Treatment Options

Breast Cancer Treatment Process

Different breast cancers start, progress and respond to treatments in different ways. At Fred Hutch Cancer Center, we choose, combine and schedule your treatments based on what works for your situation. Your care team will make sure you understand each type of treatment and all of your choices.

Lumpectomy

The goal of a lumpectomy is to remove all your tumor while leaving as much healthy breast tissue as possible.

If your tumor is larger compared to your breast but you do not need a mastectomy, you may have another option. It is called oncoplastic surgery. In this approach, a breast surgeon takes out the cancer, and in the same operation, a reconstructive surgeon reshapes the breast. Sometimes they reshape the other breast too, reducing or lifting it to even out the breasts.

Sometimes, cancer does not make a lump that surgeons can feel. In this case, they need help to locate and remove exactly the right tissue. At Fred Hutch, we have two methods to choose from:

• SAVI SCOUT® surgical guidance — Before your surgery, a breast radiologist will use ultrasound or mammogram to see where your tumor is. They will put a tiny radar-reflecting chip (SAVI SCOUT®) into the tumor through a needle. During surgery, your surgeon will scan your breast with a small wand that sends out a radar signal. The signal bounces back from the chip, showing your surgeon which tissue to remove.
• Wire localization — On the morning of your surgery, a breast radiologist will use mammography or ultrasound to see where your cancer is. They will insert a thin guide wire into your breast to mark the cancer. During surgery, the wire will show your surgeon which tissue to remove.

Sentinel Lymph Node Biopsy

The sentinel lymph nodes are the first lymph nodes in the armpit that breast cancer would spread to. Typically, surgeons remove these nodes for testing to check if breast cancer has spread there. 

The fewer lymph nodes that are removed, the lower your risk of side effects. (Side effects can include nerve problems or lymphedema, which means swelling in the arm.) This is why we do sentinel lymph node biopsy whenever possible rather than automatically removing more nodes. 

If the sentinel lymph nodes are cancer-free, you do not need to have any more taken out. If the sentinel lymph nodes have cancer, you may or may not need to have more taken out.

Lymphedema

Lymphedema is a type of swelling that can happen after surgery or radiation therapy that affects lymph flow. Our breast and reconstructive surgeons offer advanced ways to prevent or treat this condition. Preventive techniques include axillary reverse mapping (ARM) and microsurgery to restore lymph flow (known as LYMPHA), which is done at the same time as lymph nodes are removed. We also offer surgery to treat lymphedema after it starts, such as lymphovenous bypass (also called lymphaticovenular anastomosis, or LVA) and microsurgical transfer of lymph nodes to the affected area (vascularized lymph node transfer, or VLNT). At Fred Hutch, we also have physical therapists who know how to prevent, detect and treat lymphedema.

Chemotherapy

Chemotherapy uses medicines to kill fast-growing cells (like cancer cells) or to keep them from dividing (which is how cancers grow). Your breast medical oncologist prescribes your chemotherapy and other medicine-based treatments. They also set your treatment schedule. 

Chemotherapy can be given by infusion or by mouth. For an infusion, liquid medicine is put into a vein through an intravenous (IV) line. This can be a line in your arm (peripheral venous catheter) or a port in your chest (central venous catheter). Cancer nurses who are experts in infusions give you these treatments. They will also watch over you during the treatment. They will help with any medical issues that come up and will keep you comfortable.

Some types of chemotherapy are given as a pill that you take at home. 

Who Needs Chemotherapy?

If you are having surgery, your Fred Hutch care team may recommend chemotherapy, targeted therapy or both before surgery. This is done to shrink your tumor. It may be the best choice if any of these is true:

• The tumor is too large to remove with surgery alone. 
• You have inflammatory breast cancer or another type that is aggressive or locally advanced. (This means it involves tissue outside but near your breast, like skin or many lymph nodes.)

Shrinking the tumor might mean you can avoid a mastectomy. Instead, you might be able to have a lumpectomy.

Another reason to have chemotherapy (or targeted therapy) before surgery is to see how your cancer responds to the medicine. This may help your team plan your treatment. 

Most people start chemotherapy after they have surgery. If you have early-stage breast cancer, you will probably have four to six cycles of treatment. (Early stage means it is not outside your breast and nearby lymph nodes.) The goal is to keep your cancer from coming back. Chemotherapy may reduce the risk of cancer coming back by 30 to 50 percent.

If cancer has spread beyond your breast to distant parts of your body, physicians often recommend systemic therapies — which include chemotherapy, endocrine therapy and targeted therapies — without surgery. Systemic therapies travel throughout your body and fight cancer cells wherever they may be. The goal is to give you the longest, healthiest life. If your medicine stops working or the side effects are too difficult, you have other options. The next step is to look at switching to another medicine. 

Targeted Therapy for Breast Cancer

Targeted therapies work in one of these ways:

• They target a gene or protein that causes cancer growth.
• They damage cancer cells directly.
• They tell your immune system to attack certain cells. This is also called immunotherapy.

Sometimes, targeted therapies are a pill that you take at home. Or they can be given by infusion in repeating cycles. They can be used alone or with other treatments. Some can improve the effects of endocrine therapy and are only used along with endocrine therapy.

There are many options for both early-stage and advanced or metastatic breast cancer.

For HER2-Positive Breast Cancer   

Several therapies target breast cancer that is HER2-positive. This means the cancer cells make too much of a protein called HER2/neu. HER-targeted therapies may be given alone or with chemotherapy or another targeted therapy. They include:

• Ado-trastuzumab emtansine 
• Fam-trastuzumab deruxtecan 
• Lapatinib 
• Neratinib 
• Pertuzumab 
• Trastuzumab 
• Tucatinib 

For HR-Positive Breast Cancer   

Cell-cycle inhibitors are an option for advanced or metastatic breast cancer that is HR+ and HER2-negative. HR+ means the cancer cells have places where hormones can attach. These medicines block proteins in the life cycle of cancer cells. They help stop the growth and spread of breast tumors. Examples include CDK4/6 inhibitors, such as palbociclib, ribociclib or abemaciclib. If cancer cells have changes in the gene PIK3CA, a targeted medication called alpelisib may be recommended.

Everolimus is an mTOR inhibitor. It targets a protein that allows breast cancer cells to grow out of control. Everolimus is sometimes used for patients who are past menopause with advanced cancer that is HR+ and HER2-negative. 

All of these can be used along with endocrine therapy.

For BRCA Gene Mutations 

Patients with BRCA gene changes may benefit from therapy with PARP inhibitors. These medicines help kill cancer cells by making DNA repair harder for them. Cells that cannot repair their DNA are more likely to be killed by other treatments, like chemotherapy and radiation. PARP inhibitors include olaparib and talazoparib.