with standard treatment in women with certain low-risk, hormone-receptor-positive DCIS. Early results found that after two years, active monitoring did not result in a higher rate of invasive breast cancer.
This is promising, but follow-up remains relatively short. Active monitoring is therefore an emerging option for selected women, rather than the established approach for everyone with DCIS.
Is a Second Opinion Worthwhile?
Breast cancer treatment often involves more than one reasonable option. A second opinion may be particularly useful when major surgery is being considered or there is uncertainty about chemotherapy, radiation, or another treatment.
It can also be useful to have the pathology reviewed by another breast pathologist, since the cancer's type, grade, ER, PR, and HER2 results can directly affect treatment.
A second opinion is a way to make sure the diagnosis is clear, alternatives have been considered, and the benefits and disadvantages of each option are understood.
Questions to Ask Your Doctor
What treatment do you recommend, and why?
How much will it reduce my risk of recurrence?
Will it improve survival, or mainly reduce recurrence?
What are the short- and long-term side effects?
What would happen if I chose not to have this treatment?
Is there a less intensive treatment that would give me nearly the same benefit?
Would a genomic test help determine whether I need chemotherapy?
If radiation is recommended, what is my risk with and without it?
Would a second opinion be useful?
Learn More
A comprehensive overview of surgery, radiation, chemotherapy, hormone therapy, targeted therapy, and treatment by stage.
A patient-friendly overview of breast cancer treatment choices and how treatment varies by type and stage.
Long-term randomized trial in women age 70 and older with selected early-stage, estrogen-receptor-positive breast cancer. Radiation reduced local recurrence but did not improve overall survival.
Ten-year randomized trial in women age 65 and older with selected hormone-receptor-positive early breast cancer. Radiation substantially reduced local recurrence, but overall survival was virtually identical.
Randomized trial comparing active monitoring with standard treatment for selected women with low-risk DCIS. Early results suggest some women may be able to avoid immediate surgery, although longer follow-up is needed.
An evidence-focused discussion of whether some women with low-risk DCIS may be able to choose active monitoring rather than immediate surgery.
A discussion of evidence showing that many women with certain early-stage, hormone-receptor-positive breast cancers can avoid chemotherapy.
Video
Mastectomy or Lumpectomy for Breast Cancer? A Complete Guide for Surgery - 8 Minutes
A concise explanation of the differences between lumpectomy and mastectomy and factors that can influence the choice of breast-cancer surgery.