Treatment overview

The treatment of breast cancer is individual for each woman. Your doctor will discuss all the options available to you, and you can ask any questions that will help you decide on the best treatment for you.

The treatment you have will depend on many factors, including:

• the stage and grade of the cancer
• your age
• whether or not you have had the menopause
• the size of the tumour
• whether the cancer cells have receptors for certain hormones (such as oestrogen) or particular proteins (such as HER2).

Secondary breast cancer

This booklet discusses the treatments for primary (stages 1-3) breast cancer. Our booklet on secondary breast cancer discusses the treatments for breast cancer that has spread to other parts of the body (stage 4) or come back after treatment (recurrent breast cancer).

Most primary breast cancers will be treated with surgery to remove the tumour. All or part of the breast tissue may be removed. If the whole breast is removed (mastectomy), breast reconstruction may be carried out, either at the same time as the initial surgery or later.

Sometimes chemotherapy or hormonal therapy may be given to shrink a cancer before surgery. This is known as neo-adjuvant therapy.

After surgery, radiotherapy will be given to any remaining breast tissue, and may be given to the chest wall if the breast has been removed. This is to make sure that any cancer cells that may be left in the area are destroyed.

You may have further treatment with hormonal therapies, chemotherapy and/or a drug called Herceptin®, depending on how likely your doctors think it is that the cancer could come back.

Further treatment

After surgery, the doctors can tell the stage and the grade of the cancer, and they can look at several other factors to predict how likely the cancer is to come back or spread. Factors which affect the chance of the cancer coming back include:

• the size of the tumour
• whether the lymph nodes in the armpit were affected
• the grade of the tumour
• whether the cancer cells have spread into lymph or blood vessels close to the tumour (the pathologist checks for this)
• whether the cells have receptors for oestrogen or particular proteins (such as HER2) on their surface. Cancers with oestrogen receptors are less likely to recur in the short term, whereas those with HER2 receptors are more likely to come back unless Herceptin is given.

If the chance of the cancer spreading or coming back is very low, you won't need to have any further treatment. However, if there is a risk of recurrence, many women who have oestrogen receptor negative (ER-) breast cancer will be advised to have treatment with chemotherapy, and those with oestrogen receptor positive (ER+) breast cancer are usually advised to have hormonal therapy. This treatment is known as adjuvant therapy. Many women who are ER+ will have both treatments, but not at the same time.

Some women have a large number of HER2 protein receptors on the surface of their cancer cells. This is known as being HER2-positive. In this situation, treatment with trastuzumab (Herceptin®) may be helpful. Your cancer specialist can discuss this with you.

Planning treatment for breast cancer

Learn more about the specialists who will plan your care and the factors they use to decide which treatments are best for you.

The multi-disciplinary team

If you have been diagnosed with breast cancer, you will be looked after by a breast care team. This is a team of staff who specialise in treating breast cancer and in giving information and support. It is known as a multidisciplinary team, and will normally include:

• surgeons who are experienced in breast surgery
• breast care nurses, who give information and support
• oncologists, doctors who have experience in breast cancer treatment using chemotherapy, radiotherapy, hormonal therapy and biological therapy
• radiologists, who help to read mammograms
• pathologists, who advise on the type and extent of the cancer.

Other staff will also be available to help you if necessary, such as:

• physiotherapists
• counsellors and psychologists
• social workers.

How do doctors plan my care?

Doctors can use various methods of calculating the chance of the cancer spreading or coming back. These are only a rough guide and can't predict what will happen to an individual woman with breast cancer. However, they can give some idea of the outlook (prognosis) and help your doctor choose the best treatment plan for you. These methods use the following factors:

• stage of the cancer
• grade of the cancer
• whether the cells have oestrogen or HER2 receptors.

One of the most commonly used methods in the UK is the Nottingham Prognostic Index, a formula developed by breast cancer specialists some years ago. Another method is Adjuvant! Online. This is a website that uses the factors above and results from clinical trials in breast cancer. The information helps to predict a woman's chance of being alive ten years after diagnosis, if she has particular treatments after surgery and radiotherapy. It can help to show which of these treatments are likely to reduce the chance of the cancer coming back or spreading, and by how much. Many women with early breast cancer will live for much longer than ten years.

These figures are often used because if someone has no sign of the cancer returning for ten years after their treatment, it is unlikely to come back and they have a good chance of being cured.

Surgery for breast cancer

Overview

Most women with breast cancer will have surgery to remove the tumour. There are two main types of surgery for breast cancer:

• Surgery to remove the breast lump and some of the breast tissue surrounding it (a lumpectomy or segmental incision ). This is known as breast-conserving surgery and is usually followed by radiotherapy.
• Surgery to remove the whole breast ( mastectomy ) and sometimes the muscles underneath. Women who have a mastectomy may choose to have surgery to reconstruct the breast, either at the same time or later.

As part of any operation for breast cancer, doctors also will remove lymph nodes to check for cancer cells. This tells doctors whether the cancer has spread and whether further treatment is needed.

Your doctor will discuss with you the most appropriate type of surgery for you, depending on the size and position of the cancer. Some women with early breast cancer may have a choice of treatment. This can be a difficult decision to make, so make sure you have fully discussed your options with your surgeon, including the benefits and disadvantages of each.

Remember the choice of which type of surgery is used should always be fully discussed with you, including why the particular operation is being recommended and what it involves. You should also let your surgeon know your own preferences so that the two of you reach an agreed joint decision on what should be done.

In this section, you will learn more about:

• The types of breast cancer surgery , including the advantages and disadvantages to consider if you are given achoice of treatment
• The methods doctors use tocheck the lymph nodes
• What to expect after surgery , including when you're likely go home and what side effects you might experience

Types of surgery for breast cancer

This page describes the different types of surgery for breast cancer. You may be given a choice of treatment, depending on the size and position of the cancer. Your doctor will discuss your options with you. We also have information on the benefits and disadvantages of each type of surgery.

Breast-conserving surgery

Lumpectomy (wide local excision)

This is the removal of a breast lump, together with some surrounding tissue. A lumpectomy is usually followed by radiotherapy treatment to the remaining breast tissue. It removes the least amount of breast tissue but leaves a small scar and sometimes a small dent in the breast. For most women, the appearance of the breast after lumpectomy is good.

Sometimes, if the lump is very small, a fine wire (guide wire) is used to mark the area so that the surgeon can find the lump more easily. A local anaesthetic is given, and the wire is then inserted by a radiologist, using x-ray or ultrasound guidance. This procedure is known as wire localisation.

After a lumpectomy, the breast tissue that has been removed is sent to the laboratory to be examined under a microscope by a specialist (pathologist). The pathologist looks to see whether there is an area of healthy cells all around the cancer - this is known as a clear margin. If there are cancerous or precancerous (DCIS) cells at the edge of the area of breast tissue that has been removed, there is a higher chance that the cancer will come back in the breast.

In this case, more breast tissue will need to be removed a few weeks later. Approximately 1 in 8 (12.5%) of women will need to have a second operation to remove more breast tissue. Sometimes, the results from the laboratory show that another lumpectomy is unlikely to remove all the cancer cells completely. In this situation, a mastectomy (removal of the whole breast) will need to be done.

Segmental excision (quadrectomy)

This is similar to a lumpectomy but involves removing more of the breast tissue. It is only used if a larger area of the breast needs to be removed. The effect of this type of surgery is more noticeable than lumpectomy, particularly in women who have small breasts. The treated breast is usually smaller than the other breast and may have a dent in the area where the surgery is done. In women with large breasts it is usually less noticeable. Radiotherapy to the breast is usually recommended after a segmental excision.

Mastectomy

Removal of the whole breast (mastectomy) may be necessary if:

• The breast lump is large in proportion to the rest of the breast tissue.
• There are several areas of cancer cells in different parts of the breast.
• The lump is just behind the nipple - although if the lump is very small it is usually possible to save the breast.
• There is a small invasive breast cancer but a widespread area of DCIS (ductal carcinoma in situ).

There are several different types of mastectomy, and the type you have will depend on a

Breast reconstruction

Breast reconstruction is an operation to try to restore the shape of the breast after surgery for breast cancer. The aim is to match the remaining natural breast as closely as possible. This can be done with an implant, your own body tissue, or a combination of these techniques. Your surgeon will advise you on the type of reconstruction that is most suitable for you.

number of factors, including your breast size, the size and position of the tumour, and whether it has spread.

A simple mastectomy removes only the breast tissue.

A simple mastectomy and sentinel node biopsy or node sampling removes the breast tissue and the lower lymph nodes, within the armpit.

A modified radical mastectomy removes all the breast tissue and all of the lymph nodes in the armpit. It may also be referred to as a total mastectomy and axillary clearance.

A radical mastectomy removes all the breast tissue and the lymph nodes in the armpit, together with the muscles behind the breast tissue. This is only done if the cancer is found in the muscle under the breast.

A new breast shape can often be created either at the same time as the mastectomy, or some months or years later. This is known as breast reconstruction. There are several different types of breast reconstruction. If you would like to consider having breast reconstruction, you can discuss it with your surgeon, so that he or she can tell you about the methods that would be suitable for you.

Choice of surgery

Research has shown that for many women with early breast cancer, lumpectomy followed by radiotherapy is as effective at curing the cancer as mastectomy. So you may be asked to choose the treatment that you feel suits you best.

The treatments have different benefits and side effects, which are described below. This can be a difficult decision to make. It is important to discuss both options fully with your doctor, breast care nurse, or one of the support organisations so that you feel confident you have made the choice that is right for you.

Lumpectomy followed by radiotherapy

Advantages

• It is as effective at curing the cancer as mastectomy.
• It keeps the shape of the breast but leaves a small scar.
• It causes less change to the body than mastectomy and so is less likely to affect a woman's feelings about her appearance and sexuality .

Disadvantages

• It is necessary to attend hospital each weekday for between 3-6 weeks for radiotherapy.
• The radiotherapy may cause short-term side effects such as skin soreness for a few weeks and tiredness for a few months.
• Some women worry that the cancer has not all been removed because some of the breast tissue is left. However, the risk of the cancer coming back is no higher than after mastectomy.
• The radiotherapy may cause long-term side effects - pain in the arm (in fewer than than 1 in 50 women), lung damage (in fewer than 1 in 50 women) and a change in the size of the breast.

Mastectomy

Advantages

• After mastectomy it may not be necessary to have radiotherapy, which means avoiding the risk of radiotherapy side effects.
• Although the chances of a cure are the same with a mastectomy and with a lumpectomy and radiotherapy, some women feel that if all the breast tissue is removed, there is less risk of the cancer coming back, and feel less anxious after their treatment.

Disadvantages

• The whole breast is taken away, which some women find very distressing. It may be possible to have immediate reconstruction to form a new breast, but it may take a few weeks or months until the reconstruction is complete.
• Your body will look different, which may reduce your confidence and affect sexuality and relationships.
• Sometimes radiotherapy is still required after a mastectomy, so if you have a choice and choose mastectomy, it doesn't mean you will always avoid radiotherapy.

Checking the lymph nodes

As part of any operation for breast cancer, the surgeon will usually remove lymph nodes (also known as lymph glands) from under your arm on the side of the cancer. There are approximately 20 lymph nodes in the armpit (axilla), although the exact number varies from person to person. The lymph nodes are examined to check if any cancer cells have spread into them from the breast. This helps the doctors to decide what other treatment is needed. Removing lymph nodes can sometimes lead to swelling of the arm on the affected side (lymphoedema). This usually starts some months or years after the breast surgery.

There are several approaches to checking the lymph nodes:

Sampling

A few lymph nodes may be removed, which is known as axillary (under the arm) node sampling. If any of the lymph glands contain cancer cells, the rest of them may need to be removed in a further operation (axillary clearance). Chemotherapy treatment may also be recommended or the nodes may be treated with radiotherapy. Lymph node sampling is not done that often, and you are more likely to have a sentinel lymph node biopsy.

Sentinel lymph node biopsy

Sentinel lymph node biopsy is a way of checking just one or two of the lymph glands to see if they contain cancer. It involves injecting a tiny amount of radioactive liquid into the area of the cancer before the operation. The lymph nodes are then scanned to see which has taken up the radioactive liquid first. A blue dye is also injected into the area of the cancer during the operation. The dye stains the lymph nodes blue. The nodes that become blue or radioactive first are known as the sentinel nodes. The surgeon removes only the sentinel nodes so that they can be tested to see whether they contain cancer cells.

Results of research trials suggest that sentinel node biopsy is as effective at detecting cancer cells in the lymph glands as lymph node sampling or clearance. Sentinel node biopsy does not increase the chance of a cure, but it does reduce the chances of side effects such as arm stiffness and swelling (lymphoedema) of the arm that can occur after sampling or clearance of the lymph nodes. It can also cause less pain and does not need a drain into the wound afterwards.

If the sentinel nodes do not contain cancer cells, no further surgery is needed. If the nodes do contain cancer cells, either a further operation will be done to remove the lymph nodes from the armpit (axillary clearance - see below) or the rest of the lymph glands need to be treated with radiotherapy.

Axillary clearance

Sometimes, all the lymph nodes under the arm are removed. This is known as axillary clearance and allows the doctor to check all of the nodes. In this situation, any glands affected by cancer have been removed and so radiotherapy to the glands under the arm is not needed, although treatment with hormonal therapy or chemotherapy will usually be recommended.

If all of the lymph nodes are removed there is a risk of swelling (lymphoedema) of the arm. About 1 in 8 women who have a full axillary clearance will develop lymphoedema at some point. (Giving radiotherapy to the axilla after surgery also increases the risk of developing lymphoedema.)

After surgery for breast cancer

• After your operation
• Time in hospital
• Possible side effects
• Breast prosthesis
• Going home

Most women are able to go home within a week of their breast cancer operation and in as little as a day or two, depending on the extent of the surgery, age and general fitness. Each of us is unique and responds differently to treatment, but most women can get back to gentle everyday activities within a couple of weeks of surgery.

Like any operation, breast cancer surgery can cause scarring and discomfort. Other possible effects include a swelling of the arm (lymphoedema) due to a build-up of a fluid called lymph, shoulder stiffness, and numbness and tingling in the arm. If you experience any of these effects, talk to your doctor or specialist nurse. There are often medications and exercises that can help.

After your operation

You will be encouraged to get out of bed and start moving around as soon as possible after your operation. You may have a drainage tube to drain fluid from the wound. This will usually be taken out by the nurses on the ward within a few days of the operation. You may be able to go home with the drainage tube still in place. In this case, it will be removed a few days later by a community or district nurse.

Time in hospital

The length of time you are in hospital will depend on the type of surgery you have had. After a lumpectomy or segmental excision, your stay in hospital will probably only be 1-2 days. Women who have had a mastectomy, or have had all their lymph nodes removed, usually stay in hospital for 3-5 days after their operation. If you choose to have breast reconstruction at the same time as the initial surgery, your stay in hospital could be up to a week, depending on the type of reconstruction.

A specialist breast care nurse will monitor your progress after the operation and ensure you do not go home until you are well enough. Before you go home, your nurse will give you detailed guidance on what you can and cannot do after surgery.

Possible side effects

Pain or soreness

After your operation you may have some pain or discomfort around your wound and under your arm. This may continue for some weeks. You will be given painkillers. If you still have pain it's important to tell your doctor or nurse as soon as possible, so that more effective painkillers or physiotherapy can be prescribed.

Some women find that their breast and arm are sore for up to a year after the treatment. It can sometimes continue after this. If you have continuing pain or soreness, you can ask your doctor to refer you to a pain control specialist. They can assess your pain and advise you on treatments that may help.

Some women have a pain which feels like a tight cord running from their armpit to the back of the hand. This is called cording. It is thought to be due to hardened lymph vessels. Sometimes it can make it difficult to move the arm. Physiotherapy can help, and sometimes antibiotics may be prescribed. The pain usually gets better gradually over a few months, but can sometimes come back.

Lymphoedema

Removing lymph nodes can sometimes lead to swelling of the arm on the affected side (lymphoedema). This usually starts some months or years after the breast surgery. Lymphoedema is more likely to occur if all of the lymph nodes are removed. Giving radiotherapy to the axilla after surgery also increases the risk of developing lymphoedema.

Stiff shoulder

Some women find that they have stiffness in the shoulder. This is more likely after a mastectomy than a lumpectomy. It is important to do exercises to help maintain the movement in the shoulder. Our cancer support specialists or Breast Cancer Care can send you a leaflet about the exercises. You will normally be taught how to do them by a physiotherapist.

Swelling around the wound

The area around the wound will be bruised and there may also be a build up of fluid, which can make it swollen and puffy for a while. This should gradually disappear over a few weeks. Occasionally, quite a lot of fluid can build up in the area around the wound; this is known as a seroma. It may need to be drained off by your nurse or doctor. If you have a seroma it can be very upsetting, but the amount of fluid gradually lessens. It will usually stop within a few weeks.

Numbness and tingling in the upper arm

You may have numbness and tingling in your upper arm. This is because nerves in the area have been affected by the surgery. These effects may last for some months and for some women can be permanent. It is more likely to occur after axillary clearance than after axillary sampling or sentinel node biopsy.

Scars

All breast surgery leaves some type of scar, and the appearance of the breast afterwards depends on the type of surgery used. It can help to discuss with the doctor or nurse beforehand what your breast will look like after surgery. The surgeon may have photographs that they can show you, and you can talk to women who have already had the surgery - contact them through Breast Cancer Care.

You could also ask your specialist or breast cancer nurse if they have anyone they have already treated who would be happy to speak with you. Your breast care nurse may be aware of a local breast cancer support group where you might be able talk to someone who has had a similar operation.

Breast prosthesis

After a mastectomy, unless you've had breast reconstruction, you will be given a lightweight foam prosthesis (false breast), which you can put inside your bra. This is sometimes called a cumfie or softie. It is designed to be worn immediately after the operation when the area feels tender. Your breast care team will arrange this for you.

When your wound has fully healed, you will be able to choose a permanent prosthesis. This is a false breast that closely matches the size and shape of your other breast and is worn inside your bra. They are made of soft plastic (silicone) and feel pliable. Prostheses are available in all skin colours. Several types of prosthesis are available from the NHS. Breast Cancer Care can give you a list of stockists throughout the UK.

Going home

Outpatient appointment

Before you leave hospital, you will be given an appointment to attend the outpatient clinic so that the surgeon can check that the wound is healing properly. At the outpatient clinic you will also be told the stage of the cancer (how large it was and whether it had spread to the lymph nodes). Your doctors will discuss with you any further treatment that you may need. This is a good time for you to talk to them about any problems or questions you have.

Taking care of yourself

When you get home, take things gently for a while. You may feel physically and emotionally exhausted, so try to have plenty of rest and eat a well-balanced diet . You will be advised not to lift or carry anything heavy, nor to drive for a few weeks. Some insurance policies give specific time limits for not driving after surgery; you may need to check this with your insurance company.

Radiotherapy for breast cancer

Radiotherapy treats cancer by using high-energy rays to destroy the cancer cells, while doing as little harm as possible to normal cells. The treatment is often used after surgery for breast cancer, most commonly after surgery to remove part of the breast (lumpectomy or segmental excision). It may occasionally be used before, or instead of, surgery.

How it's given

The treatment is normally given in the hospital radiotherapy department as a series of short daily sessions. The treatments are usually given from Monday to Friday, with a rest at the weekend. Each treatment takes 10-15 minutes. A course of radiotherapy for breast cancer may last from 3-6 weeks. It is usually given as an outpatient.

Radiotherapy can cause side effects such as skin soreness and tiredness, but most will improve once your treatment has finished. Sometimes radiotherapy can cause long-term side effects. Your doctor will discuss the treatment and possible side effects with you.

External radiotherapy does not make you radioactive and it's perfectly safe for you to be with other people, including children, after your treatment.

When it's used

If part of the breast has been removed (lumpectomy or segmental excision), radiotherapy is usually given to the remaining breast tissue to reduce the risk of the cancer coming back in that area. The radiotherapy is normally given to the whole breast area, and may also include the underarm (axilla), and the area around the collar bone and at the top of the chest by the breast bone (sternum), where there are lymph nodes.

After a mastectomy, radiotherapy to the chest wall may be given if your doctor thinks there is a risk that any cancer cells have been left behind.

If a few lymph nodes have been removed and these contained cancer cells, or if no lymph nodes have been removed, radiotherapy may be given to the armpit to treat the remaining lymph nodes. If all the nodes have been removed from under the arm, radiotherapy to the armpit is not usually needed.

Some women may have an extra dose given to the area of the breast where the cancer was. This is known as a booster dose.

Planning radiotherapy

To ensure that you receive maximum benefit from your radiotherapy, it has to be carefully planned. This is done using a CT scanner, which takes x-rays of the area to be treated. Treatment planning is a very important part of radiotherapy and it may take a few visits before the clinical oncologist (the doctor who plans and supervises your treatment) is satisfied with the result.

Marks are usually drawn on your skin to help the radiographer (who gives you your treatment) to position you accurately and to show where the rays will be directed. These marks must stay throughout your treatment, and permanent marks (tattoos) may be used. These are tiny and will only be done with your permission. You may feel a little discomfort while it is being done.

Treatment sessions

At the beginning of each session of radiotherapy, the radiographer will position you carefully on the couch and make sure you are comfortable. During your treatment you will be left alone in the room, but you will be able to talk to the radiographer, who will be watching you from the next room. Radiotherapy is not painful, but you do have to lie still for a few minutes while the treatment is being given.

Positioning

If you are going to have radiotherapy, you will need to be able to get your arm into position so that the radiotherapy machine can give the treatment effectively. After surgery for breast cancer, your muscles and shoulder joint may feel sore or stiff. If you can't move your shoulder normally, it may be painful or difficult to give the treatment. A physiotherapist may teach you some exercises to make the position for treatment feel easier.

Side effects of radiotherapy

Radiotherapy to the breast sometimes causes side effects such as:

• reddening and soreness of the skin
• tiredness
• feeling sick (nausea)

These side effects gradually disappear once your course of treatment has finished. The tiredness may continue for some months.

Preventing skin irritation

Perfumed soaps, creams or deodorants may irritate your skin and should not be used during the treatment. At the beginning of your treatment you will be given advice on how to look after your skin in the area being treated.

Long-term side effects

Radiotherapy may make your breast tissue feel firmer. Over a few months or years your breast may shrink slightly. The radiotherapy may also, rarely, leave small red marks on your skin, which are due to tiny broken blood vessels. For many women, however, the appearance of their breast is very good.

Radiotherapy to the breast can sometimes lead to other long-term side effects. Your doctor will give you more information about the possible side effects of radiotherapy, and we have more information you might find helpful.

Chemotherapy for breast cancer

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. The aim of chemotherapy is to do the maximum damage to cancer cells while causing the minimum damage to healthy tissue. Women with breast cancer may have chemotherapy:

• Before surgery to shrink the cancer. This is known as neo-adjuvant chemotherapy.
• After surgery if doctors think there is a risk of the cancer coming back. This is known as adjuvant chemotherapy.

How it is given

Chemotherapy drugs are usually given to you as an outpatient, either by injection into a vein (intravenously) or as tablets. Chemotherapy into the vein is given as a session of treatment, usually over a few hours. This is followed by a rest period of a few weeks, which allows your body to recover from any side effects of the treatment. A complete course of chemotherapy is likely to take 4-6 months.

The drugs used

There are many different chemotherapy drugs used to treat breast cancer, and they are often used in combinations (called a chemotherapy regimen).

The commonly used chemotherapy drugs include:

• cyclophosphamide
• epirubicin
• fluorouracil (5FU)
• methotrexate
• paclitaxel (Taxol)
• doxorubicin (Adriamycin®)
• docetaxel (Taxotere®).

Other drugs may also be used.

Commonly used chemotherapy combinations are:

• FEC - 5FU, epirubicin and cyclophosphamide
• AC - doxorubicin (Adriamycin®) and cyclophosphamide
• CMF - cyclophosphamide, methotrexate and 5FU
• E-CMF - epirubicin and CMF
• FEC-T - FEC plus docetaxel (Taxotere®).

You may be offered a choice of chemotherapy treatments, as the different combinations have different side effects.

Research is always being carried out to improve the effectiveness of chemotherapy while reducing the side effects, and you may be asked to take part in research trials comparing different types of chemotherapy.

Benefits of chemotherapy

In women whose cancer is very unlikely to come back, chemotherapy may only reduce the chance of the cancer coming back (recurrence) by a small amount. In women whose chance of the cancer coming back is higher, chemotherapy may greatly reduce the chance of recurrence. Your doctor can let you know how likely chemotherapy is to make a difference in your case. They can also tell you about the possible side effects.

Side effects

Chemotherapy drugs can cause unpleasant side effects, but these can usually be well controlled with medicines. The side effects you experience will depend on the drugs you are given, but they may include:

• nausea and vomiting
• tiredness
• sore mouth
• increased risk of infection
• hair loss

Everyone is different and will react to chemotherapy treatment in a different way. Some people may have very few side effects while others will have a lot. Almost all side effects are only short-term and will gradually disappear once the treatment has stopped.

Contraception

It is not a good idea to become pregnant while taking any of the chemotherapy drugs used to treat breast cancer, as they may harm the developing foetus. It is important to use effective contraception during your treatment and for a year afterwards. You can discuss this with your doctor or specialist nurse.

Condoms should be used during sex within the first 48 hours after chemotherapy, to protect your partner from any of the drug that may be present in vaginal fluid.

Hormonal therapies for breast cancer

Hormonal therapies are treatments to reduce the levels of hormones in the body or block their effects on cancer cells. They are often given after surgery , radiotherapy and chemotherapy for breast cancer to reduce the chance of the cancer coming back.

Hormonal therapies are only effective in women whose cancer cells have receptors for oestrogen and/or progesterone on their surface. This is known as being oestrogen-receptor positive (ER+) or progesterone-receptor positive (PR+). It means that the breast cancer cells are affected by oestrogen or progesterone. These are female hormones that the body produces naturally and that can stimulate breast cancer cells to grow.

Treatment options

There are many different types of hormonal therapy , and they work in slightly different ways. Hormonal therapies for breast cancer include the drug tamoxifen , drugs known as aromatase inhibitors , and treatment to stop the ovaries from working (ovarian ablation ).

There are many issues to consider when deciding which type of hormonal therapy is appropriate for you, including:

• your age
• whether you have had your menopause (change of life)
• the stage and grade of the cancer
• which other treatments are being used
• whether the cancer cells are HER2-positive .

Your doctor will be able to discuss which type of hormonal therapy treatment is best for you, based on your relevant medical details.

The side effects will depend on the type of hormonal therapy you are given, but the most common are menopausal symptoms such as hot flushes, vaginal dryness and a reduced sex drive.

Hormonal therapy for postmenopausal women

Postmenopausal women may be offered hormonal treatment with either an anti-oestrogen (such as tamoxifen ) or an aromatase inhibitor (such as Anastrozole ), or a combination of the two different types, where one type is given after the other.

Tamoxifen has been the most widely used hormonal therapy for breast cancer and has been shown to be highly effective in reducing the chance of the cancer coming back. Research has shown that for some women, giving aromatase inhibitors instead of tamoxifen, or after a period of tamoxifen treatment, can further reduce the chance of the cancer coming back.

Your doctor will be able to discuss which type of hormonal therapy treatment is best for you, based on all your relevant medical details. You may be advised to have:

• tamoxifen on its own for five years
• an aromatase inhibitor on its own for a few years
• tamoxifen for 2-3 years followed by an aromatase inhibitor for a few years
• tamoxifen for five years followed by an aromatase inhibitor for a few years.

Hormonal therapy for premenopausal women

Premenopausal women may be offered hormonal treatment with:

• an anti-oestrogen medicine (such as tamoxifen )
• treatment to stop the ovaries from producing oestrogen (ovarian ablation). This can be done using surgery, radiotherapy, or a drug called goserelin

(Zoladex® ).

Unfortunately, ovarian ablation by surgery or radiotherapy brings on an early menopause, which can be very upsetting, especially for women who were hoping to have children. The effects of medicines are usually temporary. Once treatment has stopped the ovaries will begin working again, usually within six months.

Your doctor may give you a choice between treatments. It's important to ask any questions you may have to help you make a decision about the right treatment.

Tamoxifen

Tamoxifen is a hormonal therapy used to treat breast cancer. It is known as an anti- oestrogen drug, and it works by preventing oestrogen in the body from attaching to breast cancer cells and encouraging them to grow.

It can be used for women who have had their menopause and also for those who haven't. For women who have not yet had their menopause and women with very early-stage breast cancers, tamoxifen is the standard treatment. It is available as tamoxifen and Nolvadex® and is taken as a daily tablet. The side effects may include:

• hot flushes and sweats
• a tendency to put on weight (although this may be due to other effects such as going into the menopause)
• dryness of the vagina or an increased discharge from the vagina.

For many women, these side effects are mild and may reduce over time.

Some women continue to find the side effects of tamoxifen are a problem. If this happens, it can help to discuss it with your doctor, as there are sometimes ways of reducing the effects. Our section on breast cancer and menopausal symptoms has some helpful tips.

In postmenopausal women, tamoxifen can slightly increase the risk of womb cancer, blood clots in the leg, and strokes. Although this sounds very frightening, these effects are very rare and are usually curable and treatable. The benefits of tamoxifen in reducing the chance of the breast cancer coming back far outweigh the risks of side effects for most women.

Aromatase inhibitors

Aromatase inhibitors (AIs) are a type of hormonal therapy that reduce the levels of oestrogen in the body. They work by blocking the production of oestrogen in body tissues. For many postmenopausal women it is helpful to have an aromatase inhibitor as part of hormonal therapy treatment. AIs may be given on their own or in combination with the drug tamoxifen.

There are three AIs currently in use:

• anastrozole (Arimidex®)
• exemestane (Aromasin®)
• letrozole (Femara®).

Many women can take aromatase inhibitors without any problems, but some may experience mild to moderate side effects, including hot flushes, feelings of sickness, joint pains and vaginal dryness.

How do they work?

To understand how AIs work, it helps to know a little about the way oestrogen is made.

In women who have not had their menopause (premenopausal women), the main source of oestrogen is the ovaries. In women who have had their menopause (postmenopausal women) oestrogen is made by a process known as aromatisation. This is an activity in which sex hormones (androgens) produced by the adrenal glands are turned into oestrogen in the fatty tissue of the body. A chemical in the body called aromatase makes this happen.

Aromatase inhibitors block the process of aromatisation, and so reduce the amount of oestrogen in the body. This means that the hormone receptors are exposed to less oestrogen and the cancer cells receive fewer signals to grow. AIs are currently only suitable for post-menopausal women, although research is being carried out into using them in pre- menopausal women who have been put into a temporary menopause by using medicines such as Zoladex®. Your doctor can give you more information on this or you can talk to our nurses.

When are they given?

Aromatase inhibitors and early breast cancer

Several studies have looked at the effectiveness of AIs in primary (early) breast cancer when compared with tamoxifen. The results have been encouraging, and the three main aromatase inhibitors are now licensed to treat post-menopausal women with ER-positive early breast cancer.

Aromatase inhibitors and advanced breast cancer

Aromatase inhibitors have been used to treat women with advanced (secondary or metastatic) breast cancer since the mid-1990s, and their use in this situation is well established. This information is about AIs for early breast cancer, but if you would like information about their use in advanced breast cancer you can contact our nurses.

How are they taken?

Arimidex, Aromasin and Femara are all taken as tablets once a day. They should ideally be taken at around the same time every day.

Deciding which hormonal therapy to use

Your doctor will discuss the different types of hormonal therapy with you and will outline the possible side effects. Together you can decide which one is right for you. NICE (National Institute for Clinical Excellence) published its recommendations for the treatment of early and localised breast cancer in February 2009. This includes information on aromatase inhibitors.

NICE recommends anastrozole or letrozole as the first line hormonal therapy for postmenopausal women with early breast cancer if their cancer has a more than low-risk of coming back. Aromatase inhibitors can also be used in people who aren't able to take tamoxifen, or for whom tamoxifen causes severe side effects.

NICE recommends that women who have already had 2-3 years treatment with tamoxifen can be offered exemestane or anastrozole.

For women who had cancer in their lymph nodes when they first had surgery, and who have already had 5 years of tamoxifen, NICE recommends offering treatment with letrozole for another 2-3 years.

Things to remember about taking AIs

• AIs may interact with other medicines. Let your doctor know about any medicines you are taking, including non-prescribed drugs such as complementary therapies and herbal drugs.
• Keep the tablets in a safe place where children can't reach them.
• If your doctor decides to stop the treatment, return any remaining tablets to the pharmacist. Do not flush them down the toilet or throw them away.
• If you are sick just after taking the tablet tell your doctor, as you may need to take another.
• If you forget to take your tablet, do not take a double dose. Let your doctor or nurse know. Don't worry, the levels of the drug in your blood will not change very much, but try not to miss more than one or two tablets in a row.
• Remember to get a new prescription a few weeks before you run out of tablets, and make sure that you have plenty for holidays, etc.

Herceptin® (trastuzumab) for breast cancer

Trastuzumab (also known as Herceptin®) is a treatment that may be given to some women with breast cancer. It is a type of drug known as a monoclonal antibody. It works by attaching to HER2 receptors (proteins) on the surface of breast cancer cells. This stops the cancer cells from dividing and growing. It may also allow the body's defences to fight better against the cancer cells.

Herceptin can reduce the chance of breast cancer coming back after initial treatment for early breast cancer. However, it is only effective for women whose breast cancer cells have a large number of the HER2 receptors on their surface. This is known as being HER2- positive. Around 1 in 5 women (20%) with breast cancer are HER2-positive. When your breast cancer is diagnosed, the cells will be tested for the HER2 protein.

In women who have early breast cancer and are HER2-positive, Herceptin may be used alongside, or after, other treatments.

Side effects are usually mild, but some women may have:

• flu-like symptoms
• diarrhoea
• headaches
• an allergic reaction.

In some women, Herceptin may cause damage to the heart muscle, which could lead to heart failure. If this happens the Herceptin® will be stopped. Usually, the effect on the heart is mild and reversible. Because the long term effects of any heart damage is not known, Herceptin is not given to women who have serious heart problems. You can discuss with your doctor whether Herceptin may be a suitable treatment for you.

Herceptin and early breast cancer

Recent research suggests that Herceptin is useful for women with early breast cancer to help reduce the risk of the cancer coming back. It is currently known that chemotherapy and/or hormonal therapy can reduce this risk. A number of research trials looked at giving Herceptin alongside chemotherapy (comparing the results of this with those of using chemotherapy alone) to see if this further reduced the risk of cancer coming back. The results of the trials were very promising: the cancer came back in half as many women who had Herceptin combined with chemotherapy, compared to those who had chemotherapy alone.

Herceptin was licensed in the UK for early breast cancer in 2006. The National Institute for Health and Clinical Excellence (NICE), which advises doctors on the prevention and treatment of ill-health, produced guidance on the use of Herceptin for women with HER2 positive early breast cancer in June 2006. The guidance states that Herceptin should be considered as a possible treatment after surgery and adjuvant chemotherapy (and radiotherapy, if appropriate). The guidance recommends that Herceptin is given every three weeks for one year.

Herceptin and secondary breast cancer

Herceptin is also licensed to treat secondary or advanced breast cancer (cancer that has spread). It can be used on its own or in combination with chemotherapy.

In 2002, NICE published guidance on Herceptin for women with secondary breast cancer and approved its use in particular circumstances:

• Women with HER2 positive advanced breast cancer who have not had any previous chemotherapy treatment and can't have a type of chemotherapy called an anthracycline (eprirbicin or doxorubicin) should be treated with Herceptin and a chemotherapy called Taxol.
• Women who have had two or more previous chemotherapy treatments which included an anthracylcline drug (epirubicin or doxorubicin) and a taxane (Taxol or Docetaxel) should have Herceptin alone.

About clinical trials

Cancer research trials are carried out to try to find new and better treatments for cancer. Trials that are carried out on patients are known as clinical trials.

Clinical trials may be carried out to:

• test new treatments, such as new chemotherapy drugs, gene therapy or cancer vaccines
• look at new combinations of existing treatments, or change the way they are given, to make them more effective or to reduce side effects
• compare the effectiveness of drugs used to control symptoms
• find out how cancer treatments work
• see which treatments are the most cost-effective.

Trials are the only reliable way to find out if a different operation, type of chemotherapy, radiotherapy, or other treatment is better than what is already available.

Taking part in a trial

You may be asked to take part in a treatment research trial. There can be many benefits in doing this. Trials help to improve knowledge about cancer and develop new treatments. You will also be carefully monitored during and after the study. Usually, several hospitals around the country take part in these trials. It's important to bear in mind that some treatments that look promising at first are often later found not to be as good as existing treatments, or to have side effects that outweigh the benefits.

If you decide not to take part in a trial your decision will be respected and you don't have to give a reason. There will be no change in the way that you're treated by the hospital staff and you will be offered the best standard treatment for your situation.

Blood and tumour samples

Many blood samples and tumour biopsies may be taken to help make the right diagnosis. You may be asked for your permission to use some of your samples for research into cancer. If you're taking part in a trial you may also be asked to give other samples which may be frozen and stored for future use, when new research techniques become available. These samples will have your name removed from them so you can't be identified.

The research may be carried out at the hospital where you are treated, or it may be at another hospital. This type of research takes a long time, and results may not be available for many years. The samples will, however, be used to increase knowledge about the causes of cancer and its treatment. This research will, hopefully, improve the outlook for future patients.

Follow up after treatment for breast cancer

After your treatment has ended, you may have regular check-ups, which will include a physical examination, and mammograms. These check-ups will usually be once a year, but may be more frequent at first. You may also need to see your specialist or GP every few months if you are having ongoing treatment with hormonal therapy, or if you have any side effects following surgery, radiotherapy or chemotherapy treatment. If you have had a mastectomy, the breast prosthesis fitter will also be at your first appointment.

The appointments are a good opportunity to discuss with your doctor any worries or problems you may have. However, if you notice any new symptoms or are anxious about anything else between your appointments, you can contact your doctor or nurse for advice. Many people find that they get very anxious for a while before the appointments. This is natural and it may help to get support from family, friends or a support organisation during this time.

Our booklet on life after cancer gives useful advice on how to keep healthy and adjust to life once treatment has ended.