Ask a question

Consult Dr. Sangeetha Kolluri

MONDAY | 9am - 4pm
Austin Cancer Centers - Park St. David's
900 E. 30th Street, Suite 100
Austin, TX 78705
512.334.2777

WEDNESDAY | 9am - 4pm
Austin Cancer Centers - Lakeway
200 Medical Parkway, Suite 120
Lakeway, TX 78738
512.334.2881

FRIDAY | 9am - 4pm
Austin Cancer Centers - Kyle
1180 Section Pkwy, Suite 150
Kyle, TX 78640
512.334.5202

Breast cancer treatment

Breast cancer treatments are advancing all the time. People today have more options than ever before.

Your treatment plan will depend on the type of breast cancer, breast cancer stage and your overall health status. Even then, your treatment plan may vary vastly from another person with the same type and stage of breast cancer as you.

In cancer care, doctors specializing in different areas of cancer treatment—such as surgery, radiation oncology, and medical oncology—work together with radiologists and pathologists to create a patient’s overall treatment plan that combines different types of treatments. This type of cooperative team-based care is called multidisciplinary breast care, and is considered the gold standard for breast cancer treatment today.

Additionally, cancer care teams include a variety of other health care professionals, such as physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, nutritionists, and others.

Factors affecting your treatment

There is no single treatment course for breast cancer. Sometimes a tumor may be small but fast growing and other times a large tumor may be slow glowing. When it comes to breast cancer treatment, options and recommendations are personalized depending on several factors, such as:

  • your type of breast cancer
  • how advanced is your cancer, including how far it has spread outside of the breast
  • tumor receptor status: estrogen, progesterone and HER2
  • presence of hereditary genetic mutations such as BRCA1 and BRCA 2

Additionally, factors such as your age, other medical conditions and your personal preferences also play a major role in determining your breast cancer treatment plan.

DCIS and early-stage breast cancer

In both DCIS and early-stage breast cancer, your breast surgeon will discuss your options for surgery to remove the tumor. An important feature of breast cancer surgery is achieving negative margins around the tumor – this means making sure that the tumor is completely surrounded by healthy normal breast tissue before it is removed, to minimize leaving behind any cancer cells.

In addition to surgery, further radiation or chemotherapy may be recommended to prevent any microscopic cancer causing cells to grow into a new tumor.

Large breast cancer tumors

In both large breast cancer tumors and tumors that are fast growing, doctors may recommend chemotherapy before performing surgery. The goal of this approach is to reduce the size of the tumor and thereby make it easier to remove the tumor through surgery. In fact, your breast surgeon may be able to perform a lumpectomy rather than a mastectomy if the tumor is significantly smaller.

Shared decision making

Your breast cancer treatment plan includes treatment for symptoms and side effects, which is 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.

Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. Shared decision making is particularly important for breast cancer because there are different treatment options. It is also important to check with your health insurance company before any treatment begins to make sure the treatment is covered.

Surgery for breast cancer

In breast cancer patients, surgery is performed to remove tumors. Surgery is also used to examine the nearby axillary lymph nodes, which are under the arms. These procedures are performed by surgical oncologists who specialize in treating breast cancer.

Depending on the type of your breast cancer and its staging two types of surgery are performed.

Lumpectomy / Partial Mastectomy

During lumpectomy, a small portion of your breast which contains the tumor is removed. Because you are able to keep your breast, this is called breast conserving surgery. The goal of lumpectomy is to remove tumor while maintaining the appearance of the breast.

Dr. Kolluri routinely uses the BioZorb device in combination with oncoplastic rearrangement to minimize the appearance of the lumpectomy site and decrease the defect associated with lumpectomy. In patients with significant breast ptosis (breast droopiness), a lumpectomy can be combined with a breast reduction or breast lift / mastopexy, performed by a plastic surgeon at the same time as lumpectomy. This is considered breast cancer reconstruction surgery, and is covered by insurance.

Mastectomy

Mastectomy is a surgical procedure to remove the entire breast mound. All mastectomies leave behind 2-5% of breast tissue.

Newer mastectomy techniques can preserve breast skin and allow for a more natural breast appearance following the procedure. This is also known as skin-sparing mastectomy. Additionally, certain patients may be a candidate to save the nipple skin, which is called a nipple-sparing mastectomy.

Surgery to restore shape to your breast — called breast reconstruction — may be done at the same time as your mastectomy or during a second operation at a later date. There are many options for breast reconstruction including DIEP flap, latissimus flap and implant-based reconstruction.

Lymph node removal and analysis

When breast cancer travels in the body, typically the first place it will travel to is the lymph nodes that live in the underarm region. For this reason, it is important to assess whether those lymph nodes have cancer.

Patients with invasive breast cancer will have either a sentinel lymph node biopsy or an axillary lymph node dissection. If a patient has non-invasive breast cancer (DCIS), lymph node surgery may not be indicated.

Sentinel lymph node biopsy

Sentinel nodes are the first few lymph nodes into which cancer drains. Sentinel node biopsy is a surgical procedure to determine whether the primary breast cancer has spread to the lymph nodes as well. Prior to surgery, the breast will be injected with a tracer dye that helps your breast surgeon locate the sentinel lymph nodes during surgery. During the procedure, your surgeon typically identifies 1-3 sentinel nodes and and removes them. This can be done via a small incision in the underarm, or through the mastectomy incision.

If the nodes turn out to be free of any cancer, then your surgeon is unlikely to remove any more nodes. But if cancer is found in your lymph nodes then your surgeon may recommend removal of more lymph nodes and further chemotherapy treatment.

Axillary lymph node dissection

In an axillary lymph node dissection, the surgeon removes all of the lymph nodes from the underarm. Typically, this will be 20-30 lymph nodes.

The goal of this procedure is to check for cancer in lymph nodes of the armpit - how many nodes contain cancer and how much cancer has spread of them.

This procedure significantly increases the risk of lymphedema, which is chronic arm swelling due to lymphatic fluid accumulation. For this reason, lymphedema therapy with a certified therapist is critical to avoiding this complication of surgery and restoring function to the arm.

Breast reconstruction surgery

Women who have had a mastectomy or lumpectomy may want to consider breast reconstruction. You also can choose whether or not to reconstruct your nipple.

For patients having a lumpectomy, reconstruction may be done at the same time to improve the look of the breast and to make both breasts look similar.

For patients who have had a mastectomy, reconstruction surgery involves using either tissue taken from another part of the body or breast implants. Reconstruction is usually performed by a plastic surgeon. A person may be able to have reconstruction at the same time as the mastectomy or may have it at any time in the future.

Autologous or flap reconstruction surgery

This technique uses muscle and tissue from elsewhere in the body such as the back or belly or buttocks or upper thigh and moved to the chest to reshape the breast. During the procedure, blood vessels are cut and the surgeon attaches the moved tissue to new blood vessels in the chest. The gold standard of breast reconstruction is the DIEP flap, which uses skin, fat and blood vessels from the abdomen.

Because blood vessels are involved with flap procedures, these strategies 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.

Talk with your doctor for more information about reconstruction options and a referral to a plastic surgeon. Remember to discuss the pros and cons of each procedure with your plastic surgeon and with women in your support group who have had similar procedures done.

Implant reconstruction

A breast implant uses saline-filled or silicone gel-filled forms to reshape the breast. Before having permanent implants, you may temporarily have a tissue expander placed that will create the correct sized pocket for the implant.

However, there can be problems with breast implants. Some women have problems with the shape or appearance. The implants can rupture or break, cause pain and scar tissue around the implant, or get infected. If subsequent radiation is needed, implants have a higher rate of wound breakdown and infection. Implants have also been rarely linked to other types of cancer.

Although these problems are very unusual, talk with your doctor about the risks. It is also advised to talk to women in your support group who have had breast reconstruction surgery with implants to have a better idea of what it feels like to have an implant.

Breast prosthesis

An external breast prosthesis is an artificial breast, which fits into a special mastectomy bra. It provides an option for women who plan to delay or not have reconstructive surgery. These can be made of silicone or soft material such as a Knitted Knocker. Breast prostheses can be made to provide a good fit and natural appearance for each woman.

Radiation treatment for breast cancer

Radiation therapy for breast cancer involves using high energy x-rays or other particles to kill breast cancer as cancer cells are susceptible to its effects than normal cells. This form of treatment usually involves quick weekday appointments in an outpatient radiation center for 3-6 weeks. External beam radiation is the most common type of radiation treatment and is given from a machine outside the body. This can be done for a full 6 week course, but accelerated and partial breast radiation options are available for select breast cancer candidates which include a faster or lesser course of treatment.

Side effects of radiation therapy

Radiation therapy can cause side effects including fatigue, swelling of the breast, redness and/or skin discoloration and pain or burning in the skin where the radiation was directed, sometimes with blistering or peeling. Your doctor can recommend topical medication to apply to the skin to treat some of these side effects. Most patients recover fully without long term complications, and radiation is extremely well tolerated.

Chemotherapy for breast cancer

Chemotherapy for breast cancer uses drugs to target and destroy breast cancer cells usually by keeping the cancer cells from growing, dividing, and making more cells. These drugs are usually given intravenously through a needle or orally as a pill. A chemotherapy regimen, or schedule, usually consists of a combination of drugs given in a specific number of cycles over a set period of time. The schedule varies depending on the drugs used. Doctors have found that giving the cycles of certain chemo drugs closer together can lower the chance of recurrence and improve survival for women with advanced inoperable breast cancer.

Chemotherapy for breast cancer frequently is used in addition to other treatments, such as surgery, radiation or hormone therapy. Receiving chemotherapy for breast cancer may increase the chance of a cure, decrease the risk of the cancer returning, alleviate symptoms from the cancer or help people with cancer live longer with a better quality of life.

If the cancer has recurred or spread, chemotherapy may control the breast cancer to help you live longer. Or it can help ease symptoms the cancer is causing.

Adjuvant chemotherapy

After you have surgery to remove a tumor, your doctor may recommend chemotherapy to kill any undetected cancer cells which, if left, may continue to form new tumors in the future.

Your doctor may recommend adjuvant chemotherapy if you have a high risk of the cancer recurring or spreading to other parts of your body, even if there is no evidence of cancer after surgery. You may be at higher risk of developing cancer in other parts of your body if cancer cells are found in lymph nodes near the breast with the tumor.

Neoadjuvant chemotherapy

Your doctor may recommend chemotherapy before surgery to shrink larger tumors. This may provide your surgical oncologist the best chance of removing the tumor completely. Neoadjuvant chemotherapy can also lead to a lumpectomy where a mastectomy would have otherwise been the only treatment option.

Neoadjuvant chemotherapy also enables evaluation of the tumor response to therapy, which helps clarify prognosis and the best chemotherapy drug choice.

Side effects of chemotherapy

The side effects of chemotherapy depend on the individual, the drugs used, whether the chemotherapy has been combined with other drugs, the schedule and dose used.

Side effects can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, diarrhea, constipation, numbness and tingling, pain, early menopause, weight gain, and chemo-brain or cognitive dysfunction. These side effects can often be very successfully prevented or managed during treatment with supportive medications, and they usually go away after treatment is finished.

Rarely, long-term side effects may occur, such as heart damage, permanent nerve damage, or secondary cancers such as leukemia or lymphoma.

Hormone therapy for breast cancer

Hormonal therapy, also called endocrine therapy, is an effective treatment for those types of breast cancer with tumors that test positive for either estrogen or progesterone receptors.

This type of tumor uses hormones produced by the body naturally to fuel its growth. Blocking these hormones can help reduce the size of the existing tumor, prevent a cancer recurrence and death from breast cancer.

Hormonal therapy is used either by itself or after chemotherapy.

Neoadjuvant hormonal therapy is sometimes recommended before a breast surgery to remove tumor to shrink the tumor and enable the surgeon to do an effective operation, if chemotherapy cannot be given.

Adjuvant hormonal therapy can be recommended - sometimes for up to 10 years - to prevent the recurrence of cancer in patients with high-risk of developing breast cancer.

Hormonal therapy for premenopausal women

Ovaries produce estrogen and progesterone. These hormones not only govern the menstrual cycles in a premenopausal woman but they also help maintain a healthy skeletal system. But when these hormones fuel your type of breast cancer, then ovarian suppression or ovarian ablation may be recommended

Ovarian suppression and ovarian ablation

Ovarian suppression is the use of drugs to stop the ovaries from producing estrogen. Ovarian ablation is the use of surgery to remove the ovaries. These options may be used in addition to hormonal therapy.

For ovarian suppression, gonadotropin or luteinizing releasing hormone agonist drugs are used to stop the ovaries from making estrogen, causing temporary menopause. Since they are not very effective for treating breast cancer on their own, they are typically given in combination with other hormonal therapy.

For ovarian ablation, surgery to remove the ovaries is used to stop estrogen production. While this is permanent, it can be a good option for women who no longer want to become pregnant, especially since the cost is typically lower over the long term.

Hormonal therapy for women after menopause

Aromatase inhibitors are a class of medicines that reduce the amount of estrogen in your body, depriving breast cancer cells of the hormones they need to grow. Aromatase inhibitors are only used in women who have undergone menopause. They cannot be used unless your body is in natural menopause or in menopause induced by medications or removal of the ovaries.

Aromatase inhibitors are given as pills. Your doctor determines how long you continue aromatase inhibitors depending on your specific situation. Current research suggests that the standard approach would be to take these medications for up to 10 years, but every person is different and you and your doctor should carefully assess how long you should take them.

Targeted therapy for breast cancer

Targeted therapy for breast cancer is a treatment course that uses drugs to target specific genes and proteins that are the root cause for the growth and survival of cancer cells. For example, targeted therapy may block the action of an abnormal protein (such as HER2) that stimulates the growth of breast cancer cells.

Doctors often use targeted therapy along with chemotherapy and other treatments.

Monoclonal antibodies

Monoclonal antibodies are laboratory-manufactured proteins that bind with the certain cancer cancer cells and prevent them from growing and multiplying.

Monoclonal antibody drugs such as Herceptin target HER2-positive tumors. If cancer cells are positive for the HER2 receptors that means there is an overabundance of receptors on the cancer cell for the growth-stimulating HER2 protein.

The tumor acts almost like a magnet for growth hormones, and when the tumor cells connect with growth hormone cells, the cancer can quickly grow and multiply. Herceptin helps shrink these HER2-positive tumors by finding the cells, binding with them, and blocking the action of the receptor.

Side effects that most commonly occur during the first treatment include fever and chills. Other possible side effects include weakness, nausea, vomiting, diarrhea, headaches, difficulty breathing, and rashes.

These side effects generally reduce after the first treatment. Herceptin also may cause heart damage, heart failure, and serious breathing problems. Before and during treatment, your doctor will most likely check your heart and lungs.

Small-molecule drugs

Drugs called small-molecule drugs can block the process that helps cancer cells multiply and spread. Angiogenesis inhibitors are an example of this type of targeted therapy. Angiogenesis is the process for making new blood vessels. A tumor needs blood vessels to bring it nutrients. The nutrients help it grow and spread. Angiogenesis inhibitors starve the tumor by keeping new blood vessels from forming in the tissue around it.

Immunotherapy for breast cancer

Immunotherapy is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. Your immune system is designed to protect you from disease or infection causing bacteria, virus or fungus foreign. When these invaders enter your body, your immune system works to kill them. This self-defense system works to keep you from getting sick.

Immunotherapy uses substances either made naturally by your body or in laboratories to boost the immune system to stop, kill, spread or slow the growth of cancer cells.

To start an immune system response to a foreign invader, the immune system has to be able to tell the difference between cells or substances that are “self” (part of you) vs. “foreign” (not part of you and possibly harmful). Your body’s cells have proteins in them to help the immune system recognize them as “self.” This is part of the reason the immune system usually doesn’t attack your body’s own tissues.

“Foreign” cells have proteins and other substances on their surfaces and inside them that the body doesn’t recognize, called antigens. Foreign antigens trigger the immune system to attack them to either destroy them or keep them in check so they can’t harm the body.

There are two main reasons that stop your immune system from attacking breast cancer tumors.

A breast cancer cell starts out as a normal, healthy cell. Cancer forms out of cells that were once normal and functional to the body. Early breast cancer cells don’t look any different from normal cells. They don’t produce antigens the way that bacteria, viruses, and other foreign materials do — which makes it challenging for the immune system to detect and attack them. But as cells transform into cancer, they do create proteins that the immune system sees as “foreign” antigens. In some cases, the immune system is able to recognize some cancer cells as harmful and stop the process before a cancer can grow further.

Cancer cells develop the ability to avoid the immune system. Breast cancer doesn’t happen overnight; it develops over a period of time. As healthy cells gradually change into cancer cells, the genetic information inside them also changes. Some of these genetic changes allow the cancer cells to avoid detection by the immune system. Other changes allow cancer cells to speed up their growth rate and multiply much more quickly than normal cells do. This process can overwhelm the immune system and allow the breast cancer to grow unchecked.

Immunotherapy medicines can be divided into two main groups:

Active immunotherapy

Active immunotherapy is a treatment in which your immune system is stimulated to attack the cancer cells. Cells from a cancer are examined in the lab to find antigens specific to that tumor. Then an immunotherapy treatment is created that makes the immune system target those antigens. Cancer vaccines and adoptive cell therapy are examples of active immunotherapies.

Passive immunotherapy

Passive immunotherapy gives the body man-made immune system components to help it fight cancer. Passive immunotherapies don’t stimulate your immune system to actively respond the way active immunotherapies do. Immune checkpoint inhibitors and cytokines are examples of passive immunotherapies.

Because immunotherapy medicines help your immune system to kill cancer, the process can take a long time. Right now, it’s not clear how long someone should be treated with immunotherapy. Many experts believe that combining immunotherapies — for example, a vaccine with a checkpoint inhibitor — may be a good way to jump start a strong immune response to cancer. It’s also likely that immunotherapies will be combined with other cancer treatments, such as targeted therapies.

Ask a question

Consult Dr. Sangeetha Kolluri

MONDAY | 9am - 4pm
Austin Cancers Centers - Park St. David's
900 E. 30th Street, Suite 100
Austin, TX 78705
512.334.2777

WEDNESDAY | 9am - 4pm
Austin Cancer Centers - Lakeway
200 Medical Parkway, Suite 120
Lakeway, TX 78738
512.334.2881

FRIDAY | 9am - 4pm
Austin Cancer Centers - Kyle
1180 Section Pkwy, Suite 150
Kyle, TX 78640
512.334.5202