Version July 2025
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INTRODUCTION —
Breast cancer is the most common female cancer in the United States, the second most common cause of cancer death in women (after lung cancer), and the primary cause of death in women ages 45 to 55. Finding and treating the cancer in the early stages can often lead to a cure.
Occasionally, a breast cancer will not be discovered until it is fairly large or locally advanced. The term locally advanced breast cancer (LABC) is used to describe a breast cancer that has progressed locally but has not yet spread outside the breast and local lymph nodes.
This article will cover the treatment of locally advanced breast cancer, including inflammatory breast cancer (IBC). Breast cancer is a very complex topic. An introduction to breast cancer and an overview of treatment is available elsewhere. (See "Patient education: Breast cancer guide to diagnosis and treatment (Beyond the Basics)".)
WHAT IS LOCALLY ADVANCED BREAST CANCER? —
Locally advanced breast cancer (LABC) includes:
●Large breast tumors (more than 5 centimeters in diameter)
●Cancers that involve the skin of the breast or the underlying muscles of the chest
●Cancers that involve multiple local lymph nodes (those located in the arm pit or the soft tissues above and below the collarbone)
●Inflammatory breast cancer – This is a rapidly growing type of cancer that makes the breast appear red or discolored and swollen. The skin of the breast often appears to have tiny pits and resembles an orange peel.
Although the likelihood of curing LABC is lower than it would be if the cancer were small and confined to the breast, cure is possible with aggressive treatment started as promptly as possible. For inflammatory and non-inflammatory locally advanced breast cancers, this typically includes a combination of chemotherapy, surgery, and radiation therapy.
SIGNS AND SYMPTOMS
Locally advanced breast cancer (LABC) — Most LABCs can be felt by both the person and their doctor; the cancer may also be visible.
Inflammatory breast cancer — IBC is a specific type of breast cancer that has unique symptoms. IBC often does not produce a lump that can be felt within the breast. Instead, it causes thickening and swelling of the skin of the breast, which may be reddened or discolored and warm to the touch, or may resemble the texture of an orange peel. The breast is often painful and enlarged, and appears inflamed.
DIAGNOSIS AND STAGING —
Once the diagnosis of a breast cancer is suspected, several tests should be done without delays to confirm the diagnosis. Most people with locally advanced breast cancer have lymph nodes or glands that can be felt in the axilla (arm pit) and sometimes in the area above the collarbone. Testing with a biopsy, including the skin, can be done to confirm this finding and to show what other areas are affected by the cancer.
Mammogram — A mammogram of both breasts is needed to see any changes caused by the cancer, how large the cancer is (if there is a mass), and whether the opposite breast is affected. Other imaging tests, such as breast magnetic resonance imaging (MRI), positron emission tomography (PET)-computed tomography (CT), or ultrasound are also recommended.
Biopsy of the tumor — In order to confirm the diagnosis and type of breast cancer, a biopsy is required. The biopsy technique depends upon whether a lump is present in the breast. If the physician feels a lump, the biopsy can often be performed in the office. In IBC, a skin biopsy must be performed as well.
If a person shows signs of IBC, she should be referred immediately for a biopsy to a breast center or a surgeon. Delays in establishing the diagnosis of IBC can have negative consequences.
If the abnormality is only seen on the mammogram and the breast feels normal, then a test is needed to guide where to perform the biopsy. A mammogram is often used for this purpose. An ultrasound or MRI can also be used to guide a biopsy. The radiologist finds the abnormality on the mammogram and marks its location, often with a thin wire that is inserted into the abnormal area. A surgeon then uses the wire to know which area to biopsy. This procedure is called a needle localization biopsy.
A doctor will examine the biopsy tissue with a microscope to see if there are signs of cancer. They will also perform other tests to see if the tumor is making hormone receptors (ER or PR) and a protein called HER2. These two factors are important in selecting the best treatment.
Hormone receptors — About 50 to 70 percent of breast cancers express the protein that is capable of binding and responding to the female hormone estrogen (estradiol) to grow; other breast cancers may be able to grow without the protein that binds estrogen (called estrogen receptor) being present. Estrogen-dependent breast cancer cells produce molecules called hormone receptors, which are essential for the cell to use estrogen for growth. These hormone receptors can be estrogen receptors (ER), progesterone receptors (PR), or both.
●If a breast cancer contains hormone receptors, the person is significantly more likely to benefit from treatments that lower estrogen levels or block the actions of estrogen. These treatments are referred to as endocrine or hormone therapy, and such tumors are referred to as "hormone-responsive."
●People whose tumors do not contain any hormone receptors are not given endocrine therapy.
HER2 expression — HER2 is a protein that is present on about one-third of breast tumors. Having HER2 determines if the cancer will respond to a medicine called trastuzumab. (See 'Trastuzumab (Herceptin)' below.)
TREATMENT OF LOCALLY ADVANCED BREAST CANCER —
LABC is often treated with a combination of chemotherapy, surgery, and radiation therapy.
Chemotherapy — Chemotherapy refers to medicines used to stop or slow the growth of cancer cells anywhere in the body. In most cases, chemotherapy includes a combination of two or more drugs, most often given intravenously (IV). These combinations are referred to as regimens.
Chemotherapy is not given every day but instead is given in cycles. A cycle of chemotherapy refers to the time it takes to give the chemotherapy and then allow the body to recover. A cycle of chemotherapy typically ranges from two to four weeks.
Preoperative chemotherapy — For most people with LABC, chemotherapy is recommended before surgery. Chemotherapy must always be given before surgery in IBC. Preoperative (also called neoadjuvant) chemotherapy can successfully shrink the breast tumor. In about 20 to 30 percent of cases, chemotherapy removes all traces of the cancer from the breast and lymph nodes. This is termed a complete response. If no cancer cells are seen under the microscope after surgery, then the response is called "complete pathological" response.
Shrinking a large breast tumor with chemotherapy might allow you to have less aggressive surgery. As an example, it might be possible to remove only the tumor (lumpectomy, also called breast-conserving surgery) rather than the entire breast (mastectomy). This is, however, not the case for IBC, where standard care requires a mastectomy after completion of neoadjuvant chemotherapy. (See 'Surgery and radiation therapy' below.)
Endocrine therapy — Breast cancers that produce hormone receptors are responsive to endocrine therapy. In some cases, endocrine therapy is given instead of chemotherapy as the first treatment for locally advanced breast cancer.
●Taking endocrine therapy before surgery (called neoadjuvant therapy) can successfully shrink breast cancers that are hormone-responsive. Endocrine therapy has fewer side effects than chemotherapy (and can be taken by mouth rather than IV). Thus, it might be recommended as a first-line treatment, instead of chemotherapy, for people who are older or who are not healthy enough to tolerate chemotherapy.
●For most people with hormone-responsive LABC, endocrine therapy is recommended after surgery for five or more years. When endocrine therapy is given after surgery, it is referred to as adjuvant therapy. The purpose of this treatment is to get rid of any tumor cells that remain in the body (often termed micrometastases) after surgery.
Adjuvant endocrine therapy is usually started after the entire course of chemotherapy is completed.
Trastuzumab (Herceptin) — Trastuzumab (Herceptin) is a unique drug that works differently than chemotherapy. It targets a protein called HER2, which is found on the cells of some breast cancers. About 20 percent of breast cancers express very high levels of HER2, and trastuzumab appears to work well in this situation. (See 'HER2 expression' above.)
Surgery and radiation therapy — Following chemotherapy, tests are performed to see how the tumor responded to treatment. You will have an exam and imaging studies (using mammography, breast ultrasound, or MRI or PET scans) to see how much of the cancer remains. If there are still signs of cancer, surgery may be recommended.
●A surgery to remove part of the breast (called breast-conserving surgery) is an option for many people with LABC, as long as they never had a diagnosis of IBC. (See 'Inflammatory breast cancer' above.)
●Mastectomy (total removal of the breast) is necessary if skin involvement was present (like in all cases of IBC) or if the tumor is still fixed to the underlying chest wall after chemotherapy.
After surgery, radiation therapy is always recommended for people who had breast-conserving surgery. This can significantly lower the chance that the tumor will come back in the remaining breast tissue. (See "Radiation therapy techniques for newly diagnosed, non-metastatic breast cancer".)
People who have had a mastectomy will likely receive radiation therapy to the chest wall and likely to the lymph nodes as well. This is especially true if there were involved lymph nodes or IBC. Having a combination of surgery and radiation therapy decreases the chance that the breast cancer will return in the breast or the chest wall. Radiation therapy is given every day (five days a week) for a period of six to seven weeks.
INFLAMMATORY BREAST CANCER —
The treatment of IBC is similar to that of other types of locally advanced breast cancer (LABC), but there are some differences. Treatment must include neoadjuvant chemotherapy, trastuzumab if appropriate, surgery, and radiation therapy. As with other forms of LABC, two types of chemotherapy agents (anthracyclines and a taxane) are usually used. Once the diagnosis of IBC is established, it is important to proceed rapidly to treatment, as this is considered a rapidly spreading cancer.
There are some important differences in the treatment of IBC compared with LABC. In IBC, a mastectomy is always recommended, even if the cancer responded well to neoadjuvant chemotherapy and all signs of redness, discoloration, or swelling have resolved. After mastectomy, radiation therapy to the chest wall and lymph nodes is required. Immediate reconstruction is never recommended in IBC.
WHERE TO GET MORE INFORMATION —
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Breast cancer (The Basics)
Patient education: Inflammatory breast cancer (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Breast cancer guide to diagnosis and treatment (Beyond the Basics)
Patient education: Lymphedema after cancer surgery (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Inflammatory breast cancer: Pathology and molecular pathogenesis
Inflammatory breast cancer: Clinical features and treatment
Overview of the treatment of newly diagnosed, invasive, non-metastatic breast cancer
General principles of neoadjuvant management of breast cancer
Neoadjuvant management of newly diagnosed hormone receptor-positive, HER2-negative breast cancer
Neoadjuvant therapy for patients with HER2-positive breast cancer
Radiation therapy techniques for newly diagnosed, non-metastatic breast cancer
The following organizations also provide reliable health information.
●National Cancer Institute 1-800-4-CANCER
●Cancer.net: The cancer information website of the American Society of Clinical Oncology
(http://www.cancer.net/cancer-types/breast-cancer)
●American Cancer Society 1-800-ACS-2345
●National Library of Medicine
●Susan G. Komen Breast Cancer Foundation
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