Chemotherapy for breast cancer

Overview

Chemotherapy for breast cancer uses drugs to target and destroy breast cancer cells. These drugs are usually injected directly into a vein through a needle or taken by mouth as pills.

Chemotherapy for breast cancer frequently is used in addition to other treatments, such as surgery, radiation or hormone therapy. Chemotherapy can be used to 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 breast cancer

After you have surgery to remove the breast cancer, your doctor may recommend chemotherapy to destroy any undetected cancer cells and 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 have a higher risk of metastasis if cancer cells are found in lymph nodes near the affected breast.

Chemotherapy before surgery for breast cancer

Chemotherapy is sometimes given before surgery (known as neoadjuvant therapy or preoperative chemotherapy) to shrink larger cancers. This may:

• Allow the surgeon the best chance of removing the cancer completely
• Enable the surgeon to remove only the cancer, rather than the entire breast
• Decrease the extent of disease in lymph nodes, allowing for less invasive lymph node surgery
• Decrease the chance the cancer will return
• Help your doctor understand how well your cancer responds to chemotherapy, 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 cancer
• High-grade breast cancers
• Cancers that have spread to the lymph nodes
• Larger breast cancers

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. Sometimes 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. 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.

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, also known as chemo brain

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 the 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 or after treatment is completed. But because the effects of chemotherapy are dangerous to the fetus, talk with your doctor about appropriate birth control options before treatment begins.

• Bone thinning. 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. Certain chemotherapy medications are associated with a higher risk of future 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 is 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 or other health care 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 hotline, support group or online community for people who have been treated for cancer.

How you prepare

Assess the potential benefit of chemotherapy

When deciding whether chemotherapy is right for you, your doctor considers:

• Cancer size and grade. Larger cancers and higher grade cancers are more likely to recur and are more likely to benefit from chemotherapy.
• Lymph node status. If your breast cancer has spread to your lymph nodes, your doctor may recommend chemotherapy.
• Age. Breast cancer that occurs at a younger age may be more aggressive than cancer that develops later in life. So doctors may recommend that younger people with breast cancer undergo chemotherapy.
• Previous treatments. If you've had chemotherapy before, your doctor considers this when developing your treatment plan.
• 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.
• Hormone receptor status. If your cancer cells have receptors for the hormones estrogen and progesterone, your doctor may recommend hormone therapy in addition to chemotherapy.
• 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.

• Genetic profile. For certain types of breast cancer such as hormone receptor positive breast cancer, your doctor may have your cancer cells tested to learn more about their genetic makeup.

  Gene expression profiling tests, such as Oncotype DX, EndoPredict and MammaPrint, may help predict the risk of recurrence and give your doctor an idea of how your cancer cells might respond to chemotherapy. If it's not clear whether you'd benefit from chemotherapy, these tests can be helpful. But they're not useful for everyone and are only used in certain situations.

• Your preferences. Talk with your doctor about your preferences for your care. These can be taken into consideration, especially when multiple options for therapy are available.

Take steps to improve your overall health

Make healthy choices before cancer treatment so you'll feel strong as your treatment begins. Continuing healthy choices during treatment may help minimize side effects.

Your doctor may recommend that you:

• 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 is safer for you.

Plan ahead for side effects

Ask your doctor what side effects you can expect during and after chemotherapy. If you know what to expect, you can prepare. For example, 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 a head covering, or talk to your doctor about measures that may prevent hair loss.

Make arrangements for help at home and at work

Most people are able to continue working and doing their usual activities during chemotherapy. Your doctor can give you an idea of 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 at home 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

Medications or supplements you're taking, including any herbal supplements, vitamins or over-the-counter drugs, 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 happens after chemotherapy.

Common drug combinations

There are many chemotherapy drugs available. Because each person is different, your doctor will tailor the type and dose of medications (regimen) — often a combination of two or three chemotherapy drugs — to your type of breast cancer and medical history.

Where chemotherapy is given

Breast cancer chemotherapy sessions can take place at your doctor's office, at an outpatient unit in a hospital or clinic, or at home.

How chemotherapy is given

Chemotherapy drugs can be given in a variety of ways, including as 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 plan events accordingly.

Following your treatment plan closely is the best way to get the most benefit from 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 to monitor for long-term side effects and check for cancer recurrence. Expect appointments every few months and then less frequently the longer you remain cancer-free.

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