Chemotherapy

Last modified on October 27, 2012 at 8:17 am

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Chemotherapy treatment uses medicine to weaken and destroy cancer cells in the body, including cells at the original cancer site and any cancer cells that may have spread to another part of the body. Chemotherapy, often shortened to just "chemo," is a systemic therapy, which means it affects the whole body by going through the bloodstream. There are quite a few chemotherapy medicines. In many cases, a combination of two or more medicines will be used as chemotherapy treatment for breast cancer. Chemotherapy is used to treat:

early-stage invasive breast cancer to get rid of any cancer cells that may be left behind after surgery and to reduce the risk of the cancer coming back

advanced-stage breast cancer to destroy or damage the cancer cells as much as possible

In some cases, chemotherapy is given before surgery to shrink the cancer. In this section, you'll learn more about how chemotherapy works, chemotherapy medicines, and what to expect with chemotherapy. You also can learn about chemotherapy side effects and ways to manage them.

How Chemotherapy Works

Who Gets Chemotherapy? Chemotherapy Medicines Choosing a Chemotherapy Combination Talking to Your Doctor About Chemotherapy Chemotherapy: What to Expect Managing Chemotherapy Side Effects Dealing with Chemotherapy Fears Staying on Track with Chemotherapy

The medical experts for Chemotherapy are:

Francene M. Fleegler, M.D., medical oncologist/hematologist, University of Pennsylvania Health System, Philadelphia, PA

Jennifer Griggs, M.D., MPH, medical oncologist and breast cancer specialist, University of Michigan, Ann Arbor, MI

Blanche Reiner, RN, OCN, University of Pennsylvania Health System, Philadelphia, PA

Barbara Reville, M.S., CRNP, oncology nurse practitioner, University of Pennsylvania Health System, Philadelphia, PA

Sandra F. Schnall, M.D., medical oncologist/hematologist, Thomas Jefferson University Health System, Philadelphia, PA

Marisa C. Weiss, M.D., breast radiation oncologist, Lankenau Hospital, Main Line Health System, Philadelphia, PA

Lisa Weissmann, M.D., medical oncologist, Mount Auburn Hospital, Cambridge, MA

These experts are members of the Breastcancer.org Professional Advisory Board, which includes more than 70 medical experts in breast cancer-related fields.

How Chemotherapy Works

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Chemotherapy medicines prevent cancer cells from growing and spreading by destroying the cells or stopping them from dividing. Cancer cells tend to grow and divide very quickly with no order or control. Because they're growing so fast, sometimes cancer cells break away from the original tumor and travel to other places in the body. Chemotherapy weakens and destroys cancer cells at the original tumor site AND throughout the body. Most normal cells grow and divide in a precise, orderly way. Still, some normal cells do divide quickly, including cells in hair follicles, nails, the mouth, digestive tract, and bone marrow (bone marrow makes blood cells). Chemotherapy also can unintentionally harm these other types of rapidly dividing cells, possibly causing chemotherapy side effects. Chemotherapy is used to treat:

early-stage invasive breast cancer to get rid of any cancer cells that may be left behind after surgery and to reduce the risk of the cancer coming back

advanced-stage breast cancer to destroy or damage the cancer cells as much as possible

When treating early-stage breast cancer, it's fairly common for chemotherapy to be given after surgery, as soon as you recover. Doctors call this "adjuvant" chemotherapy because it's given in addition to surgery, which is considered the primary treatment. In some cases, chemotherapy is given before surgery to shrink the cancer so that less tissue has to be removed. When chemotherapy is given before surgery, it's called "neoadjuvant" chemotherapy. In many cases, chemotherapy medicines are given in combination, which means you get two or three different medicines at the same time. These combinations are known as

chemotherapy regimens. In early-stage breast cancer, standard chemotherapy regimens lower the risk of the cancer coming back. In advanced breast cancer, chemotherapy regimens make the cancer shrink or disappear in about 30-60% of people treated. Keep in mind that every cancer responds differently to chemotherapy.

Who Gets Chemotherapy?

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Chemotherapy is used to treat all stages of breast cancer, including cancer that has come back in the breast area and breast cancer that has spread to other parts of the body (metastatic disease). Chemotherapy treatments are tailored specifically for each person's unique situation. When deciding on which chemotherapy medicines would be best for you, you and your doctor will take into account the stage and other characteristics of the cancer, such as hormone-receptor status and HER2 status. You'll also consider your menopausal status and any other treatments you've had. Women who are pregnant can safely have chemotherapy after the first trimester. Visit the Treatment for Breast Cancer During Pregnancy page for more information.

Chemotherapy for early-stage disease

Early-stage breast cancer generally means cancer that is classified as:

stage 0 stage I stages IIA and IIB some stage III

(For more information on the specific characteristics of each cancer stage, visit the Breastcancer.org Stages of Breast Cancerpage.) Chemotherapy is used after surgery to remove the breast cancer to get rid of any cancer cells that may be left behind and to reduce the risk of the cancer coming back. In some cases, chemotherapy may be used before surgery to shrink the tumor so less tissue needs to be removed.

Each person's treatment plan will be different, but there are some general guidelines about who would benefit from chemotherapy:

Chemotherapy is almost always recommended if there is cancer in the lymph nodes, regardless of tumor size or menopausal status.

Doctors recommend more aggressive treatments for premenopausal women diagnosed with invasive breast cancer. Breast cancer in premenopausal women tends to be more aggressive, so chemotherapy is often part of the treatment plan.

Chemotherapy may be recommended for some women diagnosed with early-stage breast cancer if the cancer is hormone-receptor-negative and HER2-positive. Both of these characteristics are associated with cancer that is more aggressive.

The Oncotype DX test may help some women diagnosed with estrogen-receptorpositive breast cancer and their doctors decide if the cancer is likely to come back and if chemotherapy would offer benefits.

Chemotherapy usually is NOT recommended for non-invasive, in situ cancers such as DCIS because they have very little risk of spreading to other parts of the body.

Chemotherapy for advanced-stage/metastatic disease

Advanced-stage breast cancer generally means cancer that is classified as:

some stage III stage IV

Metastatic disease is breast cancer that has spread beyond the breast area and nearby lymph nodes to other parts of the body. Metastatic cancer is considered stage IV. Chemotherapy is used to treat advanced-stage breast cancer by destroying or damaging the cancer cells as much as possible. Because chemotherapy medicines affect the entire body, chemotherapy is commonly used to treat advanced-stage breast cancer. Research has shown that newer chemotherapy medicines, such as:

Taxol (chemical name: paclitaxel) Abraxane (chemical name: albumin-bound paclitaxel) Taxotere (chemical name: docetaxel) Adriamycin (chemical name: doxorubicin) Ellence (chemical name: epirubicin)

are helping women diagnosed with advanced-stage breast cancer live longer. Other chemotherapies used in metastatic breast cancer include Gemzar (chemical name: gemcitabine), Xeloda (chemical name: capecitabine), Navelbine (chemical name: vinorelbine), and Ixempra (chemical name: ixabepilone). Each person's treatment plan will be different, but there are some general guidelines that doctors follow when using chemotherapy to treat advanced-stage breast cancer:

If you've had chemotherapy before, your doctor may recommend using only one chemotherapy medicine at a time to treat advanced-stage disease. This way you get benefits with fewer possible side effects.

In general, most chemotherapy medicines can be used until side effects become a problem or the medicine stops being effective.

Some chemotherapy medicines seem to work better against cancer tumors when used in combination. So your doctor may recommend a combination of medicines for you because research has shown that combining treatments has contributed to a better overall prognosis for some advanced-stage cancers.

If you've had chemotherapy before and the cancer came back or didn't respond, your doctor will likely recommend a different combination of medicines. There are many chemotherapy medicines and if one medicine or combination of medicines doesn't seem to be working, there is almost always something else you can try.

If the cancer is hormone-receptor-positive, your doctor may choose to use hormonal therapy before or after initiating chemotherapy. If you have metastatic breast cancer and chemotherapy is part of your treatment plan, your doctor may use different tests to determine how well the chemotherapy is working and how you're handling the chemotherapy:

Blood cell counts Blood tumor marker tests Bone scans Chest X-rays, or X-rays of other parts of the body MRI CT (CAT) scans PET scans

Chemotherapy Medicines
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Chemotherapy medications for breast cancer include:

Abraxane (chemical name: paclitaxel) Adriamycin (chemical name: doxorubicin) carboplatin (brand name: Paraplatin) Cytoxan (chemical name: cyclophosphamide) daunorubicin (brand names: Cerubidine, DaunoXome) Doxil (chemical name: doxorubicin) Ellence (chemical name: epirubicin) fluorouracil (also called 5-fluorouracil or 5-FU; brand name: Adrucil) Gemzar (chemical name: gemcitabine) Halaven (chemical name: eribulin) Ixempra (chemical name: ixabepilone) methotrexate (brand names: Amethopterin, Mexate, Folex) Mitomycin (chemical name: mutamycin) mitoxantrone (brand name: Novantrone) Navelbine (chemical name: vinorelbine) Taxol (chemical name: paclitaxel) Taxotere (chemical name: docetaxel) thiotepa (brand name: Thioplex) vincristine (brand names: Oncovin, Vincasar PES, Vincrex) Xeloda (chemical name: capecitabine)

In many cases, chemotherapy medicines are given in combination, which means you get two or three different medicines at the same time. These combinations are known as chemotherapy regimens. In early stage breast cancer, standard chemotherapy regimens lower the risk of the cancer coming back. In advanced breast cancer, chemotherapy

regimens make the cancer shrink or disappear in about 30-60% of people treated. Keep in mind that every cancer responds differently to chemotherapy. Standard chemotherapy regimens include:

AT: Adriamycin and Taxotere AC T: Adriamycin and Cytoxan, with or without Taxol or Taxotere CMF: Cytoxan, methotrexate, and fluorouracil CEF: Cytoxan, Ellence, and fluorouracil FAC: fluorouracil, Adriamycin, and Cytoxan CAF: Cytoxan, Adriamycin, and fluorouracil (The FAC and CAF regimens use the same medicines but use different doses and frequencies)

TAC: Taxotere, Adriamycin, and Cytoxan GET: Gemzar, Ellence, and Taxol

Depending on the characteristics of the cancer, a targeted therapy medicine, such as Herceptin (chemical name: trastuzumab), may be used in combination with some chemotherapy regimens. For example, the TCH regimen includes Taxotere, Herceptin, and carboplatin. Your doctor may talk about certain groups of chemotherapy medicines:

Anthracyclines are chemically similar to an antibiotic. Anthracyclines damage the genetic material of cancer cells, which makes the cells die. Adriamycin, Ellence, and daunorubicin are anthracyclines.

Taxanes interfere with the way cancer cells divide. Taxol, Taxotere, and Abraxane are taxanes.

Most standard chemotherapy regimens include a medicine from one or both of these groups.

Choosing a Chemotherapy Combination

Last modified on December 16, 2012 at 4:29 am

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It may seem like you're facing a big alphabet soup of medicine combinations when you and your doctor start to talk about which chemotherapy regimen might be best for you. There are a number of tried-and-true chemotherapy regimens used to treat breast cancer, including:

AC: Adriamycin and Cytoxan AT: Adriamycin and Taxotere CMF: Cytoxan, methotrexate, and fluorouracil FAC: fluorouracil, Adriamycin, and Cytoxan CAF: Cytoxan, Adriamycin, and fluorouracil (The FAC and CAF regimens use the same medicines but use different doses and frequencies)

Your doctor also may recommend using only one medicine at a time such as Adriamycin or another anthracycline, or a taxane (Taxotere, Taxol, or Abraxane). You and your doctor will consider several important factors when deciding on a chemotherapy regimen:

The characteristics of the cancer. The cancer's stage, hormone-receptor status, HER2 status, and lymph node status will influence the chemotherapy regimen your doctor recommends.

Your menopausal status and general health. Your doctor will take into account your general health and menopausal status when recommending a chemotherapy regimen. If you have heart problems, high blood pressure, or another condition for which you're being treated, this will likely affect the chemotherapy medicines that will work best for you. Chemotherapy is effective for people of all ages -- your age shouldn't stop you from being offered chemotherapy.

It's important to remember that while there are many standard chemotherapy regimens, each person's treatment plan will be unique because each cancer is unique. Doctors have developed and tested effective treatment plans of different lengths and dosages using different medicines. Most short-term chemotherapy side effects can be managed with lifestyle changes and medicines that can help reduce nausea, fatigue, and the risk of infection. If you're concerned about side effects, talk to your doctor.

After reviewing all the options, you and your doctor will decide on a chemotherapy regimen, dosage, and length of time to receive it that's right for you. Your ideal chemotherapy regimen will:

attack all the different kinds of cells in the cancer use medicines that work together (if you're getting combination therapy), without overlapping benefits or side effects

work in a way that keeps the cancer cells from figuring out how to protect themselves

balance the benefits you'll get from the medicine with any possible side effects

Talking to Your Doctor About Chemotherapy

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Talking to your doctor about chemotherapy and all the different regimens and medicines might seem overwhelming at first. Ask your doctor for written chemotherapy information that you can take home with you. Doctors often have special kits or booklets with information about chemotherapy and how it's given. Don't be afraid to ask questions. Ask for a phone number so you can call someone if you think of questions after your appointment. A doctor or oncology nurse should be available to answer questions in between appointments. If you have a question, don't hesitate to call. To help you figure out the benefits and risks of chemotherapy, you might want to ask your doctor these questions:

Why are you recommending chemotherapy? What are the chances that I'll get more benefits from chemotherapy compared to the treatments I'm already getting?

Is chemotherapy likely to make me live longer? Will chemotherapy reduce the risk of the cancer coming back (recurrence)? By how much?

(To learn more, visit the Understanding the Risk of Recurrence page.)

Which chemotherapy medicine or combination of medicines is best for me? What are the pros and cons of the regimen you're recommending for me? How will we know if the chemotherapy is working? If this chemotherapy regimen doesn't work, are there others we can try? What are my other treatment options? Are there clinical trials on chemotherapy that you think would be beneficial for me?

While there may not be perfect answers for every question, your doctor should be able to discuss the risks and benefits of a chemotherapy regimen with you and help you make the best decision for you and your unique situation.

Chemotherapy: What to Expect

Last modified on September 17, 2012 at 6:57 pm

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Even after you and your doctor have decided on a chemotherapy regimen, you may still have questions about what to expect and how chemotherapy will affect your daily routine.

Your doctor and oncology nurse can answer your questions. They will give you a lot of information before your chemotherapy starts and will be there for you as your treatment goes on. If you are receiving chemotherapy as an infusion through a thin needle in your hand or arm, an oncology nurse will be with you during the whole procedure. If the

chemotherapy is in pill form, you will take it at home. With either form of chemotherapy, you should contact your doctor or nurse by phone if you're experiencing severe side effects such as mouth sores, nausea that doesn't go away after you take the medicine, diarrhea, or fever. Most cancer doctors' offices and treatment centers have a doctor or nurse available 24 hours a day to answer questions. Make sure you know how to contact someone outside of regular office hours in case you have questions or concerns. It's important to remember that each person responds differently to chemotherapy. There are certain general reactions that most people can expect, but don't worry if your reactions -- physically or emotionally -- are different from someone else's. In this section, you can read about what to expect if you're having chemotherapy:

When Do You Get Chemotherapy? How Is Chemotherapy Given? Where Will You Go for Chemotherapy? Before You Begin Chemotherapy Getting a Chemotherapy Infusion Step by Step

Managing Chemotherapy Side Effects

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Chemotherapy destroys cancer cells because the medicines target rapidly dividing cells. But normal cells in your blood, mouth, intestinal tract, nose, nails, vagina, and hair also divide rapidly. So chemotherapy affects them, too. The healthy cells in your body can repair the damage that chemotherapy causes -- your hair will grow back and your energy levels will rise. But cancer cells can't repair themselves very well. The side effects you may have from chemotherapy depend on the regimen you're on, the amount of medicine you're getting, the length of treatment, and your general health. The side effects you have may be different from someone else who is on the same regimen.

While your body is recovering from chemotherapy, other medicines can help ease many of the side effects you may have. It's important to tell your doctor and oncology nurse about any side effects you're having. If medicines aren't controlling the side effects, your doctor or nurse can help you find something that works. Most chemotherapy side effects go away shortly after you've finished chemotherapy. Still, some side effects may take several months or longer to go away completely. When you and your doctor are deciding on a chemotherapy regimen, weighing the benefits versus the side effects is part of the process. Your doctor can give you an idea of the side effects you're likely to have. Learn more about some of the most common chemotherapy side effects by clicking on the links below:

anemia/low red blood cell counts diarrhea fatigue fertility issues hair changes infection memory loss menopause and menopausal symptoms mouth and throat sores nail changes nausea neuropathy (problems with hands and feet) taste and smell changes vaginal dryness vomiting weight changes

Chemotherapy also may cause other side effects that are less common, but more serious:

bone loss/osteoporosis

heart problems vision/eye problems

Dealing with Chemotherapy Fears

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It's perfectly normal to be anxious about chemotherapy, especially if you've never had it before. "Chemotherapy and other breast cancer treatments make the disease real," says Dr. Mitch Golant, a health psychologist and senior vice president of research and training for The Wellness Community. "Before you start treatment, you may not have any symptoms and feel fine. So you may worry about whether you've made the right treatment decision -- whether the benefits of treatment outweigh the side effects. For people who have more severe side effects from chemotherapy, these worries may be greater." To help manage any chemotherapy fears you may have, Dr. Golant recommends first figuring out what your fears are: Are you afraid of chemotherapy side effects such as pain, fatigue, or nausea? Are you afraid of losing your hair or other changes to your appearance? Once you've determined what your concerns are, then you can talk about your specific fears with your doctors, your nurse, or a counselor who specializes in helping cancer patients. A support group also might be helpful. If you can't say exactly what you're afraid of -- just that the whole idea of chemotherapy makes you anxious and scared -- Dr. Golant says that finding a chemotherapy support group may help. "Support groups can make the experience of chemotherapy more normal," he explains. "These people have been through chemotherapy and have coped with it and they can probably help you cope with it, too. They can help you talk about your fears, figure out what's distressing you, and then help you develop a plan of action that you can take to your healthcare team."

Explain your fears

Once you know your fears, you can tell your doctor or nurse exactly what you're afraid of -- whether it's needles or having an IV put in, being in a hospital or clinic, or the way you'll feel while getting chemotherapy. If you can tell your health team what makes you

nervous, they can usually figure out a way to help you. For example, if you're afraid of getting an IV put in your hand or arm, your doctor can make sure you have a sedative or a local anesthetic to numb the area. "The key to the best treatment is good communication between you and your doctors -this is especially true regarding managing any fears related to chemotherapy," says Dr. Golant. "Trying do deal with fear by yourself can make your anxiety worse. Information is power, so talking to your healthcare team or a support group can empower you and help you take actions that will reduce your fear."

Complementary/holistic techniques to reduce stress

While scientific research on most complementary therapies is relatively new and the studies are small, early results show that some complementary therapies may help ease physical and emotional symptoms in some people. When combined with conventional medicine, complementary therapies may offer a more integrated approach to healing. There are several complementary/holistic techniques that may help ease fear and stress :

aromatherapy guided imagery hypnosis journaling massage meditation music therapy progressive muscle relaxation prayer support groups tai chi yoga

Visit the Breastcancer.org Complementary & Holistic Medicinesection to learn more about different ways to manage fear.

Staying on Track with Chemotherapy

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Chemotherapy works best when you get the amount of medicine for the number of cycles recommended by your doctor. It's best if chemotherapy is given on time, with no major delays. When treating early-stage breast cancer, chemotherapy usually starts as soon as you've recovered from surgery. When treating advanced-stage or metastatic breast cancer, chemotherapy can begin when your doctor recommends it. Chemotherapy usually is given in cycles -- a specific period of treatment followed by a period of recovery. The total chemotherapy regimen usually lasts between 3 and 6 months. Because chemotherapy can last up to 6 months, you might encounter challenges in sticking to your treatment plan:

Your treatment schedule may conflict with the demands of your job or family. Getting to the treatment facility also can be a challenge for some people. Both of these situations may make you miss or postpone appointments.

Common chemotherapy side effects include nausea, fatigue, and a higher risk of infections. If you're feeling bad from side effects, you may be tempted to skip appointments or interrupt treatment.

If you're taking any of your chemotherapy medicines as pills or liquid, it can be hard to remember to take the correct amount each day. This is especially true if you're taking more than one medicine.

Here are some tips to help you stick to your treatment plan:

In general, it's not a good idea to skip chemotherapy for vacations or other personal events. But you can ask the staff members at your treatment center to help you plan your treatment cycles so that any events take place when you're likely to be feeling good.

If you are working, try to schedule your chemotherapy infusion treatments for Thursday or Friday afternoons. That way you'll have all weekend to rest and manage any side effects you may have.

Remember that side effects have nothing to do with how well your treatment is working. Whether or not you have side effects, the chemotherapy is working to try to

kill cancer cells in your body. And the medicine works best when you get the full amount of the recommended regimen on schedule.

If you have any side effects, call your doctor or oncology nurse and ask for help. You're not bothering them and there is no reason for you to suffer. It's important that your doctor or nurse know about the side effects and they can prescribe medicine to help ease any problems you're having.

To help you remember to take any chemotherapy medicines in pill or liquid form, you may want to note when you take each medicine on your calendar. You can use a paper calendar or the calendar feature on your computer or in your phone. Some people program their phones or watches so an alarm reminds them to take their medicine each day.

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