Overview
Cancer of the breast is the most frequently diagnosed cancer in U.S. women.*
If you have been diagnosed with inflammatory breast cancer (IBC), you probably have many questions and concerns about treatment. This treatment summary, which is based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™)for Breast Cancer, will help you understand the best available treatments for IBC.
Talk with your doctor about these therapies so that together you can decide on a treatment plan that is right for you.
Background
Inflammatory breast cancer (IBC) is a rare form of invasive breast cancer and tends to grow more quickly than other invasive breast cancers. Invasive means that the cancer has spread from the tissue from where it began into the surrounding healthy tissue of the breast, and can spread to other parts of your body. Because IBC grows quickly and frequently spreads to other parts of your body, it is important to start treatment promptly.
Diagnosis
IBC is a very aggressive type of breast cancer in which the skin on one third or more of the breast is red, and the breast is likely to feel warm. The breast may also be swollen, and the skin of the breast may look dimpled, like the skin of an orange. IBC can be mistaken for a breast infection, but the redness and swelling of the breast in IBC is caused by small pieces of tumor that interfere with the flow of lymphatic fluid through breast tissue. With IBC, you or your doctor may not always be able to feel a lump inside the breast.
A mammogram or ultrasound can detect IBC, but IBC may be less apparent than other breast cancer tumors using these imaging tools. Only a biopsy of breast tissue or skin can be used to confirm or rule out IBC. In addition to confirming a diagnosis of cancer, your biopsy sample provides the doctor with information about whether important breast cancer tumor markers are present in high amounts on the tumor cells (see Hormone Therapy and Targeted Therapy sections below).
Your doctor will order tests to determine whether your cancer has spread from the breast to other parts of your body and to determine your general health so that a treatment plan can be recommended that is right for you.
Stage
Staging describes the extent or severity of the cancer. The stages of IBC range from stage I through stage IV, with a higher stage indicating more widespread disease.
Women with stage I or stage II breast cancer generally have smaller tumors, with either no or minimal lymph node involvement and no spread of disease beyond breast tissue. When breast cancer is diagnosed as stage IV, this means that the cancer has spread (metastasized) to other organs within the body, such as lung, bone, or liver. See the Cancer Staging Guide.
In the case of IBC, tumor size is not always the main consideration in determining the stage of the disease; in some cases, no tumor mass will be detected and staging depends on how widespread the cancer is in the breast, the number of lymph nodes involved, and whether the cancer has spread to other parts of the body. If there is no spread to distant organs, it is considered to be stage IIIB. In stage IV IBC, breast cancer cells have spread to other organs (metastasized).
Treatment
The factors that will determine which specific treatment is right for you are tumor stage, estrogen and progesterone receptor tumor status, and HER2 tumor status. Estrogen and progesterone are hormones in the body that can stimulate the growth of breast cancer cells that have estrogen and/or progesterone receptors. Breast cancer cells with too many HER2 receptors are more aggressive and grow faster.
Treatment for a woman with IBC is highly individualized; no single treatment plan is right for everyone. Because IBC is a fast-growing and aggressive form of breast cancer, your treatment plan is likely to involve chemotherapy, surgery, and radiation therapy, as well as other possible treatments. To make the best decisions for you, talk to your doctor about the benefits, risks, and possible side effects of treatment options discussed below.
Your doctor should provide you with a written care plan explaining what treatments you will have, when they will occur (and how often if you are undergoing chemotherapy or radiation), and what type of side effects you may experience. Some side effects can be anticipated and you can be given pretreatment to minimize them. You will be asked to sign an informed consent form indicating that you have been told about your treatment and what you can expect.
It is very important that you ask your doctor or nurse any questions that you have. Cancer and its treatment are complicated, and most patients have questions.
Chemotherapy
The NCCN Guidelines
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for Breast Cancer recommend chemotherapy (drugs that kill cancer cells) as the first treatment for women with IBC. The drugs are given before surgery to kill as many cancer cells as possible. While you are receiving chemotherapy, your medical oncologist and your surgeon will work together to decide the best time for you to have surgery. This is sometimes a complex decision, and your doctors may suggest that you undergo surgery before you have completed your planned chemotherapy. If this happens, you should complete chemotherapy after surgery. If your cancer does not respond to the first chemotherapy regimen, your doctor may recommend trying a different regimen or that you have radiation therapy to your breast.
Chemotherapy is typically given for a period of 3 to 6 months. The NCCN Guidelines for Breast Cancer lists recommended chemotherapy regimens that you can discuss with your doctor. See also the Guide to Chemotherapy.
Some chemotherapy regimens have uncomfortable side effects, such as hair loss, stomach problems (including nausea and vomiting), and decreased production of certain types of blood cells, which can lead to other conditions, including anemia or bleeding problems. Talk to your doctor or oncology nurse about how to manage these effects.
Although most side effects are not serious, some chemotherapy drugs, such as doxorubicin, can affect the heart, and you may need to have periodic testing to monitor your heart function when taking these drugs. Make sure you discuss this possibility with your health care professionals and understand fully what you can expect.
If you are premenopausal, your menstrual periods may stop either temporarily or permanently after you undergo chemotherapy, possibly resulting in permanent infertility.
Talk to your doctor about what to expect from each treatment and what can be done to help you cope with these side effects.
Surgery
A total mastectomy (removal of the breast) with removal of lymph nodes is recommended for most women with IBC after their cancer responds to a course of chemotherapy. A lumpectomy, in which only a portion of the breast is removed, is not an option for women with IBC.
During mastectomy, the surgeon will remove a number of lymph nodes in the area under the arm of the affected breast to check for the spread of cancer.
A possible side effect of lymph node surgery is lymphedema, which is swelling of the arm and hand on the side of the body where the breast surgery was performed. Exercises and other interventions can help manage lymphedema if it develops.
Breast Reconstruction After Mastectomy
If you have a mastectomy to treat IBC, you may have surgery to reconstruct the breast immediately after the mastectomy or in a separate operation at a later time, depending on factors such as the specific type of breast reconstruction and whether radiation therapy is planned. Reconstruction may be performed using tissue removed from the abdomen or another part of the body, using an artificial implant, or using a combination of the two methods.
Breast reconstruction surgery has potential risks and complications. Doctors usually recommend it only for otherwise healthy women who do not have certain conditions (such as diabetes) or who do not smoke, because women with these conditions have an increased risk for experiencing complications from the surgery. If you think the procedure may be right for you, ask your doctor to refer you to a plastic surgeon before you schedule the mastectomy.
Radiation therapy
Radiation therapy, which uses high-energy beams to kill cancer cells, is recommended for women with IBC after total mastectomy. It may also be used before surgery if your cancer did not respond to chemotherapy. It is usually given for a period of weeks. Afterwards, you may tire more easily and/or notice redness or swelling of the breast, although these side effects are usually mild and do not last for long periods. See Fighting Cancer Fatigue.
Hormone therapy
If you have breast cancer that has tested positive for the estrogen receptor and/or the progesterone receptor tumor markers, you may be a candidate for hormone therapy. Hormone therapies include tamoxifen, which binds to hormone receptors and blocks the hormonal stimulation of tumor growth, and aromatase inhibitors (such as anastrozole, letrozole, or exemestane), which stop estrogen from being produced in postmenopausal women. Aromatase inhibitors are appropriate only for postmenopausal women, because premenopausal women produce much higher amounts of estrogen that cannot be significantly reduced with these drugs.
Hormone therapy is given after surgery and after completion of chemotherapy. Hormone therapies are usually taken as pills and are often given for at least 5 years. It is important that you do not stop hormone therapy without informing your doctor, because these drugs are more effective when taken for long periods of time.
Side effects associated with the hormone therapy tamoxifen include hot flashes and a slightly increased risk for blood clots and developing cancer of the uterus. Aromatase inhibitors can cause joint and muscle pain and decreased bone mass.
Strategies for early detection of these side effects include monitoring bone health through periodic measurements of bone mineral density and prompt investigation of abnormal uterine bleeding and symptoms/signs of a blood clot, such as swelling and pain in a leg or arm.
Targeted therapies
Some treatments are specifically directed toward certain markers on tumor cells or certain processes that occur in tumor cells. For example, drugs like trastuzumab (Herceptin) target cancer cells that have high quantities of the HER2 receptor. The NCCN Guidelines for Breast Cancer recommend that trastuzumab (Herceptin) be given as part of only certain chemotherapy regimens; you and your doctor can view the preferred regimens in the NCCN Guidelines for Breast Cancer.
Trastuzumab (Herceptin) is most often given for one year and is commonly started close to the time that chemotherapy is first given and continued after chemotherapy has been completed. Herceptin is administered intravenously. Because Herceptin can affect the heart, you may need to undergo periodic testing to monitor your heart function if you are taking this drug.
Herceptin has not been shown to be effective in women with breast cancer that does not have high quantities of HER2 on the tumor cells. Thus, it is very important that testing for the HER2 tumor marker is accurate.
Ask your doctor whether the laboratory that will be used is accredited by either the College of American Pathologists or The Joint Commission. If your doctor doesn’t know, you can call the head of the laboratory (often a pathologist) and ask about accreditation. If the laboratory is not accredited to perform HER2 testing, ask your doctor to send your tumor sample to a laboratory that is accredited by one of these organizations. Laboratories that are connected with large cancer centers and perform a high volume of HER2 tests are more likely to meet the standards for accreditation. More information is available in HER2 Testing: Summary for Breast Cancer Patients.
Prognosis
In determining a prognosis (the likely course or outcome of a disease and its treatment) a doctor may look at cancer survival statistics taken from studies of large groups of patients. However, such statistics:
- Are estimates only
- Can vary widely with each cancer stage
- Are sometimes based on older data that do not reflect recent advances in early detection and treatment
- Cannot be used to precisely predict your survival
Your individual prognosis will be affected by many factors, including:
- Your age
- Your overall health
- The type, stage, and grade of your cancer (the extent to which the cancer cells resemble normal breast cells) of your cancer
- The presence or absence of certain tumor markers, such as estrogen receptor, and/or progesterone receptor, and/or HER2
- Your response to the treatment(s) being used
Ask your doctor which treatment(s), in his or her judgment, will give you the best life expectancy and quality of life. You may want to find out if you are eligible to participate in a clinical trial, in which new and experimental therapies are tested against standard treatments.
Life After Treatment
After completing your treatment, you will begin a period called follow-up. During this period, you will visit your doctor every 6 to 12 months to ensure your continued good health. These visits to your doctor will give you a chance to ask questions and share your concerns. You will need an annual mammogram to ensure that if you develop a new breast cancer, it can be found and treated at an early stage.
*Fewer than 1% of breast cancer cases occur in men. Because this summary is focused only on women’s breast cancer, men in search of information about male breast cancer may want to begin by visiting the National Cancer Institute’s overview of male breast cancer.