My treatment plan

This section will outline the general treatment plan for the following personalization options:
Newly diagnosed
Any type
Triple negative

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 sub-type 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 surgeon should take no longer than 2 weeks from the date of your referral.[1]
• Surgeons 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

At your first appointment with your oncologist, you will discuss your treatment options along with the pathology results of your breast biopsy.

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.

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. 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.

If you are first referred to a medical oncologist, or if your surgeon thinks you may be a candidate for neoadjuvant therapy (systemic treatment administered before your surgery) this may indicate your stage. Ask your doctor if they know or suspect your cancer stage.

In many provinces, triple-negative breast cancer is eligible for BRCA genetic testing. See our section on genetic and genomic testing to see if you are eligible based on your province and ask your oncologist about referring you for testing.

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]

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 this, along with 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 your doctor has yet to order additional imaging, be sure to ask for a referral.

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 the 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 begin your adjuvant treatment.

Standards of Care:

• Final surgical pathology should be reported to your surgeon within 2 weeks of your operation.[4]

6. Referral to medical oncologist

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

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. Most triple-negative breast cancers are considered at high risk of recurrence regardless of stage.

Chemotherapy

If you are at a moderate or high risk of recurrence your oncologist may recommend adjuvant chemotherapy. Your triple-negative sub-type as well as your stage can determine whether this 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.

Although the idea of chemotherapy 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. 

Targeted therapy and immunotherapy

Patients who have inherited BRCA 1 or 2 mutation related cancer may be eligible to receive a targeted therapy called olaparib (Lynparza™).

If you were given the immunotherapy called pembrolizumab (Keytruda™) with your neoadjuvant therapy you will be offered pembrolizumab on its own as adjuvant treatment.

Some newer treatments, like olaparib and pembrolizumab, may not be listed on the public drug formulary for your province. This means that these drugs are not funded through the 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.

Tip: Speak with your oncologist about the benefits of receiving these treatments compared to the current standard of care. Ask how to access funding for these drugs and if there are any programs or drug access navigators at your cancer centre who can assist with the cost. This drug may also be covered by your private insurance.

Standards of Care:

• Chemotherapy regimens containing anthracycline/taxanes are optimal for adjuvant chemotherapy.[5]
• Immunotherapy is offered with preop neoadjuvant chemotherapy for stage 2 (or greater) triple-negative 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 begin your radiation treatment. In these circumstances, radiation treatment is standard practice to help further reduce the risk of your cancer coming back. If there were undetected microscopic cancer cells present in the remaining tissue or lymph nodes, radiation helps to ensure that those cells are destroyed.

Timelines:

• A typical course of radiation therapy is 5 days a week for 1 to 6 weeks.
• Typically, if your treatment plan calls for adjuvant chemotherapy, radiation will begin a few weeks after your chemotherapy ends.[6]

Standards of Care:

• Radiation should begin within 1 month from when you are ready to begin adjuvant treatment.[7]

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.

[1] Canadian Partnership Against Cancer, Pan-Canadian standards for breast cancer surgery 2019, page 19 https://s22457.pcdn.co/wp-content/uploads/2019/05/Breast-Cancer-Surgery-Standards-EN-April-2019.pdf
[2] Canadian Partnership Against Cancer, Pan-Canadian standards for breast cancer surgery 2019, page 17 https://s22457.pcdn.co/wp-content/uploads/2019/05/Breast-Cancer-Surgery-Standards-EN-April-2019.pdf
[3] Canadian Partnership Against Cancer, Pan-Canadian standards for breast cancer surgery 2019, page 17 https://s22457.pcdn.co/wp-content/uploads/2019/05/Breast-Cancer-Surgery-Standards-EN-April-2019.pdf
[4] Canadian Partnership Against Cancer, Pan-Canadian standards for breast cancer surgery 2019, page 19 https://s22457.pcdn.co/wp-content/uploads/2019/05/Breast-Cancer-Surgery-Standards-EN-April-2019.pdf
[5] Cancer Care Ontario, Optimal Systemic Therapy for Early Female Breast Cancer Summary PDF, page 11 https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/331
[6] BC Cancer, Early Invasive Breast Cancer Management Guidelines http://www.bccancer.bc.ca/books/breast/management/hepb-screening
[7] Canadian Partnership Against Cancer, Pan-Canadian standards for breast cancer surgery 2019, page 20 https://s22457.pcdn.co/wp-content/uploads/2019/05/Breast-Cancer-Surgery-Standards-EN-April-2019.pdf