What Are My Treatment Options?

Breast cancer treatment has improved significantly over the past 5–10 years. Care is now tailored to individual tumour types and patient needs, rather than a one-size-fits-all approach.

The main components of breast cancer treatment may include:

Breast surgery
Systemic chemotherapy
Radiation therapy (XRT)
Endocrine (hormonal) therapy
Targeted therapy

If breast imaging shows an abnormality or you feel a lump, a biopsy is required to confirm a diagnosis. This is most commonly a core biopsy, which involves taking a small sample of tissue from the tumour to determine its type and guide treatment planning.

Treatment varies between individuals because no two tumours — or patients — are the same. Comparing treatments can be confusing, as even small differences in tumour biology can significantly influence the recommended approach.

While many people proceed directly to surgery after diagnosis, chemotherapy is sometimes recommended before surgery, particularly for certain breast cancer types such as HER2-positive and triple-negative breast cancer. Dr Green works closely with a multidisciplinary team of medical oncologists, radiation oncologists, surgeons, and specialist nursing staff to develop an individualised treatment plan.

What Type of Breast Cancer Do I Have?

Breast cancer includes several different tumour types, most commonly classified as invasive carcinoma.

The term invasive means cancer cells have spread from the breast ducts or lobules into the surrounding breast tissue. Importantly, this does not mean the cancer has spread elsewhere in the body. Cancer confined to the ducts is known as ductal carcinoma in situ (DCIS).

Common Types of Invasive Breast Cancer

The most common types include:

Invasive carcinoma of no special type (NST)
Invasive lobular carcinoma

Less common subtypes include:

Tubular
Mucinous
Medullary
Papillary

Invasive carcinoma NST accounts for approximately 75–85% of breast cancers.

Invasive lobular carcinoma represents 10–20% of breast cancers and behaves differently. It can be more difficult to detect on standard imaging, and MRI is often recommended. Lobular carcinoma also has a higher likelihood of being present in the opposite breast (approximately 10%) compared with invasive ductal carcinoma (around 2%).

What Is DCIS?

DCIS (Ductal Carcinoma In Situ) is often referred to as pre-invasive breast cancer. Abnormal cells are confined to the breast ducts and have not spread into surrounding tissue.

While DCIS cannot spread to lymph nodes or other organs, it can progress to invasive breast cancer if left untreated. Higher-grade DCIS tends to progress more quickly.

Standard treatment usually involves surgical removal of the DCIS, followed by radiation therapy (XRT) to significantly reduce the risk of recurrence.

What Type of Surgery Do I Need?

Breast cancer surgery generally has two components:

Surgery to the breast
Surgery to the lymph nodes

Types of Breast Surgery

There are two main types of breast cancer surgery:

Breast-conserving surgery (lumpectomy)
Mastectomy

The type of breast surgery does not determine whether chemotherapy is required. Chemotherapy decisions are based on tumour biology rather than the extent of surgery.

What Factors Influence the Type of Breast Surgery Needed?

Breast Size and Tumour Size

Removing more than 10% of breast volume can cause deformity. Oncoplastic techniques allow safe removal of 20–30% of breast tissue while maintaining shape, particularly important in smaller breasts.

If a tumour occupies 30–40% or more of the breast, mastectomy is usually required. In some cases, chemotherapy before surgery can reduce tumour size and allow breast-conserving or oncoplastic surgery.

Number of Tumours

Multiple tumours within the breast (multifocal disease), particularly in different areas, often require mastectomy. MRI is commonly used to clarify the extent of disease.

Genetic Mutations

In younger patients with BRCA1 or BRCA2 mutations, mastectomy may be recommended even for small tumours. This is discussed with patients under 40 who have a strong family history or confirmed mutation.

Ability to Have Radiation Therapy

Breast-conserving surgery requires postoperative radiation therapy. Without radiation, the risk of recurrence is 5–6 times higher. If radiation is not possible or declined, mastectomy is recommended.

Do My Lymph Nodes Need to Be Removed?

Breast cancer commonly spreads first to lymph nodes in the armpit (axilla). Even when nodes appear normal on imaging, surgical assessment is required using a sentinel lymph node biopsy (SLNB).

Sentinel Lymph Node Biopsy Results

Possible findings include:

No cancer cells — negative node
Isolated tumour cells (≤0.2 mm) — considered negative
Micrometastases (0.2–2 mm) — positive node
Macrometastases (>2 mm) — positive node

Typically, 1–4 lymph nodes are removed.

Axillary Lymph Node Clearance (ALNC)

ALNC involves removal of most lymph nodes from the armpit (usually 10–40). It is reserved for more extensive disease. Due to risks such as lymphoedema and shoulder stiffness, radiation therapy is often preferred when only one node is involved.

Targeted Axillary Dissection (TAD)

In patients receiving chemotherapy before surgery, a cancerous lymph node may be marked with a clip. After chemotherapy, both the sentinel node and the clipped node are removed.

If chemotherapy is effective, full axillary clearance may be avoided, although radiation therapy is usually still required.

Do I Need Chemotherapy?

The decision to recommend chemotherapy is based on a combination of factors, including:

Grade 3 tumours
Tumour size >2 cm
Triple-negative breast cancer
HER2-positive breast cancer
Involved lymph nodes
Younger age (<40 years)

Chemotherapy may be given before surgery (neoadjuvant) or after surgery (adjuvant).

What Is HER2-Positive Breast Cancer?

Approximately 20% of breast cancers are HER2-positive. These cancers grow more aggressively and are treated with targeted therapy alongside chemotherapy.

Treatment usually begins before surgery. In 60–70% of cases, treatment completely eradicates the cancer. If residual disease remains, additional therapy such as Kadcyla may be recommended. HER2-targeted therapy typically continues for 12 months and is generally well tolerated.

Do I Need Radiation Therapy?

Radiation therapy is essential after breast-conserving surgery and reduces recurrence risk by 5–6 times. After mastectomy, radiation is usually not required unless high-risk features are present.

Treatment is painless and typically delivered over 3–5 weeks. Side effects may include mild skin redness and fatigue.

What Is Hormonal (Endocrine) Therapy?

Approximately 70–80% of breast cancers are hormone-receptor positive:

Estrogen receptor (ER+)
Progesterone receptor (PR+)

Hormonal therapy is taken for 5–10 years after surgery.

Common Treatments

Pre-menopausal: Tamoxifen
Post-menopausal: Aromatase inhibitors (Anastrozole, Letrozole)

Triple-negative breast cancers do not respond to hormonal therapy and are treated with chemotherapy.

How Do I Know the Cancer Has Not Spread?

Most breast cancers are detected early and have an excellent prognosis, with a 91% 10-year survival rate.

Staging scans are not routinely required unless the cancer is larger, aggressive, or lymph nodes are involved. When needed, scans may include: