National Cancer Institute


Posted Date: Jan 26, 2016

Expert-reviewed information summary about the treatment of ductal carcinoma in situ and invasive breast cancer.

This PDQ cancer information summary has current information about the treatment of breast cancer. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary ("Date Last Modified") is the date of the most recent change. The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Adult Treatment Editorial Board.

Breast Cancer Treatment

General Information About Breast Cancer

Key Points for this Section

  • Breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast.
  • A family history of breast cancer and other factors increase the risk of breast cancer.
  • Breast cancer is sometimes caused by inherited gene mutations (changes).
  • The use of certain medicines and other factors decrease the risk of breast cancer.
  • Signs of breast cancer include a lump or change in the breast.
  • Tests that examine the breasts are used to detect (find) and diagnose breast cancer.
  • If cancer is found, tests are done to study the cancer cells.
  • Certain factors affect prognosis (chance of recovery) and treatment options.

Breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast.

The breast is made up of lobes and ducts. Each breast has 15 to 20 sections called lobes. Each lobe has many smaller sections called lobules. Lobules end in dozens of tiny bulbs that can make milk. The lobes, lobules, and bulbs are linked by thin tubes called ducts. Anatomy of the female breast. The nipple and areola are shown on the outside of the breast. The lymph nodes, lobes, lobules, ducts, and other parts of the inside of the breast are also shown.

Each breast also has blood vessels and lymph vessels. The lymph vessels carry an almost colorless fluid called lymph. Lymph vessels carry lymph between lymph nodes. Lymph nodes are small bean-shaped structures that are found throughout the body. They filter substances in lymph and help fight infection and disease. Clusters of lymph nodes are found near the breast in the axilla (under the arm), above the collarbone, and in the chest.

The most common type of breast cancer is ductal carcinoma, which begins in the cells of the ducts. Cancer that begins in the lobes or lobules is called lobular carcinoma and is more often found in both breasts than are other types of breast cancer. Inflammatory breast cancer is an uncommon type of breast cancer in which the breast is warm, red, and swollen.

See the following PDQ summaries for more information about breast cancer:

  • Breast Cancer Prevention
  • Breast Cancer Screening
  • Breast Cancer Treatment and Pregnancy
  • Male Breast Cancer Treatment
  • Unusual Cancers of Childhood Treatment (for information about breast cancer in childhood)

A family history of breast cancer and other factors increase the risk of breast cancer.

Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk to your doctor if you think you may be at risk for breast cancer.

Risk factors for breast cancer include the following:

Older age is the main risk factor for most cancers. The chance of getting cancer increases as you get older.

NCI's Breast Cancer Risk Assessment Tool uses a woman's risk factors to estimate her risk for breast cancer during the next five years and up to age 90. This online tool is meant to be used by a health care provider. For more information on breast cancer risk, call 1-800-4-CANCER.

Breast cancer is sometimes caused by inherited gene mutations (changes).

The genes in cells carry the hereditary information that is received from a person’s parents. Hereditary breast cancer makes up about 5% to 10% of all breast cancer. Some mutated genes related to breast cancer are more common in certain ethnic groups.

Women who have certain gene mutations, such as a BRCA1 or BRCA2 mutation, have an increased risk of breast cancer. These women also have an increased risk of ovarian cancer, and may have an increased risk of other cancers. Men who have a mutated gene related to breast cancer also have an increased risk of breast cancer. For more information, see the PDQ summary on Male Breast Cancer Treatment.

There are tests that can detect (find) mutated genes. These genetic tests are sometimes done for members of families with a high risk of cancer. See the PDQ summary on Genetics of Breast and Gynecologic Cancers for more information.

The use of certain medicines and other factors decrease the risk of breast cancer.

Anything that decreases your chance of getting a disease is called a protective factor.

Protective factors for breast cancer include the following:

  • Taking any of the following: Estrogen-only hormone therapy after a hysterectomy.Selective estrogen receptor modulators (SERMs). Aromatase inhibitors.
    • Estrogen-only hormone therapy after a hysterectomy.
    • Selective estrogen receptor modulators (SERMs).
    • Aromatase inhibitors.
  • Less exposure of breast tissue to estrogen made by the body: Early pregnancy.Breastfeeding.
    • Early pregnancy.
    • Breastfeeding.
  • Getting enough exercise.
  • Having any of the following procedures: Risk-reducing mastectomy.Risk-reducing oophorectomy.Ovarian ablation.
    • Risk-reducing mastectomy.
    • Risk-reducing oophorectomy.
    • Ovarian ablation.

Signs of breast cancer include a lump or change in the breast.

These and other signs may be caused by breast cancer or by other conditions. Check with your doctor if you have any of the following:

  • A lump or thickening in or near the breast or in the underarm area.
  • A change in the size or shape of the breast.
  • A dimple or puckering in the skin of the breast.
  • A nipple turned inward into the breast.
  • Fluid, other than breast milk, from the nipple, especially if it's bloody.
  • Scaly, red, or swollen skin on the breast, nipple, or areola (the dark area of skin around the nipple).
  • Dimples in the breast that look like the skin of an orange, called peau d’orange.

Tests that examine the breasts are used to detect (find) and diagnose breast cancer.

Check with your doctor if you notice any changes in your breasts. The following tests and procedures may be used:

  • Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
  • Clinical breast exam (CBE): An exam of the breast by a doctor or other health professional. The doctor will carefully feel the breasts and under the arms for lumps or anything else that seems unusual.
  • Mammogram: An x-ray of the breast. Mammography. The breast is pressed between two plates. X-rays are used to take pictures of breast tissue.
  • Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.
  • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of both breasts. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
  • Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. If a lump in the breast is found, a biopsy may be done. There are four types of biopsy used to check for breast cancer: Excisional biopsy: The removal of an entire lump of tissue. Incisional biopsy: The removal of part of a lump or a sample of tissue. Core biopsy: The removal of tissue using a wide needle. Fine-needle aspiration (FNA) biopsy: The removal of tissue or fluid, using a thin needle.

If cancer is found, tests are done to study the cancer cells.

Decisions about the best treatment are based on the results of these tests. The tests give information about:

  • how quickly the cancer may grow.
  • how likely it is that the cancer will spread through the body.
  • how well certain treatments might work.
  • how likely the cancer is to recur (come back).

Tests include the following:

  • Estrogen and progesterone receptor test: A test to measure the amount of estrogen and progesterone (hormones) receptors in cancer tissue. If there are more estrogen and progesterone receptors than normal, the cancer is called estrogen and/or progesterone receptor positive. This type of breast cancer may grow more quickly. The test results show whether treatment to block estrogen and progesterone may stop the cancer from growing.
  • Human epidermal growth factor type 2 receptor (HER2/neu) test: A laboratory test to measure how many HER2/neu genes there are and how much HER2/neu protein is made in a sample of tissue. If there are more HER2/neu genes or higher levels of HER2/neu protein than normal, the cancer is called HER2/neu positive. This type of breast cancer may grow more quickly and is more likely to spread to other parts of the body. The cancer may be treated with drugs that target the HER2/neu protein, such as trastuzumab and pertuzumab.
  • Multigene tests: Tests in which samples of tissue are studied to look at the activity of many genes at the same time. These tests may help predict whether cancer will spread to other parts of the body or recur (come back).Oncotype DX: This test helps predict whether stage I or stage II breast cancer that is estrogen receptor positive and node negative will spread to other parts of the body. If the risk that the cancer will spread is high, chemotherapy may be given to lower the risk.MammaPrint: This test helps predict whether stage I or stage II breast cancer that is node negative will spread to other parts of the body. If the risk that the cancer will spread is high, chemotherapy may be given to lower the risk.

Based on these tests, breast cancer is described as:

This information helps the doctor decide which treatments will work best for your cancer.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

  • The stage of the cancer (the size of the tumor and whether it is in the breast only or has spread to lymph nodes or other places in the body).
  • The type of breast cancer.
  • Estrogen receptor and progesterone receptor levels in the tumor tissue.
  • Human epidermal growth factor type 2 receptor (HER2/neu) levels in the tumor tissue.
  • Whether the tumor tissue is triple negative (cells that do not have estrogen receptors, progesterone receptors, or high levels of HER2/neu).
  • How fast the tumor is growing.
  • How likely the tumor is to recur (come back).
  • A woman’s age, general health, and menopausal status (whether a woman is still having menstrual periods).
  • Whether the cancer has just been diagnosed or has recurred (come back).

Stages of Breast Cancer

Key Points for this Section

  • After breast cancer has been diagnosed, tests are done to find out if cancer cells have spread within the breast or to other parts of the body.
  • There are three ways that cancer spreads in the body.
  • Cancer may spread from where it began to other parts of the body.
  • The following stages are used for breast cancer:
    • Stage 0 (carcinoma in situ)
    • Stage I
    • Stage II
    • Stage IIIA
    • Stage IIIB
    • Stage IIIC
    • Stage IV

After breast cancer has been diagnosed, tests are done to find out if cancer cells have spread within the breast or to other parts of the body.

The process used to find out whether the cancer has spread within the breast or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.

The following tests and procedures may be used in the staging process:

  • Sentinel lymph node biopsy: 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. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes.
  • Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
  • Bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.
  • PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

  • Tissue. The cancer spreads from where it began by growing into nearby areas.
  • Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
  • Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

  • Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor ( metastatic tumor) in another part of the body.
  • Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bone, the cancer cells in the bone are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

The following stages are used for breast cancer:

This section describes the stages of breast cancer. The breast cancer stage is based on the results of testing that is done on the tumor and lymph nodes removed during surgery and other tests.

Stage 0 (carcinoma in situ)

There are 3 types of breast carcinoma in situ:

  • ductal carcinoma in situ (DCIS) is a noninvasive condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast. In some cases, DCIS may become invasive cancer and spread to other tissues. At this time, there is no way to know which lesions could become invasive.Ductal carcinoma in situ (DCIS). Abnormal cells are found in the lining of a breast duct.
  • Lobular carcinoma in situ (LCIS) is a condition in which abnormal cells are found in the lobules of the breast. This condition seldom becomes invasive cancer. Information about LCIS is not included in this summary.Lobular carcinoma in situ (LCIS). Abnormal cells are found in the lobules of the breast.
  • Paget disease of the nipple is a condition in which abnormal cells are found in the nipple only.

Stage I

In stage I, cancer has formed. Stage I is divided into stages IA and IB.

  • In stage IA, the tumor is 2 centimeters or smaller. Cancer has not spread outside the breast.
  • In stage IB, small clusters of breast cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes and either:no tumor is found in the breast; orthe tumor is 2 centimeters or smaller.
    • no tumor is found in the breast; or
    • the tumor is 2 centimeters or smaller.

Stage II

Stage II is divided into stages IIA and IIB.

  • In stage IIA:no tumor is found in the breast or the tumor is 2 centimeters or smaller. Cancer (larger than 2 millimeters) is found in 1 to 3 axillary lymph nodes or in the lymph nodes near the breastbone (found during a sentinel lymph node biopsy); or the tumor is larger than 2 centimeters but not larger than 5 centimeters. Cancer has not spread to the lymph nodes.Stage IIA breast cancer. No tumor is found in the breast and cancer is found in 1 to 3 axillary lymph nodes or lymph nodes near the breastbone (left panel); OR the tumor is 2 centimeters or smaller and cancer is found in 1 to 3 axillary lymph nodes or lymph nodes near the breastbone (middle panel); OR the tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the lymph nodes (right panel).
    • no tumor is found in the breast or the tumor is 2 centimeters or smaller. Cancer (larger than 2 millimeters) is found in 1 to 3 axillary lymph nodes or in the lymph nodes near the breastbone (found during a sentinel lymph node biopsy); or
    • the tumor is larger than 2 centimeters but not larger than 5 centimeters. Cancer has not spread to the lymph nodes.
  • In stage IIB, the tumor is: larger than 2 centimeters but not larger than 5 centimeters. Small clusters of breast cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes; or larger than 2 centimeters but not larger than 5 centimeters. Cancer has spread to 1 to 3 axillary lymph nodes or to the lymph nodes near the breastbone (found during a sentinel lymph node biopsy); or larger than 5 centimeters. Cancer has not spread to the lymph nodes. Stage IIB breast cancer. The tumor is larger than 2 centimeters but not larger than 5 centimeters and small clusters of cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes (left panel); OR the tumor is larger than 2 centimeters but not larger than 5 centimeters and cancer is found in 1 to 3 axillary lymph nodes or lymph nodes near the breastbone (middle panel); OR the tumor is larger than 5 centimeters and has not spread to the lymph nodes (right panel).
    • larger than 2 centimeters but not larger than 5 centimeters. Small clusters of breast cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes; or
    • larger than 2 centimeters but not larger than 5 centimeters. Cancer has spread to 1 to 3 axillary lymph nodes or to the lymph nodes near the breastbone (found during a sentinel lymph node biopsy); or
    • larger than 5 centimeters. Cancer has not spread to the lymph nodes.

Stage IIIA

In stage IIIA:

Stage IIIB

In stage IIIB, the tumor may be any size and cancer has spread to the chest wall and/or to the skin of the breast and caused swelling or an ulcer. Also, cancer may have spread to:

Cancer that has spread to the skin of the breast may also be inflammatory breast cancer. See the section on Inflammatory Breast Cancer for more information.

Stage IIIC

In stage IIIC, no tumor is found in the breast or the tumor may be any size. Cancer may have spread to the skin of the breast and caused swelling or an ulcer and/or has spread to the chest wall. Also, cancer has spread to:

Cancer that has spread to the skin of the breast may also be inflammatory breast cancer. See the section on Inflammatory Breast Cancer for more information.

For treatment, stage IIIC breast cancer is divided into operable and inoperable stage IIIC.

Stage IV

In stage IV, cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain.

Inflammatory Breast Cancer

In inflammatory breast cancer, cancer has spread to the skin of the breast and the breast looks red and swollen and feels warm. The redness and warmth occur because the cancer cells block the lymph vessels in the skin. The skin of the breast may also show the dimpled appearance called peau d’orange (like the skin of an orange). There may not be any lumps in the breast that can be felt. Inflammatory breast cancer may be stage IIIB, stage IIIC, or stage IV.

Inflammatory breast cancer of the left breast showing peau d’orange and inverted nipple.

Inflammatory breast cancer of the left breast with redness, peau d'orange, and inverted nipple.
Inflammatory breast cancer of the left breast showing peau dâ??orange and inverted nipple.

Recurrent Breast Cancer

Recurrent breast cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the breast, in the chest wall, or in other parts of the body.

Treatment Option Overview

Key Points for this Section

  • There are different types of treatment for patients with breast cancer.
  • Five types of standard treatment are used:
    • Surgery
    • Radiation therapy
    • Chemotherapy
    • Hormone therapy
    • Targeted therapy
  • Some treatments for breast cancer may cause side effects months or years after treatment has ended.
  • New types of treatment are being tested in clinical trials.
    • High-dose chemotherapy with stem cell transplant
  • Patients may want to think about taking part in a clinical trial.
  • Patients can enter clinical trials before, during, or after starting their cancer treatment.
  • Follow-up tests may be needed.

There are different types of treatment for patients with breast cancer.

Different types of treatment are available for patients with breast cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Five types of standard treatment are used:

Surgery

Most patients with breast cancer have surgery to remove the cancer.

Sentinel lymph node biopsy 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 where the cancer is likely to spread. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. After the sentinel lymph node biopsy, the surgeon removes the tumor using breast-conserving surgery or mastectomy. If cancer cells are not found, it may not be necessary to remove more lymph nodes. If cancer cells are found, more lymph nodes will be removed through a separate incision. This is called a lymph node dissection.

Types of surgery include the following:

  • Breast-conserving surgery is an operation to remove the cancer and some normal tissue around it, but not the breast itself. Part of the chest wall lining may also be removed if the cancer is near it. This type of surgery may also be called lumpectomy, partial mastectomy, segmental mastectomy, quadrantectomy, or breast-sparing surgery.Breast-conserving surgery. The tumor and some normal tissue around it are removed, but not the breast itself. Some lymph nodes under the arm may be removed. Part of the chest wall lining may also be removed if the cancer is near it.
  • Total mastectomy: Surgery to remove the whole breast that has cancer. This procedure is also called a simple mastectomy. Some of the lymph nodes under the arm may be removed and checked for cancer. This may be done at the same time as the breast surgery or after. This is done through a separate incision. Total (simple) mastectomy. The dotted line shows where the entire breast is removed. Some lymph nodes under the arm may also be removed.
  • Modified radical mastectomy: Surgery to remove the whole breast that has cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscles. Modified radical mastectomy. The dotted line shows where the entire breast and some lymph nodes are removed. Part of the chest wall muscle may also be removed.

Chemotherapy may be given before surgery to remove the tumor. When given before surgery, chemotherapy will shrink the tumor and reduce the amount of tissue that needs to be removed during surgery. Treatment given before surgery is called preoperative therapy or neoadjuvant therapy.

Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given radiation therapy, chemotherapy, or hormone therapy after surgery, to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called postoperative therapy or adjuvant therapy.

If a patient is going to have a mastectomy, breast reconstruction (surgery to rebuild a breast’s shape after a mastectomy) may be considered. Breast reconstruction may be done at the time of the mastectomy or at some time after. The reconstructed breast may be made with the patient’s own (nonbreast) tissue or by using implants filled with saline or silicone gel. Before the decision to get an implant is made, patients can call the Food and Drug Administration's (FDA) Center for Devices and Radiologic Health at 1-888-INFO-FDA (1-888-463-6332) or visit the FDA website for more information on breast implants.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

The way the radiation therapy is given depends on the type and stage of the cancer being treated. External radiation therapy is used to treat breast cancer.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body ( systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (

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