Treatment Options

Treatment Process

Different breast cancers start, progress and respond to treatments in different ways. At Fred Hutchinson Cancer Center, we choose, combine and schedule your treatments based on what works for your situation. Your care team will make sure you understand each type of treatment and all of your choices.


Breast surgery is very personal, and we want to help you make decisions you feel comfortable with. We will take the time to talk with you about your options, what to expect and any questions you have.

You may be able to have surgery to remove your cancer and keep your healthy breast tissue (lumpectomy), or you may need surgery to remove the entire breast, including the cancer (mastectomy). This will depend mainly on the size of the cancer, where it is and if you have one tumor or several tumors in the breast.

If you have metastatic disease, meaning the cancer has spread to other places in your body, your cancer cannot be fully removed by surgery. So your care team will probably not recommend this form of treatment. However, we may suggest surgery to help with symptoms.

UW Medicine breast surgeons do surgery for Fred Hutch patients at UW Medical Center – Montlake and UW Medical Center – Northwest. All of our surgeons are fellowship-trained in breast surgery/surgical oncology, which means that they are physicians who have done extra training to specialize in cancer surgery.

Your first step will be to meet with your breast surgeon. They will carefully look at your imaging, biopsy results and health needs. They will tell you about your surgery options and explain what we recommend for you and why.

For patients who want it, our breast reconstructive surgeons, who are also from UW Medicine, offer many options. These include same-day reconstruction, which means that reconstruction can be done at the same time as the cancer is removed. Some people decide they do not want reconstruction (also known as “going flat” or aesthetic flat closure). We support whatever you choose.

Our team at the Fred Hutch Breast Health Clinic specializes in helping you prepare for surgery and recover afterward. We are here to understand your needs and help you heal.

Guide to Your Breast Surgery


If a lumpectomy is not an option for you, you might have a mastectomy. Also, some patients who could have a lumpectomy choose to have a mastectomy instead. A mastectomy is when all breast tissue is removed. 

You might need a mastectomy if:

  • You have certain types of cancer, like inflammatory breast cancer.
  • Your cancer has advanced and is large compared to your breast size.
  • You already had a lumpectomy and radiation of your breast.

There are many ways to do the surgery. Your surgeon will talk with you about the options, what you prefer and what we recommend for you. Whatever you choose, we will take care to remove your cancer and still get you the best cosmetic results. 

Non-Skin-Sparing Mastectomy

This means your surgeon will remove all your breast tissue. This is also called a total mastectomy. This type of mastectomy provides an aesthetic flat closure. They also remove your nipple and the first lymph nodes where your cancer might have spread (sentinel nodes). 

You might have a total mastectomy if you do not want reconstruction the same day or if you cannot have it the same day for health reasons. 

Skin-Sparing Mastectomy

For this option, your cancer surgeon will make an incision (cut) around your nipple and areola (the darker skin around your nipple). They will remove the nipple and areola. They will also remove your breast tissue through this small opening. During the same operation, your reconstructive surgeon will use the small opening to reconstruct the breast. They will put in tissue from your abdomen, or they will put in a tissue expander (a temporary inflatable implant that makes space for a future implant). 

This may be right for you if your cancer does not involve your skin and you want breast reconstruction right away.

Nipple-Sparing Mastectomy

This surgery involves making an incision (cut) under the fold of your breast or a vertical incision below the nipple. Your nipple and areola will stay intact. This is an option for many patients with cancer that does not involve the nipple or areola. Like a skin-sparing mastectomy, a nipple-sparing mastectomy is combined with immediate breast reconstruction.

This type of surgery is also an option if you are having a preventive mastectomy. Some people choose this because they have genetic changes or a family history that raises their breast cancer risk. 


The goal of a lumpectomy is to remove all your tumor while leaving as much healthy breast tissue as possible.

If your tumor is larger compared to your breast but you do not need a mastectomy, you may have another option. It is called oncoplastic surgery. In this approach, a breast surgeon takes out the cancer, and in the same operation, a reconstructive surgeon reshapes the breast. Sometimes they reshape the other breast too, reducing or lifting it to even out the breasts.

Sometimes, cancer does not make a lump that surgeons can feel. In this case, they need help to locate and remove exactly the right tissue. At Fred Hutch, we have two methods to choose from:

  • SAVI SCOUT® surgical guidance — Before your surgery, a breast radiologist will use ultrasound or mammogram to see where your tumor is. They will put a tiny radar-reflecting chip (SAVI SCOUT®) into the tumor through a needle. During surgery, your surgeon will scan your breast with a small wand that sends out a radar signal. The signal bounces back from the chip, showing your surgeon which tissue to remove.
  • Wire localization — On the morning of your surgery, a breast radiologist will use mammography or ultrasound to see where your cancer is. They will insert a thin guide wire into your breast to mark the cancer. During surgery, the wire will show your surgeon which tissue to remove.

Sentinel Lymph Node Biopsy

The sentinel lymph nodes are the first lymph nodes in the armpit that breast cancer would spread to. Typically, surgeons remove these nodes for testing to check if breast cancer has spread there. 

The fewer lymph nodes that are removed, the lower your risk of side effects. (Side effects can include nerve problems or lymphedema, which means swelling in the arm.) This is why we do sentinel lymph node biopsy whenever possible rather than automatically removing more nodes. 

If the sentinel lymph nodes are cancer-free, you do not need to have any more taken out. If the sentinel lymph nodes have cancer, you may or may not need to have more taken out.


Lymphedema is a type of swelling that can happen after surgery or radiation therapy that affects lymph flow. Our breast and reconstructive surgeons offer advanced ways to prevent or treat this condition. Preventive techniques include axillary reverse mapping (ARM) and microsurgery to restore lymph flow (known as LYMPHA), which is done at the same time as lymph nodes are removed. We also offer surgery to treat lymphedema after it starts, such as lymphovenous bypass (also called lymphaticovenular anastomosis, or LVA) and microsurgical transfer of lymph nodes to the affected area (vascularized lymph node transfer, or VLNT). At Fred Hutch, we also have physical therapists who know how to prevent, detect and treat lymphedema.

Breast Reconstruction

The surgeon will go over a range of options with you and explain the timeline for reconstruction so you have all the information to make a decision that meets your goals.

Typically, this visit about reconstruction will happen after your cancer care team makes your treatment plan. This gives you a chance to think about the plan and then decide the next step. We will schedule your reconstruction visit to meet your needs.

It is normal for your first consultation to be just the start. Patients often have more than one visit with their surgeon to talk about and think through all their choices.

Our plastic surgeons are all UW Medicine physicians. They are highly skilled in both ways to restore your breast — with either implants or natural tissue. Implants use synthetic materials (like saline or silicone) to reconstruct the breast. Natural-tissue methods restore your breast using tissue from your own body.

Based on your needs and wishes, we offer reconstruction on the same day as your cancer surgery (while you are still under anesthesia) or later, after you finish cancer treatment. We use many advanced techniques to get the best outcomes. This includes complex options for people with different body types or health concerns and people who want breast reduction.

If you decide not to have reconstruction (also known as “going flat” or aesthetic flat closure), we support you in making the choice that is right for you.

Learn more about Reconstructive Surgery

Oncoplastic Surgery

If you are having a lumpectomy, your surgeons may be able to remove your cancer and also reshape one or both breasts.

One option is a breast reduction or breast lift, done at the same time as your lumpectomy, to adjust your remaining breast tissue and give you a natural breast shape and symmetry. Another option is using tissue from the side of your chest wall to fill the space left by the lumpectomy (lateral intercostal artery perforator, or LICAP, flap). This is also known as volume-replacement surgery.


A saline or silicone implant is another option. Your surgeon can explain the differences and show you samples during a consultation. 

To make room for an implant, most patients need a tissue expander first. This is a balloon-like device. It goes under your skin and is slowly filled with saline over several weeks to months, which stretches your skin (and, if needed, your chest muscle). It can be put in the same day as your mastectomy or weeks, months or years later. When the skin and muscle has stretched enough, your surgeon will remove the expander and put in your implant.

Natural Tissue

After mastectomy, many patients have their breast restored using skin and fat from their own body. The abdomen is the most natural match and is also the most common area to have extra tissue. The name for this method is deep inferior epigastric perforator (DIEP) flap. It is also called tummy-tuck reconstruction. 

There are other options, too. We can use tissue from your upper buttock (superior gluteal artery perforator, or SGAP, flap), your inner thigh (transverse upper gracilis, or TUG, flap), or your back (latissimus flap).

Tissue reconstruction may involve using a tissue expander, like for implants, or it may be done later without needing an expander. 

Wearing a Prothesis or "Going Flat" or Aesthetic Flat Closure

Keep in mind that many people choose not to have reconstructive surgery. Instead, some people decide to wear a breast form, or breast prosthesis. Others decide to “go flat” and get used to their new chest. This is a personal choice, and only you will know what is right for you. We support whatever you decide.

If you are interested, the American Cancer Society has resources about breast prosthesesShine, Fred Hutch’s retail store in South Lake Union, has breast prostheses and can do mastectomy fittings (to fit you for a prosthesis and related garments). 

Radiation Therapy

Radiation therapy uses high-energy rays to kill cancer cells. Often, it is done to clear cancer cells that may be left behind in your breast, chest wall or nearby lymph nodes after surgery. A radiation oncologist decides on the type, dose and schedule of your treatment.

Your Fred Hutch radiation oncology team specializes in treating breast cancer. We have extensive experience with every type, grade and stage of the disease. To give you the best outcome, we use our expertise along with state-of-the art equipment and technology to carefully plan and deliver your treatment.

Who Needs Radiation Therapy?

After a lumpectomy, we recommend that most patients have radiation therapy. This lowers the chance of cancer coming back in your breast.

After a mastectomy, some patients with higher-risk features may have radiation to reduce the chance of the cancer coming back in the chest wall or nearby lymph nodes.  

Sometimes, radiation therapy is used to relieve symptoms in people with metastatic breast cancer.

High Dose Rate (HDR) Brachytherapy

Accelerated partial breast irradiation can be done by putting a small radioactive source into the breast for a short time. It is placed through a catheter and sends out radiation from the inside out. 

This type of internal radiation therapy is called brachytherapy. It may be an option for some patients with early-stage breast cancer who have had a lumpectomy.

Treatment is done twice a day for five days. 

At Fred Hutch, we use the SAVI brachytherapy system for accelerated partial breast irradiation.

External-Beam Radiation Therapy (EBRT) with X-Ray Radiation

For breast cancer, most people who need radiation have EBRT. In this treatment, a machine aims beams of X-ray radiation (photons) at areas that might still have cancer cells. Usually, this means the whole breast, chest wall and nearby lymph nodes. Treatment is done every day, Monday through Friday, for three to seven weeks. Each appointment takes about 30 minutes.

Some patients who have a lumpectomy for early-stage cancer need radiation on only one area of the breast. This is called partial breast irradiation or accelerated partial breast irradiation. Often, these patients can have a shorter course of treatment.

At Fred Hutch, we offer both whole and partial breast radiation therapy.

To make sure your treatment is exact, we use a multi-camera system. It will read the 3D surface of your body when we plan and set up your treatment, and it will do this again each time you come for a treatment session. The system will track your position to within less than 1 millimeter. We use this surface-guidance system along with deep inspiration breath hold to reduce the amount of radiation that might otherwise reach your heart.

Proton Therapy

Proton therapy is like conventional external-beam radiation therapy (EBRT), but it uses beams of protons instead of photons. 

Using protons instead of photons helps because physicians can aim radiation at the target with less radiation exposure for nearby healthy tissues. This has to do with the way protons deliver radiation to your body. A high dose can be sent to the right area, but the radiation does not keep going to other parts of your body. The goal is to kill cancer cells while reducing the risk of side effects.

proton therapy and conventional radiation

Advantages of Proton Therapy in Locally Advanced Stage III Breast Cancer

Proton therapy (right, above) has unique features that reduce radiation exposure for normal, healthy organs. This is especially important in left-sided breast cancer, because the cancer is close to critical organs like the heart and lungs. Patients with left-sided breast cancer are more likely to develop cardiovascular diseases after getting radiation treatment than patients with right-sided breast cancer.

Our radiation oncologists will look at each case, but protons are often useful in treating:

  • Node-positive breast cancer
  • Triple-negative breast cancer
  • Lobular carcinoma
  • Early-stage breast cancer
  • Locally advanced breast cancer (stage II and III)
  • Recurrent breast cancer
  • Certain patients who have had radiation in the past

Fred Hutchinson Cancer Center – Proton Therapy Offers a Breast Cancer Clinical Trial to Qualifying Patients

The Patient-Centered Outcomes Research Institute (PCORI) provided $11.8 million to support a study that will give patients and physicians answers to many important questions about breast cancer control and survival. This is the first clinical trial designed to see how well proton beam therapy works, compared to conventional photon radiation therapy, to treat certain breast cancers and reduce radiation exposure for healthy tissue. 

Where Will You Be Seen?

We offer this treatment at our proton therapy facility on the campus of UW Medical Center – Northwest.

If you are ready to request an appointment, you can call us at 844.538.3485. Keep in mind that we will need your medical records to decide if you are a candidate for proton therapy.

Learn more about Proton Therapy


Chemotherapy uses medicines to kill fast-growing cells (like cancer cells) or to keep them from dividing (which is how cancers grow). Your breast medical oncologist prescribes your chemotherapy and other medicine-based treatments. They also set your treatment schedule. 

Chemotherapy can be given by infusion or by mouth. For an infusion, liquid medicine is put into a vein through an intravenous (IV) line. This can be a line in your arm (peripheral venous catheter) or a port in your chest (central venous catheter). Cancer nurses who are experts in infusions give you these treatments. They will also watch over you during the treatment. They will help with any medical issues that come up and will keep you comfortable.

Some types of chemotherapy are given as a pill that you take at home. 

Who Needs Chemotherapy?

If you are having surgery, your Fred Hutch care team may recommend chemotherapy, targeted therapy or both before surgery. This is done to shrink your tumor. It may be the best choice if any of these is true:

  • The tumor is too large to remove with surgery alone. 
  • You have inflammatory breast cancer or another type that is aggressive or locally advanced. (This means it involves tissue outside but near your breast, like skin or many lymph nodes.)

Shrinking the tumor might mean you can avoid a mastectomy. Instead, you might be able to have a lumpectomy.

Another reason to have chemotherapy (or targeted therapy) before surgery is to see how your cancer responds to the medicine. This may help your team plan your treatment. 

Most people start chemotherapy after they have surgery. If you have early-stage breast cancer, you will probably have four to six cycles of treatment. (Early stage means it is not outside your breast and nearby lymph nodes.) The goal is to keep your cancer from coming back. Chemotherapy may reduce the risk of cancer coming back by 30 to 50 percent.

If cancer has spread beyond your breast to distant parts of your body, physicians often recommend systemic therapies — which include chemotherapy, endocrine therapy and targeted therapies — without surgery. Systemic therapies travel throughout your body and fight cancer cells wherever they may be. The goal is to give you the longest, healthiest life. If your medicine stops working or the side effects are too difficult, you have other options. The next step is to look at switching to another medicine. 

Endocrine Therapy

Most people with breast cancer have hormone receptor-positive (HR+) disease. This means the breast cancer cells have receptors where the hormones estrogen or progesterone can attach. These hormones help the cancer cells multiply quickly. 

Endocrine therapy helps control HR+ breast cancer in two ways. One is that it reduces or blocks the body’s production of hormones. The other is that it reduces or blocks the effects of the hormones. This form of treatment is also called hormonal therapy. 

Who Needs Endocrine Therapy? 

For patients with early-stage HR+ breast cancer, endocrine therapies reduce the risk that the same cancer will come back. They may also lower the chance of getting a new breast cancer.

If HR+ breast cancer is in distant parts of your body, endocrine therapies can help you live longer. They can be effective against tumors for a long time.

Estrogen-Receptor Blockers

These medicines bind to estrogen receptors on cells in your breast tissue and keep estrogen from attaching to the cells. This stops cancer cells from being able to grow and divide. The options include medicines called SERMs or SERDs. 

  • SERMs are selective estrogen receptor modulators. Examples are tamoxifen, toremifene and raloxifene. 
  • SERDs are selective estrogen receptor degraders/downregulators. They bind to estrogen receptors and reduce the number and shape of receptors. This makes it harder for cancer to grow and divide. Fulvestrant is a common SERD.

Aromatase Inhibitors

These medicines reduce the amount of estrogen moving through your body. They are helpful in people who have gone through menopause. Options include anastrozole, letrozole and exemestane.

Ovarian Suppression

Before menopause, your physicians might recommend medicine that stops your ovaries from making estrogen. Some examples are leuprolide or goserelin. 

Targeted Therapy for Breast Cancer

Targeted therapies work in one of these ways:

  • They target a gene or protein that causes cancer growth.
  • They damage cancer cells directly.
  • They tell your immune system to attack certain cells. This is also called immunotherapy.

Sometimes, targeted therapies are a pill that you take at home. Or they can be given by infusion in repeating cycles. They can be used alone or with other treatments. Some can improve the effects of endocrine therapy and are only used along with endocrine therapy.

There are many options for both early-stage and advanced or metastatic breast cancer.

For HER2-Positive Breast Cancer   

Several therapies target breast cancer that is HER2-positive. This means the cancer cells make too much of a protein called HER2/neu. HER-targeted therapies may be given alone or with chemotherapy or another targeted therapy. They include:

  • Ado-trastuzumab emtansine 
  • Fam-trastuzumab deruxtecan 
  • Lapatinib 
  • Neratinib 
  • Pertuzumab 
  • Trastuzumab 
  • Tucatinib 

For HR-Positive Breast Cancer   

Cell-cycle inhibitors are an option for advanced or metastatic breast cancer that is HR+ and HER2-negative. HR+ means the cancer cells have places where hormones can attach. These medicines block proteins in the life cycle of cancer cells. They help stop the growth and spread of breast tumors. Examples include CDK4/6 inhibitors, such as palbociclib, ribociclib or abemaciclib. If cancer cells have changes in the gene PIK3CA, a targeted medication called alpelisib may be recommended.

Everolimus is an mTOR inhibitor. It targets a protein that allows breast cancer cells to grow out of control. Everolimus is sometimes used for patients who are past menopause with advanced cancer that is HR+ and HER2-negative. 

All of these can be used along with endocrine therapy.

For BRCA Gene Mutations 

Patients with BRCA gene changes may benefit from therapy with PARP inhibitors. These medicines help kill cancer cells by making DNA repair harder for them. Cells that cannot repair their DNA are more likely to be killed by other treatments, like chemotherapy and radiation. PARP inhibitors include olaparib and talazoparib.


A healthy immune system attacks bacteria, viruses and sometimes harmful cells, like cancer cells. It leaves harmless cells alone. Sometimes, cancer cells survive by sending false signals that make them look harmless, which tricks the immune system. 

Medicines called immune checkpoint inhibitors block these false signals. This allows your natural defenses to work better. Immune checkpoint inhibitors are now approved for some patients with triple-negative breast cancer (and many other types of solid tumors). 

Fred Hutchinson Cancer Research Center has been a leader in developing cellular immunotherapy. With this treatment, a patient’s own immune cells (lymphocytes) are genetically changed in a laboratory to attack certain proteins on cancer cells. Examples of cellular immunotherapy include chimeric antigen receptor T cells (CAR T-cell therapy) and T-cell receptor (TCR) therapy. These therapies, while promising, have not been approved for breast cancer yet. Patients may choose to join clinical trials testing these new approaches. 

Which Immunotherapy Is Right for You? 

The options for breast cancer include:

  • Atezolizumab (Tecentriq ®). This is used in people with advanced triple-negative breast cancer that makes the protein PD-L1.
  • Pembrolizumab (Keytruda®). This is used for other cancers that have a certain molecular change called microsatellite instability-high (MSI-H) or DNA mismatch repair deficiency (dMMR). Pembrolizumab is approved for:
    • Patients with advanced triple-negative breast cancer expressing PD-L1 
    • Patients with early-stage triple-negative breast cancer in combination with chemotherapy before surgery 

Learn more about Immunotherapy