How Breast Cancer Is Treated

Breast cancer treatment has evolved in recent years with a growing number of hormone therapies, targeted drugs, and immunotherapies supporting more traditional approaches, like surgery, radiation, and chemotherapy.

Due to these and other advances, the overall five-year survival rate for breast cancer is 96%, meaning that 96 out of every 100 newly diagnosed women will live for at least five years. With newer drugs in the pipeline—including those better able to cure or manage triple-negative breast cancer more common in Black women—researchers are hoping to extend survival rates even further.

Breast Cancer Surgery

Most women with breast cancer undergo some form of surgery as part of the treatment plan. The principal aims are to remove as much of the cancer as possible and determine if the cancer has spread to nearby lymph nodes.

Surgery may also be used to reconstruct the breast after surgery or relieve symptoms in people with metastatic breast cancer (where cancer has spread beyond the primary site).

Breast-Conserving Surgery

If cancer is detected early, breast-conserving surgery (BCS)—also known as a lumpectomy—can be a safe and effective option. For this procedure, extra tissue surrounding the cancerous tumor will be removed, followed by radiation to destroy all remaining cancerous cells.

Depending on how much tissue is removed, the surgery may also be called quadrantectomy, partial mastectomy, or segmental mastectomy.

Mastectomy

A mastectomy involves surgical removal of the entire breast. A bilateral or double mastectomy is when both breasts are removed. Sometimes other tissues, such as the muscle lying behind the breast, are removed as well.

Mastectomy is not reserved only for women who have breast cancer; it is sometimes performed for those who are at high risk of developing breast cancer.

While mastectomy may be the only option for some women, others may pursue it to reduce the chance of cancer coming back. Whether this is needed is debatable. Studies have shown that, when used appropriately for early-stage cancer, BCS with radiation offers the same survival rate as mastectomy.

Axillary Lymph Node Resection

One of two types of surgery may be used to remove (resect) lymph nodes under your arm to see if they contain cancer cells:

• Sentinel lymph node biopsy (SLNB) is the removal of one or several axillary (underarm) lymph nodes where cancer is most likely to have spread first. Removing only one or a few lowers the risk of lymphedema caused when lymph fluid overloads surrounding tissues, causing swelling.
• Axillary lymph node dissection (ALND) is the removal of usually less than 20 lymph nodes. Though less commonly performed today, ALND may still be the best option for more advanced cancers (although it increases the risk of lymphedema).

The resection and evaluation of lymph nodes help with cancer staging and grading (the process used to determine how advanced and aggressive a cancer is). The resection may be performed as part of breast cancer surgery or on its own.

Breast Reconstruction

Breast reconstruction is used by many women to restore the breast’s appearance after breast cancer surgery. It can be performed at the same time as breast cancer surgery (immediate reconstruction) or a later date (delayed reconstruction).

There are three surgeries commonly used:

• Fat grafting is used to fill in dimples or small pockets following BCS.
• Flap surgery, also known as autologous tissue reconstruction, uses tissues from your abdomen, back, thighs, or buttocks to rebuild the breast following mastectomy.
• Implant surgery involves the insertion of a water balloon (called a "tissue expander") to create a pocket to insert a permanent breast implant.

Other procedures may be used to reconstruct the nipple or improve the overall look of the breast.

As beneficial as breast reconstruction is, the cost of the procedures can be prohibitive. Compared to White women in the United States, Black women are 36% to 71% less likely to pursue breast reconstruction due to cost.

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Radiation Therapy

A type of radiation, called hypofractionated radiation therapy, often follows breast surgery to kill any remaining cancer cells, reducing the risk of recurrence.

Hypofractionated radiation is different from conventional radiation in that higher doses of radiation are given over a shorter period. Conventional radiation consists of lower doses of radiation over six to seven weeks versus three to four weeks with hypofractionated radiation.

Hypofractionated radiation therapy offers the following advantages:

• It may lower the risk of short- and long-term side effects
• It can be less costly (overcoming cost barriers that often limit access for Black and economically disadvantaged women)
• It reduces the number of trips needed to and from the cancer center (which can also impact care)

Chemotherapy

Chemotherapy ("chemo") is any systemic (whole-body) treatment that targets rapidly dividing cells, including cancer cells. Some chemo drugs are pills that you take by mouth, while most are delivered directly into the bloodstream through intravenous (IV) infusion.

Not all women with breast cancer need chemo, but there are several situations in which chemo is recommended:

• Adjuvant chemotherapy is used to kill any remaining cancer cells after treatment to prevent cancer from coming back.
• Neoadjuvant chemotherapy is used to shrink a tumor before breast cancer surgery. In women with triple-negative breast cancer or HER2-positive breast cancer, it can sometimes remove all evidence of cancer.

There are different chemo drugs used for early-stage cancer, including 5-fluorouracil (5-FU) and Cytoxan (cyclophosphamide). Others commonly used for metastatic breast cancer include Adriamycin (doxorubicin and Cisplatin (platinum complex),

Hormone Therapy

The growth of some breast cancer tumors is influenced by the hormone estrogen. Tumors can be tested to determine if they have receptors for estrogen. Those that have receptors are referred to as estrogen-receptor-positive (ER+), while those that don't are estrogen-receptor-negative (ER-).

Around two out of every three breast cancers are ER+. For these cancers, hormone therapies can be prescribed to block the action of estrogen (by binding to the receptors) or lower the amount of estrogen in the body.

Hormone therapy is often used as adjuvant therapy, typically for five years, to reduce the risk of cancer recurrence. It is also sometimes used as neoadjuvant therapy.

Drugs that block estrogen receptors include:

• Selective estrogen receptor modulators (SERMs) like tamoxifen and toremifene
• Selective estrogen receptor degraders (SERDs) like Faslodex (fulvestrant) and Orserdu (elacestrant)

Drugs that lower estrogen levels include:

• Aromatase inhibitors like Femara (letrozole), Arimidex (anastrozole), and Aromasin (exemestane)

Targeted Drug Therapy

Targeted therapy involves drugs that target and bind to specific proteins on cancer cells to kill them or limit their growth.

These targets include a growth-promoting protein called HER2 and certain proteins found on ER+ breast tumors called CDK, mTOR, PI3K, and AKT.

Targeted drugs are also available for tumors with the BRCA gene mutations and those classified as triple-negative breast cancer (which are negative for HER2, estrogen receptors, and progesterone receptors).

The list of targeted drugs used for breast cancer includes:

• Monoclonal antibodies for HER+ breast cancer such as Herceptin (trastuzumab), Perjeta (pertuzumab), and Margenza (argetuximab)
• Kinase inhibitors for HER2+ breast cancer such as Tykerb (lapatinib), Nerlynx (neratinib), and Tukysa (tucatinib)
• CDK inhibitors or ER+ breast cancer such as Ibrance (palbociclib), Kisqali (ribociclib) and Verzenio (abemaciclib)
• An mTOR inhibitor for ER+ breast cancer called Afinitor (everolimus)
• A PI3k inhibitor for ER+ breast cancer called Piqray (alpelisib)
• An AKT inhibitor for ER+ breast cancer called Truqap (capivasertib)
• PARP inhibitors for BRCA mutations such as Lynparza (olaparib) and Talzenna (talazoparib)
• A monoclonal antibody for ER+ and triple-negative breast cancers called Trodelvy (sacituzumab)

Immunotherapy

Immunotherapy is a form of targeted therapy involving drugs that stimulate the immune system to work harder and smarter to detect and destroy cancer cells. Immunotherapy is sometimes combined with chemotherapy to treat triple-negative breast cancer, especially when it metastasizes (spreads).

The drugs used are referred to as immune checkpoint inhibitors. These target and block a protein called programmed cell death protein 1 (PD-1) that helps cancer cells hide from the immune system and grow unchecked.

There is currently one PD-1 inhibitor called Keytruda (pembrolizumab) which can be used for triple-negative breast cancer, either:

• As adjuvant or neoadjuvant therapy for early-stage cancer
• When metastasis has occurred
• When cancer has returned locally and cannot be removed with surgery
  

Special Report: Impact of Breast Cancer on Black Women 

While Black women and White women get breast cancer at about the same rate, Black women are 40% more likely to die from the disease. Many factors contribute to this disparity, ranging from social and economic inequalities to genetics and tumor biology.

For reasons that are not entirely clear, Black women are also twice as likely to have triple-negative breast cancer, a rare but more aggressive form of cancer that does not respond to hormonal treatment. This accounts in part for the lower survival rates among Black women.

Black women also tend to get breast cancer at a younger age than their White counterparts. According to research:

• 23% of breast cancers in Black women are diagnosed before age 50, compared with 16% in White women.
• 8% of Black women are diagnosed with metastatic breast cancer, compared with 5% to 6% of women of other races.

This reinforces the U.S. Preventive Services Task Force's recommendation of starting routine breast cancer screening as early as age 40.

Delays in diagnosis account in part for why Black women are more likely to be diagnosed with larger and more clinically advanced tumors. This means that the course of treatment is usually longer and more arduous than for White women.

Lack of Access to Quality Healthcare

Societal obstacles like a lack of insurance and lower socioeconomic status are significant contributors to delays frequently seen in breast cancer treatment for Black women.

A 2020 study published in the journal Cancer found that Black women have more delays in starting treatment than White women (13.4 % vs. 7.9% respectively) irrespective of their location, education, or socioeconomic status.

Other factors contributing to delayed diagnoses include a general mistrust of medical institutions, particularly public health clinics, and a history of biased medical practices (including the avoidance of more expensive therapies). These can impact a Black woman’s ability to comply with cancer treatments even when money is not a factor.

Summary

Breast cancer treatment can vary by the type and stage of cancer you have and may include surgery, radiation, chemotherapy, hormone therapy, targeted drug therapy, or immunotherapy. The goal may be to cure cancer or to prolong survival with a high quality of life.

Social and economic disparities can adversely affect treatment among Black women who have lower breast cancer survival rates. One way to improve outcomes is to start breast cancer screenings from as early as age 40. Doing so increases the chance of catching cancer early when it is most curable.