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Radiation therapy is usually given daily for a set number of weeks.

• After a lumpectomy.Radiation therapy after a lumpectomy is external-beam radiation therapy given Monday through Friday for 3 to 4 weeks if the cancer is not in the lymph nodes. If the cancer is in the lymph nodes, radiation therapy is given for 5 to 6 weeks. However, this duration is changing, as there is a preference for a shorter duration to be given in women who meet the criteria for shorter treatment. This often starts with radiation therapy to the whole breast, followed by a more focused treatment to where the tumor was located in the breast for the remaining treatments.

This focused part of the treatment, called a boost, is standard for women with invasive breast cancer to reduce the risk of a recurrence in the breast. Women with DCIS may also receive the boost. For women with a low risk of recurrence, the boost may be optional. It is important to discuss this treatment approach with your doctor.

• After a mastectomy.For those who need radiation therapy after a mastectomy, it is usually given 5 days a week for 5 to 6 weeks. Radiation therapy can be given before or after reconstructive surgery. As is the case following lumpectomy, some women may be recommended to have less than 5 weeks of radiation therapy after mastectomy.

Even shorter schedules have been studied and are in use in some centers, including accelerated partial breast radiation therapy (see below) for 5 days.

These shorter schedules may not be options for women who need radiation therapy after a mastectomy or radiation therapy to their lymph nodes. Also, longer schedules of radiation therapy may be needed for some women with very large breasts.

• Partial breast irradiation.Partial breast irradiation (PBI) is radiation therapy that is given directly to the tumor area instead of the entire breast. It is more common after a lumpectomy. Targeting radiation directly to the tumor area usually shortens the amount of time that patients need to receive radiation therapy. However, only some patients may be able to have PBI. Although early results have been promising, PBI is still being studied. However, it is already part of routine care in certain circumstances, including for specific people with early-stage breast cancer. You may want to discuss with your radiation oncologist the pros and cons of PBI compared to whole breast radiation therapy.

PBI can be done with standard external-beam radiation therapy that is focused on the area where the tumor was removed and not on the entire breast. PBI may also be done with brachytherapy by using plastic catheters or a metal wand placed temporarily in the breast. Breast brachytherapy can involve short treatment times, ranging from 1 dose to 1 week. It can also be given as 1 dose in the operating room immediately after the tumor is removed. These forms of focused radiation therapy are currently used only for patients with a smaller, less aggressive, and lymph node-negative tumor.

• Intensity-modulated radiation therapy.Intensity-modulated radiation therapy (IMRT) is a more advanced way to give external-beam radiation therapy to the breast. The intensity of the radiation directed at the breast is varied to better target the tumor, spreading the radiation more evenly throughout the breast. The use of IMRT lessens the radiation dose and may decrease possible damage to nearby organs, such as the heart and lung, as well as lessen the risks of some immediate side effects, such as peeling of the skin during treatment. This can be especially important for women with medium to large breasts who have a higher risk of side effects, such as peeling and burns, compared with women with smaller breasts. IMRT may also help to lessen the long-term effects on the breast tissue, such as hardness, swelling, or discoloration, that were common with older radiation techniques.

IMRT is not recommended for everyone. Talk with your radiation oncologist to learn more. Special insurance approval may also be needed for coverage for IMRT. It is important to check with your health insurance company before any treatment begins to make sure it is covered.

• Proton therapy.Standard radiation therapy for breast cancer uses x-rays, also called photon therapy, to kill cancer cells. Proton therapy is a type of external-beam radiation therapy that uses protons rather than x-rays. At high energy, protons can destroy cancer cells. Protons have different physical properties that may allow the radiation therapy to be more targeted than photon therapy and potentially reduce the radiation dose. The therapy may also reduce the amount of radiation that goes near the heart. Researchers are studying the benefits of proton therapy versus photon therapy in a national clinical trial. Currently, proton therapy is an experimental treatment and may not be widely available or covered by health insurance.

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. These treatments are very focused and work differently than chemotherapy. This type of treatment blocks the growth and spread of cancer cells and limits damage to healthy cells.

Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them. Learn more about the basics of targeted treatments.

The first approved targeted therapies for breast cancer were hormonal therapies. Then, HER2-targeted therapies were approved to treat HER2-positive breast cancer.

HER2-targeted therapy (updated 10/2020)

• Trastuzumab (FDA-approved biosimilarforms are available). This drug is approved as a therapy for non-metastatic HER2-positive breast cancer. It is given either as an infusion into a vein every 1 to 3 weeks or as an injection into the skin every 3 weeks. Currently, patients with stage I to stage III breast cancer (see Stages) should receive a trastuzumab-based regimen, often including a combination of trastuzumab with chemotherapy, followed by a total of 1 year of adjuvant trastuzumab. Patients receiving trastuzumab have a small (2% to 5%) risk of heart problems. This risk is increased if a patient has other risk factors for heart disease or receives chemotherapy that also increases the risk of heart problems at the same time. These heart problems may go away and can be treated with medication.
• Pertuzumab (Perjeta).This drug is approved for stage II and stage III breast cancer in combination with trastuzumab and chemotherapy. It is given as an infusion into a vein every 3 weeks.
• Pertuzumab, trastuzumab, and hyaluronidase–zzxf (Phesgo). This combination drug, which contains pertuzumab, trastuzumab, and hyaluronidase-zzxf in a single dose, is approved for people with early-stage HER2-positive breast cancer. It may be given in combination with chemotherapy. It is given by injection under the skin and can be administered either at a treatment center or at home by a health care professional.
• Neratinib (Nerlynx).This oral drug is approved as a treatment for higher-risk HER2-positive, early-stage breast cancer. It is taken for a year, starting after patients have finished 1 year of trastuzumab.
• Ado-trastuzumab emtansine or T-DM1 (Kadcyla). This is approved for patients with early-stage breast cancer who have had treatment with trastuzumab and chemotherapy with either paclitaxel or docetaxel followed by surgery, and who had cancer remaining (or present) at the time of surgery. ASCO recommendsthat these patients receive 14 cycles of T-DM1 after surgery unless the cancer recurs or the side effects from T-DM1 become too difficult to manage. T-DM1 is a combination of trastuzumab linked to a very small amount of a strong chemotherapy. This allows the drug to deliver chemotherapy into the cancer cell while lessening the chemotherapy received by healthy cells, which usually means that it causes fewer side effects than standard chemotherapy. T-DM1 is given by vein every 3 weeks.

This information is based on the ASCO guideline, “Selection of Optimal Adjuvant Chemotherapy and Targeted Therapy for Early Breast Cancer.” Please note that this link takes you to another ASCO website.

Talk with your doctor about possible side effects of specific medications and how they can be managed.

Bone modifying drugs block bone destruction and help strengthen the bone. They may be used to prevent cancer from recurring in the bone or to treat cancer that has spread to the bone. Bone modifying drugs are not a substitute for standard anti-cancer treatments. Certain types of bone modifying drugs are also used in low doses to prevent and treat osteoporosis. Osteoporosis is the thinning of the bones.

There are 2 types of drugs that block bone destruction:

• These block the cells that destroy bone, called osteoclasts.
• Denosumab (Prolia, Xgeva).An osteoclast-targeted therapy called a RANK ligand inhibitor. ASCO does not recommend using denosumab as an adjuvant treatment to prevent breast cancer recurrence.

All people with breast cancer who have been through menopause, regardless of the cancer’s hormone receptor status and HER2 status, should have a discussion with their doctor whether bisphosphonates are right for them. Several factors affect this decision, including your risk of recurrence, the side effects of treatment, the cost of treatment, your preferences, and your overall health.

If treatment with bisphosphonates is recommended, ASCO recommends starting within 3 months after surgery or within 2 months after adjuvant chemotherapy. This may include treatment with clodronate (multiple brand names), ibandronate (Boniva), or zoledronic acid (Reclast, Zometa). Clodronate is not available in the United States.

This information is based on the ASCO and Ontario Health (Cancer Care Ontario) guideline, “Use of Adjuvant Bisphosphonates and Other Bone-Modifying Agents in Breast Cancer.” Please note that this link takes you to another ASCO website.

Other types of targeted therapy for breast cancer (updated 04/2022)

You may have other targeted therapy options for breast cancer treatment, depending on several factors. The following drugs are used for the treatment of non-metastatic breast cancer.

• Olaparib (Lynparza).This is a type of oral drug called a PARP inhibitor, which destroys cancer cells by preventing them from fixing damage to the cells. ASCO recommends using olaparib to treat early-stage, HER2-negative breast cancer in people with an inherited BRCA1 or BRCA2 gene mutation and a high risk of breast cancer recurrence. Adjuvant olaparib should be given for 1 year following the completion of chemotherapy, surgery, and radiation therapy (if needed).
• Abemaciclib (Verzenio). This oral drug, called a CDK4/6 inhibitor, targets a protein in breast cancer cells called CDK4/6, which may stimulate cancer cell growth. It is approved as treatment in combination with hormonal therapy (tamoxifen or an AI) to treat people with hormone receptor-positive, HER2-negative, early breast cancer that has spread to the lymph nodes and has a high risk of recurrence. ASCO recommendsconsideration of 2 years of treatment with abemaciclib combined with 5 or more years of hormonal therapy for patients meeting these criteria, including for people whose cancer has a Ki-67 score higher than 20% (see Diagnosis).

Many of the following drugs are used for advanced or metastatic breast cancer.

• Alpelisib (Piqray).Alpelisib is an option along with the hormonal therapy fulvestrant for people with hormone receptor-positive, HER2-negative metastatic breast cancer that has a PIK3CA gene mutation and has worsened during or after hormonal therapy.
• Drugs that target the CDK4/6 proteinin breast cancer cells, which may stimulate cancer cell growth. These drugs include abemaciclib (Verzenio), palbociclib (Ibrance), and ribociclib (Kisqali). They are approved for women with ER-positive, HER2-negative advanced or metastatic breast cancer and may be combined with some types of hormonal therapy. They may also be used in conjunction with fulvestrant in endocrine-resistant second-line disease.
• Lapatinib (Tykerb). This may be an option for women with HER2-positive advanced or metastatic breast cancer when other medications are no longer effective at controlling the cancer’s growth. It may be combined with the chemotherapy capecitabine, the hormonal therapy letrozole, or the HER2 targeted therapy trastuzumab.
• Tucatinib (Tukysa).Tucatinib, when added to capecitabine chemotherapy and trastuzumab, is approved for the treatment of advanced unresectable or metastatic HER2-positive breast cancer, including cancer that has spread to the brain, in those who have already received 1 or more HER2-targeted therapy. Unresectable means surgery is not an option. Tucatinib is a tyrosine kinase inhibitor designed to turn off HER2. It is an oral medication that is given twice daily.
• Sacituzumab govitecan-hziy (Trodelvy). The FDA has approved the use of sacituzumab govitecan-hziy for the treatment of people with metastatic triple-negative breast cancer who have already received at least 2 treatments, including 1 treatment for metastatic disease. It is also approved for people with locally advanced triple-negative breast cancer that cannot be treated with surgery. Sacituzumab govitecan-hziy is an antibody-drug conjugate, which means the antibody attaches to a cancer cell and then delivers the anticancer drug it carries to start destroying the cancer cell. Sacituzumab govitecan-hziy is given by vein, or intravenously, on days 1 and 8 of every 21-day cycle.
• Entrectinib (Rozyltrek) and larotrectinib (Vitrakvi). These may be used for breast cancer with an NTRKfusion that is metastatic or cannot be removed with surgery and has worsened with other treatments (see Diagnosis).
• This oral drug may be used for people with metastatic HER2-negative breast cancer and an inherited BRCA1 or BRCA2 gene mutation who have previously received chemotherapy. It is a type of drug called a PARP inhibitor, which destroys cancer cells by preventing them from fixing damage to the cells.
• Talazoparib (Talzenna). This may be an option for women with locally advanced or metastatic HER2-negative breast cancer and a BRCA1or BRCA2 gene mutation. It is a PARP inhibitor.