Chemotherapy (chemo) is treatment with cancer-fighting drugs that may be given intravenously (injected into a vein) or by mouth. The drugs travel through the bloodstream to reach cancer cells in most parts of the body. Chemo is given in cycles, with each period of treatment followed by a recovery period. Chemo usually is taken over several months.
When is chemotherapy used?
There are different situations in which chemotherapy may be recommended.
Adjuvant chemotherapy: When therapy is given to patients who have no evidence of cancer after surgery, it is called adjuvant therapy. Although surgery is used to remove all of the cancer that can be seen, adjuvant therapy is used to kill any cancer cells that may have been left behind that can't be seen. Adjuvant therapy after surgery to remove breast cancer lowers the risk of breast cancer coming back.
Even in the early stages of the disease, cancer cells may break away from the primary breast tumor and spread through the bloodstream. These cells don't cause symptoms, they don't show up on imaging tests, and they can't be felt during a physical exam. But if they are allowed to grow, they can establish new tumors in other places in the body. The goal of adjuvant therapy is to kill undetected cells that have traveled from the breast. Radiation, chemo, and hormone therapy can all be used as adjuvant treatments
Neoadjuvant chemotherapy: Treatment given before surgery is called neoadjuvant therapy. Neoadjuvant therapy often uses the same chemo that is used as adjuvant therapy (only it is given before surgery instead of after). Giving these drugs before surgery seems to lower the chance that the cancer will come back and improve survival as much as giving them after surgery.
The major benefit of neoadjuvant chemo is that it can shrink large cancers so that they are more easily removed with surgery. The other advantage of neoadjuvant chemo is that doctors can see how the cancer responds to the chemo drugs. If the tumor does not shrink with the first set of drugs that are given, your doctor will know that other chemo drugs are needed.
In some cases, breast cancers are too big to be surgically removed at the time of diagnosis. These cancers are referred to as locally advanced and have to be treated with chemo to shrink them so they can be removed with surgery
Chemotherapy for advanced breast cancer: Chemotherapy can also be used as the main treatment for men whose cancer has already spread outside the breast and underarm area at the time it is diagnosed, or if it spreads after initial treatments. The length of treatment depends on whether the cancer shrinks, how much it shrinks, and how well a man tolerates treatment.
How is chemotherapy given?
In most cases of adjuvant and neoadjuvant treatment, chemotherapy is most effective when combinations of drugs are used. There are many combinations in use, and it's not clear that any single combination is clearly the best. Clinical studies continue to compare today's most effective treatments against something that may be better.
Some of the most commonly used drug combinations for adjuvant chemotherapy are:
- CMF: cyclophosphamide (Cytoxan®), methotrexate, and 5-fluorouracil (Fluorouracil, 5-FU)
- CAF (FAC): cyclophosphamide, doxorubicin (Adriamycin®), and 5-fluorouracil
- AC: doxorubicin (Adriamycin) and cyclophosphamide
- EC: epirubicin (Ellence®) and cyclophosphamide
- TAC: docetaxel (Taxotere®), doxorubicin (Adriamycin), and cyclophosphamide
- AC → T: doxorubicin (Adriamycin) and cyclophosphamide followed by paclitaxel (Taxol®) or docetaxel (Taxotere). Trastuzumab (Herceptin) may be given with the paclitaxel or docetaxel for cancers that are HER2 positive (discussed later in detail).
- A → CMF: doxorubicin (Adriamycin), followed by CMF
- CEF (FEC): cyclophosphamide, epirubicin, and 5-fluorouracil (this may be followed by docetaxel)
- TC: docetaxel (Taxotere) and cyclophosphamide
- TCH: docetaxel, carboplatin, and trastuzumab (Herceptin)
Some other chemo drugs used for treating breast cancer metastases (when it has spread) include carboplatin, cisplatin, gemcitabine (Gemzar®), mitoxantrone, vinorelbine (Navelbine®), capecitabine (Xeloda®), pegylated liposomal doxorubicin (Doxil®), ixabepilone (Ixempra®), albumin-bound paclitaxel (Abraxane®), and eribulin (Halaven™). The targeted therapy drugs trastuzumab (Herceptin) and lapatinib (Tykerb) may be used with these chemo drugs (these drugs are discussed in more detail in the "Targeted therapy" section.
Some doctors recommend that chemo for metastatic breast cancer be given one drug at a time, whereas others recommend combinations of drugs. This decision will be based on how aggressively the cancer is growing and what chemo drugs (if any) have been given before for the cancer.
Doctors give chemo in cycles, with each period of treatment followed by a rest period. Chemo begins on the first day of each cycle, but the schedule varies depending on the drugs used. For example, with some drugs, the chemo is given only on the first day of the cycle. With others, it is given every day for 14 days, or weekly for 2 weeks. Then, at the end of the cycle, the schedule of chemo repeats to start the next cycle. Cycles are most often 2 or 3 weeks long, but they vary according the specific drug or combination of drugs. Some drugs are given more often. Adjuvant chemo is often given for a total of 3 to 6 months, depending on what drugs are used. Treatment is often longer for advanced breast cancer, and is based on how well it is working and what side effects a man has.
Dose-dense chemotherapy: Doctors have found that giving the cycles of chemo closer together can lower the chance that the cancer will come back and improve survival in some patients. This usually means giving the same chemo that is normally given (such as AC → T), but giving it every 2 weeks instead of every 3 weeks. In addition, a drug (growth factor) to help boost the white blood cell count is given after the chemo to make sure the white blood cell count returns to normal in time for the next cycle. This approach can lead to more side effects and be harder to take, so it is only used to treat patients who have a higher chance of the cancer coming back after treatment.
Possible side effects of chemotherapy
Chemotherapy drugs work by attacking cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow, the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are likely to be affected by chemotherapy too, which can lead to side effects. Some men have many side effects while other men may have few.
The side effects of chemotherapy depend on the type of drugs, the amount taken, and the length of treatment. Some of the most common possible side effects include:
- Hair loss
- Mouth sores
- Loss of appetite (or increased appetitie)
- Nausea and vomiting
- Increased chance of infections (due to low white blood cell counts)
- Easy bruising or bleeding (due to low blood platelet counts)
- Fatigue (due to low red blood cell counts or other reasons)
These side effects are usually short-term and go away after treatment is finished. It's important to let your health care team know if you have any side effects, as there are often ways to lessen them. For example, drugs can be given to help prevent or reduce nausea and vomiting.
Several other side effects are also possible. Some of these are only seen with certain chemotherapy drugs. Your cancer care team will give you information about the possible side effects of the specific drugs you are getting.
Neuropathy: Several drugs used to treat breast cancer, including the taxanes (docetaxel and paclitaxel), platinum agents (carboplatin, cisplatin), vinorelbine, erubulin, and ixabepilone, can damage nerves outside the brain and spinal cord. This can sometimes lead to symptoms (mainly in the hands and feet) such as numbness, pain, burning or tingling sensations, sensitivity to cold or heat, or weakness. In most cases this goes away once treatment is stopped, but it may be long lasting in some men.
Heart damage: Adriamycin (doxorubicin), epirubicin (Ellence), and some other drugs may cause permanent heart damage (called cardiomyopathy). The risk of this occurring depends on how much of the drug is given, and is highest if the drug is used for a long time or in high doses. Doctors watch closely for this side effect. Most doctors check the patient's heart function (with a test like a MUGA or echocardiogram) before starting one of these drugs. They also carefully control the doses and watch for symptoms of heart problems, and may repeat the heart test to monitor heart function during treatment. If the heart function begins to decline, treatment with these drugs is stopped. In some patients, heart damage takes a long time to develop. They may not show signs of poor heart function until months or years after treatment ends. Heart damage from these drugs happens more often if the targeted therapy drug trastuzumab is used as well, so doctors are more cautious when these drugs are used together.
Hand-foot syndrome: Certain chemo drugs, such as capecitabine and liposomal doxorubicin, can cause problems with irritation that affects the palms of the hands and the soles of the feet. This is called hand-foot syndrome. Early symptoms include numbness, tingling, and redness. If it gets worse, the hands and feet become swollen with discomfort or even pain. The skin may blister, leading to peeling of the skin. There is no specific treatment, but these symptoms gradually get better when the drug is stopped. The best way to prevent severe hand-foot syndrome is to tell your doctor when early symptoms come up, so that the drug dose can be changed. This syndrome can also occur when the drug 5-FU is given as an IV infusion over several days (which is not common in the treatment of breast cancer).
Chemo brain: Another possible side effect of chemotherapy is "chemo brain". Many women who get chemotherapy for breast cancer report a slight decrease in mental functioning. There may be some long-lasting problems with concentration and memory. Still, most women do function well after chemotherapy. In studies that have found chemo brain as a side effect of treatment, the symptoms most often go away within a few years. There is very little research on chemo brain in men, but there is no reason to expect any differences. For more information, see our document, Chemo Brain.
Increased risk of leukemia: Very rarely, certain chemotherapy drugs can permanently damage the bone marrow, leading to acute myeloid leukemia, a life-threatening cancer of white blood cells. When this happens it is usually within 10 years of treatment. In most men, chemotherapy's benefits of helping to prevent breast cancer from coming back or extending life are likely to far exceed the risk of this serious but rare complication.
Feeling unwell or tired: Many people do not feel as healthy after receiving chemotherapy as they did before. There is often a residual feeling of body pain or achiness and a mild loss of physical functioning. This is a very subtle change that is only revealed by closely questioning those who have had chemotherapy.
Fatigue is often another common (but often overlooked) problem for those who have had chemotherapy. This may last up to several years. It can often be helped, so it is important to let your doctor or nurse know about it. Exercise, naps, and conserving energy may be recommended. If there are problems with sleep, these can be treated. Sometimes there is depression, which may be helped by counseling and/or medicines.
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