Treatments for stage 2 breast cancer

The following are treatment options for stage 2 ductal carcinoma and lobular carcinoma. Doctors consider stage 2A to be early stage breast cancer. Stage 2B is considered to be locally advanced breast cancer. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.

Surgery

Surgery is a standard treatment for stage 2 breast cancer.

Breast conserving surgery is offered if doctors can remove all of the tumour along with a margin of healthy tissue around it and there will still be enough tissue for the breast to look as natural as possible after surgery.

Modified radical mastectomy is offered if there is cancer in more than one area of the breast or in the edges of the tissue removed during breast-conserving surgery (called positive surgical margins). It is also offered if a tumour isn’t found in the breast but there is a very small amount of cancer in the lymph nodes (stage 2A).

Sentinel lymph node biopsy (SLNB) may be offered if doctors think the cancer has not spread to the lymph nodes. If the results of the SLNB show that there is cancer in the sentinel lymph node, or if the sentinel node can’t be found, doctors will do an ALND to stage the cancer.

Axillary lymph node dissection (ALND) may be done to diagnose and stage breast cancer.

Radiation therapy

External beam radiation therapy is offered after breast-conserving surgery for stage 2 breast cancer. All of the breast and the lymph nodes under the arm and near the collarbone are treated.

You may be offered radiation therapy after mastectomy for stage 2 breast cancer if it has spread to the lymph nodes.

Chemotherapy

Chemotherapy is usually offered after surgery for stage 2 breast cancer. It may be given before surgery (called neoadjuvant therapy) if:

  • the tumour is larger than 5 cm
  • the cancer has spread to lymph nodes both under the arm and around the breastbone

The most common combinations of chemotherapy drugs used are:

  • AC-T – doxorubicin (Adriamycin) and cyclophosphamide (Procytox) followed by paclitaxel (Taxol) or docetaxel (Taxotere)
  • T-AC – paclitaxel or docetaxel followed by doxorubicin and cyclophosphamide
  • TC – paclitaxel and cyclophosphamide
  • CAF (or FAC) – cyclophosphamide, doxorubicin and 5-fluorouracil (Adrucil, 5-FU)
  • CAF followed by docetaxel or paclitaxel
  • CEF (or FEC) – cyclophosphamide, epirubicin (Pharmorubicin) and 5-fluorouracil
  • CEF followed by docetaxel or paclitaxel
  • EC – epirubicin and cyclophosphamide

Hormonal therapy

Hormonal therapy is always offered for hormone receptor–positive stage 2 breast cancer. It is continued for up to a total of 10 years.

Tamoxifen (Nolvadex, Tamofen) is the most commonly used anti-estrogen hormonal therapy drug offered to both premenopausal and post-menopausal women.

Aromatase inhibitors are given only to post-menopausal women. They may be offered after tamoxifen therapy or instead of tamoxifen if you can’t take or would prefer not to take tamoxifen. The most common aromatase inhibitors used are:

  • letrozole (Femara)
  • anastrozole (Arimidex)
  • exemestane (Aromasin)

Hormonal therapy for post-menopausal women

Hormonal therapy for post-menopausal women with stage 2 breast cancer includes tamoxifen (an anti-estrogen) and aromatase inhibitors.

You may be offered one of the following options:

  • tamoxifen (Nolvadex, Tamofen) alone for up to 10 years
  • an aromatase inhibitor alone for up to 10 years
  • tamoxifen for 5 years, and then an aromatase inhibitor for up to 5 years (for up to a total of 10 years of hormonal therapy)
  • tamoxifen for 2 to 3 years followed by an aromatase inhibitor for 2 to 3 years, or starting with an aromatase inhibitor followed by tamoxifen, for a total of 5 years of hormonal therapy
  • an aromatase inhibitor for 2 to 3 years, followed by tamoxifen

Hormonal therapy for premenopausal women

Hormonal therapy options for premenopausal women with stage 2 breast cancer include the following.

You will take tamoxifen for 5 years, then your healthcare team will check if you have reached menopause:

  • If you are still premenopausal, you can continue to take tamoxifen for up to 10 years in total.
  • If you have reached menopause, your healthcare team may offer you the option to continue tamoxifen for up to 10 years in total or to switch to an aromatase inhibitor for up to 5 years (for up to a total of 10 years of hormonal therapy).

Older premenopausal women may be offered ovarian ablation or suppression, along with tamoxifen or an aromatase inhibitor, for up to 10 years.

Targeted therapy

Trastuzumab (Herceptin) is added to chemotherapy for stage 2 breast cancer that is HER2-positive and has a high risk for recurrence. Trastuzumab is usually given for up to a year after chemotherapy for breast cancer has finished.

Pertuzumab (Perjeta) may be used in combination with trastuzumab and chemotherapy:

  • for stage 2 HER2-positive breast cancer

  • for hormone receptor-negative breast cancer

  • before surgery for stage 2 HER2-positive breast cancer

Pertuzumab and trastuzumab (Phesgo) is a combination drug given under the skin (subcutaneous) instead of into the vein (intravenously). Phesgo may be used in combination with chemotherapy for stage 2 HER2-positive breast cancer that has not spread to more than 3 lymph nodes, and for hormone receptor negative breast cancer.

Trastuzumab emtansine (Kadcyla, T-DM1) may be used to treat HER2-positive breast cancer if there is still evidence of cancer after being treated with chemotherapy and trastuzumab.

Clinical trials

Many clinical trials in Canada are open to women with breast cancer. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.

Expert review and references

  • Hoffman La-Roche Limited Canada. Product Monograph Pertuzumab (Perjeta). https://www.rochecanada.com/PMs/Perjeta/Perjeta_PM_E.pdf.
  • Roche Canada. Product Monograph Trastuzumab Emtansine (Kadcyla). https://www.rochecanada.com/PMs/Kadcyla/Kadcyla_PM_E.pdf.
  • American Cancer Society. Breast Cancer. 2015: http://www.cancer.org/cancer/breastcancer/index.
  • Brackstone M, Fletcher GG, Dayes IS, Madarnas Y, SenGupta SK, Verma S, and Members of the Breast Cancer Disease Site Group . Locoregional therapy of locally advanced breast cancer: a clinical practice guideline. Current Oncology. 2015.
  • Eisen A, Fletcher GG, Gandhi S, Mates M, Freedman OC, Dent SF, Trudeau ME and members of the Early Breast Cancer Systemic Therapy Consensus Panel . Optimal systemic therapy for early breast cancer in women: a clinical practice guideline. Current Oncology. 2015.
  • Goss, PE, Ingle JN, Pritchard KJ, et al . Extending aromatase-inhibitor adjuvant therapy to 10 years. New England Journal of Medicine. 2016.
  • Hoffmann-La Roche Limited. Product Monograph: Perjeta. 2018.
  • Morrow M, Burstein HJ, and Harris JR . Malignant tumors of the breast. DeVita VT Jr, Lawrence TS, & Rosenberg SA. Cancer: Principles and Practice of Oncology. 10th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015: 79: 1117-1156.
  • National Cancer Institute. Breast Cancer Treatment for Health Professionals (PDQ®). 2015.
  • National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Breast Cancer (Version 2.2015). http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.