This section will outline the general treatment plan for the following personalization options:
Newly diagnosed
Any type
HR positive, HER2 negative

Explore Each Step:
1. Referral to cancer program
2. Your first appointment with your oncologist
3. Consultations with other breast cancer specialists
4. Undergoing surgery
5. Pathology and follow-up
6. Referral to medical oncologist
7. Adjuvant systemic therapy
8. Radiation therapy
9. Follow-up

Introduction

Oncologists follow specific guidelines when deciding on the treatment plan that is right for you. Below we outline the general guidelines and plans based on your stage, type and subtype of breast cancer. We also identify where you can make decisions about your treatment and what those options may be. Finally, we outline the pan-Canadian standards of care for access and timing of treatments.

Making decisions related to your care can feel like a heavy burden. These are decisions that can have a great impact on your quality of life in the immediate and sometimes distant future. Your first impulse may be to start treatment immediately. It’s important to understand that you have the time to get accurate information about your options, find useful resources (like this tool), get support, ask questions, and gain some perspective before having to decide on a course of treatment.

*Remember: Not all experiences may follow this exact path and you may or may not have all the tests or treatments we outline within. We hope this pathway will give you a general understanding of the process and possible timelines. The standards of care reported in this tool are based on guidelines and not everyone will fall into these standard categories. We encourage you to always consult your doctor for the most accurate information and timelines specific to your circumstances.

Knowing your breast cancer stage is an important factor in determining your treatment plan. Sometimes surgery takes place before official confirmation of your stage is determined. Ask your oncologist if they know or suspect what stage your cancer is and what treatment options they are considering.

1. Referral to cancer program

After your diagnosis, your doctor will refer you to the closest cancer program.

Standards of Care:

• Your initial consultation with a breast cancer oncologist should take no longer than 2 weeks from the date of your referral[1] but may take up to a month or longer in some cases.
• Your surgeon should have experience or up-to-date training in performing breast cancer surgeries and lymph node biopsies.[2]

2. Your first appointment with your oncologist

You will likely see a breast cancer surgeon first. You may either see a surgical oncologist or a general surgeon with expertise in breast cancer surgery.

At your first appointment with the surgeon, the discussion will depend on where you are in your diagnosis:

• If you are being assessed for a lump, your surgeon will talk to you about how to determine whether it is cancerous.
• If you already have a confirmed cancer diagnosis, your surgeon will review the results of your breast biopsy (pathology report) and discuss your surgical treatment options.

Sometimes a surgeon will perform your breast surgery before determining your stage or will use the surgery to help confirm the suspected stage. In these cases, the surgery helps to inform what stage of breast cancer you have.

A lymph node biopsy will likely be performed to help determine your staging as well. This biopsy will identify whether the cancer has spread to any of the lymph nodes in your armpit. Ask your surgeon what type of biopsy is being considered for you (sentinel lymph node biopsy or axillary lymph node biopsy).

You may be offered a choice between a lumpectomy (removal of the lump) or a mastectomy (removal of the whole breast). Here are some things to keep in mind:

• Most people who have a lumpectomy will also need radiation therapy after surgery.
• If you are thinking about having a mastectomy and are also considering breast reconstruction, ask your surgeon about your options before your surgery. You may be able to see a plastic surgeon ahead of time to learn what types of reconstruction are available in your area.

 Visit our digital decision aid, SurgeryGuide to learn more about the various surgical options.

Tip: Speak to your private insurance provider about whether you have coverage for post-surgery breast cancer products like mastectomy bras and compression sleeves for lymphedema. Some insurance companies may require a prescription or note from your doctor.

3. Consultations with other breast cancer specialists

Before your surgery date, you may be referred to other breast cancer specialists for consultations:

• If you are considering a lumpectomy, you may see a radiation oncologist for consultation as you will likely need radiation following your surgery.
• For tumours of certain types, you may see a medical oncologist to consider systemic therapy (drugs) to shrink your cancer before subsequent surgery.
• If you are considering a mastectomy, you may see a plastic surgeon specializing in reconstruction before your surgery.

Referrals for breast reconstruction vary widely by province and even by city. Consult your surgeon about the availability of reconstruction in your community.

4. Undergoing surgery

Once you make a final decision about the type, your doctor will schedule you for your surgery. Your surgery will likely be day surgery. This means that you will not be required to stay overnight at the hospital.

You may receive a lymph node biopsy during your surgery. This may require the surgeon to inject dye into the breast to determine which lymph nodes need to be removed for biopsy. Typically, a sentinel lymph node biopsy is preferred over an axillary dissection (See Surgery in Understanding my Treatment Options).

Sometimes the surgeon will place a drain into your breast area. This drain helps to remove any excess fluid after your surgery.

Upon discharge, your surgeon will provide you with instructions for pain relief and how to care for and empty your surgical drains.

Tip: Print out our checklist to help you prepare for your surgery and recovery.

Timelines:

• Depending on the surgery you choose, it can take anywhere from 1 to 3 hours to perform.
• Recovery from surgery can take 3-4 weeks. If you are receiving immediate reconstruction, this may take longer. Surgical drains may remain in for 1 to 2 weeks.

Standards of Care:

• Your treatment should begin within 4 weeks of consultation.[3]
• If you are 70 years or older, have HR positive, HER2 negative breast cancer and are clinically node-negative (T1N0), you are often not required to undergo a sentinel lymph node biopsy.[4]
• Sentinel lymph node biopsy is the standard of care for clinically node-negative early breast cancer patients who have not received neoadjuvant therapy.[5]

5. Pathology and follow-up

After your surgery is complete, the tumour and surrounding tissue will be sent to a lab for further testing. Following this, a pathology report will be created.

At your follow-up appointment with your surgeon, they will discuss the results of this pathology report. In addition to the size and grade of your tumour, the pathologist will also examine any lymph nodes that were removed. If your surgeon finds cancer cells in your lymph nodes, together the above features will help determine your stage.

If you are stage III, you may be eligible for additional imaging and tests to ensure the breast cancer has not spread beyond the breast area to other organs (known as metastases). 

If you had a lumpectomy, the pathologist would also test the surrounding tissue for cancer cells. This surrounding tissue is called the surgical margin. If cancer cells are present at the boundary of the surrounding tissue, you have positive margins and there may be some cancer cells remaining in your breast. If there was no cancer present, it means you have clear or negative margins.

You may require additional surgery if your surgical margins are positive. You may or may not have options available to you:

• Re-excision: remove more tissue from your breast to achieve negative margins.
• Mastectomy: removal of the remaining tissue in your breast for a complete mastectomy.

This decision may be based on several factors, including the amount of cancer cells present and the size of your breast.

Tip: Lymphedema can be a common side effect after breast cancer surgery due to lymph node removal. Physiotherapy is crucial in reducing your risk of developing lymphedema. Not all centres automatically provide access to a physiotherapist. Ask your oncologist about accessing one specialized in breast cancer.

For more information on understanding and reading your pathology report, visit https://www.mypathologyreport.ca/.

Tip: Ask your surgeon or your hospital’s Health Records department if you can have a copy of your pathology report. Some hospital systems provide access to online portals for patients to view their reports as soon as they are released.

In addition to discussing the results of your surgery, your surgeon will go over any questions you may have about your recovery or follow-up care. If they have not yet done so, they will refer you to a radiation and a medical oncologist for consultation and to discuss your adjuvant (postoperative) treatment.

Standards of Care:

• Final surgical pathology should be reported to your surgeon within 2 weeks of your operation.[6]

6. Referral to medical oncologist

At your first meeting with your medical oncologist, he or she may once again review your pathology report and discuss your adjuvant therapy options. Some earlier stages of HR positive breast cancer may require little to no additional therapy following surgery, while later stages may require additional treatment.

Early-stage HR positive breast cancers may be eligible for an additional test, called a genomic test, that looks at your future risk of recurrence. While the tumour stage and grade remain important, results from this test can help to better determine what adjuvant therapy is right for you. The most common and accessible test in Canada is called Oncotype DX™ (others include Mammaprint™ and EndoPredict™).

Oncotype DX looks at a set of 21 genes in a sample of tissue taken from your surgery and assigns a recurrence score from 0 to 100. The score helps to determine the risk of breast cancer recurrence (in other body organs) over 10 years and the advantage of adding chemotherapy to your treatment plan after surgery.

• For postmenopausal people, a low score (0-25) for estrogen receptor-positive, lymph node-negative breast cancers indicate a lower risk of recurrence. There is a good outcome with hormonal therapy alone and adding chemotherapy does not help more.
• A high score of 26-100 implies a higher risk of recurrence. There is a better outcome with the addition of chemotherapy and hormonal therapy together. Discuss with your doctor what the benefits would be of adding chemotherapy.
• For premenopausal people, chemotherapy may also add some benefit for scores between 16-25, depending on the other cancer features (size and grade). 

To learn more about the various genomic tests, read our Advocacy Guide: Accessing Genomic Testing  in Canada.

Tip: Ask about speaking to a social worker or patient navigator at your cancer centre. Oftentimes, these individuals can help you access practical and emotional support available at your centre or in your community to help you through your diagnosis.

7. Adjuvant systemic therapy

Adjuvant therapy largely depends on the stage of your breast cancer and your risk of recurrence.

Although the idea of adjuvant therapy can feel overwhelming, it's helpful to understand its purpose: to reduce the risk of the cancer returning and spreading to other parts of the body, where it is much more difficult to treat.

Hormonal therapy

All HR positive breast cancers are eligible to receive adjuvant hormonal therapy to help further reduce the risk of your cancer coming back. You will likely be offered hormonal therapy as an adjuvant treatment option. As you may recall from “Understanding my treatment options”, hormonal therapy targets estrogen stimulation of breast cancer cells and blocks hormone receptors or decreases estrogen levels to help kill any remaining cancer cells.

When you are referred to an oncologist, they will review your options for hormonal therapy. There are several different types of hormonal therapies offered.[7]

Tamoxifen is a “selective estrogen receptor modulator (SERM)”. It works to block the estrogen receptors so that the body’s estrogen cannot stimulate them. It is a once-daily tablet and is the oldest and best-known hormonal therapy.

If you are post-menopausal (naturally or induced), an aromatase inhibitor (AI) may also be recommended to you. Before menopause, most of the estrogen is produced by the ovaries. After menopause, it is produced solely from converting a group of hormones called androgens (male hormones) into estrogen by means of the enzyme aromatase. AIs block this enzyme from working, and therefore reduce the amount of estrogen in the body. Examples include letrozole, anastrozole and exemestane. 

Timeline:

• Hormonal therapy is given for 5-10 years.

Chemotherapy

If you are at moderate or high risk of recurrence your oncologist may recommend adjuvant chemotherapy. Your Oncotype DX™ (or similar test) score as well as your stage can determine whether chemotherapy is recommended for you. Anthracycline and taxane-based chemotherapies are often used to treat early-stage breast cancer:

• Anthracyclines target and damage the DNA of cancer cells, killing them before they can divide and multiply.
• Taxanes work by stopping the cancer cells from dividing, therefore blocking the growth of the cancer and killing cancer cells.  

Timelines:

• There are many different combinations your oncologist can recommend, and all combinations have their own schedule and duration. The choice will depend on the cancer specifics and your health. 

Standards of Care:

• Hormone therapy is given for 5 years and is the standard of care for both pre- and post-menopausal individuals with HR positive breast cancer. This may be extended up to 10 years.[8]
• AIs should be included in adjuvant hormonal therapy for postmenopausal patients.[9]
• Chemotherapy regimens containing anthracycline/taxanes are optimal for adjuvant chemotherapy.[10]

Targeted therapy

Another option that may be recommended to you is a targeted therapy called a CDK4/6 inhibitor. It targets protiens inside the cancer cells (called CDK4 and CDK6) that help the cancer grow.

CDK4/6 inhibitors, such as abemaciclib and ribociclib, are taken as pills and are used along with hormone therapy to make treatment more effective in certain people at higher risk of recurrence.

Some newer treatments may not be listed on the public drug formulary for your province. This means that these drugs are not funded through the public healthcare system and would require you to seek funding elsewhere (like private insurance or a manufacturer patient support program) or pay a high out-of-pocket cost. Use our MedSearch drug database to see what drugs may treat your breast cancer. 

8. Radiation therapy

If you have chosen to have a lumpectomy, or if cancer was found in your lymph nodes, you will be referred to a radiation oncologist to consider radiation treatment. In these circumstances, radiation treatment is standard practice to help further reduce the risk of your cancer coming back nearby. If there were undetected microscopic cancer cells present in the remaining tissue or lymph nodes, radiation helps to ensure that those cells are destroyed.

Some people with higher risk of recurrence who have undergone mastectomy may be recommended for radiation therapy.

Timelines:

• A typical course of radiation therapy is 5 days a week for 1 to 6 weeks though some patients only need 5 days in total
• Typically, if your treatment plan calls for adjuvant chemotherapy, radiation will begin after your chemotherapy ends.[11]

Standards of Care:

• Radiation should begin within 1 month from when you are recovered from surgery and ready to begin adjuvant treatment.[12] Slight delays are not worrisome.

9. Follow-up

Once you are finished active treatment you will transition to routine follow-up care. This care is first provided by your oncologist and eventually transitioned to a primary care provider. For more information on what your follow-up care will look like, see Follow-up care plan in the Finished Active Treatment section.

Reconstruction

If you have not yet had breast reconstruction surgery and are interested in learning more about your options, ask to be referred to a plastic surgeon for consultation. Ask your surgeon about wait times for referral. Availability and wait times vary widely by province and even by city.

Sometimes patients complete breast surgery and are not always happy with the outcomes of their surgery. If you are unhappy with the outcome of your primary breast surgery (mastectomy/reconstruction or lumpectomy) and would like to revisit your options, ask your oncologist for a referral to a new surgeon. See our blog post on getting a second opinion here.