How is inflammatory breast cancer treated?

How is inflammatory breast cancer treated?-For stage III patients, inflammatory breast cancer (IBC) that has not spread outside the breast or nearby lymph nodes is stage IIIB or IIIC. The usual treatment is chemotherapy (chemo) to try to shrink the tumor, followed by surgery to remove the cancer. Radiation follows surgery. In some cases, more chemo may be given after radiation. Combining these 3 types of treatment, starting with systemic chemo that reaches cells throughout the body, followed by local therapy (with surgery and radiation) has improved survival significantly over the years.

Chemo is the use of drugs for treating cancer. The drugs can be swallowed in pill form, or they can be injected by needle into a vein or muscle. Because the drugs enter the bloodstream and circulate throughout the body to reach and destroy cancer cells wherever they are, chemo is considered systemic therapy. It treats both the main tumor as well as any cancer cells that have broken off and spread to lymph nodes or distant organs.

Using chemo before surgery is called neoadjuvant or pre-operative treatment. The use of anthracyclines (such as doxorubicin/Adriamycin® and epirubicin/Ellence®) and taxanes (such as paclitaxel/Taxol® and docetaxel/Taxotere®) as chemo drugs for IBC have been shown to improve outcomes. Most women with IBC receive one of each type in some combination (although not always together – they may receive one followed by the other). Other chemo drugs may be used as well. 

When the cancer is HER2-positive (the cancer cells have too much of a protein called HER2), the targeted therapy drug called trastuzumab (Herceptin®) is given as well. Sometimes the targeted drug pertuzumab (Perjeta) is given as well. These drugs can lead to heart problems when given with an anthracycline, so one option is to give the anthracycline first (without trastuzumab or pertuzumab), followed by treatment with a taxane and trastuzumab (with or without pertuzumab). 

If the cancer is hormone-receptor negative and HER2-negative (known as triple negative), the chemo drug carboplatin may be added to paclitaxel.

Participation in a clinical trial of IBC is also a good option because IBC is so rare and these studies can allow access to drugs not available for standard treatment. More information about clinical trials can be found in our document called Clinical Trials: What You Need To Know.

If the cancer improves with chemo, surgery is then performed (as long as the cancer has not spread). The standard operation is a modified radical mastectomy, where the entire breast and the lymph nodes under the arm are removed. Because IBC affects so much of the breast and skin, breast conserving surgery (partial mastectomy or lumpectomy) or skin-sparing mastectomy is not a treatment option. It isn’t clear that sentinel lymph node biopsy (where only one or a few nodes are removed) is reliable in IBC, so it is also not an option. 

Breast reconstruction should be delayed until after the radiation that most often follows surgery. If, after chemo and surgery, no cancer is found in the breast or in the lymph nodes, the patient is far less likely to have the cancer recur (come back later). 

If the cancer has not responded to chemo (and the breast is still very swollen and red), surgery cannot be done. Either other chemo drugs will be tried or the breast may be treated with radiation. Then if the cancer responds (the breast shrinks and stops being red), surgery may be an option. 

If breast radiation isn’t given before surgery, it is given after surgery, even if no cancer is thought to remain. This is called adjuvant radiation and lowers the chance that the cancer will come back. Radiation is usually given 5 days a week for 6 weeks, but in some cases a more intense treatment (twice a day) can be used in this disease. Depending on how much tumor was found in the breast after surgery, radiation might be delayed until further chemo is given.

Treatment after surgery and radiation often includes additional systemic treatment. This is known as adjuvant therapy and can include chemo, hormonal therapy (tamoxifen or an aromatase inhibitor, if the cancer cells contain hormone receptors), and/or trastuzumab (if the cancer is HER2-positive). 

What about for stage IV patients? Patients with metastatic disease (Stage IV) are treated with some type of systemic therapy. This may include chemo, hormonal therapy, and/or targeted therapy with a drug that targets HER2 (if the cancer is HER2-positive). This could include trastuzumab (which could be given with pertuzumab, but other targeted drugs can also be used, such as ado-trastuzumab emtansine (TDM-1, Kadcyla®).