The kind of treatment that you and your doctors eventually settle on will have a lot to do with the following factors:
1. The parameters of your breast cancer (in your pathology report)
- Stage of breast cancer: How far has your cancer spread? If it has reached your lymph nodes, for instance, it generally means your nodes will have to be removed surgically and that you will be a candidate for chemotherapy and radiation.
- Grade of cancer: You cancer's grade describes how aggressive or quickly moving the cancer is.
- Whether your cancer tests positive for receptors to the hormones estrogen and/or progesterone: If your tumor is hormone receptor-positive and you are still having periods, your treatment is likely to include hormone therapy, usually the drug tamoxifen. If your tumor is positive and you are no longer having periods or are postmenopausal, you may take an aromatase inhibitor such as Femara, Aromasin, or Arimidex, which lower the amount of estrogen in the body.
- Whether your cancer tests positive for the HER2/neu gene: If positive, your treatment is likely to include the drug Herceptin (trastuzumab), which targets the protein that the HER2/neu gene makes.
If you need to choose between a lumpectomy and a mastectomy, for instance, you and your breast surgeon and/or oncologist may discuss with you how strongly you feel about keeping your breast(s).
"Some women say, 'I don't care; I need to get rid of the cancer, just take them off,'" says Karen R. Monaghan, LICSW, a clinical oncology social worker at Dana-Farber Cancer Institute in Boston. And indeed, there may be good reason to fear not only this tumor, but also a recurrence in this or the other breast. "But other women feel like it's a mutilation, an amputation," adds Monaghan. "It's a very individual reaction."
If you have a large tumor and a strong desire to keep your breast(s), you may have the option of trying neoadjuvant (before surgery) chemotherapy to shrink the tumor so that your surgeon can do a lumpectomy instead of a mastectomy. Lumpectomy followed by radiation may be another option. Research shows that most women with early stage breast cancer have the same long-term survival rate with that strategy as they do with a mastectomy.
3. Your age
A woman who's not finished having children, or hasn't started and feels strongly about the chance to become pregnant, may want to talk about treatment options that aim to preserve her fertility. Chemotherapy may lead to early menopause by shutting down estrogen production; radiation is less risky in this regard because the treatment is local to the breast. In any event, Julia A. Smith, MD, director of the NYU Cancer Institute's breast cancer screening and prevention program and director of the Lynne Cohen breast cancer preventive care program at NYU in New York City, recommends that breast cancer patients remember their first priority should be getting the lifesaving treatment they need.
4. Your health
Women with the connective-tissue disease scleroderma tend to be more sensitive to radiation side effects and may not be good candidates for radiation treatment. Similarly, if you have an underlying elevated risk for blood clots, you may want to avoid tamoxifen, since it raises that risk. The chemotherapy drug doxorubicin can cause heart damage.
5. Your family history
If you have a strong family history of breast or ovarian cancer, and/or you test positive for BRCA gene mutations, you may opt for a risk-reducing measure like bilateral mastectomy (removal of both breasts) and/or an oophorectomy, in which your ovaries are removed. (The two cancers are linked, and it's known that the hormones estrogen and progesterone are involved in both diseases.) Women who are at average risk with no history of breast cancer among their relatives, on the other hand, may opt for breast-conserving surgery (aka lumpectomy), if they can.
6. Your lifestyle
If you have noninvasive breast cancer, there are times when it may be appropriate to forgo the ordeal of daily radiation treatments, depending on your circumstances and obligations. If you have invasive disease, on the other hand, and have elected to have lumpectomy instead of mastectomy, radiation will be an essential part of your treatment.