(Early to Advanced) Breast Cancer Treatment by Stage

A diagnosis of breast cancer will come with many questions and concerns about what treatment will be needed and how treatable the cancer is. It’s important to know how cancer is staged and what the general treatment plan will be. 

This article will review the different types of treatment that may be needed based on the stage of breast cancer, which can include surgery, chemotherapy, hormonal therapy, targeted therapy and radiation. 

The Current Breast Cancer Staging System

Many cancers, breast cancer included, use the staging system published by the American Joint Committee on Cancer (AJCC). The eighth edition was published in 2018.

This staging system uses TNM staging. "T" stands for tumor and refers to the size of the original tumor. "N" stands for node status, meaning the number and location of lymph nodes involved in cancer. "M" stands for metastasis, which means the spread of cancer to distant areas of the body.

The eighth edition of the AJCC breast cancer staging system evaluates the TNM status and incorporates other factors such as the grade of the cancer (how abnormal the cells look microscopically) and biological markers, including hormone receptor status and human epidermal growth factor 2 (HER2) status.

Knowing these specifics significantly impacts how breast cancer is staged and treated.

The T stage is described as T0 (no tumor seen), Tis (noninvasive tumor), progressively increasing size in T1 through T3, or T4, which is when the tumor has grown large enough to break through the skin of the breast or is attached to the chest wall.

The N stage is described from N0 (no sign of cancer in nearby lymph nodes) to N3 (cancer has spread to many lymph nodes, and they may be enlarged). The M stage is either M0 (no distant spread of cancer) or M1 (cancer has moved into distant areas of the body).

In addition to standard staging, gene profile tests can help determine if chemotherapy after surgery will benefit someone with early-stage breast cancer. MammaPrint and Oncotype DX are two of these tests.

Genetic tests looking for BRCA gene mutations may be done as well. Those with these mutations (changes to the genetic code) are at higher risk of developing breast cancer and additional cancers.

Treatment Options By Stage

Once breast cancer has been diagnosed, and imaging has been done to provide a cancer stage, treatment plans can be made by the oncologist (cancer specialist). Treatment decisions are based on the characteristics and stage of the cancer. The following sections will review the treatment of breast cancer by stage. 

Stage 0

Stage 0 breast cancer is also called ductal carcinoma in situ (DCIS). This means that the breast cancer cells are confined to one small area of the duct and have not spread into nearby breast tissue or lymph nodes.

The main treatment of DCIS is surgery.  Surgery can include either a lumpectomy, which removes the cancer cells along with an area of healthy tissue around it (a margin) or a mastectomy, in which the entire breast is removed.

Following surgery, radiation treatment to kill any microscopic cancer cells that weren’t removed by surgery may be suggested. Radiation can be given to treat the entire breast or just in the area where the cancer was located.

Endocrine (hormone) therapy may be recommended for those whose breast cancer was positive for hormone receptors (which stimulate tumor growth in the presence of either estrogen or progesterone hormones). Endocrine therapy can block hormones from being produced in the body or can prevent hormones from being able to attach to the cancer cells.

Stage 1

This early stage of breast cancer is most often treated with surgery to remove the tumor, either a lumpectomy or a mastectomy. During surgery, lymph nodes near the breast can be removed to check for cancer.

If the breast cancer is hormone receptor-positive, treatment after surgery will likely include endocrine therapy, even if the tumor is very small. This can help reduce the risk of cancer returning.

Radiation may or may not be suggested but will most likely be recommended for someone who has a lumpectomy.

Chemotherapy may be considered based on the person’s age and other characteristics of the cancer that make it more at risk for recurrence, such as a high Oncotype DX score or a rapidly growing type of cancer.

If the cancer is HER2 positive, it will likely be treated with chemotherapy and the HER2-targeted medication Herceptin (trastuzumab). Trastuzumab therapy will continue for a year. Another HER2-targeted medication, Perjeta (pertuzumab), may be added.

Stage 2

Surgery is often done for stage 2 cancers (lumpectomy or mastectomy). During surgery, lymph nodes near the breast will be evaluated for the spread of cancer. 

If a lumpectomy is done, radiation treatment will likely be suggested, so the entire breast can be treated to reduce the risk of cancer returning.

Triple-negative breast cancer (meaning the cancer was not hormone receptor-positive or HER2-positive) can be more aggressive. Chemotherapy will probably be given for this type of breast cancer (most likely before surgery). Giving chemotherapy before surgery provides the oncologist with an idea of how well the cancer responds to this treatment.

Those with triple-negative breast cancer may also receive an immunotherapy medication called Keytruda (pembrolizumab).

Those with HER2-positive cancer will likely be recommended chemotherapy and HER2-targeted therapy before surgery. HER2-directed therapy usually continues for about a year after surgery.

Those with hormone-positive breast cancer will be recommended to take endocrine therapy following surgery and chemotherapy (if given).

Stage 3

Stage 3 breast cancer is typically treated with multiple forms of therapy, including surgery, radiation, chemotherapy, plus HER2-targeted therapy and endocrine therapy, if appropriate.

Because these tumors are larger than in earlier stages, chemotherapy is often given before surgery. This can help shrink the tumor, which can make surgery more successful. It can also help shrink the tumor enough so that not as much breast tissue has to be removed.

Chemotherapy may also need to be given after surgery, depending on how well cancer responded to chemotherapy initially.

Radiation is often given after surgery, especially if a lumpectomy was done. Radiation may be needed to the lymph nodes even if a mastectomy was performed.

Stage 4

Stage 4 breast cancer means the cancer has spread outside of the breast and local lymph nodes and into distant areas of the body. In this case, surgery is rarely used. Instead, systemic treatments that work throughout the body will be given.

The exact treatments prescribed will depend on the characteristics of the cancer but can include:

• Chemotherapy
• Endocrine therapy
• HER2-directed therapy
• Immunotherapy (treatment that uses the immune system or products of the immune system)
• Targeted therapy (aimed at specific proteins present on some cancer cells that control how they grow, divide, and spread)

Recurrence: Going Back on Treatment 

After completion of treatment for stage 1, 2, or 3 breast cancer, you'll have regular follow-ups with your oncology team. During these visits, the oncologist will evaluate your health and check for any signs of breast cancer recurrence.

Recurrence means that breast cancer has returned. It can produce locally, meaning in the same breast it was in before, locally in the lymph nodes near the original tumor, or it can be metastatic, meaning cancer has spread to other areas of the body.

If a recurrence is suspected, additional testing will be ordered, which will likely consist of a biopsy (removal of tissue to be analyzed in a lab) and imaging studies, such as computed tomography (CT) or magnetic resonance imaging (MRI), to determine where the cancer is located.

The treatment for the recurrence will depend upon many factors, just as with the initial treatment for breast cancer. The cancer's location and its characteristics (hormone receptor-positive, HER2-positive, etc.) will help determine the best treatment for recurrent breast cancer.

Resources to Have Along the Way

A breast cancer diagnosis may come as a shock and be accompanied by a lot of stress and worry. During this time, it is important to know how to cope with the diagnosis and develop a good support system to help you through the process. 

Coping Mechanisms for Patients and Caregivers

You will have to cope with the mental and emotional effects of a breast cancer diagnosis and the physical side effects of treatment. You may address these in different ways, but these must be healthy coping mechanisms.

When dealing with the emotional effects, finding a person to feel safe to talk to openly and honestly can be helpful. This can be a close friend or family member, but it may not be. Some people may find it difficult to have these conversations with someone so close to them and may seek out the support of a spiritual leader, social worker, counselor, or support group.

Recognizing your feelings, whether its fear, anxiety, or anger, is important. Engaging in destructive behaviors won't be helpful. You may want to channel your feelings into a healthy activity, such as exercise, and find ways to relax. Or, seek formal counseling or therapy to learn how to handle those feelings.

Caregivers and close loved ones will need to find healthy ways to manage their stress and emotions as well. Talk with your cancer care team to determine if there are any support groups geared for them in your area. They may also find the benefit in going to counseling or speaking with a social worker. 

Financial Support

Unfortunately, the costs associated with treating breast cancer can be high. Insurance may cover most, but possibly not all, of the costs associated with cancer. Cost-sharing expenses (deductibles, co-pays, coinsurance) can add up for those with insurance.

Those who are uninsured may have additional stress and fear of not being able to pay their medical bills. There may be the costs of transportation to frequent oncology appointments, time off from work that may not be covered by paid leave, and additional childcare expenses.

If financial concerns are present for you, talk with an oncology social worker at your cancer center. They can help assist you in finding support services. There may be options available from local or national organizations.

Summary 

Treatment decisions for breast cancer can vary based on many factors, including the stage of the cancer and if the cancer is hormone receptor-positive or HER2-positive. Additional genetic tests can be done to also help oncologists make treatment decisions. 

Treatment options for breast cancer include surgery, radiation, chemotherapy, endocrine therapy, targeted therapy, and immunotherapy. Exactly which treatment you’ll be prescribed will depend on the stage and characteristics of your cancer.

A Word From Verywell

If you're diagnosed with breast cancer, you may have many questions about what your treatment plan will be and how it will all go. Your oncology team will discuss with you the treatment options for your stage of cancer, aimed to result in the best possible outcome.

Have questions ready for your cancer team before your visits, and discuss any concerns with them.