Chemotherapy for Breast Cancer Treatment

What is Chemotherapy? 

Chemotherapy disrupts cancer cell division Chemotherapy uses drugs, called cytotoxic (cell-killing) drugs, to destroy cancer cells.  These drugs travel through the bloodstream to reach cancer cells almost anywhere in the body.  Chemotherapy can be useful in several situations.  Adjuvant chemotherapyis used after surgery as an additional tool to target any cancer cells that might have spread beyond the breast area.  Neo-adjuvant chemotherapy can be given before surgery to shrink a tumor.  A smaller tumor can be removed with breast conserving surgery instead of a mastectomy.  Pre-surgical use of chemotherapy can also verify whether the tumor responds to the particular drug chosen.  If the tumor does not shrink, another chemotherapy regimen will be tried.

Dr. Amy Krie – About chemotherapy
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Do You Need Chemotherapy?  

This decision will not be made until after your surgery.  At that time, your team of physicians will review all the data, including tumor size, spread to lymph nodes, and results of any genetic testing that you might have had, and calculate the risk of micrometastases in your individual case.

Julie Reiland, MD - MammaPrint helps decide if you need chemotherapy.

Then you and your physicians will discuss whether chemotherapy is the right choice for you.  The decision will depend on the size, grade, hormone receptor status, and rate of growth; your age, health, and menopausal status; and any lymph node involvement.  It will also depend on the stage of your disease, which is determined by tumor size, tumor cell invasion, node involvement, and spread to other organs.  And there will be a risk/benefit assessment, taking in consideration the possible side effects of treatment and the expected long term results.  Needless to say, it is a complex issue, and you need to participate in the decision process.

As a rule of thumb, chemotherapy is almost always given if the lymph nodes are positive.  Chemotherapy is more aggressive for invasive cancers. Chemotherapy is not used for non-invasive cancers.  Hormonal therapy may be added to chemotherapy for pre-menopausal women with hormone-receptor-positive cancers.  Both types of treatment may be used together to help lower future recurrence.

Your physicians will help you evaluate objectively the expected advantages and disadvantages of chemotherapy.  And remember, if you decide on chemotherapy, you will enjoy the benefits of one of the most powerful tools for fighting breast cancer available today.

How Chemotherapy Works

Cells go through several steps in the process of cell division.  Chemotherapy drugs interfere with various parts of this cycle, making it difficult for the cells to reproduce and for the tumor to grow.  The faster the growth, the more opportunity the chemotherapy drug has to disrupt the cycle.

Chemotherapy treatment affects both normal cells and cancer cells, but because cancer cells generally divide more rapidly, and are less effective at self-repair, they are more affected by the therapy than normal cells.  As a result, more cancer cells than normal cells are killed.  With proper choice and timing of chemotherapy, the tumor can be destroyed without excessive damage to normal tissues.

There are dozens of different chemotherapy drugs, each designed to interfere with a different part of the cell’s duplication process.  By using a combination of two or three different drugs, it is possible to affect several phases of the duplication cycle and increase the effectiveness of the treatment.

Your oncologist will recommend the best drug or combination of drugs, based on the characteristics of your tumor, degree of suspected spread, and your general health.

How Chemotherapy is Given

Most chemotherapy drugs are given by injection into a vein, that is, IV.  The injections can be in a private doctor’s office, in a hospital, or in a cancer center.  Some chemotherapy drugs are given orally, and you take them at home just as you would any other pill.

Chemotherapy is given in cycles.  The cycle may be as short as one week, or as long as four weeks.  This allows the normal cells in your body to recover between treatments.  The full course of therapy can be three to six months.  Chemotherapy typically begins as soon as possible after surgery.

A Chemo Day

Your experience with chemotherapy will vary depending on where you receive your treatments.

You may make friends with some of the other patients who come for treatment at the same time.  Bring a book or a portable music player, or practice relaxation or visualization, to make the session more pleasant.  Depending on how you feel after treatments, you may want to ask a friend to come with you—for moral support, or to drive you home.

Before you receive the scheduled dose of chemotherapy, the nurse will draw your blood, to check whether the blood-producing cells in your bone marrow have adequately recovered, and to verify whether chemotherapy is affecting your liver or other organs.  If the results of the tests are outside of normal limits, your oncologist may decide to lower the dose, or postpone the treatment.

If your results are acceptable, the nurse will take you to the treatment area and start the IV (intravenous line) through which the drug will be injected.  Some drugs are given as a rapid injection, others are dripped in slowly over a longer period—sometimes up to three hours.  Generally you won’t feel any discomfort.

Vascular Access Devices

Sometimes veins are thin, damaged, or covered by a layer of fat, making it difficult for the nurse to start an IV line.  In addition, a few chemo drugs can be very irritating to the veins, and can damage the vein at the injection site.  In such cases a port may be installed under the skin.

chemotherapy administered through a port

A port consists of a tube (catheter), attached to a dome-shaped chamber.  The device is surgically implanted under the skin, with the dome placed in the chest or arm, where it will be easily accessible for injections through a needle.  The catheter is threaded into a large vein, where rapid blood flow will dilute the drug, and keep it from damaging the lining of the vein.  The whole device will be completely covered by skin, so it will not interfere with your activities.  You can swim, bathe and exercise freely.

Ports can also be used for drawing blood, thus avoiding needle sticks of the arms during clinic visits.

Side Effects of Chemotherapy

“Will I have to have chemo?” is one of the first questions that many women ask. Many panic at the thought of having to go through chemotherapy, because they think of it as something that makes you deathly ill, or makes your hair fall out.

Much has changed in recent years.  Today there are very effective drugs that can greatly reduce the side effects of chemotherapy, making the experience much more tolerable.  Many people go through chemotherapy without significant ill effects.

But why do chemotherapy drugs cause side effects?  Here is why.  Anti-cancer drugs work by preventing cells from growing and dividing.  The effect is strongest on rapidly dividing cells such as cancer cells, but normal tissues can also be affected, particularly the gastrointestinal or GI tract, the bone marrow, hair follicles and the reproductive system.  So the most common side effects are related to these organs, and include nausea, fatigue, menopausal symptoms and hair loss.  The side effects will vary with the drug used, and with your own tolerance to it.

It’s not likely that you will ever look forward to your chemotherapy days, but a positive attitude, help from your healthcare team, and support from your friends and family can make chemotherapy a tolerable experience.

Dr. Amy Krie on hair loss
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Mouth sores and intestinal problems.

The mouth, stomach, and intestines are lined with cells that divide relatively rapidly.  Anti-cancer drugs can affect these organs, leading to mouth sores and diarrhea.  Do not take any over-the-counter medications unless specifically recommended by your health care provider.

It is a good idea to see your dentist before you begin chemotherapy to take care of any pre-existing problems such as cavities or abscesses.  Ask your dentist to advise you on how to brush and floss during chemotherapy.

Bone Marrow Suppression

Bone marrow cells, which produce the red blood cells, white blood cells, and platelets in your blood, are strongly affected by chemotherapy, and may lose some, or all, of their function.  This will lead to lower blood cell counts.

Your chemotherapy dose will be adjusted to achieve the maximum effect on the tumor cells, without dangerously impairing the ability of the bone marrow to produce blood cells in sufficient quantities.

If your bone marrow becomes excessively suppressed, your doctor may add other medications to your treatment, to stimulate your bone marrow to produce more blood cells.

Raising your white cell count will help you fight off infections.  Raising your red cell count will give your blood more capacity to carry oxygen, and will improve your strength.

Infections

When your white blood cell count is low, your body may not be able to fight off infections.  Report any signs of infection to your doctor right away.  This is especially important when your white blood cell count is low.

Sexual Side Effects

Chemotherapy often suppresses a woman’s ovarian function, reducing the amount of estrogen in the body, and causing menopause-like symptoms such as hot flashes and vaginal dryness.

Ask your doctor or nurse to recommend a suitable non-estrogen treatment to help reduce hot flashes.  Use a vaginal lubricant if necessary to manage any discomfort during intercourse.  Avoid oil-based lubricants such as petroleum jelly, wear cotton underwear and pantyhose with a ventilated cotton lining, and don’t wear tight slacks or shorts.

Doctors advise women of childbearing age to use birth control throughout their treatment, because anti-cancer drugs may cause birth defects.  If a woman is pregnant when her cancer is discovered, it may be possible to delay chemotherapy until after the baby is born, or until after the twelfth week of pregnancy, when the fetus is beyond the stage of greatest risk.

Chemotherapy may also result in infertility.  If a woman is young, and would like to have children after cancer treatment, it is now possible to harvest eggs from her ovaries, and preserve them by freezing.  After treatment, the eggs can be fertilized in vitro and implanted into the woman’s womb.

Many women find that their sexual interest declines because of the physical and emotional stresses.  Don’t be shy about discussing sexual issues with your nurse or doctor.  They can offer a wealth of advice on how to handle any difficulties you may be facing, and help improve your quality of life.

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