BREAST CANCER: TYPES, SYMPTOMS, STAGES, AND MORE

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The breast is made up of several tissues, ranging from very fatty to very thick. A network of lobes exists within this tissue. Each lobe is made up of lobules, which are tiny tube-like structures that contain milk glands. The glands, lobules, and lobes are linked by tiny ducts that transport milk from the lobes to the nipple. The nipple is in the center of the areola, which is the darker area surrounding the nipple. Blood and lymph vessels travel throughout the breast as well. The cells are nourished by blood. The lymphatic system discharges body waste. The lymph vessels connect to lymph nodes, which are little bean-shaped organs that aid in infection fighting. Lymph node clusters can be found in a variety of locations throughout the body, including the neck, groin, and belly. Regional lymph nodes of the breast are those that are close to the breast, such as those under the arm.

BREAST CANCER

Cancer occurs when healthy cells in the breast mutate and expand uncontrollably, generating a tumor, which is a mass or sheet of cells. A tumor might be malignant or noncancerous. A malignant tumor is one that can grow and spread to other regions of the body. A benign tumor is one that can develop but does not spread.

Breast cancer spreads when it invades nearby organs or other regions of the body, or when breast cancer cells travel to other parts of the body via blood and/or lymph channels. This is referred as as a metastasis.

Although breast cancer most usually spreads to adjacent lymph nodes, it can also migrate to other parts of the body, including the bones, lungs, liver, and brain. This is known as metastatic or stage IV breast cancer, and it is the most advanced form of the disease. However, involvement of lymph nodes alone does not usually indicate stage IV breast cancer.

Breast cancer can recur locally, meaning in the same breast and/or regional lymph nodes, following initial treatment. It can also reappear elsewhere in the body, which is known as a distant or metastatic recurrence.

TYPES OF BREAST CANCER

Breast cancer is classified as either invasive or non-invasive. Cancer that spreads into surrounding tissues and/or distant organs is referred to be invasive breast cancer. Non-invasive breast cancer does not spread beyond the breast's milk ducts or lobules. The majority of breast cancers begin in the ducts or lobes and are referred to as ductal carcinoma or lobular carcinoma:

1. Ductal carcinoma: These tumors begin in the cells that line the milk ducts and account for the vast majority of breast malignancies.

• Ductal carcinoma in situ (DCIS): This is a non-invasive cancer that has only expanded within the duct and has not spread outside of it.

• Invasive or infiltrating ductal carcinoma: Cancer has spread outside of the duct in this case.

2. Invasive lobular carcinoma: This is cancer that began in the lobules and has spread to the rest of the body.

Breast cancers that are less prevalent include:

3. Medullary.

4. Mucinous.

5. Tubular.

6. Metaplastic.

7. Papillary.

8. Inflammatory breast cancer is a dangerous type of cancer that accounts for 1% to 5% of all breast cancers.

9. Paget's disease is a form of cancer that develops in the nipple ducts. Although it is mostly non-invasive, it can also be intrusive.

SUBTYPES OF BREAST CANCER

Breast cancer is classified into three subtypes based on the results of particular tests performed on a tumor sample. These tests will assist your doctor in learning more about your cancer and recommending the best treatment approach.

The tumor sample can be tested to determine whether the cancer is:

Hormone receptor positive: "Hormone receptor positive" breast tumors express estrogen receptors (ER) and/or progesterone receptors (PR). These receptors are proteins that can be present in cells. "ER positive" tumors are those that have estrogen receptors. Tumors with progesterone receptors are referred to be "PR positive." For a tumour to be classified as hormone receptor positive, only one of these receptors must be positive. To grow, this form of cancer may rely on the hormones estrogen and/or progesterone. Hormone receptor-positive tumors can occur at any age, but are more common in menopausal women. Estrogen and/or progesterone receptors are found in around two-thirds of breast tumors. Cancers that lack these receptors are referred to as "hormone receptor negative."

HER2 positive: To grow, around 20% of breast tumors rely on the human epidermal growth factor receptor 2 (HER2) gene. These tumors are referred to as "HER2 positive" because they contain multiple copies of the HER2 gene or high amounts of the HER2 protein. These proteins are also referred to as "receptors." The HER2 gene produces the HER2 protein, which is present on cancer cells and is essential for tumor cell development. Breast tumors that are HER2-positive grow faster. They can either be hormone receptor positive or receptor negative. "HER2 negative" cancers contain no or low levels of the HER2 protein and/or few copies of the HER2 gene.

Triple negative: If a tumor does not express ER, PR, or HER2, it is referred to as "triple negative." Triple-negative breast cancer accounts for approximately 15% of all invasive breast cancers. Triple-negative breast cancer appears to be more common in younger women, especially in Black and Hispanic women. Triple-negative breast cancer is also more common in women who have a BRCA1 gene mutation. All people under the age of 60 who have triple-negative breast cancer should be examined for BRCA gene abnormalities, according to experts.

SYMPTOMS AND SIGNS OF BREAST CANCER

The majority of women with breast cancer have no physical changes (signs) or symptoms when they are first diagnosed.

The indications and symptoms listed below should be discussed with a doctor. Many times, the reason of a symptom is a medical issue other than cancer.

• A heated, red, swollen breast with or without a rash and dimpling resembling orange skin, known as "peau d'orange."

• Pain in the breast, particularly persistent breast pain Although pain is not usually a sign of breast cancer, it should be reported to a doctor.

• A firm knot-like bulge or thickening in the breast or beneath the arm. It is critical to feel the same place in the opposite breast to ensure that the change is not a result of healthy breast tissue in that area.

• Changes in breast size or form.

• Nipple discharge that happens unexpectedly, is bloody, or affects only one breast.

• Physical changes, such as a nipple that has rotated inwards or a pain in the nipple area.

• Irritation or changes in the skin, such as puckering, dimpling, scaliness, or new wrinkles

Please consult your doctor if you are concerned about any changes you are experiencing, including those listed above as well as other concerning changes that are not. In addition to other questions, your doctor will inquire how long and how frequently you have been experiencing the symptom(s). This is done to assist in determining the cause of the condition, which is referred to as a diagnostic.

If cancer is discovered, symptom relief is an important element of cancer care and treatment. This is known as palliative care or supportive care. It is frequently initiated shortly after diagnosis and continues throughout treatment. Make an appointment with your health care provider to discuss your symptoms, especially any new or changing symptoms.

STAGES OF BREAST CANCER

Staging describes the extent of the breast cancer, including the size of the tumor, if it has migrated to lymph nodes, whether it has spread to distant parts of the body, and what biomarkers are present.

Staging can be performed either before or after a patient has surgery. Doctors utilize diagnostic tests to determine the stage of cancer, therefore staging may not be complete until all tests are completed. Knowing the stage assists the doctor in determining the best course of treatment and can help estimate a patient's prognosis, or possibility of recovery. Distinct forms of cancer have different stage descriptions.

The TNM system is the most commonly used method by clinicians to describe the stage. Doctors use diagnostic test and scan results to address the following questions:

Tumor(T): How large is the initial breast tumor? What exactly are its biomarkers?

Node(N): Has the cancer spread to your lymph nodes? If so, where, what size, and how many are you looking for?

Metastasis(M): Is the cancer in other parts of the body?

The results are aggregated to establish each person's cancer stage.

Breast cancer is classified into five stages: stage 0 (zero), which is non-invasive ductal carcinoma in situ (DCIS), and stages I through IV (1–4), which are used for invasive breast cancer. The stage provides a common language for doctors to describe the cancer so that they can collaborate to determine the best treatments.

Clinical and pathological staging are both possible. Clinical staging is determined by the results of pre-surgery tests such as physical examinations, mammograms, ultrasounds, and MRI scans. Pathological staging is determined by what is discovered during breast tissue and lymph node removal surgery. Typically, the results are available few days following surgery. Pathological staging, in general, provides the most information for determining a patient's prognosis.

More information on each component of the TNM system for breast cancer can be found below:

Tumor (T)

The "T" plus a letter or number (0 to 4) is used in the TNM system to describe the size and location of the tumor. The size of a tumor is measured in millimeters (cm). A centimeter is approximately the width of a normal pen or pencil.

Stages can also be subdivided into smaller groups to assist define the tumor in greater depth. Specific tumor stage information is provided in the table below.

TX: The primary cancer cannot be evaluated.

T0: There is no sign of breast cancer.

Tis: This term refers to a carcinoma in situ. The cancer is contained to the breast tissue's ducts and has not spread to the surrounding tissue. Breast carcinoma in situ is classified into two types:

• Tis (DCIS): DCIS is a non-invasive malignancy that, if left untreated, can progress to aggressive breast cancer. DCIS indicates that cancer cells have been discovered in the breast ducts but have not spread beyond the layer of tissue where they began.

• Tis (DCIS): Paget disease of the nipple is an uncommon type of early, non-invasive cancer that solely affects the nipple's skin cells. Paget disease is sometimes linked to invasive breast cancer. If invasive breast cancer exists, it is classed based on the stage of the invasive tumor.

T1: The breast tumor is 20 millimeters (mm) or smaller in diameter at its widest point. This is a fraction of an inch. This stage is then subdivided into four substages based on tumor size:

• T1mi tumor is one that is one millimeter or less in size.

• T1a tumors are those that are greater than 1 mm but less than 5 mm in size.

• T1b tumors are those that are larger than 5 mm but smaller than 10 mm.

• T1c tumors are those that are larger than 10 mm but smaller than 20 mm.

T2: The tumor is larger than 20 mm but less than 50 mm in size.

T3: The tumor is more than 50 mm in diameter.

T4: The tumor belongs to one of the following categories:

• T4a indicates that the tumor has spread into the chest wall.

• T4b is the stage at which the tumor has penetrated the skin.

• T4c cancer has spread to the chest wall and the skin.

• T4d is an inflammatory form of breast cancer.

Node (N)

The letter "N" in the TNM staging system denotes lymph nodes. These little, bean-shaped organs aid in the battle against infection. Regional lymph nodes are lymph nodes located near the site of the cancer. Regional lymph nodes include the following:

• The axillary lymph nodes(lymph nodes found beneath the arm).

• Above and below the collarbone lymph nodes

• Internal mammary lymph nodes(lymph nodes found behind the breastbone).

Lymph nodes located in other sections of the body are referred to as distant lymph nodes. The staging is described in detail below.

NX: Lymph nodes were not examined.

N0: Any of the following:

• There was no malignancy identified in the lymph nodes.

• Only cancerous spots smaller than 0.2 mm are found in the lymph nodes.

N1: The cancer has progressed to one to three axillary lymph nodes and/or one to three internal mammary lymph nodes. If the cancer in the lymph node is more than 0.2 mm but less than 2 mm, it is referred to as "micrometastatic" (N1mi).

N2: Cancer has progressed to four to nine axillary lymph nodes. Alternatively, it has migrated to the internal mammary lymph nodes but not to the axillary lymph nodes.

N3: The cancer has spread to 10 or more axillary lymph nodes, or to lymph nodes beneath the clavicle, or collarbone. It is also possible that it has migrated to the internal mammary lymph nodes. N3 refers to cancer that has spread to the lymph nodes above the clavicle, commonly known as supraclavicular lymph nodes.

If there is cancer in the lymph nodes, doctors can plan treatment by knowing how many lymph nodes are involved and where they are. After the axillary lymph nodes are removed after surgery, the pathologist can determine the number of cancerous lymph nodes. During surgery, the supraclavicular or internal mammary lymph nodes are rarely removed. If there is cancer in these lymph nodes, treatments other than surgery are usually performed, such as radiation therapy, chemotherapy, and hormone therapy.

Metastasis (M)

The letter "M" in the TNM system indicates if the cancer has moved to other parts of the body, a condition known as distant metastasis. This type of cancer is no longer considered early-stage or locally progressed. See the Guide to Metastatic Breast Cancer on this website for further information.

MX: The long-distance spread cannot be evaluated.

M0: There are no signs of distant metastases.

M0 (i+): There is no sign of distant metastases, either clinically or radiographically. There is, however, microscopic evidence of tumor cells no larger than 0.2 mm in the blood, bone marrow, or other lymph nodes.

M1: There is evidence of metastasis to another portion of the body, which means that breast cancer cells are spreading to other organs.

Cancer stage grouping

Doctors determine cancer stage by using the T, N, and M categories, tumor grade, and ER/PR and HER2 testing results. This data will be used to assist determine your prognosis (see Diagnosis). The T, N, and M classifications are the simplest way to explain the stage of breast cancer. This is the technique taken in the next sections to describe the various steps.

The majority of patients are eager to learn the precise stage of their cancer. If you have surgery as your initial therapy for cancer, your doctor will usually confirm the stage of the cancer when the post-surgical testing is completed, which is normally 5 to 7 days following surgery. When systemic treatment is administered before to surgery, which is usually in the form of drugs and is referred to as neoadjuvant therapy, the stage of the malignancy is mostly assessed clinically. Doctors may refer to cancer in stages I to IIA as "early stage," and cancer in stages IIB to III as "locally advanced."

Stage 0: Stage zero (0) refers to illness that is limited to the ducts of the breast and has not spread to the surrounding tissue. It is also referred to as non-invasive or in situ cancer (Tis, N0, M0).

Stage IA: The tumor is tiny and invasive, but it hasn't migrated to the lymph nodes (T1, N0, M0).

Stage IB: Cancer has spread to the lymph nodes, and the size of the cancer in the lymph node is greater than 0.2 mm but less than 2 mm. There is either no indication of a breast tumor or the tumor is 20 mm or less in size (T0 or T1, N1mi, M0).

Stage IIA: Any one of the following conditions:

• Although there is no sign of a tumor in the breast, the cancer has migrated to one to three axillary lymph nodes. It hasn't spread to other sections of the body yet. (T0, N0, M0.)

• The tumor is 20 mm or less in diameter and has migrated to one to three axillary lymph nodes (T1, N1, M0).

• The tumor is more than 20 mm but less than 50 mm in size, and it has not migrated to the axillary lymph nodes (T2, N0, M0).

Stage IIB: Either of the following conditions:

The tumor has migrated to 1 to 3 axillary lymph nodes and is larger than 20 mm but not larger than 50 mm (T2, N1, M0).

The tumor is more than 50 mm, yet it has not migrated to the axillary lymph nodes (T3, N0, M0).

Stage IIIA: The disease has progressed to 4 to 9 axillary lymph nodes or internal mammary lymph nodes of any size. It hasn't spread to the rest of the body (T0, T1, T2, or T3; N2; M0). A tumor greater than 50 mm in size that has migrated to 1 to 3 axillary lymph nodes is also considered stage IIIA (T3, N1, M0).

Stage IIIB: The tumor has spread to the chest wall, or it has produced edema or ulceration of the breast, or it has been classified as inflammatory breast cancer. It could have expanded to up to nine axillary or internal mammary lymph nodes. It hasn't spread to the rest of the body (T4; N0, N1, or N2; M0).

Stage IIIC: Any size tumor that has progressed to 10 or more axillary lymph nodes, internal mammary lymph nodes, and/or lymph nodes under the collarbone. It hasn't spread to the rest of the body (any T, N3, M0).

Stage IV (metastatic): The tumor has progressed to other organs such as the bones, lungs, brain, liver, distant lymph nodes, or the chest wall (any T, any N, M1). About 6% of the time, metastatic cancer is discovered when the malignancy is first diagnosed. This is known as de novo metastatic breast cancer. Metastatic breast cancer is most typically discovered after a previous diagnosis of early breast cancer.

Recurrent: Recurrent cancer is cancer that has returned after treatment and can be local, regional, or distant. If the cancer returns, more tests will be performed to determine the degree of the recurrence. These tests and scans are frequently identical to those performed at the time of the first diagnosis.

DIAGNOSIS OF BREAST CANCER

Many tests are used by doctors to detect or diagnose breast cancer. They may also perform tests to see whether the cancer has spread to other parts of the body besides the breast and lymph nodes beneath the arm. This is referred as as a metastasis. Doctors may also conduct tests to determine which treatments are most likely to be effective.

A biopsy is the only guaranteed way for a doctor to know if a part of the body has cancer in most cases of cancer. During a biopsy, the doctor extracts a small sample of tissue for laboratory testing.

Not all of the tests described below will be administered to every individual. When selecting a diagnostic test, your doctor may take the following variables into account:

• The cancer type suspected

• Your symptoms and signs

• Your age and general well-being

• The outcomes of previous medical tests

When a woman or her doctor discovers a mass or abnormal calcifications on a screening mammography, or a lump or nodule in the breast during a clinical or self-examination, a set of tests is usually required to examine a probable breast cancer. A woman may notice a red or puffy breast or a lump or nodule beneath her arm less frequently.

The tests listed below may be used to diagnose breast cancer or as follow-up testing after a diagnosis of breast cancer.

Imaging tests 

Images of the inside of the body are produced via imaging tests. The following breast imaging tests may be performed to learn more about a questionable spot discovered during screening. Other new sorts of testing are being researched in addition to these.

Diagnostic mammography: Diagnostic mammography is comparable to screening mammography, with the exception that more images of the breast are taken. It is frequently utilized when a woman exhibits symptoms such as a new lump or nipple discharge. If something unusual is discovered on a screening mammogram, diagnostic mammography may be employed.

Ultrasound: An ultrasound creates an image of the breast tissue by using sound waves. An ultrasound can tell the difference between a solid tumor that may be cancer and a fluid-filled cyst that is not generally malignancy.

MRI: An MRI produces detailed images of the body by using magnetic fields rather than x-rays. Before the scan, a special dye called a contrast medium is administered to help provide a clear picture of the probable cancer. This dye is injected into a vein in the patient. A breast MRI may be done after a woman has been diagnosed with cancer to determine how far the disease has spread throughout the breast or to screen for cancer in the other breast. Breast MRI, in addition to mammography, is a screening option for certain women who have a very high risk of getting breast cancer and for some women who have a family history of breast cancer. If locally advanced breast cancer is discovered, or if chemotherapy or endocrine therapy is administered first, followed by a repeat MRI for surgical planning, MRI may be employed. Finally, MRI may be utilized as a form of follow-up after a breast cancer diagnosis and therapy.

Biopsy

A biopsy is the removal of a small sample of tissue for microscopic examination. Other tests can indicate the presence of cancer, but only a biopsy can provide a definitive diagnosis. The material is next examined by a pathologist (s). A pathologist is a medical professional who specializes in interpreting laboratory tests and assessing cells, tissues, and organs to identify disease. Biopsies are classed according to the technique and/or size of the needle used to collect the tissue sample.

Fine needle aspiration biopsy: A tiny needle is used in this sort of biopsy to extract a small sample of cells.

Image-guided biopsy: Using an imaging technology such as mammography, ultrasound, or MRI, a needle is guided to the area of the mass or calcifications during this treatment. A stereotactic biopsy is an image-guided biopsy that uses mammography to guide the needle. Your doctor will advise you on the appropriate form of biopsy for your situation. At the time of the biopsy, a small metal clip is usually inserted into the breast to mark the location of the biopsy sample in case the tissue is malignant and extra surgery is required. This clip is typically titanium, so it will not interfere with future imaging tests, but consult your doctor before undergoing any imaging tests.

Core needle biopsy: This form of biopsy employs a bigger needle to extract a larger sample of tissue. This is typically the preferred biopsy approach for determining whether a physical examination or imaging test anomaly is invasive cancer and, if so, what the cancer biomarkers are, such as hormone receptor status (ER, PR), and HER2 status. Biomarkers, also known as tumor markers, are compounds found in a person's blood, urine, or other bodily fluids that can also be detected in or on a tumor. They are produced by the tumor or the body in reaction to malignancy. This information will aid in the development of a treatment plan. Local anesthetic, which is pain-blocking drug, is used to reduce the patient's suffering during the surgery.

Surgical biopsy: The most tissue is removed during this sort of biopsy. A surgical biopsy is usually not suggested to identify breast cancer because surgery is best done after a cancer diagnosis has been made. Non-surgical core needle biopsies are frequently indicated to diagnose breast cancer in order to reduce the quantity of tissue removed. Because many patients who are advised to get a breast biopsy are not diagnosed with cancer, employing a needle biopsy for diagnosis minimizes the number of people who have unnecessary surgery.

Sentinel lymph node biopsy: When cancer spreads through the lymphatic system, the lymph node or group of lymph nodes that the cancer initially reaches is referred to as the "sentinel" lymph node. These are often the lymph nodes under the arms known as the axillary lymph nodes in breast cancer. The sentinel lymph node biopsy process is used to determine whether there is cancer in the lymph nodes surrounding the breast.

Examining the biopsy sample

Examining the sample(s) obtained during the biopsy can assist your doctor in learning about specific aspects of a cancer that can help select your treatment options.

Tumor features: The tumor is examined under a microscope to identify whether it is invasive or non-invasive (in situ); whether it is ductal, lobular, or another type of breast cancer; and whether the cancer has spread to the lymph nodes. The tumor's margins or edges are also evaluated, and the distance from the tumor to the edge of the excised tissue is measured, which is referred to as margin width.

Grade: A biopsy also determines the tumor grade. The term "grade" relates to how different cancer cells appear from healthy cells, as well as whether they appear slower or quicker growing. If the cancer resembles healthy tissue and contains distinct cell groupings, it is referred to as "well differentiated" or a "low-grade tumor." When malignant tissue differs significantly from healthy tissue, it is referred to as "poorly differentiated" or a "high-grade tumor." There are three grades: grade 1 (highly differentiated), grade 2 (moderately differentiated), and grade 3 (poorly differentiated).

ER and PR: Testing for ER and PR helps assess both the patient's risk of recurrence (the likelihood of the cancer returning) and the type of treatment that is most likely to reduce the risk of recurrence. In general, hormone therapy, also known as endocrine therapy, lowers the likelihood of recurrence of ER-positive and/or PR-positive malignancies. The ER and PR status of the breast tumor and/or areas of dissemination should be examined for everyone newly diagnosed with invasive breast cancer or a recurrence of breast cancer, according to guidelines. Testing for ER status is indicated for patients with DCIS to determine whether hormone therapy may minimize the risk of future breast cancer.

HER2: The cancer's HER2 status helps decide if medications that target the HER2 receptor, such as trastuzumab (Herceptin) and pertuzumab (Perjeta), can help treat it. Only aggressive tumors are subjected to this test. When you are first diagnosed with invasive breast cancer, it is recommended that you undergo HER2 testing. Furthermore, if the cancer has moved to another part of your body or recurs after treatment, testing on the new tumor or locations where the disease has spread should be repeated.

HER2 tests are often either clearly positive or negative, indicating that your malignancy has a high or low level of HER2. If your test findings are not clearly positive or negative, more testing, either on a different tumor sample or with a different test, may be required. Even with repeated testing, the results may not always be conclusive, so you and your doctor will have to decide on the best course of action.

If your cancer is HER2-positive, HER2-targeted therapy may be a good option for you. If your cancer is HER2-negative, HER2-targeted therapy is not an option for you, and your doctor will discuss other treatment choices with you.

The results of these tests can help you decide on a treatment plan.

Blood tests

Your doctor may also order a variety of blood tests. These tests can be performed either before or after surgery.

• Complete blood count: A complete blood count (CBC) is a test that counts the quantity of different types of cells in a person's blood, such as red blood cells and white blood cells. It is done to ensure that your bone marrow is working properly.

• Blood chemistry: This test determines how well your liver and kidneys are functioning.

• Hepatitis tests: While not now the standard of care, these tests are done on occasion to look for signs of prior hepatitis B and/or hepatitis C exposure. If you have active hepatitis B, you may need to take a particular drug to suppress the virus before receiving chemotherapy. Chemotherapy can cause the virus to develop and damage the liver if it is not given this medication.

Genomic tests to estimate the chance of recurrence

Doctors utilize genomic testing to seek for specific genes or proteins (substances produced by genes) that are detected in or on cancer cells. These tests assist clinicians in better understanding the specific characteristics of each patient's breast cancer. Genomic tests can also assist determine the likelihood of cancer recurrence after treatment. Knowing this information assists doctors and patients in making treatment decisions and can help some patients avoid undesirable side effects from a treatment that may not be required.

The genetic assays mentioned below can be performed on a tumor sample that has already been removed through a biopsy or surgery. Most individuals will not require a further biopsy or surgery for these tests.

Oncotype Dx™: This test is available to persons who have ER-positive and/or PR-positive, HER2-negative breast cancer that has not spread to the lymph nodes, as well as in some situations when the cancer has spread to the lymph nodes. This test can assist patients and clinicians in deciding if chemotherapy should be added to hormonal therapy. This test examines 16 cancer-related genes and 5 reference genes to calculate a "recurrence score," which indicates the likelihood of the cancer returning outside of the breast or regional lymph nodes within 10 years of diagnosis, assuming a patient receives 5 years of hormone therapy. The recurrence score is used to guide chemotherapy recommendations, which may fluctuate depending on age. The suggestions are shown below by age group.

Patients under the age of 50

• Recurrence score less than 16: Hormonal therapy is routinely advised, although chemotherapy is rarely required.

• Recurrence score of 16 to 30: Chemotherapy may be prescribed prior to hormonal therapy.

• Recurrence score of 31 or higher: Chemotherapy is frequently prescribed before hormone treatment.

Patients over the age of 50

• Recurrence score less than 26: Hormonal therapy is routinely advised, although chemotherapy is rarely required.

• Recurrence score of 26 to 30: Chemotherapy may be prescribed prior to hormonal therapy.

• Recurrence score of 31 or higher: Chemotherapy is frequently prescribed before hormone treatment.

Molecular testing of the tumor: Other laboratory tests on a tumor sample may be recommended by your doctor in order to discover specific genes, proteins, and other tumor-specific components. If you have locally advanced or metastatic breast cancer, your doctor may advise you to get tested for the following molecular characteristics:

• PD-L1: PD-L1 is located on the surface of cancer cells as well as some immune cells in the body. This protein prevents the body's immune cells from eliminating the cancer, which is particularly important in triple-negative breast cancer.

• Microsatellite instability-high (MSI-H) or DNA mismatch repair deficiency (dMMR): Tumors with MSI-H or dMMR have trouble repairing DNA damage. This signifies that they undergo a great deal of mutation or change. These modifications cause aberrant proteins to be produced on tumor cells, making it easier for immune cells to locate and fight the tumor.

• NTRK gene fusions: This is a specific genetic mutation that has been discovered in a variety of cancers, including breast cancer.

• PI3KCA gene mutation: This is a particular genetic alteration that is frequently discovered in breast cancer.

MammaPrint™: This test is an option for persons who have ER-positive and/or PR-positive breast cancer that is HER2-negative or HER2-positive and has not spread to the lymph nodes or has spread to 1 to 3 lymph nodes. This test estimates the probability of recurrence for early-stage breast cancer based on information from 70 genes. This test can assist patients and doctors decide if chemotherapy should be added to hormonal therapy for adults who have a high risk of cancer recurrence. This test is not suggested for patients who have a low risk of cancer recurrence.

Additional tests: For persons with ER-positive and/or PR-positive, HER2-negative breast cancer that has not progressed to the lymph nodes, further testing may be available. PAM50 (ProsignaTM), EndoPredict, Breast Cancer Index, and uPA/PAI are among the tests available. They can also be used to predict if the cancer will spread to other places of the body.

The above-mentioned tests have not been found to be beneficial in predicting recurrence risk in persons with HER2-positive or triple-negative breast cancer. As a result, none of these tests are currently suggested for HER2 positive or triple negative breast cancer. Other considerations will be considered by your doctor when recommending treatment alternatives for you.

Discuss genetic tests with your doctor to learn more about what they signify and how the results may impact your treatment strategy.

Following the completion of diagnostic tests, your doctor will go through the results with you. If cancer is the diagnosis, these data will also assist the clinician in describing the cancer. This is referred to as staging. Additional imaging studies may be recommended depending on the stage of the cancer and the tumor biomarkers. If a suspicious spot is discovered outside of the breast and associated lymph nodes, a biopsy of other parts of the body may be required to determine whether it is cancer.

TREATMENT OF BREAST CANCER

Doctors specializing in various areas of cancer treatment, such as surgery, radiation oncology, and medical oncology, collaborate with radiologists and pathologists to develop a patient's overall treatment plan, which incorporates many types of treatments. This is referred to as a multidisciplinary team. Other health care professionals on cancer care teams include physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, and others. A geriatric oncologist or geriatrician may be involved in the care of persons over the age of 65. Inquire with the doctor in charge of your treatment about the health care experts who will be on your treatment team and what each of them does. This may alter as your health-care needs change. You should also inquire about who will be in charge of organizing your care.

A treatment plan is a summary of your cancer and the cancer treatment that is planned. It is intended to provide basic medical history information to any doctors who may care for you during your lifetime. Before starting therapy, request a copy of your treatment plan from your doctor. You can also provide your doctor a copy of the ASCO Treatment Plan form to complete.

The treatment plan is influenced by the biology and behavior of breast cancer. Some tumors are small but rapidly growing, while others are huge but slowly growing. Treatment options and suggestions are very individualized and are determined by a variety of factors, including:

• The subtype of the tumor, which includes hormone receptor status (ER, PR), HER2 status, and nodal status.

• The cancer's stage.

• If necessary, genomic markers such as Oncotype DXTM or MammaPrintTM can be used.

• Age, general health, menopausal status, and preferences of the patient

• The existence of known mutations in breast cancer genes such as BRCA1 or BRCA2.

Although each patient's treatment will be tailored by the breast cancer care team, there are certain common measures for treating early-stage and locally advanced breast cancer.

Doctors typically prescribe surgery to remove the tumor in both DCIS and early-stage invasive breast cancer. The surgeon will also remove a tiny area of healthy tissue around the tumor, known as a margin, to ensure that the entire tumor is gone. Although the goal of surgery is to remove all visible cancer from the breast, tiny cancer cells may be left behind. In some cases, this may necessitate a second surgery to eliminate any leftover cancer cells. There are several methods for detecting tiny cells and ensuring a clean edge. It is also possible for tiny cells to be present outside of the breast, which is why, as detailed below, systemic treatment with medicine is frequently suggested after surgery.

Doctors may offer systemic treatment with chemotherapy or hormonal therapy before surgery for bigger malignancies or those that are growing quickly. This is known as neoadjuvant therapy. There may be various advantages to undergoing different therapies prior to surgery:

• Because the tumor is smaller, surgery may be less difficult.

• Your doctor may investigate whether some cancer treatments are effective.

• A clinical study may also allow you to explore a new medicine.

• If you have any microscopic distant disease, it will be addressed as soon as possible.

• If the tumor decreases enough before surgery, women who might have needed a mastectomy may be able to receive breast-conserving surgery (lumpectomy).

Following surgery, the next step in treating early-stage breast cancer is to reduce the chance of recurrence and remove any leftover cancer cells from the body. These cancer cells are undetectable by current diagnostics, but they are thought to be responsible for cancer recurrence since they can multiply over time. Adjuvant therapy refers to treatment given after surgery. Radiation therapy, chemotherapy, targeted therapy, and/or hormone therapy are examples of adjuvant therapies.

The necessity for adjuvant therapy is determined by the likelihood that any cancer cells remain in the breast or body, as well as the likelihood that a certain treatment will work to treat the cancer. Although adjuvant therapy reduces the likelihood of recurrence, it does not eliminate it entirely.

Other tools, in addition to staging, can help assess prognosis and assist you and your doctor in making decisions about adjuvant therapy. This includes tests that can predict the probability of recurrence by examining your tumor tissue (such as Oncotype DxTM or MammaPrintTM), depending on the subtype of breast cancer. These tests may also assist your doctor in determining whether treatment will help minimize the chance of recurrence.

When surgery to remove the cancer is not possible, the cancer is said to be inoperable. The doctor will then offer alternative cancer treatments. To shrink the cancer, chemotherapy, targeted therapy, radiation therapy, and/or hormone therapy may be used.

Treatment options for recurring cancer are determined by how the cancer was initially treated as well as the tumour's features, such as ER, PR, and HER2.

The following are descriptions of the most frequent forms of therapy used for early-stage and locally progressed breast cancer. Treatment for symptoms and side effects is also part of your care plan, which is an important element of cancer care. Take the time to read about all of your treatment options, and don't be afraid to ask clarifying questions. Discuss the aims of each treatment with your doctor, as well as what you can expect during treatment. These discussions are known as "shared decision making." When you and your doctors collaborate to choose therapies that meet the goals of your care, this is referred to as shared decision making. Because there are various treatment choices for breast cancer, shared decision making is very crucial. It is also critical to check with your health insurance company before beginning any treatment to ensure that the treatment is covered.

Surgery

During a surgery, the tumor and some surrounding healthy tissue are removed. Surgery is frequently performed to evaluate the axillary lymph nodes, which are located beneath the arm. A surgical oncologist is a specialist who specializes in the surgical treatment of cancer.

The smaller the tumor, in general, the more surgical options a patient has. Breast cancer surgery options include the following:

Lumpectomy: This entails removing the tumor as well as a small, cancer-free zone of healthy tissue around it. The majority of the breast is still present. Radiation therapy to the residual breast tissue is frequently indicated following surgery for invasive cancer, particularly in younger patients, patients with hormone receptor negative tumors, and patients with bigger tumors. Radiation therapy following surgery for DCIS may be an option depending on the patient, the tumor, and the type of surgery. A lumpectomy is also referred to as a breast-conserving surgery, a partial mastectomy, a quadrantectomy, or a segmental mastectomy. Women who have BRCA1 or BRCA2 gene mutations who are newly diagnosed with breast cancer may be eligible for breast-conserving surgery. Women with newly diagnosed breast cancer who have a moderate-risk gene mutation, such as CHEK2 or ATM, are also at risk. Your genetic mutation status should not be used to determine which course of treatment is best for you.

Mastectomy: This procedure involves the surgical removal of the whole breast. Mastectomies are classified into numerous categories. Discuss with your doctor if the skin, known as a skin-sparing mastectomy, or the nipple, known as a nipple-sparing mastectomy or total skin-sparing mastectomy, can be retained. A nipple-sparing mastectomy may be an option for certain women who have a BRCA1 or BRCA2 gene mutation, as well as women who have a moderate-risk gene mutation, such as CHEK2 or ATM. In deciding the best form of surgery for you, your doctor will also examine the size of the tumor in comparison to the size of your breast.

Removal, analysis, and treatment of lymph nodes

In some tumors, cancer cells can be discovered in the axillary lymph nodes. Knowing whether any of the lymph nodes near the breast are cancerous might help determine treatment and prognosis.

Sentinel lymph node biopsy: The surgeon detects and removes 1 to 3 or more lymph nodes from under the arm that receive lymph drainage from the breast during a sentinel lymph node biopsy (also known as a sentinel node biopsy or SNB). For individuals whose sentinel lymph nodes are generally cancer-free, this treatment can prevent removing a larger number of lymph nodes with an axillary lymph node dissection. The smaller lymph node surgery reduces the likelihood of a number of potential side effects. These adverse effects include lymphedema (arm swelling), numbness, and arm movement and range of motion issues with the shoulder. These are long-term concerns that can have a negative impact on a person's quality of life. Importantly, the risk of lymphedema rises in direct proportion to the amount of lymph nodes and lymph arteries removed or injured during cancer treatment. This suggests that women who undergo a sentinel lymph node biopsy are less likely than those who have an axillary lymph node dissection to acquire lymphedema.

Before a sentinel lymph node biopsy, your doctor may propose ultrasound imaging of your lymph nodes and/or an image-guided lymph node biopsy to see if the cancer has spread there. This is frequently performed if your lymph nodes are palpable during a clinical examination or if you are receiving chemotherapy prior to surgery. However, if your malignancy is little and your lymph nodes cannot be touched during a clinical examination, ASCO does not advocate doing so.

The surgeon frequently injects a radioactive tracer and sometimes a dye behind or around the nipple to locate the sentinel lymph node. The injection, which can be painful, lasts roughly 15 seconds. The dye or tracer moves to the lymph nodes, first reaching the sentinel node. If a radioactive tracer is utilized, it will emit radiation that will aid the surgeon in locating the lymph node. When dye is employed, the surgeon can identify the lymph node because it changes color.

The pathologist then looks for cancer cells in the lymph nodes. If the sentinel lymph node(s) are cancer-free, research indicates that the remaining lymph nodes are likewise likely to be cancer-free. This indicates that no additional lymph nodes will need to be removed. In general, sentinel lymph node biopsy is the standard of therapy for most women with early-stage breast cancer who have tumors that can be removed surgically and whose underarm lymph nodes are not enlarged. However, in some cases, it may be preferable not to have any axillary surgery. You should consult with your surgeon to see if this is the best option for you.

Axillary lymph node dissection: The surgeon removes several lymph nodes from under the arm during an axillary lymph node dissection. A pathologist then examines these for cancer cells. The amount of lymph nodes excised varies from patient to patient. Women undergoing a lumpectomy and radiation therapy with a smaller tumor (less than 5 cm) and two or fewer sentinel lymph nodes with cancer may be able to avoid a full axillary lymph node dissection. In addition, some women undergoing a mastectomy may be spared an axillary lymph node dissection. This helps to lessen the likelihood of negative effects while not reducing survival. If cancer is discovered in the sentinel lymph node, whether additional surgery to remove more lymph nodes is required depends on the unique situation.

Because the danger of dissemination is very minimal in persons with DCIS and no invasive malignancy, the lymph nodes are usually not checked. However, if a patient with DCIS chooses or requires a mastectomy, the surgeon may consider a sentinel lymph node biopsy. If invasive cancer is discovered with DCIS during the mastectomy, which happens from time to time, the lymph nodes will need to be checked. A sentinel lymph node biopsy, on the other hand, is usually not possible. In that case, an axillary lymph node dissection may be advised.

A sentinel lymph node biopsy or an axillary lymph node dissection will be performed on the majority of persons with invasive breast cancer. A sentinel lymph node biopsy will be performed on the majority of women under the age of 70 who have early-stage breast cancer to detect if there is cancer in the axillary lymph nodes, as this information is utilized to decide treatment recommendations. ASCO does not advocate sentinel lymph node biopsy for most patients 70 and older with hormone receptor-positive and HER2-negative illness and no clinically visible malignancy in the lymph nodes. Patients over the age of 70 with other types of breast cancer or clinically visible lymph nodes will generally be advised to have their axillary lymph nodes evaluated.

There was no chemotherapy prior to surgery, yet there was cancer in the sentinel lymph nodes: ASCO advises radiation therapy over axillary lymph node dissection for the majority of persons in this condition. In the case of three or more sentinel lymph nodes having malignancy, an axillary lymph node dissection may be paired with radiation therapy. If the tumors are in specific locations or have high-risk features, further radiation therapy to the lymph nodes may be required following surgery for some persons in this group.

There was no chemotherapy before surgery, and there was no cancer in the sentinel lymph nodes: ASCO does not advocate an axillary lymph node dissection for the majority of persons in this condition. A small subset of patients having malignancies in specific locations or with high-risk traits may be provided lymph node radiation therapy.

Chemotherapy is administered prior to surgery: Treatment for persons who have had chemotherapy prior to surgery is determined by whether the cancer in the lymph nodes was eradicated by the chemotherapy. As a result, patients are re-staged by sentinel lymph node biopsy following chemotherapy.

• Radiation therapy is not advised if there is no sign of malignancy in the lymph nodes before or after chemotherapy.

• Radiation therapy is appropriate if there was evidence of cancer in the lymph nodes prior to chemotherapy and there is no longer evidence of cancer in the lymph nodes following chemotherapy.

• If there is evidence of malignancy in the lymph nodes following chemotherapy, an axillary lymph node dissection as well as radiation therapy are both suggested.

Reconstructive (plastic) surgery

Breast reconstruction may be an option for women who have had a mastectomy or a lumpectomy. This is a procedure in which a breast is recreated using either tissue from another region of the body or synthetic implants. A plastic surgeon is usually in charge of reconstruction. Immediate reconstruction is when a person can receive reconstruction at the same time as a mastectomy. They may potentially have it in the future, which is known as delayed reconstruction.

For individuals undergoing a lumpectomy, reconstruction may be performed concurrently to improve the appearance of the breast and to make both breasts look comparable. This is known as oncoplastic surgery. Many breast surgeons can do this procedure without the assistance of a plastic surgeon at the same time as the lumpectomy. Surgery on the healthy breast at the same time as the lumpectomy may be recommended to ensure that both breasts look identical.

The following techniques are commonly employed to shape a new breast: 

Breast implants: Breast implants remodel the breast by using saline-filled or silicone gel-filled forms. A saline-filled implant has a silicone exterior and is filled with sterile saline, which is salt water. Silicone gel-filled implants are made of silicone rather than saline. They were assumed to induce connective tissue problems, but no conclusive evidence has been identified. Before getting permanent implants, a woman may have a tissue expander implanted to produce the proper sized pocket for the implant. Implants can be positioned either above or below the pectoralis muscle. Discuss the advantages and disadvantages of silicone versus saline implants with your doctor. The longevity of an implant is determined by the woman. Some women, on the other hand, never need to have them changed. Other key aspects to consider when selecting implants are as follows:

• Many women do not find it troublesome enough to replace saline implants since they "ripple" at the top or shift with time.

• Saline implants have a different feel than silicone implants. They are frequently more firm to the touch than silicone implants.

Breast implants can cause complications. Some women are self-conscious about their shape or appearance. The implants may rupture or shatter, resulting in pain and scar tissue around the implant, or they may get infected. Breast implants have also been linked to a rare form of cancer known as breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Despite the fact that these issues are quite rare, you should discuss the risks with your doctor.

Tissue flap procedures: These treatments reconstruct the breast by using muscle and tissue from other parts of the body. Tissue flap surgery can be performed using a "pedicle flap," which involves moving tissue from the back or abdomen to the chest without harming the blood vessels. A "free flap" indicates that the blood vessels have been severed and that the surgeon must reconnect the relocated tissue to new blood arteries in the chest. There are various flap procedures:

• Transverse rectus abdominis muscle (TRAM) flap: This technique, which can be performed as a pedicle flap or a free flap, employs muscle and tissue from the lower stomach wall.

• Latissimus dorsi flap: The upper back muscle and tissue are used in this pedicle flap technique. During this flap operation, implants are frequently implanted.

• Deep inferior epigastric artery perforator (DIEP) flap: The DIEP free flap removes tissue from the abdomen, and the blood vessels are attached to the chest wall by the surgeon.

• Gluteal free flap: The gluteal free flap creates the breast using tissue and muscle from the buttocks, and the surgeon also attaches the blood arteries. Transverse upper gracilis (TUG), which utilises upper thigh tissue, may also be an option.

Because blood arteries are involved in flap procedures, these tactics are usually not indicated for women who have a history of diabetes, connective tissue or vascular illness, or who smoke, because the risk of complications during and after surgery is substantially higher.

DIEP and other flap operations are more involved and need more recuperation time. The appearance of the breast, on the other hand, may be preferable, especially if radiation therapy is part of the treatment plan.

Speak with your doctor to learn more about reconstruction possibilities and to be sent to a plastic surgeon. Choose a plastic surgeon who has experience with a wide range of reconstructive surgeries, such as implants and flap procedures, when looking for one. They can debate the benefits and drawbacks of each procedure.

External breast forms (prostheses)

Women who intend to postpone or avoid reconstructive surgery may benefit from an external breast prosthesis or artificial breast shape. These are made of silicone or soft material and are designed to fit into a mastectomy bra. Breast prostheses can be customized to fit each lady and appear natural.

Radiation therapy

The use of high-energy x-rays or other particles to eliminate cancer cells is known as radiation therapy. A radiation oncologist is a doctor who specializes in the use of radiation therapy to treat cancer. Radiation therapy is classified into numerous types:

• External-beam radiation therapy: This is the most prevalent type of radiation treatment, and it is delivered by a machine located outside the body. This comprises full breast radiation therapy, partial breast radiation therapy, and expedited breast radiation therapy, which can be completed in a matter of days rather than weeks.

• Intra-operative radiation therapy: This is when radiation therapy is administered in the operating room with the help of a probe.

• Brachytherapy: Radiation therapy of this type is administered by inserting radioactive sources into the tumor.

Despite promising study findings, intra-operative radiation treatment and brachytherapy are not commonly employed. They may be possibilities for a patient with a tiny tumor that has not migrated to the lymph nodes, if they are accessible.

A radiation therapy regimen, or schedule (see below), often consists of a predetermined number of treatments administered over a predetermined time period, such as 5 days per week for 3 to 6 weeks. Radiation therapy frequently reduces the risk of recurrence in the breast. In fact, with contemporary surgery and radiation therapy, recurrence rates in the breast are now less than 5% after 10 years of treatment, and 6–7% after 20 years. Survival is the same whether the procedure is a lumpectomy or a mastectomy. If cancer is found in the lymph nodes beneath the arm, radiation therapy may be administered to the same side of the neck or underarm near the breast or chest wall.

Radiation therapy can be administered either after or before surgery: 

Adjuvant radiation therapy: It is typically administered following a lumpectomy and, in some cases, chemotherapy. Depending on the characteristics of the tumor, patients who have had a mastectomy may or may not require radiation therapy. Radiation therapy may be recommended after mastectomy if the patient has a bigger tumor, cancer in the lymph nodes, cancer cells outside of the lymph node capsule, or cancer that has spread into the skin or chest wall, among other things.

Neoadjuvant radiation therapy: Neoadjuvant radiation therapy is radiation therapy that is administered before to surgery to reduce a big tumor, making it easier to remove. This method is uncommon and is usually chosen only when surgery cannot eradicate a tumor.

Adjuvant radiation therapy should be administered to women with breast cancer who have BRCA1 or BRCA2 mutations when appropriate, according to ASCO. Women who have a TP53 mutation are at a higher risk of radiation therapy problems and should have a mastectomy instead of a lumpectomy and radiotherapy. Those who have an ATM mutation or other associated mutations should consult their doctor to see if adjuvant radiation therapy is appropriate for them. There is currently insufficient evidence to advocate avoiding radiation therapy in all women with ATM mutations.

Radiation therapy can produce fatigue, breast swelling, redness and/or skin discoloration, and soreness or burning in the area where the radiation was focused, sometimes accompanied by blistering or peeling. To alleviate some of these adverse effects, your doctor may prescribe a topical drug to be applied to the skin.

A tiny portion of the lung may be impacted by radiation therapy, resulting in pneumonitis, a radiation-related swelling of the lung tissue. This risk is proportional to the size of the area that underwent radiation therapy, and it usually heals with time.

Women who got treatment for breast cancer on the left side of the body in the past had a little increase in the long-term risk of heart disease due to older equipment and radiation therapy procedures. Modern approaches, such as respiratory gating, which uses technology to guide radiation delivery while a patient breathes, can now protect the great majority of the heart from the effects of radiation therapy.

You may be able to choose from a variety of radiation therapies with varying schedules. Discuss the benefits and drawbacks of each choice with your doctor.

Schedule for radiation therapy

Radiation therapy is typically administered on a daily basis for a specified number of weeks.

• After a lumpectomy: External-beam radiation therapy is given Monday through Friday for 3 to 4 weeks after a lumpectomy if the malignancy is not in the lymph nodes. If the cancer has spread to the lymph nodes, radiation therapy is administered for 5 to 6 weeks. This duration is evolving, since there is a preference for a shorter duration in women who fit the criteria for shorter treatment. This is frequently preceded with radiation therapy to the entire breast, followed by a more concentrated treatment to the location of the tumor in the breast for the remaining sessions.

This targeted element of the treatment, known as a boost, is usual for women with invasive breast cancer to lower the likelihood of a breast recurrence. Women with DCIS may potentially benefit from the treatment. The increase may be optional for women who have a low risk of recurrence. It is critical to discuss this treatment strategy with your doctor.

• After a mastectomy: Radiation therapy is normally administered 5 days a week for 5 to 6 weeks to people who require it after a mastectomy. Radiation therapy can be administered either before or after reconstructive surgery. As with lumpectomy, some women may be advised to receive less than 5 weeks of radiation therapy after mastectomy.

Even shorter schedules, such as 5 days of accelerated partial breast radiation therapy, have been researched and are in use in some locations.

These shorter schedules may not be an option for women who require radiation therapy following a mastectomy or to their lymph nodes. In addition, some women with very big breasts may require lengthier radiation therapy schedules.

• Partial breast irradiation: Partial breast irradiation (PBI) is radiation therapy that targets only the tumor area rather than the entire breast. It is more common following a lumpectomy. Directly targeting radiation to the tumor location usually reduces the amount of time patients need to receive radiation therapy. However, PBI may be available to only a subset of patients. PBI is still being explored, despite encouraging early results. However, in some cases, such as for persons with early-stage breast cancer, it is already part of standard care. You should explore the benefits and drawbacks of PBI versus whole breast radiation therapy with your radiation oncologist.

PBI can be performed using normal external-beam radiation therapy that focuses on the area where the tumor was removed rather than the entire breast. PBI can also be used with brachytherapy, with plastic catheters or a metal wand temporarily implanted in the breast. Breast brachytherapy treatment periods might range from one dosage to one week. It can also be administered as a single dose in the operating room shortly following tumor removal. These types of targeted radiation therapy are currently reserved for patients with tumors that are smaller, less aggressive, and lymph node-negative.

• Proton therapy: To kill cancer cells, standard radiation therapy for breast cancer employs x-rays, commonly known as photon therapy. Proton treatment is a type of external-beam radiation therapy in which protons are used instead of x-rays. Protons have the ability to destroy cancer cells at high energies. Because protons have different physical properties than photons, they may allow radiation therapy to be more focused and potentially minimize the radiation dose. The therapy may help lower the quantity of radiation that is delivered to the heart. In a national clinical trial, researchers are comparing the benefits of proton therapy vs photon therapy. Proton therapy is currently an experimental treatment that may not be widely available or reimbursed by health insurance.

• Intensity-modulated radiation therapy: Intensity-modulated radiation treatment (IMRT) is a more advanced method of treating the breast with external-beam radiation therapy. To better target the tumor and disperse the radiation more uniformly throughout the breast, the strength of the radiation directed at it is changed. The use of IMRT reduces the radiation dose and may reduce potential harm to surrounding organs such as the heart and lungs, as well as the risks of some immediate adverse effects such as skin peeling during treatment. This is especially crucial for women with medium to large breasts, who are more likely to experience adverse effects such as peeling and burning than women with smaller breasts. IMRT may also assist to reduce the long-term effects on breast tissue that were typical with previous radiation treatments, such as hardness, edema, or discolouration.

IMRT is not suitable for everyone. To learn more, speak with your radiation oncologist. Coverage for IMRT may also necessitate special insurance approval. It is critical to verify with your health insurance company before beginning any treatment to ensure that it is covered.

Concerns about adjuvant radiation therapy for older individuals and/or those with a tiny tumor

Recent studies have looked into the possibility of avoiding radiation therapy for women 65 and older who have an ER-positive, lymph node-negative, early-stage malignancy or a small tumor. Importantly, these trials suggest that women with tiny, less aggressive breast tumors who get a lumpectomy have a very low risk of cancer returning in the same breast. Radiation therapy minimizes the chance of breast cancer recurrence in the same breast even more than surgery alone. Radiation therapy, on the other hand, does not extend the lifespan of women.

The National Comprehensive Cancer Network (NCCN) continues to recommend radiation therapy as the recommended treatment option following a lumpectomy. They do, however, point out that women in rare circumstances or with a low-risk tumor may be able to avoid radiation therapy and instead rely on systemic therapy after a lumpectomy. This includes women above the age of 70, as well as those with medical issues that could shorten their life expectancy within the next five years. People who chose this option will have a slight increase in the risk of breast cancer recurrence. It is critical that these women explore the benefits and drawbacks of skipping radiation therapy with their oncologist.

Chemotherapy

Chemotherapy is the use of medications to eradicate cancer cells, typically by preventing the cancer cells from growing, dividing, and proliferating. It is called neoadjuvant chemotherapy because it is administered before surgery to shrink a large tumor, make surgery easier, and/or lower the risk of recurrence. Adjuvant chemotherapy is also used after surgery to lower the chance of recurrence.

A chemotherapy regimen, or schedule, often consists of a combination of medications administered in a predetermined number of cycles over a predetermined time period. Chemotherapy can be administered on a variety of schedules, based on what worked best in clinical studies for that particular type of treatment. It can be administered once a week, twice a week, three times a week, or even four times a week. Chemotherapy is used to treat breast cancer in a variety of ways. Commonly used medications include:

• Eribulin (Halaven)

• Fluorouracil (5-FU)

• Gemcitabine (Gemzar)

• Ixabepilone (Ixempra)

• Methotrexate (Rheumatrex, Trexall)

• Protein-bound paclitaxel (Abraxane)

• Vinorelbine (Navelbine)

• Docetaxel (Taxotere)

• Paclitaxel (Taxol)

• Doxorubicin (available as a generic drug)

• Epirubicin (Ellence)

• Pegylated liposomal doxorubicin (Doxil)
• 
  
• Capecitabine (Xeloda)

• Carboplatin (available as a generic drug)

• Cisplatin (available as a generic drug)

• Cyclophosphamide (available as a generic drug)

A patient may be administered one medicine at a time or a mixture of drugs at the same time. Combinations of certain medications have been demonstrated in studies to be more effective than single agents for adjuvant treatment. ASCO does not advocate routinely combining platinum chemotherapy (cisplatin or carboplatin) with anthracycline (doxorubicin or epiribicin) or taxane (paclitaxel or docetaxel) chemotherapy before or after surgery to treat persons with hereditary BRCA mutations.

Adjuvant therapy for early-stage and locally progressed breast cancer may include the following medications or drug combinations:

• AC (doxorubicin and cyclophosphamide)

• EC (epirubicin, cyclophosphamide)

• AC or EC followed by T (paclitaxel or docetaxel), or the reverse)

• CAF (cyclophosphamide, doxorubicin, and 5-FU)

• CEF (cyclophosphamide, epirubicin, and 5-FU)

• CMF (cyclophosphamide, methotrexate, and 5-FU)

• TAC (docetaxel, doxorubicin, and cyclophosphamide)

• TC (docetaxel and cyclophosphamide)

For HER2-positive breast cancer, therapies that target the HER2 receptor may be used with chemotherapy (see "Targeted therapy," below). Trastuzumab, for example, is an antibody. Combination regimens for HER2-positive breast cancer in its early stages may include:

• AC-TH (doxorubicin, cyclophosphamide, paclitaxel or docetaxel, trastuzumab)

• AC-THP (doxorubicin, cyclophosphamide, paclitaxel or docetaxel, trastuzumab, pertuzumab)

• TCH (paclitaxel or docetaxel, carboplatin, trastuzumab)

• TCHP (paclitaxel or docetaxel, carboplatin, trastuzumab, pertuzumab)

• TH (paclitaxel, trastuzumab)

Chemotherapy side effects vary according to the individual, the drug(s) used, whether the chemotherapy was coupled with other medications, and the schedule and dose employed. Fatigue, infection risk, nausea and vomiting, hair loss, loss of appetite, diarrhea, constipation, numbness and tingling, discomfort, early menopause, weight gain, and chemo-brain or cognitive dysfunction are all possible adverse effects. These adverse effects are frequently prevented or treated successfully during therapy using supportive drugs, and they normally go away after treatment is completed. Check with your doctor to see if they use cold cap procedures to reduce hair loss. Long-term side effects, such as heart damage, chronic nerve damage, or secondary malignancies such as leukemia or lymphoma, may occur in rare cases.

Many people feel well during chemotherapy and are actively caring for their families, working, and exercising, despite the fact that everyone's experience is unique. Discuss the potential side effects of your specific chemotherapy plan with your health care provider, and get medical help promptly if you develop a fever during chemotherapy.

Hormonal therapy

Hormonal therapy, also known as endocrine therapy, is a successful treatment for the majority of cancers that test positive for estrogen or progesterone receptors (called ER positive or PR positive). Hormones are used to stimulate the growth of this form of tumor. When hormonal therapy is administered alone or in conjunction with chemotherapy, blocking the hormones can help reduce cancer recurrence and mortality from breast cancer.

Breast cancer hormone therapy is not the same as menopausal hormone therapy (MHT). MHT is sometimes referred to as postmenopausal hormone therapy or hormone replacement therapy (HRT). Breast cancer hormone therapies function as "anti-hormone" or "anti-estrogen" therapies. They either inhibit hormone function or reduce hormone levels in the body. Hormonal therapy is also known as endocrine therapy. Hormones are produced by the body's endocrine system.

Hormonal therapy may be administered prior to surgery in order to shrink a tumor, make surgery easier, and/or reduce the risk of recurrence. This is referred to as neoadjuvant hormonal treatment. When administered before to surgery, it is usually given for at least 3 to 6 months and is continued after surgery. It may also be administered alone following surgery to lower the chance of recurrence. This is referred to as adjuvant hormonal therapy.

Hormonal therapy types

Tamoxifen: Tamoxifen is a hormone-blocking medication that prevents estrogen from attaching to breast cancer cells. It reduces the chance of recurrence in the cancerous breast, the danger of developing cancer in the other breast, and the risk of distant recurrence. Tamoxifen is effective in both menopausal women and women who have not yet reached menopause.

Tamoxifen is a tablet that is taken every day by mouth for 5 to 10 years. It may be taken with medicine to prevent the ovaries from releasing estrogen in premenopausal women. It is critical to discuss any other medications or supplements you are taking with your doctor, especially any anti-depression meds, as some may conflict with tamoxifen. Tamoxifen's most common side effects include hot flashes and vaginal dryness, discharge, or bleeding. Cancer of the uterine lining, cataracts, and blood clots are all extremely unusual hazards. Tamoxifen, on the other hand, may improve bone health and cholesterol levels.

Ovarian suppression or ablation: The use of medicines to prevent the ovaries from producing estrogen is known as ovarian suppression. Ovarian ablation is the surgical removal of the ovaries. For women who have not gone through menopause, these choices may be utilized in addition to another type of hormonal therapy.

• Gonadotropin or luteinizing releasing hormone (GnRH or LHRH) agonist medications are used to prevent the ovaries from producing estrogen, resulting in temporary menopause. These medications include goserelin (Zoladex) and leuprolide (Eligard, Lupron). Because they are ineffective on their own in treating breast cancer, they are usually used in conjunction with other hormonal therapies. They are administered by injection every four weeks and prevent the ovaries from producing estrogen. When GnRH medicines are withdrawn, the side effects fade.

• Ovarian ablation uses a surgical procedure that removes the ovaries in order to cease estrogen production. While this is a permanent solution, it can be a viable alternative for women who no longer wish to become pregnant, especially since the long-term costs are often lower.

Aromatase inhibitors (AIs): By inhibiting the aromatase enzyme, AIs reduce the amount of estrogen produced in organs other than the ovaries in postmenopausal women. When the ovaries stop producing estrogen during menopause, this enzyme converts weak male hormones known as androgens into estrogen. Anastrozole (Arimidex), exemestane (Aromasin), and letrozole are examples of these medications (Femara). All of the AIs are pills that are taken orally once a day. AIs are only available to women who have completed menopause or who are taking medications to prevent the ovaries from producing estrogen (see "Ovarian suppression," below). Treatment with AIs, either as the first hormone therapy or after tamoxifen, may be more successful than tamoxifen alone in lowering the risk of recurrence in postmenopausal women. Women who are postmenopausal and have hormone receptor-positive breast cancer can:

• Begin hormone replacement therapy with an AI. When AI is the only hormone therapy used, it is administered for 5 to 10 years.

• Begin hormone therapy with tamoxifen and then transition to an AI after a few years. When taking an AI following tamoxifen, the medications are taken for a total of 5 to 10 years.

AIs can cause muscle and joint pain, hot flashes, vaginal dryness, an increased risk of osteoporosis and broken bones, and, in rare cases, elevated cholesterol levels and hair thinning. According to research, all AIs perform equally well and have identical side effects. Women who experience negative side effects when using one AI medicine may experience fewer side effects with a different AI for unknown reasons.

Women who haven't gone through menopause and aren't getting shots to stop their ovaries from working (see below) should avoid AIs because they don't inhibit the effects of estrogen produced by the ovaries. Blood estrogen levels are frequently monitored in women whose monthly cycles have just stopped, those whose periods have stopped due to chemotherapy, or those who have had a hysterectomy but their ovaries remain in place, to ensure that the ovaries are no longer releasing estrogen.

Hormonal therapy for women after menopause

Women who have experienced menopause and have been prescribed hormone therapy have numerous options:

• Tamoxifen for a period of 5 to 10 years

• An AI for 5 to 10 years. 

• Tamoxifen for 5 years, then an AI for up to 5 years. This would amount to ten years of hormonal therapy.

• Tamoxifen for 2 to 3 years, then an AI for 2 to 8 years for a total of 5 to 10 years of hormone therapy.

In average, women should anticipate to be on hormonal therapy for 5 to 10 years. Tumor biomarkers and other cancer characteristics may potentially influence who is suggested to have a lengthier course of hormone therapy.

Hormonal therapy for premenopausal women

As previously stated, premenopausal women should avoid taking AI drugs without ovarian suppression because they do not lower estrogen levels. Adjuvant hormonal therapy for premenopausal women includes the following options:

1. Tamoxifen prescribed for 5 years. Then, treatment is determined depending on their risk of cancer recurrence as well as whether or not they had experienced menopause in the previous 5 years.

• If a woman has not reached menopause after the first five years of medication and is advised to continue treatment, she can take tamoxifen for another five years, for a total of ten years. Alternatively, a woman could begin ovarian suppression and then switch to an AI for the next 5 years.

• If a woman experiences menopause within the first five years of treatment and is advised to continue treatment, she can take tamoxifen for another five years or switch to an AI for another five years. This would amount to ten years of hormonal therapy. Only definitely postmenopausal women should consider taking an AI.

2. Depending on a woman's age and risk of recurrence, ovarian suppression for 5 years together with supplemental hormonal therapy, such as tamoxifen or an AI, may be suggested in the following situations:

• For young ladies who have been diagnosed with breast cancer.

• For women who are at high risk of recurrence of cancer.

• Chemotherapy is also suggested for women with stage II or stage III cancer. However, data currently reveals that there are benefits that are not contingent on the use of chemotherapy.

• For women with stage I or stage II cancer who are at a higher risk of recurrence, chemotherapy may be considered.

• For women who are unable to take tamoxifen due to other health issues, such as a history of blood clots, an AI drug is available.

3. In the following cases, ovarian suppression should not be used in conjunction with another type of hormone therapy:

• For women who have cancer, it is unlikely to recur.

• When chemotherapy is not indicated for women with stage I cancer.

Targeted therapy

Targeted therapy is a type of cancer treatment that targets specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. These treatments are far more concentrated and operate in a different manner than chemotherapy. This method of treatment inhibits cancer cell growth and spread while limiting damage to healthy cells.

The targets of all cancers are not the same. Your doctor may order tests to determine the genes, proteins, and other variables in your tumor in order to find the most effective treatment. Furthermore, research studies are continuing to learn more about specific molecular targets and new treatments aimed at them.

The first targeted medicines for breast cancer that were approved were hormone medications. Then, in order to treat HER2-positive breast cancer, HER2-targeted treatments were licensed.

HER2-targeted therapy

Trastuzumab (FDA-approved biosimilar forms are available): This medication is licensed for the treatment of non-metastatic HER2-positive breast cancer. It is administered as an infusion into a vein every 1 to 3 weeks or as a skin injection every 3 weeks. Patients with stage I to stage III breast cancer should currently get a trastuzumab-based treatment, commonly combining trastuzumab with chemotherapy, followed by a total of 1 year of adjuvant trastuzumab. Trastuzumab patients have a low (2 to 5%) risk of developing heart issues. This risk is exacerbated if a patient has other risk factors for heart disease or is receiving chemotherapy, both of which enhance the risk of heart problems. These heart disorders may resolve and can be treated with medication.

Pertuzumab (Perjeta): In conjunction with trastuzumab and chemotherapy, this medication is approved for stage II and stage III breast cancer. Every three weeks, it is infused into a vein.

Pertuzumab, trastuzumab, and hyaluronidase–zzxf (Phesgo): This combination medicine is approved for adults with early-stage HER2-positive breast cancer and combines pertuzumab, trastuzumab, and hyaluronidase-zzxf in a single dose. It may be administered in conjunction with chemotherapy. It is provided by injection beneath the skin and can be done in a treatment center or at home by a health care provider.

Ado-trastuzumab emtansine or T-DM1 (Kadcyla): This is approved for patients with early-stage breast cancer who have received trastuzumab plus chemotherapy with either paclitaxel or docetaxel, followed by surgery, and who still have cancer at the time of surgery. The American Society of Clinical Oncology (ASCO) recommends that these patients receive 14 cycles of T-DM1 after surgery unless the cancer recurs or the side effects of T-DM1 become too difficult to manage. T-DM1 is a combination of trastuzumab and a little amount of a powerful chemotherapy. This permits the medicine to deliver chemotherapy into the cancer cell while reducing the amount of chemotherapy delivered to healthy cells, resulting in fewer adverse effects than traditional chemotherapy. T-DM1 is administered intravenously every three weeks.

Neratinib (Nerlynx): This oral medication is approved as a therapy for HER2-positive, early-stage breast cancer. It is administered for a year, beginning after patients have completed a year of trastuzumab.

Discuss with your doctor the potential side effects of specific medications and how to manage them.

Bone modifying medications

Bone modifying medications help to build bones by preventing bone loss. They may be used to treat cancer that has spread to the bone or to prevent it from returning. Bone modifying medicines are not a replacement for regular anti-cancer therapies. In addition, several bone-modifying medications are used in low dosages to prevent and cure osteoporosis. The term "osteoporosis" refers to bone weakening.

There are two kinds of medications that prevent bone destruction:

• Bisphosphonates: These inhibit the osteoclasts, or bone-destroying cells.

• Denosumab (Prolia, Xgeva: A RANK ligand inhibitor is an osteoclast-targeted treatment. The American Society of Clinical Oncology (ASCO) does not suggest using denosumab as an adjuvant treatment to prevent breast cancer recurrence.

All women with breast cancer who have gone through menopause, regardless of their cancer's hormone receptor status or HER2 status, should consult with their doctor about whether bisphosphonates are appropriate for them. Several factors influence this decision, including your risk of recurrence, treatment side effects, treatment expense, your preferences, and your overall health.

If bisphosphonate medication is required, ASCO recommends commencing it after 3 months of surgery or within 2 months of adjuvant chemotherapy. This may involve clodronate (various brand names), ibandronate (Boniva), or zoledronic acid treatment (Reclast, Zometa). Clodronate is not commercially available in the United States.

Other types of targeted therapy for breast cancer

Depending on a number of criteria, you may have various targeted therapy options for breast cancer treatment. The following medication is used to treat non-metastatic breast cancer.

• Olaparib (Lynparza): Olaparib is a kind of antibiotic (Lynparza). This is a PARP inhibitor, which is a sort of oral medicine that eliminates cancer cells by stopping them from repairing damage to the cells. ASCO recommends olaparib for the treatment of early-stage, HER2-negative breast cancer in persons with a hereditary BRCA1 or BRCA2 gene mutation and a high risk of breast cancer recurrence. Adjuvant olaparib should be administered for a year following the completion of chemotherapy, surgery, and radiation therapy (if needed).

• Abemaciclib (Verzenio): This oral medicine, known as a CDK4/6 inhibitor, targets a protein called CDK4/6 in breast cancer cells, which may encourage cancer cell development. It is approved for use in conjunction with hormonal therapy (tamoxifen or an AI) to treat persons with hormone receptor-positive, HER2-negative early breast cancer that has progressed to the lymph nodes and is at high risk of recurrence. For patients who match these criteria, ASCO advises 2 years of abemaciclib medication paired with 5 years or more of hormonal therapy.

Many of the medications listed below are used to treat advanced or metastatic breast cancer.

Alpelisib (Piqray): For persons with hormone receptor-positive, HER2-negative metastatic breast cancer that includes a PIK3CA gene mutation and has worsened during or after hormonal therapy, alpelisib is an option in addition to fulvestrant.

Drugs that target the CDK4/6 protein: Drugs that target the CDK4/6 protein in breast cancer cells, potentially promoting cancer cell proliferation. Abemaciclib (Verzenio), palbociclib (Ibrance), and ribociclib are examples of these medications (Kisqali). They are approved for women with ER-positive, HER2-negative advanced or metastatic breast cancer and can be used in conjunction with certain types of hormone therapy. In endocrine-resistant second-line illness, they may also be administered in concert with fulvestrant.

Sacituzumab govitecan-hziy (Trodelvy): The FDA has approved sacituzumab govitecan-hziy for the treatment of persons with metastatic triple-negative breast cancer who have already received at least two therapies, including one for the disease's progression. It is also recommended for patients with locally advanced triple-negative breast cancer who cannot be treated surgically. Sacituzumab govitecan-hziy is an antibody-drug conjugate, which implies that the antibody binds to a cancer cell and then delivers the anticancer medication it carries to begin eliminating the cancer cell. On days 1 and 8 of every 21-day cycle, sacituzumab govitecan-hziy is administered intravenously or via vein.

Lapatinib (Tykerb): When other treatments are no longer successful at limiting the tumour's growth, this may be an option for women with HER2-positive advanced or metastatic breast cancer. It can be coupled with capecitabine chemotherapy, letrozole hormonal therapy, or trastuzumab, a HER2 targeted therapy.

Tucatinib (Tukysa): Tucatinib, in combination with capecitabine chemotherapy and trastuzumab, is licensed for the treatment of advanced unresectable or metastatic HER2-positive breast cancer, including disease that has spread to the brain, in patients who have previously received one or more HER2-targeted therapies. Surgery is not an option if the tumor is unresectable. Tucatinib is a tyrosine kinase inhibitor that inhibits HER2. It's an oral drug that's taken twice a day.

Entrectinib (Rozyltrek) and larotrectinib (Vitrakvi): These could be used to treat breast cancer with an NTRK fusion that is metastatic, cannot be removed surgically, and has deteriorated with conventional treatments.

Olaparib: This oral medicine may be utilized in persons who have already had chemotherapy and have metastatic HER2-negative breast cancer with an inherited BRCA1 or BRCA2 gene mutation. It is a PARP inhibitor, which eliminates cancer cells by stopping them from repairing damage to the cells.

Talazoparib (Talzenna): Women with locally advanced or metastatic HER2-negative breast cancer and a BRCA1 or BRCA2 gene mutation may be candidates for this treatment. It works as a PARP inhibitor.

Neoadjuvant systemic therapy for non-metastatic breast cancer

Neoadjuvant systemic therapy is a treatment that is administered prior to surgery in order to decrease a big tumor and/or lower the risk of recurrence. Chemotherapy, immunotherapy, hormonal therapy, and targeted therapy are all possible neoadjuvant treatments for specific kinds of breast cancer.

For people with inflammatory breast cancer, for example, neoadjuvant chemotherapy is frequently indicated. It is also the treatment of choice for persons with locally advanced cancer (big tumor(s) and/or multiple lymph nodes affected) or cancer that would be difficult to remove with surgery at the time of diagnosis but may become detachable with surgery after neoadjuvant treatment. To determine if neoadjuvant chemotherapy should be part of your treatment plan, your doctor will assess numerous aspects, including the type of breast cancer you have, including its grade, stage, and estrogen, progesterone, and HER2 status.

ASCO recommends that persons with high-risk HER2-positive breast cancer or triple-negative breast cancer get neoadjuvant systemic therapy before surgery, followed by adjuvant therapy if cancer persists. Neoadjuvant therapy may also be offered to lessen the amount of surgery required and allow someone who would otherwise need a mastectomy to consider having a lumpectomy.

When postponing surgery is unavoidable or preferable (for example, waiting for genetic test results to guide additional treatment options or to enable time to decide on breast reconstruction options), neoadjuvant systemic therapy may be offered.

Regular examinations should be performed on people taking neoadjuvant chemotherapy to check the cancer's response to treatment. After therapy, your doctor will most likely recommend breast imaging for surgical planning and if they suspect the cancer has advanced despite treatment. In your follow-up care, your doctor will most likely utilize the same sort of imaging test that was most helpful when your breast cancer was first diagnosed. Blood tests or biopsies are not generally suggested for monitoring response to therapy in persons receiving neoadjuvant chemotherapy.

Neoadjuvant systemic therapy options based on type of non-metastatic breast cancer 

For people with triple-negative breast cancer

ASCO advises neoadjuvant chemotherapy for persons with triple-negative breast cancer that has progressed to the lymph nodes and/or is larger than 1 centimeter (cm). Additional medications, such as carboplatin, a chemotherapy drug, and pembrolizumab, an immunotherapy treatment (see below), may be prescribed in addition to standard chemotherapy drugs to boost the likelihood of a full response. A complete response occurs when no cancer is discovered in the tissue when it is removed following surgery. Before surgery, discuss with your doctor the potential benefits and dangers of receiving carboplatin with pembrolizumab.

People with early-stage (1 cm or less, and no aberrant lymph nodes) triple-negative breast cancer should not be administered neoadjuvant therapy unless they are enrolled in a clinical study.

For people with HER2-negative, hormone receptor-positive breast cancer

Any person with HER2-negative, hormone receptor-positive breast cancer can receive neoadjuvant chemotherapy instead of adjuvant chemotherapy in cases where a recommendation for chemotherapy can be made without having all of the information obtained from surgery, such as the actual size of the tumor or the number of involved lymph nodes. Meanwhile, hormonal therapy with an aromatase inhibitor may be recommended to postmenopausal women with big tumors or other reasons why surgery may not be a good option at the time of cancer diagnosis. If surgery is not an option, it may be utilized to control the malignancy. However, outside of a clinical trial for premenopausal women with early-stage HER2-negative, hormone receptor-positive breast cancer, hormonal therapy should not be regularly administered in this setting.

For people with HER2-positive breast cancer

Neoadjuvant chemotherapy in combination with the targeted therapy drug trastuzumab should be administered to persons with HER2-positive breast cancer that has progressed to the lymph nodes or is larger than 2 cm in size. When taken before surgery, another anti-HER2 targeted therapy medication, pertuzumab, may be used with trastuzumab. However, outside of a clinical study, persons with early stage (1 cm or smaller and no abnormally appearing lymph nodes) HER2-positive cancer should not be routinely provided neoadjuvant chemotherapy or medications that target HER2 (such as trastuzumab and pertuzumab).

Immunotherapy

Immunotherapy, also known as biologic therapy, is intended to increase the body's natural defenses against cancer. It employs components created by the body or in a laboratory to enhance, target, or restore immune system activity. The following immunotherapy medicine, known as an immune checkpoint inhibitor, is used to treat high-risk, early-stage triple-negative breast cancer.

Pembrolizumab (Keytruda): This is a form of immunotherapy that has been licensed by the FDA for the treatment of high-risk, early-stage, triple-negative breast cancer in conjunction with chemotherapy prior to surgery. Following surgery, it might then be given alone.

Skin rashes, flu-like symptoms, diarrhea, and weight fluctuations are all common adverse effects. Other severe but less common side effects are possible. Discuss with your doctor the potential adverse effects of the immunotherapy that has been prescribed for you, as well as what you can do to prepare for and manage them.

Concerns about systemic therapy for elderly individuals

Age should never be the sole determinant of therapy options. Chemotherapy and other systemic treatments often work just as well for older individuals as they do for younger patients. However, elderly people may be more likely to experience side effects that have a negative influence on their quality of life.

Tratuzumab, for example, may increase the risk of heart issues in older people. This is more likely in patients who already have heart problems and in those who take particular chemotherapy combinations.

It is critical for all patients to discuss the systemic therapy alternatives offered with their doctors, including the advantages and hazards. They should also inquire about potential adverse effects and how to handle them.

Recurrent breast cancer

Recurrent cancer occurs when cancer returns after therapy for early-stage disease. Breast cancer may recur in the following areas of the body if it recurs:

• In the same location as the original cancer. This is known as a local recurrence.

• The chest wall, as well as lymph nodes under the arm or in the chest on the same side as the original cancer. This is known as a localized recurrence.

• Another location, which includes distant organs such the bones, lungs, liver, and brain. This is referred as as a distant recurrence or metastatic recurrence.

When breast cancer recurs, a fresh round of testing is initiated in order to understand as much as possible about the recurrence. Imaging tests, such as those outlined in the Diagnosis section, may be included in the testing. In addition, another biopsy will almost certainly be required to confirm the recurrence of breast cancer and learn more about the tumour's characteristics.

Following the completion of this testing, you and your doctor will discuss treatment choices. The above-mentioned treatments, as well as surgery, radiation therapy, chemotherapy, targeted therapy, and hormone therapy, may be included in the treatment plan. They may be utilized in a different order or at a different rate. The following factors influence treatment options for recurrent breast cancer:

• Previous treatment(s) for the cancer that was first discovered

• The amount of time since the initial diagnosis

• The occurrence's location

• Tumor characteristics such as ER, PR, and HER2 status

People suffering from recurrent breast cancer may experience emotions such as bewilderment or anxiety. You are urged to discuss these feelings with your health care provider and inquire about support options to assist you in coping.

Treatment options for a local or regional recurrence of breast cancer

A recurrence on a local or regional scale is often controllable and may even be cured. The following are the therapy options:

• A mastectomy is frequently advised for women who have a local recurrence of breast cancer following initial treatment with a lumpectomy and adjuvant radiation therapy. With this treatment, the cancer is usually fully eradicated.

• The recommended treatment for women who have a local or regional recurrence in the chest wall after an initial mastectomy is surgical excision of the recurrence followed by radiation therapy to the chest wall and lymph nodes. However, if radiation therapy was already administered for the primary malignancy, this may not be an option. Radiation therapy cannot normally be administered to the same location at full dose more than once. Systemic therapy is sometimes used before surgery to shrink the malignancy and make it easier to remove.

• Radiation therapy, chemotherapy, hormone therapy, and targeted therapy are some of the various treatments utilized to lower the likelihood of a distant recurrence in the future. These are employed depending on the tumor and the type of previous treatment.

Palliative care will be essential for reducing symptoms and side effects regardless of the treatment plan you choose. Your doctor may recommend that you participate in clinical studies that are looking for new ways to treat this sort of recurring cancer.