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Breast cancer treatment isn't "one size fits all," which means you may be faced with choices to make, both before and after surgery. Keep in mind, there's rarely a need to rush things, says Dale Collins Vidal, M.D., professor of surgery at Dartmouth Medical School in Lebanon, New Hampshire. "In most cases you can safely take a few weeks to mull over your options, get more advice, and develop a plan you feel confident with." The major decisions you may encounter:
Lumpectomy versus mastectomy. A lumpectomy (breast-conserving surgery) makes sense if your tumor is tiny and limited to one area, since the results won't be disfiguring. When combined with radiation afterward, women with relatively small breast cancers who have a lumpectomy are just as likely to be alive and disease-free 20 years later as women treated with a mastectomy (the entire breast is removed), according to two large studies. Still, a mastectomy might be a better choice if a lot of tissue (especially if in different areas) needs to be taken. And in many instances you won't need radiation if you have a mastectomy.
Reconstructive surgery. If you decide to have a mastectomy, think about whether you want surgery to re-build your breast—by law, this is a benefit your health insurer must cover. Immediate breast reconstruction often spares you a second operation and has the best cosmetic results. To learn more about the newest reconstruction options, including nipple-sparing procedures, search "Breast Reconstruction After Mastectomy" at cancer.org.
Chemotherapy. Undergoing chemo to lower the risk of a cancer comeback is a given for most women, unless you have early-stage (I or II) estrogen receptor-positive breast cancer that has not spread to the lymph nodes (and you're undergoing hormone therapy). In this scenario your oncologist will order an Oncotype DX test, which analyzes the activity of different genes (from a tissue sample) that control the growth of cancer cells. Test results are reported as a "Recurrence Score" between 0 and 100. The lower your score, the less likely the cancer is to recur within 10 years of your initial diagnosis; higher scores indicate you would benefit from chemo. The trickiest score is between 18 and 31 because it doesn't provide a clear signal as to what the best course of action is.
External versus internal radiation therapy. External beam radiation, which is the most common type, is administered from a machine outside the body to the breast from which the cancer is being removed. Typically, you're given treatments five days a week for about six weeks. With internal therapy (a widely used type is MammoSite), radioactive seeds or pellets are placed directly into the breast tissue next to the cancer. This treatment is much faster—it's twice a day for five days. Not everyone's a candidate, but if you are, be aware that internal radiation is newer, so the evidence is still incomplete (although promising) as to whether it reduces the chances of a recurrence as much as the external version.
Hormone or targeted therapy. If your cancer is positive for estrogen and/or progesterone receptors, you can increase the odds your cancer won't return by 23 percent by taking anti-hormone pills such as tamoxifen, letrozole, or anastrozole. But these meds can cause fatigue, hot flashes, and mood swings. In fact, up to 50 percent of women quit taking them sooner than recommended. In some cases you may be able to switch to another type of hormone therapy if you're experiencing side effects. Work with your oncologist to find a regimen you can tolerate. If you have early-stage HER2-positive cancer, you'll need to decide whether to take the drug trastuzumab; it can lower your risk of a recurrence by 52 percent when used in combination with chemotherapy, but it may trigger serious heart complications in some women.