Chemotherapy for breast cancer

Overview

Chemotherapy for breast cancer uses drugs to target and destroy breast cancer cells. These drugs are usually given directly into a vein through a needle or as a pill.

Chemotherapy for breast cancer frequently is used in addition to other treatments, such as surgery, radiation or hormone therapy. Receiving chemotherapy for breast cancer may increase the chance of a cure, decrease the risk of the cancer returning, alleviate symptoms from the cancer or help people with cancer live longer with a better quality of life.

If the cancer has recurred or spread, chemotherapy may control the breast cancer to help you live longer. Or it can help ease symptoms the cancer is causing.

Chemotherapy for breast cancer also carries a risk of side effects — some temporary and mild, others more serious or permanent. Your doctor can help you decide whether chemotherapy for breast cancer is a good choice for you.

Why it's done

Chemotherapy for breast cancer may be given in the following situations:

Chemotherapy after surgery for early breast cancer

After you have surgery to remove a tumor from a breast, your doctor may recommend chemotherapy to destroy any undetected cancer cells and to reduce your risk of the cancer recurring. This is known as adjuvant chemotherapy.

Your doctor may recommend adjuvant chemotherapy if you have a high risk of the cancer recurring or spreading to other parts of your body (metastasizing), even if there is no evidence of cancer after surgery. You may be at higher risk of metastasis if cancer cells are found in lymph nodes near the breast with the tumor.

When considering adjuvant chemotherapy, ask your doctor about how much the chemotherapy will reduce your chance of the cancer coming back. Together you can weigh this decrease in risk against the side effects of the chemotherapy. Also discuss with your doctor other alternatives, such as hormone-blocking therapy, that might be effective in your situation.

Chemotherapy before surgery for early breast cancer

Chemotherapy is sometimes given before surgery (neoadjuvant therapy) to shrink larger tumors. This may:

• Allow the surgeon the best chance of removing the tumor completely
• Enable the surgeon to remove only the tumor, rather than the entire breast
• Decrease the extent of disease in lymph nodes, thus allowing for less invasive lymph node surgery
• Decrease the chance the cancer will return
• Enable evaluation of the tumor response to therapy, which helps clarify prognosis and the best chemotherapy drug choice

Neoadjuvant therapy is often used for:

• Inflammatory breast cancer
• HER2-positive breast cancer
• Triple-negative breast cancers
• High-grade tumors
• Cancers that have spread to the lymph nodes
• Larger tumors

Treatment to reduce breast cancer risk

Preventive medications (known as chemoprevention) reduce the risk of breast cancer in women with a high risk of the disease. They usually include estrogen-blocking medications, such as selective estrogen receptor modulators and aromatase inhibitors. These medications carry a risk of side effects, so doctors reserve these medications for women who have a high risk of breast cancer. Discuss the benefits and risks with your doctor.

Chemotherapy as the primary treatment for advanced breast cancer

If breast cancer has spread to other parts of your body and surgery isn't an option, chemotherapy can be used as the primary treatment. It may be used in combination with targeted therapy.

The main goal of chemotherapy for advanced breast cancer is generally to improve quality and length of life rather than to cure the disease.

Risks

Chemotherapy medications travel throughout the body. Side effects depend on the drugs you receive and your reaction to them. Side effects may get worse during the course of treatment. Most side effects are temporary and subside once treatment is finished. In some cases, chemotherapy can have long-term or permanent effects.

Short-term side effects

In the process of targeting fast-growing cancer cells, chemotherapy drugs can also damage other fast-growing healthy cells, such as those in the hair follicles, bone marrow and digestive tract.

Several chemotherapy drugs can affect nerve endings in your hands and feet, leading to numbness, pain, burning or tingling, sensitivity to cold or heat, or weakness in your extremities. These side effects often go away after treatment is finished or within a year after completing chemotherapy. In some cases, they may be long lasting.

"Chemo brain," "chemo fog" and "chemo memory" are terms used to describe controversial and little-understood short-term memory and concentration problems that may occur after chemotherapy. In most cases, these problems go away within a year of completion of the chemotherapy.

Common short-term side effects include:

• Hair loss
• Fatigue
• Loss of appetite
• Nausea and vomiting
• Constipation or diarrhea
• Mouth sores
• Skin and nail changes
• Increased risk of developing infection (due to fewer white blood cells that help fight infection)
• Nerve damage (neuropathy)
• Problems with cognitive function that affect memory and concentration

Your doctor can prescribe drugs to help reduce nausea and vomiting caused by chemotherapy. You can also talk with your doctor and chemotherapy nurse about measures you can take to minimize side effects.

If chemotherapy damages your infection-fighting blood cells, your doctor may adjust your doses or add medications that help your bone marrow to recover more quickly.

Long-term side effects

Certain chemotherapy drugs for breast cancer can cause long-term side effects, including:

• Infertility. One possible side effect that may not go away is infertility. Some anti-cancer drugs damage ovaries. This may cause menopause symptoms, such as hot flashes and vaginal dryness. Menstrual periods may become irregular or stop (amenorrhea). If ovulation ceases, pregnancy becomes impossible.

  Depending on your age, chemotherapy may induce a premature permanent menopause. Discuss with your doctor your risk of permanent menopause and its consequences.

  If you continue to menstruate, you may still be able to get pregnant, even during treatment. But because the effects of chemotherapy are dangerous to the fetus, talk with your doctor about birth control options before treatment begins.

• Osteopenia and osteoporosis. Women who experience menopause early because of chemotherapy may have a higher risk of the bone-thinning conditions osteopenia and osteoporosis. It's generally recommended that these women have periodic bone density tests and, possibly, treatments to prevent further bone loss.
• Heart damage. Chemotherapy carries a small risk of weakening the heart muscle and causing other heart problems.
• Leukemia. Rarely, chemotherapy for breast cancer can trigger a secondary cancer, such as cancer of the blood cells (leukemia), several years after the chemotherapy was completed.

Other side effects

Feelings of fear, sadness and isolation can compound the physical side effects of chemotherapy, both during and after treatment. During chemotherapy, you have regular contact with and support from oncologists and nurses. Everyone involved is working toward the same goal — completion of treatment with the best possible outcome. When it's over, you can feel as if you're alone, with no one to help you return to normal life or deal with fears of breast cancer recurrence.

Consider talking with a mental health professional who works with people who have cancer. It may also help to talk with someone who has been in the same situation. Connect with others through a cancer-survivor hotline, support group or online community.

How you prepare

Assess the potential benefit of chemotherapy

Chemotherapy for breast cancer may not work in all people. Your doctor considers a number of factors to determine whether and what kind of chemotherapy would benefit you. The higher your risk of recurrence or metastasis, the more likely chemotherapy will be of benefit. In some cases, characteristics of the breast cancer itself may suggest other more beneficial, less harsh treatments, such as endocrine therapy (hormone therapy) with estrogen-blocking medications.

Discuss your treatment goals and preferences with your doctor. Factors commonly considered include:

• Tumor size and grade. The larger the tumor and the higher the grade, the higher the chance of stray cancer cells and the more likely your doctor will recommend chemotherapy.
• Lymph node status. Breast cancer cells found in your lymph nodes during or before surgery signal a higher risk of recurrence. Your doctor may be more prone to recommend chemotherapy.
• Genetic profile. For certain types of breast cancer such as hormone receptor positive breast cancer, your doctors may do genetic testing of your tumor tissue to learn the genetic makeup of your specific breast cancer. These tests known as Oncotype DX, Prosigna and MammaPrint may help predict the risk of recurrence and how your breast cancer would respond to chemotherapy. These tests can be particularly useful in helping you and your doctor determine whether chemotherapy is necessary, or if you only need hormone-blocking treatments. These tests currently do not apply to cancers that are not hormone sensitive.
• Age. Some studies suggest that breast cancer that occurs at a young age is more aggressive than breast cancer that develops later in life. So doctors may opt for adjuvant chemotherapy when treating those diagnosed at a younger age to decrease the chances of the cancer returning.
• Previous treatments. Whether you've had chemotherapy before may affect your current treatment regimen.
• Your general health and other medical conditions. Your overall health may affect your ability to tolerate side effects of chemotherapy. Certain health problems, such as heart disease or diabetes, may affect which drugs are selected for your chemotherapy.
• Hormonal status. If your breast cancer is sensitive to the hormones estrogen and progesterone, hormone therapy with estrogen blockers may be a better option for adjuvant therapy. This therapy uses drugs such as tamoxifen, which is a pill taken daily for about five years, or aromatase inhibitors, such as anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin). These drugs may also be considered in addition to chemotherapy. Your doctor may recommend that you start taking these after you have completed your chemotherapy or radiation therapy.
• HER2 status. If your breast cancer produces too much of a growth-promoting protein known as HER2, your doctor may recommend chemotherapy and drugs that specifically target this protein. These include trastuzumab (Herceptin), pertuzumab (Perjeta), lapatinib (Tykerb) and others.
• Your preferences. When you talk with your oncologist, talk about your preferences for your care. These can be taken into consideration, especially when options for therapy are available.

Take steps to improve your overall health

Because chemotherapy can affect fast-growing healthy cells, such as your white blood cells, platelets and red blood cells, it helps to be as healthy as possible before you begin treatment, to minimize its side effects.

Your doctor may recommend that you take the following steps to optimize your overall health:

• Get plenty of rest.
• Stay active and make the time to exercise.
• Eat a balanced diet rich in fruits, vegetables and whole grains.
• Minimize stress.
• Avoid infections, such as the common cold and the flu. Talk with your doctor about recommended vaccinations, including annual flu vaccines. Also engage in behavior to reduce the risk of infection while on active chemotherapy, such as washing hands or using hand sanitizer before eating and using gloves while doing yardwork.
• See your dentist for any signs of infection in your teeth or gums.
• Undergo blood tests to check your liver and kidney function and tests to check your heart function. If problems show up, your doctor may delay your treatment or select a chemotherapy drug and dosage that are safer for you.

Plan ahead for side effects

Ask your doctor what side effects you can expect during and after chemotherapy and prepare. For instance, if your chemotherapy treatment will cause infertility, you may wish to store sperm, fertilized eggs (embryos) or eggs for future use. If your chemotherapy will cause hair loss, consider a wig or head covering or scalp cooling therapy.

Make arrangements for help at home and at work

Most chemotherapy treatments are given in an outpatient clinic. Most people are able to continue working and doing their usual activities during chemotherapy. Your doctor can give you an idea how much the chemotherapy will affect your usual activities, but it's difficult to predict just how you'll feel.

Prepare by asking for time off work or help around the house for the first few days after treatment. If you'll be in the hospital during chemotherapy treatment, arrange to take time off work, and find someone to take care of your usual responsibilities at home.

Tell your doctor about any drugs or supplements you're taking

Be sure your doctor knows about any medications or supplements you're taking, including any herbal supplements, vitamins or over-the-counter drugs. These may affect the way the chemotherapy drugs work. Your doctor may suggest alternative medications or that you not take the medications or supplements for a period before or after a chemotherapy session.

The day of treatment

Your doctor or nurse will let you know what you can and can't eat or drink on the day of your chemotherapy session. It may help to take a family member or friend with you to the treatment session for support and companionship.

What you can expect

Timing and frequency of chemotherapy sessions

Chemotherapy for breast cancer is given in cycles. The cycle for chemotherapy can vary from once a week to once every three weeks. Each treatment session is followed by a period of recovery.

Typically, if you have early-stage breast cancer, you'll undergo chemotherapy treatments for three to six months, but your doctor will adjust the timing to your circumstances. If you have advanced breast cancer, treatment may continue beyond six months.

If you have early-stage breast cancer and you are also scheduled to receive radiation therapy, it usually follows chemotherapy.

Common drug combinations

There's an array of chemotherapy drugs available. Because each person is different, doctors tailor certain types and doses of medications (regimens) — often a combination of two or three chemotherapy drugs — to the type of breast cancer and the person's medical history.

Where chemotherapy is given

Most breast cancer chemotherapy sessions take place at an outpatient unit in a hospital or clinic.

How chemotherapy is given

Chemotherapy drugs can be given in a variety of ways, including pills you take at home. Most often they're injected into a vein (IV). This can be done through:

• An IV needle and tube (catheter) in your hand or wrist.
• A catheter port implanted in your chest before beginning chemotherapy. This port stays in place for the duration of your chemotherapy treatment and eliminates the need to find a suitable vein at each treatment session.

A typical chemotherapy session

Not all chemotherapy sessions are alike, but a session might follow this order:

• You have a blood sample drawn for a blood count and other blood tests.
• You meet with your doctor to review your blood test results and assess your overall health.
• Your doctor orders the chemotherapy.
• You meet with the member of your health care team who's administering your chemotherapy.
• You undergo a brief physical exam to check your temperature, pulse and blood pressure.
• You have the IV catheter inserted.
• You receive medications to prevent side effects such as nausea, anxiety or inflammation.
• You receive the chemotherapy drugs. This may take up to several hours.

After a chemotherapy session

Following a chemotherapy session, you may:

• Have your temporary IV catheter removed.
• Have your vital signs checked.
• Review side effects with your doctor.
• Receive prescriptions for medications you can take at home to help with side effects.
• Be advised on what to eat and drink.
• Receive instructions on proper handling of bodily fluids, such as urine, stool, vomit, semen and vaginal secretions, as these may contain some of the chemotherapy drugs for the next 48 hours. This may simply involve flushing the toilet twice after use.

Some people feel fine after a chemotherapy session and can return to their schedules and activities. Others may feel side effects more quickly. You may want to arrange for someone to drive you home afterward, at least for the first few sessions, until you see how you feel.

During the course of chemotherapy

After a few sessions, you may be able to predict more accurately when you'll feel fine and when you may need to cut back on activities. Marking your calendar or keeping a journal may help you track your general response to chemotherapy sessions and help you plan events accordingly.

Following your treatment plan closely is the best way to get the most benefit from your chemotherapy. If side effects become too bothersome, discuss them with your doctor. He or she may be able to adjust the dose or type of chemotherapy medication you're receiving or prescribe other medications to help relieve some symptoms such as nausea. If the number of white cells in your blood drops, your doctor may stop your chemotherapy until your white cells return to a safe level.

Relaxation techniques such as meditation and deep breathing may help reduce stress. And exercise has been shown to help improve sleep and lessen fatigue caused by chemotherapy. Wearing wigs, hats or turbans can make hair loss less obvious.

Results

After you complete chemotherapy treatment, your doctor will schedule follow-up visits — usually every four to six months at first and then less frequently the longer you remain cancer-free. This is to monitor you for long-term side effects and to check for recurrence of the breast cancer. Make a list of questions you want to ask your doctor or nurse.

Your doctor will perform a physical exam, including a breast exam, and ask you about any new symptoms you're experiencing.

You will undergo yearly mammograms as part of your follow-up. Other tests, such as tumor marker tests, liver function tests, PET scans, CT scans, bone scans and chest X-rays, generally aren't recommended unless there is a specific need. Additional imaging tests are typically needed only when a recurrence is suspected or new symptoms or physical exam findings warrant.