Breast Cancer Treatments and Medications

What is breast cancer?

Breast cancer is a common cancer of the breast tissues; about 270,000 women in the United States were diagnosed with breast cancer this year. Breast cancer can begin in any of the breast tissues: milk glands (lobules), ducts, or the connective tissue that holds the breast together and attaches it to the chest wall.

• Hormone-sensitive breast cancer. Tumors that begin in lobules and ducts usually have high numbers of female hormone receptors. These cancer cells grow and divide when they attach to estrogen (ER+ breast cancers) or progesterone (PR+). Reducing the levels of female hormones in the body is a central pillar of post-surgical treatment.
• HER2 positive breast cancer. Many breast tissue cells have a protein called human epidermal growth factor 2. Its primary purpose is to stimulate cells to divide and grow. As a result, HER2 positive breast cancer is particularly aggressive and invasive breast cancer. However, HER2 receptors also make these tumors particularly vulnerable to many drugs.
• Triple-negative breast cancer. About 10% to 20% of breast cancers don’t have many estrogen receptors, progesterone receptors, or HER2 receptors, so they’re classified as triple-negative (ER-/PR-/HER-) breast cancer. Other than chemotherapy, many of the drugs developed to fight breast cancer will not work against triple-negative breast cancer tumors.
• Lobular carcinoma. Tumors that begin in milk glands are often estrogen-sensitive (ER+). They can be small and benign (lobular carcinoma in situ) or spread to other parts of the breast and the body (invasive lobular carcinoma).
• Ductal carcinoma. Tumors that begin in the ducts are usually benign (ductal carcinoma in situ) at first, but they have a high probability of invading other breast tissues and the rest of the body if left untreated (invasive ductal carcinoma).
• Breast sarcomas. Though less common, breast cancer can also begin in connective tissues. These cancers are usually not hormone-sensitive.

How is breast cancer diagnosed?

The diagnosis of breast cancer involves several complex steps that only starts with identifying the cancer. Imaging and a physical examination identify the presence of a tumor, but the final diagnosis will require a tissue biopsy to determine the type and stage of the cancer.

Breast cancer screening

Most patients discover breast cancer in the earliest stages through a routine screening mammogram. There remain some discrepancies amongst organizations as to the appropriate age to routinely begin mammography screening, but overall women 40 to 49 years old at average risk for breast cancer may consider undergoing a mammography every one or two years, and once a woman reaches 50 years of age and is at average risk for breast cancer they should routinely undergo a mammography every one or two years. For women at a high risk of breast cancer based on certain genetic predispositions, the American Cancer Society recommends a yearly mammogram and breast MRI, typically starting at age 30. Overall risk factors for breast cancer include:

• Advancing age
• Female gender
• Personal or family history of breast cancer
• Genetic mutations
• Early menstruation
• Early pregnancy
• Late menopause
• History of hormone replacement therapy

Breast cancer symptoms

The majority of patients have no symptoms when they are first diagnosed with breast cancer. When people do notice symptoms, the most common ones are a lump in the breast, breast pain, and nipple discharge. Advanced breast cancer might have symptoms such as “orange peel skin,” swelling, redness, or sores.

Evaluation

Once a concern for breast cancer has been identified through routine screening, the next step is to determine the type and stage of cancer such as:

• Ultrasound images may be used on women with dense breast tissues. An MRI may be used to get a better picture of the cancer.
• Definitive diagnostics include biopsy, in which a sample of the suspicious tissue is removed for microscopic examination and genetic and receptor testing by a pathologist. This will help determine the presence and type of breast cancer, along with appropriate treatment options. The sample tissue will most likely be removed by a needle. In cases where a biopsy comes up negative but suspicions remain high, the doctor may remove the entire lump for evaluation, a procedure called excision. This is more invasive than a needle biopsy and will require more time to heal.

Treatment plan

The final product of a breast cancer diagnosis will be a treatment plan. The cancer care team will consist of many healthcare professionals which could include a surgical oncologist, radiation oncologist, medical oncologist, endocrinologist (a doctor who specializes in hormone diseases), plastic surgeon, radiologist, and pathologist. Clinical pharmacists are also often very involved in assisting the medical oncologists identify the best medications and dosages.

Breast cancer treatment options

Surgery is the foundation of breast cancer treatment. Radiation therapy and medications are used to shrink a tumor before surgery or eradicate any remaining cancer cells after surgery. Most patients will take two to five years of hormone therapy medications to prevent a recurrence.

Surgery

The first-line treatment for breast cancer treatment is the surgical removal of the breast tumor. The type of surgery will depend on the cancer’s stage. Ovary removal may also be offered to prevent a recurrence.

• Breast-sparing surgery. For early-stage breast cancer, a surgeon can perform a partial mastectomy (lumpectomy) in which the tumor is removed along with surrounding tissues and one or more nearby sentinel lymph nodes, if necessary. Breast-conserving surgery may be preceded by chemotherapy or radiation therapy to shrink the tumor. Radiation therapy or chemotherapy will usually be administered after the surgery to eradicate any remaining cancer cells
• Mastectomy. For more advanced breast cancer, the entire breast, as well as nearby lymph nodes, will be removed in a procedure called a total or simple mastectomy. A radical modified mastectomy will remove the whole breast along with tissues lining the chest muscle, nearby lymph nodes, and the axillary lymph nodes. A mastectomy will be followed by radiation therapy, chemotherapy, and other medical therapies.
• Breast reconstruction. A total mastectomy may be followed by breast reconstructive therapy. Patients can choose implant surgery or tissue flap surgery, in which a plastic surgeon recreates the breast shape using tissues taken from other parts of the body.
• Oophorectomy. Treatment or prevention of hormone-sensitive breast cancer may involve permanently disabling the ovaries through radiation therapy (ovarian oblation) or surgical removal (oophorectomy)

Radiation therapy

Radiation treatment kills cancer cells with high-energy X-rays. Radiation therapy may be used to shrink a tumor before breast cancer surgery, kill any remaining cancer cells following surgery, or permanently suppress the ovarian estrogen production in patients with hormone-sensitive cancer.

Medications

For breast cancer, medications are used to ensure the success of surgical treatment. Neoadjuvant treatment refers to medications used to shrink a tumor before breast cancer surgery. Medications used to eradicate cancer cells after surgery are called adjuvant treatments. Most breast cancer patients will undergo chemotherapy, but the type and length of treatment will depend on the stage of the cancer. Hormone therapy, targeted therapy, and, in very rare cases, immunotherapy will also be used depending on the type of cancer.

Monitoring

Breast cancer has a high recurrence rate, so the key to surviving breast cancer is follow-up monitoring. Regular doctor visits, mammograms, bone density tests, and pelvic exams (for patients taking selective estrogen receptor modulator drugs) will be required for at least five years.

Breast cancer medications

Surgery is the primary treatment for breast cancer. Medications (systemic therapy) are only used to shrink a tumor before surgery, eradicate remaining cancer cells after surgery, or prevent a recurrence. The type of medication prescribed will depend on the tumor cells’ sensitivity to hormones (ER+ or PR+), if the cancer cells have a large number of HER2 receptors (HER2+), the patient’s menopausal status, and the cancer stage.

Chemotherapy

Chemotherapy uses drugs that kill fast-growing cells like tumor cells. Chemotherapy may be used before or after breast cancer surgery and may be combined with other types of drugs. Chemotherapy for breast cancer typically involves a combination of intravenous drugs including anthracyclines (doxorubicin or epirubicin), taxanes (paclitaxel or docetaxel), cyclophosphamide, methotrexate, and platinum agents (carboplatin and cisplatin).

Hormone therapy

Hormone-sensitive breast cancers will be treated with hormone therapy in addition to chemotherapy. Not to be confused with menopausal hormone replacement therapy, breast cancer hormone therapy reduces female hormones in the body to slow the growth of breast cancer tissues.

Selective estrogen receptor modulators (SERMs)

Tamoxifen is the most common first-line treatment for hormone-sensitive breast cancer. Taken for two to five years following surgery, tamoxifen significantly reduces recurrence and mortality. As a selective estrogen receptor modulator, tamoxifen and other drugs such as toremifene and raloxifene slow down tumor growth by preventing estrogen from attaching to tumor cells. However, these drugs do not block estrogen’s effects on other tissues in the body. Both tamoxifen and raloxifene are also FDA-approved to prevent breast cancer in high-risk women.

Aromatase inhibitors

Aromatase inhibitors such as anastrozole and letrozole are also taken for two to five years as a first-line therapy for hormone-sensitive breast cancer. These drugs shut down estrogen production by inactivating an enzyme called aromatase. The ovaries use aromatase to produce estrogen. Another aromatase inhibitor, exemestane, permanently disables aromatase. Doctors may also prescribe anastrozole or exemestane off-label to prevent breast cancer in high-risk, postmenopausal women.

Antiestrogens

Also called estrogen blockers, antiestrogens such as fulvestrant block the effects of estrogen in every cell of the body, not just hormone-sensitive breast cancer cells.

Gonadotropin-releasing hormone agonists

Ovary suppressants such as leuprolide and Synarel (nafarelin) lower estrogen levels in the body. They work by blocking the effects of a hormone, gonadotropin-releasing hormone (GnRH), which stimulates the ovaries to produce estrogen. However, small amounts of estrogen will continue to be produced by the adrenal glands. GnRH agonists can be administered as an injection, or nasal spray.

Targeted therapy

Targeted therapy is called such because it uses drugs or other substances to identify and attack specific components of cancer cells. Targeted therapies are therefore generally less like to cause harm to normal cells, in comparison to conventional chemotherapy. The drug prescribed will depend on the patient’s menopausal status and the cancer’s hormone sensitivity. Types of targeted therapies include monoclonal antibodies and cyclin-dependent kinase inhibitors. Ibrance (palbociclib) is a cyclin-dependent kinase inhibitor used as a first-line targeted therapy for advanced HER-2 negative breast cancer.

Monoclonal antibodies

Monoclonal antibodies are a type of targeted therapy in that they recognize specific proteins on the surface of cancer cells, which they then bind to and block its function, ultimately leading to cancer cell death. Monoclonal antibodies used in breast cancer recognize the HER2 protein in HER2 positive breast cancers. They attach to the protein and ultimately prevent the cancer cells from growing. The three FDA-approved HER2 antibodies, Herceptin (trastuzumab), Perjeta (pertuzumab), and Margenza (margetuximab), are all administered as an intravenous infusion either weekly or tri-weekly and are often combined with chemotherapy agents.

Immunotherapy

For particular types of metastatic triple-negative breast cancer that cannot be removed by surgery, intravenous immunotherapy agents might be added to a chemotherapy regimen. Specific immunotherapy agents used in breast cancer are of a class known as checkpoint inhibitors and include drugs Keytruda (pembrolizumab) and Tecentriq (atezolizumab). These drugs utilize the immune system to kill off the tumor. However, they have limited effectiveness for breast cancer unless combined with other drugs. Breast cancer is an immunologically “cold” cancer, that is, the immune system does not recognize breast cancer cells as a problem. Still, among new treatments for breast cancer, immunotherapy does increase survival rates.

What is the best medication for breast cancer?

The medication used to treat breast cancer will vary based on the type and stage of cancer as well as the patient’s age, medical situation, and tolerance for side effects. Most patients will take a combination of drugs. There is, then, no “best” medication for breast cancer.

What are the common side effects of breast cancer medication?

Side effects of breast cancer medications will vary based on the type of medication, the dose, and the patient’s physical health. This is not a complete list of side effects. A healthcare professional can answer any questions about possible side effects and drug interactions.

What is the best home remedy for breast cancer?

Breast cancer can only be treated with surgery, radiation, and medications. Natural or home remedies will not help, but home treatment can contribute to the success of breast cancer treatment.

Keep all follow-up appointments

Follow-up care is the key to breast cancer treatment success. Your primary physician and cancer care team will schedule regular monitoring, testing, and imaging appointments for several years. The schedule will taper off the longer you are cancer-free.

Avoid infections

Chemotherapy and radiation treatment can leave you vulnerable to infections. Fighting breast cancer is hard enough all by itself, so avoid infections by washing your hands regularly, showering regularly, avoiding people who are sick, and keeping your surgical wounds clean and dressed.

Drink fluids and replace electrolytes

Diarrhea and vomiting are common after breast cancer surgery, after radiation treatment, or during chemotherapy. You will need to take in extra fluids and electrolytes. Diluted apple juice or oral rehydration solutions are the best choices.

Manage your diet

Loss of appetite, nausea, diarrhea, and weight loss are commonly caused by breast cancer surgery, radiation treatment, and chemotherapy. Getting the right nutrition keeps your body in the fight. You can manage nausea and vomiting by eating several small meals a day rather than three large ones. Eat bland or liquified foods. Above all, eat foods rich in nutrition.

How does breast cancer treatment affect the body?

All cancer treatment is hard on the body. No matter what the cancer, surgery, radiation, and chemotherapy are often accompanied by noticeable side effects such as swollen arms or legs due to removal of or damage to lymph nodes (lymphedema) and infections. Breast cancer, however, is also treated with drugs that lower female hormones in the body. When taking these drugs, many patients will experience symptoms similar to menopause: hot flashes, night sweats, vaginal dryness, loss of libido, and bone loss.

What are the side effects of breast cancer chemotherapy?

The side effects of chemotherapy vary depending on the types of drugs used and the doses. Common chemotherapy side effects include digestive system problems, hair loss, mouth sores, fatigue, weakness, and flu-like symptoms.

What is the five-year pill for breast cancer?

Some types of breast cancer grow and spread in the presence of female hormones. Women with any of these types of breast cancer will be given a two- to five-year regimen of a drug that reduces estrogen or the body’s sensitivity to estrogen. The most commonly prescribed hormonal therapy drug is tamoxifen, the so-called “five-year pill.”

What is the most common treatment for breast cancer?

Except for the most advanced cases, breast cancer is primarily treated with surgery. Radiation therapy, chemotherapy, and other drug treatments are used to either shrink the tumor before breast cancer surgery or to kill off residual cancer cells after surgery.

Can you be completely cured of breast cancer?

The prognosis for breast cancer depends on the type and stage of cancer. Even if treatment is successful and years go by without recurrence, breast cancer is never really “cured.” People who have had breast cancer are at a much higher risk of breast cancer in the future, so constant monitoring and follow-up treatment is required.

How long does it take to treat breast cancer?

After surgery, chemotherapy typically takes three to six months. However, patients with hormone-sensitive breast cancers will often be put on two to five years of hormone therapy to prevent recurrence. Of course, even early-stage breast cancer puts people at a higher risk for breast cancer. Follow-up monitoring will be a lifelong project.

What is the treatment for stage 1 breast cancer?

The standard treatment for stage 1 breast cancer is surgery followed by radiation therapy, and also sometimes chemotherapy. Patients with hormone-sensitive breast cancer will often be offered a multi-year treatment with hormone therapy drugs to prevent a recurrence.

Can breast cancer be treated with tablets?

Breast cancer is primarily treated with surgery. Radiation therapy and chemotherapy may be used before surgery to shrink the size of a tumor or after surgery to eradicate residual cancer cells. Most chemotherapy drugs are administered as injections or intravenous infusions. Dependent upon the type of cancer, adjunctive hormonal therapies are available as tablets.

• Breast Cancer. American Cancer Society
• Breast Cancer. Centers for Disease Control and Prevention (CDC)
• Breast Cancer. National Cancer Institute
• Breast cancer information and support. Breastcancer.org
• TLC: Tender Loving Care. American Cancer Society