Senior Consultant, Medical Oncology, BLK-Max Super Speciality Hospital, New Delhi
Part 6 of 9 in Diagnosis and Management of Breast Cancer
Treating Breast Cancer by Subtype: Surgery, Hormone Therapy, Chemotherapy and Immunotherapy
March 2, 2025
Breast cancer treatment is multifaceted at every age: local therapies (surgery and radiation), endocrine (hormone) therapy, chemotherapy, and genetic-factor-based treatment all have a role, alongside attention to fertility, premature menopause, sexual health and body image, psychosocial wellbeing, and rehabilitation after treatment.
Surgery is one part of the journey, not the first word
Surgery is often mistaken for the entirety of treatment; in reality it may not even be the first step. In many cases, chemotherapy is given first to reduce the bulk of the disease, and surgery is planned afterward based on the response. When surgery is presented to patients as curative, many assume the disease is fully gone once they have been operated on and see no need for further treatment. That isn't necessarily true, and patients need to understand from the outset that surgery is one part of a longer treatment journey, so that they accept the chemotherapy and hormonal treatment, sometimes running for a couple of years, that the actual extent of their disease requires.
Choosing treatment by receptor subtype
For hormone receptor positive, HER2 negative disease, whose growth is driven by hormones, surgery and chemotherapy are both offered, but hormone treatment is prioritised. For hormone receptor positive, HER2 positive disease, hormone therapy is combined with anti-HER2 treatment, antibodies that act specifically against the HER2 receptor. For triple-negative disease, where neither HER2 nor hormones drive growth, immunotherapy can be offered before surgery to reduce the extent of disease, continued alongside surgery at the appropriate point if the disease is early enough; in metastatic disease, surgery is no longer an option regardless of subtype.
Deciding between breast conservation and mastectomy
For early disease with a tumour under 2cm where surgery is possible, breast-conserving surgery is the standard approach. Where conservation isn't wanted, isn't possible, or the disease has spread further, complete surgery is considered instead. For tumours over 2cm, or where downstaging is a realistic possibility, induction chemotherapy, sometimes combined with immunotherapy, is used first; the response to that initial therapy then decides whether a complete or a more selective, breast-conserving surgery follows.
This article is based on a Jivo Masterclass session conducted by Dr. Sahil Bambroo, Senior Consultant, Medical Oncology, BLK-Max Super Speciality Hospital, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Sahil Bambroo taught doctors across Africa on March 2, 2025.
FROM THE LIVE Q&A
Dr. Morris Kumwama
Does an effective curative treatment for breast cancer really exist? If so, what is the therapeutic protocol, and if not, why are anti-cancer drugs used?
Dr. Sahil Bambroo
Definitive, curative treatment absolutely exists for early breast cancer: stage one and stage two patients see close to 100% results with protocols matched to the tumour's subtype, adjusted further for the patient's comorbidities and financial circumstances. For metastatic breast cancer, a cure isn't currently possible, but survival and quality of life have improved substantially compared with a few years ago. Breast cancer is the most common cancer among women, but most cancer deaths are actually from lung cancer, not breast cancer, which is part of why even stage four disease now sees meaningfully better survival than before. There is no single protocol; treatment has to be customised to the patient's age, subtype and disease status in each case.
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Frequently Asked Questions
Speaking of biopsy, from which specific region should the tissue sample be taken, and what is the sampling technique?▼
In early breast cancer, biopsy is usually a guided procedure taken directly from the lesion itself, using a simple technique: fixation of the tissue followed by histopathology, then immunohistochemistry to determine oestrogen receptor, progesterone receptor and HER2 status. If HER2 comes back equivocal on immunohistochemistry, a FISH test confirms it. In metastatic disease involving organs such as the lung, bone or liver, the biopsy is taken from whichever site is most accessible and least risky for the patient, often the liver or the lung. In patients too unwell for any other biopsy, such as those presenting with severe anaemia, a bone marrow biopsy can confirm metastatic breast cancer directly, including its subtype through immunohistochemistry on that same sample, allowing treatment to proceed with good results.
What are the causes and major signs of breast cancer?▼
The most common cause is advancing age; risk rises with it. Other contributing factors include early menarche, late menopause, never having children, having a first child after age 35, reduced breastfeeding, smoking, and alcohol consumption of any quantity. Genetic factors matter too: a first-degree relative with breast or ovarian cancer, or a positive result for high-penetrance genes such as BRCA1, BRCA2 or PTEN, raises risk. Chest radiation received for an earlier childhood lymphoma also raises the risk of a thoracic malignancy later in life.
Does an effective curative treatment for breast cancer really exist? If so, what is the therapeutic protocol, and if not, why are anti-cancer drugs used?▼
Definitive, curative treatment absolutely exists for early breast cancer: stage one and stage two patients see close to 100% results with protocols matched to the tumour's subtype, adjusted further for the patient's comorbidities and financial circumstances. For metastatic breast cancer, a cure isn't currently possible, but survival and quality of life have improved substantially compared with a few years ago. Breast cancer is the most common cancer among women, but most cancer deaths are actually from lung cancer, not breast cancer, which is part of why even stage four disease now sees meaningfully better survival than before. There is no single protocol; treatment has to be customised to the patient's age, subtype and disease status in each case.
Does every breast cancer patient need surgery first?▼
No. Chemotherapy is often given first to reduce the bulk of disease, with surgery planned afterward based on how the tumour responds, particularly for larger tumours or when downstaging could make breast conservation possible.
How does receptor subtype change breast cancer treatment?▼
Hormone receptor positive disease is treated with hormone therapy prioritised alongside surgery and chemotherapy; HER2 positive disease adds anti-HER2 antibody treatment; triple-negative disease is treated with immunotherapy, chemotherapy and surgery, since neither hormones nor HER2 drive its growth.
In This Series: Diagnosis and Management of Breast Cancer
- 1.Diagnosis and Management of Breast Cancer
- 2.Breast Cancer Warning Signs and How to Perform a Breast Self-Examination
- 3.Diagnosing a Breast Lump: Imaging, Biopsy and Why a Guided Biopsy Is Safe
- 4.Breast Cancer Types: Invasive, Non-Invasive and Receptor Subtypes
- 5.Staging Breast Cancer and What Each Stage Means for Prognosis
- 6.Treating Breast Cancer by Subtype: Surgery, Hormone Therapy, Chemotherapy and Immunotherapy
- 7.Breast Cancer in Younger Women: Rising Incidence and Genetic Risk
- 8.When Chemotherapy Can Be Avoided: Genomic Testing in Early Breast Cancer
- 9.Life After Breast Cancer: Menopause, Bone Health, Fertility and Reconstruction