- How is breast cancer treated?
- Surgery for breast cancer
- Radiation therapy for breast cancer
- Chemotherapy for breast cancer
- Hormone therapy for breast cancer
- Targeted therapy for breast cancer
- Bone-directed therapy for breast cancer
- Treatment of lobular carcinoma in situ
- Treatment of ductal carcinoma in situ
- Treatment of invasive breast cancer, by stage
- Treatment of breast cancer during pregnancy
Chemotherapy for breast cancer
Chemotherapy (chemo) is treatment with cancer-killing 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. Treatment usually lasts for several months.
When is chemotherapy used?
There are several situations in which chemo may be recommended.
After surgery (adjuvant chemotherapy): When therapy is given to patients with no evidence of cancer after surgery, it is called adjuvant therapy. Surgery is used to remove all of the cancer that can be seen, but adjuvant therapy is used to kill any cancer cells that may have been left behind or spread but can't be seen, even on imaging tests. If these cells are allowed to grow, they can establish new tumors in other places in the body. Adjuvant therapy after breast-conserving surgery or mastectomy reduces the risk of breast cancer coming back. Radiation, chemo, targeted therapy, and hormone therapy can all be used as adjuvant treatments.
Before surgery (neoadjuvant chemotherapy): Neoadjuvant therapy is like adjuvant therapy, except you get the treatments (or at least start them) before surgery instead of after. In terms of survival and the cancer coming back, there is no difference between getting chemo before or after surgery. But neoadjuvant chemo does have two benefits. First, chemo may shrink the tumor so that it can be removed with less extensive surgery. That is why neoadjuvant chemo is often used to treat cancers that are too big to be surgically removed at the time of diagnosis (called locally advanced). Also, by giving chemo before the tumor is removed, doctors can better see how the cancer responds. If the first set of drugs do not shrink the tumor, your doctor will know that other drugs are needed.
For advanced breast cancer: Chemo can also be used as the main treatment for women whose cancer has spread outside the breast and underarm area, either when it is diagnosed or after initial treatments. The length of treatment depends on whether the cancer shrinks, how much it shrinks, and how well you tolerate treatment.
How is chemotherapy given?
In most cases (especially adjuvant and neoadjuvant treatment), chemo is most effective when combinations of more than one drug are used. Many combinations are being used, 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.
The most common chemo drugs used for early breast cancer include the anthracyclines (such as doxorubicin/Adriamycin® and epirubicin/Ellence®) and the taxanes (such as paclitaxel/Taxol® and docetaxel/Taxotere®). These may be used in combination with certain other drugs, like fluorouracil (5-FU), cyclophosphamide (Cytoxan®), and carboplatin.
For cancers that are HER2 positive, the targeted drug trastuzumab (Herceptin®) is often given with one of the taxanes. Pertuzumab (Perjeta®) can also be combined with trastuzumab and docetaxel for HER2 positive cancers. (See “Targeted therapy for breast cancer” for more information about these drugs.)
Many chemo drugs are useful in treating women with advanced breast cancer, such as:
- Platinum agents (cisplatin, carboplatin)
- Vinorelbine (Navelbine®)
- Capecitabine (Xeloda®)
- Liposomal doxorubicin (Doxil®)
- Gemcitabine (Gemzar®)
- Ixabepilone (Ixempra®)
- Albumin-bound paclitaxel (nab-paclitaxel or Abraxane®)
- Eribulin (Halaven®)
Although drug combinations are often used to treat early breast cancer, advanced disease is more often treated with single chemo drugs. Still some combinations, such as carboplatin or cisplatin plus gemcitabine are commonly used to treat advanced breast cancer.
One or more drugs that target HER2 may be used with chemo for tumors that are HER2-positive (these drugs are discussed in more detail in the "Targeted therapy for breast cancer" section).
Doctors give chemo in cycles, with each period of treatment followed by a rest period to give the body time to recover from the effects of the drugs. 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 chemo schedule repeats to start the next cycle. Cycles are most often 2 or 3 weeks long, but they vary according to the specific drug or combination of drugs. Some drugs are given more often. Adjuvant and neoadjuvant chemo is often given for a total of 3 to 6 months, depending on the drugs that are used. Treatment may be longer for advanced breast cancer and is based on how well it is working and what side effects you have.
Dose-dense chemotherapy: Doctors have found that giving the cycles of certain chemo agents closer together can lower the chance that the cancer will come back and improve survival in some women. This usually means giving the same chemo that may be given every 3 weeks (such as AC → T), but giving it every 2 weeks. A drug (growth factor) to help boost the white blood cell count is given after chemo to make sure the white blood cell count returns to normal in time for the next cycle. This approach can be used for neoadjuvant and adjuvant treatment. It can lead to more problems with low blood cell counts, so it isn’t for everyone.
Possible side effects
Chemo drugs work by attacking cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, like those in the bone marrow, the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemo, which can lead to side effects. Some women have many side effects; others may only have few.
Chemo side effects 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 and nail changes
- Mouth sores
- Loss of appetite or increased appetite
- Nausea and vomiting
- Low blood cell counts
Chemo can affect the blood forming cells of the bone marrow, which can lead to:
- Increased chance of infections (from low white blood cell counts)
- Easy bruising or bleeding (from low blood platelet counts)
- Fatigue (from low red blood cell counts and other reasons)
These side effects usually last a short time and go away after treatment is finished. It's important to tell your health care team 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.
Other side effects are also possible. Some of these are more common with certain chemo drugs. Your cancer care team will tell you about the possible side effects of the specific drugs you are getting.
Menstrual changes: For younger women, changes in menstrual periods are a common side effect of chemo. Premature menopause (not having any more menstrual periods) and infertility (not being able to become pregnant) may occur and may be permanent. Some chemo drugs are more likely to cause this than others. The older a woman is when she receives chemotherapy, the more likely it is that she will become infertile or go through menopause as a result. When this happens, there is an increased risk of bone loss and osteoporosis. There are medicines that can treat or help prevent problems with bone loss.
Even if your periods have stopped while you were on chemo, you may still be able to get pregnant. Getting pregnant while receiving chemo could lead to birth defects and interfere with treatment. If you are pre-menopausal before treatment and are sexually active, it is important to discuss using birth control with your doctor. For women with hormone receptor-positive breast cancer, some types of hormonal birth control (like birth control pills) are not good idea, so it is important to talk with both your oncologist and your gynecologist (or family doctor) about what options would be best in your case. Women who have finished treatment (like chemo) can safely go on to have children, but it's not safe to get pregnant while on treatment.
If you are pregnant when you get breast cancer, you still can be treated. Certain chemo drugs can be given safely during the last 2 trimesters of pregnancy. (See “Treatment of breast cancer during pregnancy.”)
If you think you might want to have children after being treated for breast cancer, talk with your doctor before you start treatment. See Fertility and Women With Cancer for more information.
Neuropathy: Many drugs used to treat breast cancer, including the taxanes (docetaxel and paclitaxel), platinum agents (carboplatin, cisplatin), vinorelbine, erubulin, and ixabepilone, can damage nerves outside of the brain and spinal cord. This can sometimes lead to symptoms (mainly in the hands and feet) like 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 might last a long time in some women. See Peripheral Neuropathy Caused By Chemotherapy for more information.
Heart damage: Doxorubicin, epirubicin, 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 will check your heart function with a test like a MUGA or an echocardiogram before starting one of these drugs. They also carefully control the doses, watch for symptoms of heart problems, and may repeat the heart test to monitor function. If the heart function begins to decline, treatment with these drugs will be stopped. Still, in some people, heart damage takes a long time to develop. Signs might not appear until months or years after treatment stops. Heart damage from these drugs happens more often if other drugs that can cause heart damage, such as trastuzumab and other drugs that target HER2 are 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 irritate 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 can become swollen and uncomfortable or even painful. The skin may blister, leading to peeling of the skin or even open sores. There is no specific treatment, although some creams may help. These symptoms gradually get better when the drug is stopped or the dose is decreased. 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 (this is not commonly used to treat breast cancer).
Chemo brain: Another possible side effect of chemo is "chemo brain." Many women who are treated for breast cancer report a slight decrease in mental functioning. They may have some problems with concentration and memory, which may last a long time. Although many women have linked this to chemo, it also has been seen in women who did not get chemo as a part of their treatment. Still, most women function well after treatment. In studies that have found chemo brain to be a side effect of treatment, the symptoms most often go away in a few years. For more information, see Chemo Brain.
Increased risk of leukemia: Very rarely, certain chemo drugs can permanently damage the bone marrow, leading to a disease called myelodysplastic syndrome or even acute myeloid leukemia, a life-threatening cancer of white blood cells. When this happens it is usually within 10 years after treatment. In most women, the benefits of chemo in preventing breast cancer from coming back or in extending life are likely to far exceed the risk of this rare but serious complication.
Feeling unwell or tired: Many women do not feel as healthy after receiving chemo as they did before. There is often a residual feeling of body pain or achiness and a mild loss of physical functioning. These may be very subtle changes that are only revealed by closely questioning women who have undergone chemo.
Fatigue is another common (but often overlooked) problem for women who have received chemo. 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. For more information on what you can do about fatigue, read Fatigue in People with Cancer. Exercise, naps, and conserving energy may be recommended. If you have sleep problems, they can be treated. Sometimes there is depression, which may be helped by counseling and/or medicines.
Last Medical Review: 09/25/2014
Last Revised: 01/15/2016