Breast Cancer Treatment by Stage

Breast Cancer
Treatment by Stage
What is breast cancer?
Breast cancer, a common cancer in women, is a disease in which
cancer cells are found in the tissues of the breast. Each breast has 15
to 20 sections called lobes. Lobes have many smaller sections called
lobules. The lobes and lobules are connected by thin tubes called
ducts. The most common type of breast cancer is ductal cancer. It is
found in the cells of the ducts. Cancer that begins in the lobes or
lobules is called lobular carcinoma. Lobular carcinoma is found in
both breasts more often than other types of breast cancer.
Inflammatory breast cancer is an uncommon type of breast cancer.
In this disease, the breast is warm, red, and swollen.

Figure 1. The Breast
The genes in your cells carry the hereditary information that you
received from your parents. Sometimes, a test can be done to look for a gene that may be
associated with a certain hereditary trait. A gene was found to be defective in 5 percent of breast
cancer patients. Relatives of breast cancer patients who carry this defective gene may be more
likely to develop breast or ovarian cancer. Tests have been developed to determine the people
who have the genetic defect long before any cancer appears.

You should see your doctor if you notice changes in your breast. Women over the age of 40
should also have a special x-ray called a mammogram, which may find tumors that are too small
to feel. Check with your doctor on how often you should have this x-ray.

If you have a lump in your breast, it may be necessary to cut out a small piece of it and look at it
under the microscope to see if there are any cancer cells present. This is called a biopsy.
Sometimes the biopsy is done by inserting a needle into the breast and drawing out some of the
tissue. If the biopsy shows that there is cancer, it is important that certain tests (called estrogen
and progesterone receptor tests) be done on the cancer cells.

Estrogen and progesterone receptor tests may tell whether hormones affect how the cancer
grows. They may also give information about the chances of the tumor coming back (recurring).
The results help your doctor decide whether or not to use hormone therapy to stop the cancer
from growing. Tissue from the tumor needs to be taken for estrogen and progesterone tests at the
time of biopsy because it may be difficult to get enough cancer cells later on. Newer techniques
Adapted from NCI's Breast Cancer PDQ/PIF
© 1995, 2005 The University of Texas MD Anderson Cancer Center, Revised 01/29/08
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now can be used on tissue that has been stored. Your physician may order another type of test,
HER2/neu, to see if you will be a candidate for a medication called trastuzumab (Herceptin®).

Your chance of recovery and choice of treatment depend on:
the stage of your cancer (whether it is just in the breast or has spread to other places in the
body),
the type of breast cancer,
certain characteristics of the cancer cells, and
your age and the general state of your health.

What is "staging"?
Once breast cancer has been found, more tests will be done to find out if the cancer has spread
from the breast to other parts of the body. This is called staging. Your doctor needs to know the
stage of your disease to plan treatment. The following stages are used for breast cancer:
Breast cancer in situ (Stage 0)
About 15-20 percent of breast cancers are very early cancers. They are sometimes called
carcinoma in situ. There are two types of breast cancer in situ. One type is ductal carcinoma
in situ (also known as intraductal carcinoma); the other type is lobular carcinoma in situ.
Lobular carcinoma in situ is not cancer, but for the purpose of classifying the disease, it is
called breast cancer in situ, carcinoma in situ, or stage 0 breast cancer. Lobular carcinoma in
situ is found on some occasions when a biopsy is done for another lump or abnormality that
was found on the mammogram. Patients with this condition have a 10-15 percent chance of
developing breast cancer in either breast in the next 30 years.
Stage I
The cancer is no bigger than 2 centimeters (about 1 inch) and has not spread outside the
breast.
Stage II
Any of the following may be true:
- The cancer is no bigger than 2 centimeters but has spread to the lymph nodes under the
arm (the axillary lymph nodes).
- The cancer is between 2 and 5 centimeters (from 1 to 2 inches). The cancer may or may
not have spread to the lymph nodes under the arm.
- The cancer is bigger than 5 centimeters (larger than 2 inches), but has not spread to the
lymph nodes under the arm.
Stage III
Stage III is divided into stages IIIA, IIIB and IIIC.
- Stage IIIA is defined by either of the following:
 The cancer is bigger than 5 centimeters, it has spread to the lymph nodes under the
arm, and the lymph nodes have grown into each other or into other structures.
 The cancer is bigger than 5 centimeters and has spread to lymph nodes under the arm.
- Stage IIIB is defined by either of the following:
 The cancer has spread to tissues near the breast (skin, chest wall, including the ribs
and the muscles in the chest).
 The cancer has spread to lymph nodes inside the chest wall along the breastbone.
Adapted from NCI's Breast Cancer PDQ/PIF
© 1995, 2005 The University of Texas MD Anderson Cancer Center, Revised 01/29/08
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Stage IIIC is defined by the following:
 The cancer has spread to the lymph nodes, inside the neck, near the collarbone.
Stage IV
The cancer has spread to other organs of the body, most often the bones, lungs, liver, or
brain.

Inflammatory Breast Cancer
Inflammatory breast cancer is a special class of breast cancer that is rare. The breast looks as if it
is inflamed because of its red appearance and warmth. The skin may show signs of ridges and
wheals (raised areas) or it may look pitted. This type of cancer tends to spread quickly.

Recurrent
Recurrent disease means that the cancer has come back (recurred) after it has been treated. It
may come back in the breast, in the soft tissues of the chest (the chest wall), or in another part of
the body.

How is breast cancer treated?
There are treatments for all patients with breast cancer. Four types of treatment are used:
- Surgery (an operation to remove the cancer)
- Radiation therapy (using high-dose x-rays to kill cancer cells)
- Chemotherapy (using drugs to kill cancer cells)
- Hormone therapy (using hormones to stop the cells from growing)
In addition, biological therapy (using your body's immune system to fight cancer) and bone
marrow transplantation are being tested in clinical trials.
Surgery has a role in the treatment of most patients with breast cancer. It is used to remove
the cancer from the breast. Usually, some of the lymph nodes under the arm also are taken
out and looked at under the microscope to see if cancer cells are present.

A Number Of Different Therapies Are Used
Surgery To Conserve The Breast
Excisional biopsy (sometimes called lumpectomy or wide local excision) takes out the lump
in the breast and some of the tissue around it. It may be followed by radiation therapy to the
part of the breast that remains. Doctors may also take out some of the lymph nodes under the
arm.
Segmental mastectomy takes out the cancer and some of the breast tissue around it. In
addition, there may be an axillary node dissection to take out some of the lymph nodes under
the arm. In most cases, radiation therapy follows. This is the most common operation for
breast cancer.



Adapted from NCI's Breast Cancer PDQ/PIF
© 1995, 2005 The University of Texas MD Anderson Cancer Center, Revised 01/29/08
Patient Education Office

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Other Types Of Surgery
Total or simple mastectomy removes the breast. Sometimes lymph nodes under the arm are
also taken out.
Modified radical mastectomy removes the breast, some of the lymph nodes under the arm,
the lining over the chest muscles and sometimes part of the chest wall muscles.

Lymph Node Mapping - Sentinel Node Biopsy
Sentinel node biopsy (SNB) is a new advance in breast cancer treatment. SNB is the removal of
the sentinel lymph node during surgery. The sentinel lymph node is the first lymph node to
receive lymphatic drainage from a tumor. It is the first lymph node the cancer is likely to spread
to from the tumor.

SNB is a simple procedure that may reduce the amount of surgery needed. In some cases, SNB
can replace a formal axillary node dissection with fewer side effects. It can also provide the
physician with the necessary information he or she needs to make a prognosis (the chances of
getting better). Please ask your physician or nurse for further details about this procedure.

Breast Reconstruction
If you are going to have a mastectomy, you may want to think about having breast reconstruction
(having a new breast made). This can be done at the time of the mastectomy or at some time in
the future. The breast may be made with your own tissue, or by using implants. Different types
of implants can be used. The Food and Drug Administration (FDA) has announced that breast
implants filled with silicone gel may be used only in clinical trials. Saline-filled breast implants,
which contain salt water rather than silicone gel, may also be used. Before you decide to get an
implant, you may want to discuss any questions you have with your doctor.

Radiation Therapy
This treatment uses high-energy x-rays to kill cancer cells and shrink tumors. Radiation may
come from a machine outside the body (external radiation therapy) or from putting materials that
produce radiation through thin plastic tubes into the area where the cancer cells are found
(internal radiation therapy).

Chemotherapy
Chemotherapy is the use of special drugs to kill cancer cells. Chemotherapy may be taken by
mouth, or it may be put into the body by a needle in a vein or muscle. Chemotherapy drugs enter
the bloodstream, travel through the body, and can kill cancer cells outside the breast area.

Hormone Therapy
If tests show that the breast cancer cells contain estrogen and progesterone receptors you may be
given hormone therapy. Hormone therapy is used to change the way hormones in the body help
cancers grow. This may be done by using drugs that block the action of hormones or by surgery
that removes organs that make hormones, such as the ovaries.

Hormone therapy with tamoxifen can act on cells all over the body and may increase your
chance of getting cancer of the uterus. Therefore, you should be checked regularly for this type
of cancer. You should immediately report any uterine bleeding other than your menstrual period
Adapted from NCI's Breast Cancer PDQ/PIF
© 1995, 2005 The University of Texas MD Anderson Cancer Center, Revised 01/29/08
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to your doctor. For women over the age of 50, an aromatase inhibitor may be used instead of
tamoxifen.

Adjuvant Therapy
If your doctor removes all the cancer that can be seen at the time of the operation, you may be
given radiation therapy, chemotherapy, or hormone therapy after surgery to try to kill any cancer
cells that may be left. Therapy given after an operation when there are no cancer cells that can be
seen is called adjuvant therapy.

Biological Therapy
This treatment tries to get your own body to fight the cancer. It uses materials made by your
body or made in a laboratory to boost, direct, or restore your body's natural defenses against
disease. Biological therapy is sometimes called biological response modifier (BRM) therapy or
immunotherapy.

Bone Marrow Transplantation
This procedure offers a newer type of treatment. Sometimes breast cancer becomes resistant to
treatment with radiation therapy or chemotherapy. In clinical trials, very high doses of
chemotherapy may then be used to treat the cancer. Because the high doses of chemotherapy can
destroy your bone marrow, marrow is taken from your bones before treatment. The marrow is
then frozen and you are given high-dose chemotherapy with or without radiation therapy to treat
the cancer. The marrow you had taken out is then thawed and given to you through a needle in a
vein to replace the marrow that was destroyed. This type of transplant is called an autologous
transplant. If the marrow is taken from another person (to give to you) for the transplant, it is
called an allogeneic transplant. Peripheral blood stem cells may also be used.

Treatment for Breast Cancer In Situ
Your treatment depends on whether you have ductal carcinoma in situ or lobular carcinoma in
situ. Since it is difficult to distinguish between these two possibilities, it may be helpful to get a
second opinion and have your biopsy preparations (slides) observed through the microscope by
pathologists at another hospital.

If you have ductal carcinoma in situ (DCIS), your treatment may be one of the following:
- Surgery to remove the whole breast (total mastectomy).
- Surgery to remove only the cancer (lumpectomy), followed by radiation therapy.
- Rarely, some of the lymph nodes under the arm may also be removed during the above
surgeries.
If you have lobular carcinoma in situ (LCIS), you have a marker for a higher risk of an
invasive cancer in both breasts. This gives you about a 10-15 percent chance of developing
breast cancer in either breast over the next 30 years. Many women with LCIS never develop
an invasive breast cancer. A large clinical trial found that women at high risk for developing
breast cancer who were treated with the hormonal therapy drug tamoxifen were almost 50
percent less likely to develop cancer than women at high risk who did not receive the drug.

Adapted from NCI's Breast Cancer PDQ/PIF
© 1995, 2005 The University of Texas MD Anderson Cancer Center, Revised 01/29/08
Patient Education Office

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For more information, call the Cancer Information Service at (800) 4-CANCER
(1-800-422-6237). The treatment options for LCIS are varied and quite controversial. Your
treatment may include:
- a biopsy to diagnose the LCIS, followed by regular exams and mammograms to make
sure you don't develop invasive cancer,
- or surgery to remove both breasts (prophylactic mastectomy).

Treatment By Stage
Treatment for breast cancer depends on the type and stage of your disease, your age, and your
overall health.

You may receive treatment that is considered standard based on its effectiveness in a number of
patients in past studies, or you may choose to go into a clinical trial. Not all patients are cured
with standard therapy, and some standard treatments may have more side effects than are
desired. For these reasons, clinical trials are designed to find better ways to treat cancer patients
and are based on the most up-to-date information. Clinical trials are taking place in most parts of
the country for all stages of breast cancer. If you want more information, call the Cancer
Information Service toll-free at 1-800-4-CANCER (1-800-422-6237).

Stage I Breast Cancer
Your treatment may be one of the following:
- Surgery to remove only the cancer and some surrounding breast tissue (lumpectomy) or
to remove part of the breast (partial or segmental mastectomy). Some of the lymph nodes
under the arm are also removed. Both types of surgery are followed by radiation therapy.
This treatment provides identical long-term cure rates to those from a mastectomy. Your
doctor's recommendation on which procedure to have is based on tumor size and location
and the tumor's appearance on a mammogram.
- Surgery to remove the whole breast (total mastectomy) or the whole breast and some of
the lymph nodes under the arm (modified radical mastectomy).
- Adjuvant therapy (following surgery):
 Chemotherapy
 Hormone therapy
 Clinical trials of adjuvant chemotherapy or hormone therapy
 Clinical trials of no adjuvant therapy for patients with a good chance of recovery.

Stage II Breast Cancer
Your treatment may be one of the following:
- Surgery to remove only the cancer and some surrounding breast tissue (lumpectomy) or
to remove part of the breast (partial or segmental mastectomy). Some of the lymph nodes
- under the arm are also removed. Radiation therapy is given following surgery. This
treatment provides identical long-term cure rates to those from a mastectomy. Your
doctor's recommendation on which procedure to have is based on tumor size and location
and the tumor's appearance on mammogram.
Adapted from NCI's Breast Cancer PDQ/PIF
© 1995, 2005 The University of Texas MD Anderson Cancer Center, Revised 01/29/08
Patient Education Office

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- Surgery to remove the whole breast (total mastectomy) or the whole breast and some of
the lymph nodes under the arm (modified radical mastectomy).
- Adjuvant therapy (following surgery):
 Chemotherapy
 Hormone therapy
 Clinical trials of chemotherapy and/or hormone therapy after surgery
 Clinical trial of no more therapy after surgery for patients with a good chance of
recovery.
- Clinical trial of chemotherapy before surgery (neoadjuvant therapy).

Stage III Breast Cancer
Stage III breast cancer is further divided into stage IIIA (can be operated on) and IIIB
(surgery cannot take place until chemotherpy or hormonal therapy shrinks the tumor).
- Stage IIIA cancer treatment often includes surgery, radiation therapy and multi-agent
chemotherapy for most patients. Clinical trials are testing new chemotherapy with or
without hormonal drugs. They are also testing chemotherapy before surgery (neoadjuvant
therapy) and high-dose chemotherapy with bone marrow or peripheral stem cell
transplantation. The treatments you receive will provide the greatest potential for keeping
your cancer from spreading and killing the cancer cells (throughout your system) that can
not be seen.
- Stage IIIB cancer is considered to be inoperable. Treatment generally consists of
combination chemotherapy, followed by surgery, additional chemotherapy and radiation
therapy. Clinical trials are testing new chemotherapy with or without hormonal drugs.
They are also testing chemotherapy before surgery (neoadjuvant therapy) and high-dose
chemotherapy with bone marrow or peripheral stem cell transplantation.

Stage IV Breast Cancer
You may have a biopsy and then be given one or more of the following:
- Radiation therapy, or, in some case, a mastectomy to reduce your pain or symptoms
- Hormonal therapy
- Chemotherapy
- Clinical trials of new chemotherapy and hormonal drugs and new combinations of drugs
and biological therapy
- Clinical trials of high-dose chemotherapy with bone marrow or peripheral stem cell
transplantation

Inflammatory Breast Cancer
Your treatment will probably be a combination of chemotherapy, hormonal therapy and radiation
therapy, which may be combined with surgery to remove the breast. The treatment is usually
similar to that for stage IIIB or stage IV breast cancer.

Recurrent Breast Cancer
Breast cancer that comes back (recurs) can often be treated but usually cannot be cured when it
recurs in another part of the body. Some patients with recurrence in the breast or chest wall can
be cured, however. Your choice of treatment depends on hormone receptor levels, the kind of
Adapted from NCI's Breast Cancer PDQ/PIF
© 1995, 2005 The University of Texas MD Anderson Cancer Center, Revised 01/29/08
Patient Education Office

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treatment you had before it recurred, the length of time from first treatment to when the cancer
came back, where the cancer recurred, whether you still have menstrual periods, and other
factors.

Your treatment may be one or more of the following:
Hormonal therapy
Surgery and/or radiation therapy for the small group of patients whose cancer has come back
in only one place.
Radiation therapy to help relieve pain due to the spread of the cancer to the bones and other
places.
Chemotherapy
A clinical trial of new chemotherapy drugs, new hormonal drugs, biological therapy, or bone
marrow transplantation.

To Learn More About Breast Cancer
“What Would I Do? - Breast Cancer Treatment Options” (Video)
To view this video, visit one of the Learning Center locations below.

The Learning Center
The Learning Center is a consumer health library with the latest information on cancer care,
support, prevention and general health and wellness issues. Locations include:
Law Learning Center
Main Building, Floor 4, near Elevator A, Room R4.1100 – 713-745-8063
Levit Learning Center
Mays Clinic, Floor 2, near The Tree Sculpture, Room ACB2.1120 – 713-563-8010

The Nellie B. Connally Breast Center Web site
www.mdanderson.org/care_centers/breastcenter
Detailed information is provided on breast reconstruction and sentinel lymph node mapping.

National Cancer Institute’s Cancer Information Service
1 – 800- 4-CANCER (1-800-422-6237)
By dialing this toll-free number, you can speak with someone who can answer your questions.
The Cancer Information Service can also send you free booklets. Visit The Learning Center to
find out how you can get copies of the following booklets:
What You Need to Know About Cancer of the Breast
Chemotherapy and You
Radiation Therapy and You
Eating Hints for Cancer Patients: Before, During and After Treatment
Coping With Advanced Cancer
When Cancer Returns: Support for People With Cancer

Adapted from NCI's Breast Cancer PDQ/PIF
© 1995, 2005 The University of Texas MD Anderson Cancer Center, Revised 01/29/08
Patient Education Office

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