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Chemotherapy



 

What is Chemotherapy?
Chemotherapy uses drugs, called cytotoxic (cell-killing) drugs, to destroy cancer cells. It is often used as additional, or adjuvant therapy, in conjunction with local treatments like surgery and radiation therapy.


Chemotherapy can also be given before surgery to shrink a tumor. This pre-treatment is called neo-adjuvant chemotherapy. Chemotherapy may also be used for treating metastatic disease—tumors that have spread to other parts of the body.

When first told that they have breast cancer, many women panic at the thought of having to go through chemotherapy, because they have heard of chemotherapy as something that makes you deathly ill, or makes your hair fall out. "Will I have to have chemo?" is one of the first questions that many women ask.

Much has changed in recent years. Today there are very effective drugs that can greatly reduce—and sometimes eliminate—the side effects of chemotherapy, making the experience much more tolerable than it was rumored to be in the past.

 


Do You Need Chemotherapy?
Do you personally need chemotherapy? This decision will not be made until after the initial surgery. At that time, your team of physicians will review all the data, including tumor size and spread to lymph nodes, and calculate your risk of having micrometastases.

The question of whether to use chemotherapy is a complex issue, and you need to participate in the decision process. Here is one way for you to evaluate the possible benefits: Chemotherapy reduces the risk of recurrence by about one third. So if the risk that your cancer has spread is high—say, 60%—chemotherapy will improve your odds by a third (20%). In other words, your risk of recurrence will go down from 60% to 40%. That's a significant improvement.

But suppose your cancer is not very aggressive, or the tumor was small, and your physician estimates that your chance of a recurrence is only 6%. Now a reduction by a third amounts to only 2%—from 6% down to 4%. That is a very small improvement, and may not be worth the side effects that you may have. 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. First, the genetic material (DNA) in the nucleus forms strands called chromosomes (see step #1 in the diagram below). Then the chromosomes divide into two sets (see step #2) and the body of the cell enlarges. Finally the cell splits into two identical cells, each with its own set of DNA (step #3.) Chemotherapy drugs interfere with various parts of this cycle, making it difficult for the cells to reproduce and repair themselves.

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. You may want to participate actively in this decision. Some drug combinations are more likely than others to put you into early menopause, or make you sterile.

The most common drugs used for breast cancer are cyclophosphamide, methotrexate, fluorouracil (5-FU), Adriamycin and the taxane drugs Taxol and Taxotere.

Drugs are often given in combination. For example, CMF—which stands for cyclophosphamide, methotrexate, and fluorouracil; AC—for Adriamycin, and cyclophosphamide; TAC—Taxotere, Adriamycin and Cytoxan; or XT—Xeloda and Taxotere. Your physician will give you the latest information on new drug developments.

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How Chemotherapy is Given
Most chemotherapy drugs are given by injection into a vein, or IV. These injections can be given in a private doctor's office, in a hospital, or in a cancer center. Some chemotherapy drugs are given orally, and you take them just as you would any other pill. Taking the drugs orally requires more attention to timing and dosing on the part of the patient.

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 takes three to six months.

 


Dose Dense Chemotherapy
In a new method called dose dense chemotherapy, drugs are given more frequently. Recent studies have shown that by keeping the doses the same, but reducing the interval between doses, it is possible to improve the outcome of the treatment in women whose cancers have spread to lymph nodes.

The decreased interval between doses may cause a decrease in red blood cell production, but this side effect can be decreased by use of medications that help stimulate bone marrow. In addition, the increased frequency translates into a shorter course.

Scientists are continuing to conduct studies to verify whether this very promising approach is equally effective in early stage cancers that have not yet spread.

Do not confuse "dose dense chemotherapy" with "bone marrow transplants" or "peripheral or stem cell harvesting." A few years ago clinicians attempted treating advanced breast cancer with extra-high doses of chemotherapy. To deal with the life-threatening damage to the bone marrow, the patient also underwent a procedure known as bone marrow transplant—her bone marrow cells where harvested, preserved by freezing, then reimplanted after chemotherapy. The procedure was complex and expensive. Unfortunately, recently completed studies showed that this procedure has no advantages over conventional treatment.

 

 


Typical IV Chemotherapy Day
Your experience with chemotherapy will vary depending on where you receive your treatments, but healthcare professionals realize that chemotherapy may be a stressful experience for you, and try to make your visit as pleasant as possible.

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 of chemo, 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. If your veins are easy to reach, this will take a few seconds, and feel like a pinprick. Then the drug will be administered. 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.

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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 over the course of treatment, can damage the vein at the injection site. In such cases a port may be installed under the skin.

Ports consist of a tube (catheter), attached to a dome-shaped part. 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.

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Side Effects of Chemotherapy

Why Side Effects?
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.


 

While it is important to be prepared for possible side effects of chemotherapy, it is equally important not to assume that you will have all, many, or even a few of them. Many people go through chemotherapy without significant ill effects.

Don't compare your treatment with that of another patient, because there are so many different varieties of breast cancer, and so many variables on which the decision is based. Also, do not be alarmed by other women's reports about side effects. Their drugs, and their ability to tolerate them, may be quite different from yours. And remember, if you don't have side effects, it does not mean that the drugs are not working.

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.

 

Nausea
Today, thanks to powerful antiemetic drugs, such as Kytril and others, nausea is much less common than in years past. There are several effective medications available that will control, if not completely eliminate, nausea. Discuss this with your healthcare professionals, and make sure that you are receiving the best anti-nausea medication for your particular needs.

In addition to medications, consider other options, such as relaxation or imagery, that have proven to be quite effective for many patients. You can find more information on this subject in Chapter 9.

Nausea can lead to loss of appetite. Since good nutrition is very important to help you fight cancer and retain strength, you should make sure that you have adequate food intake, especially proteins and fluids. Eat small frequent meals avoiding stomach-bloating carbonated liquids.

If you do experience nausea, it usually won't be until for hours or even days after the injection. It may last from a few hours to up to several days, depending on the individual person. In rare instances, the nausea can be severe. Sometimes even the fear of nausea itself is so bad that a woman becomes nauseated at the mere sight of the medication, or of the nurse administering it. This is called anticipatory nausea. Remember, effective control of nausea may make the difference between completing the full course of therapy, or quitting too early.

Despite the possible loss of appetite, many women notice an increase in weight as a result of treatment with most chemotherapy drugs. Weight gain of up to twenty pounds is not uncommon, and can be a distressing side effect. For the sake of maintaining your well being, be cautious of any weight gain.

Fatigue
Chemotherapy can make you feel tired, especially on the first day after each treatment. Adjust your schedule so that you can rest if you want. Many women find that given some flexibility they can keep a fairly normal level of activity. If you feel totally unable to function at a reasonable level, tell your oncologist about it. Your drug dose may be too high, and may need to be readjusted. In addition, your physician may recommend medications to help your body rebuild red blood cells, which may increase your energy level.

Hair Loss
One of the side effects of chemotherapy that causes women the most sadness is hair loss. How much hair you lose—some or all‹will depend on which drugs you are getting. The good news is that hair lost due to chemotherapy always grows back, sometimes thicker than it was originally.


Usually hair falls out over a period of a few weeks, starting around the third week after the first dose of chemotherapy. You may find large clumps on your pillow, or in the shower, or notice a lot of hair in your comb. Some women experience a sudden loss of hair.

Buy a wig before your hair falls out, and try to pick one that resembles your natural hair. Insurance may cover some of the cost. Ask your beautician to style your wig the way you usually wear your hair.


Look Good...Feel Better is a public service program sponsored by the Cosmetic, Toiletry, and Fragrance Association Foundation in partnership with the American Cancer Society and the National Cosmetology Association. The program helps women manage changes in their appearance resulting from cancer treatment. You will find their contact information in the Resources section.

Suppression
Bone marrow cells, which produce red blood cells, white blood cells, and platelets in your blood, are particularly affected by chemotherapy, and may lose some, or all, of their function, leading to lower blood cell counts.


Red blood cells (RBC's) transport oxygen. The normal value, measured in mg (milligrams) of hemoglobin (Hb, the oxygen carrying protein in the cell) is twelve to fourteen. A low red blood cell count, called anemia, will generally give you fatigue.

White blood cells (WBC's) help fight infection. A normal WBC count is in the 4,000-10,000 range. There are several different types of white blood cells. The most important for fighting infection are called neutrophils. Oncologists use the absolute neutrophil count (ANC) to monitor patients under treatment, and to determine whether the next dose can be given. A neutrophil count of less than '000 is called neutropenia, and makes you susceptible to colds or infections, including skin wound infections.

Platelets help the blood clot. A low platelet count, below 150,000, can predispose to bleeding. This can take the form of excessive bleeding from wounds, or slow bleeding into the stomach or intestine, which could appear as black stools.

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, even if you take extra care. Most infections come from bacteria normally found on the skin, in the intestines, and in the genital tract.

Be alert to signs that you might have an infection, such as:

• Fever over 100 degrees Fahrenheit
• Sweating and chills
• Loose bowels
• A burning feeling when you urinate
• A severe cough or sore throat
• Unusual vaginal discharge or itching
• Redness, swelling, or tenderness around a wound.

Report any signs of infection to your doctor right away. This is especially important when your white blood cell count is low. If you have a fever, don't use aspirin, acetaminophen (Tylenol), or any other medicine to bring your temperature down without first checking with your doctor.

Other Side Effects
Some of the less-frequent side effects of chemotherapy can include 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.

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

Maintaining good mouth care and using a soft toothbrush will help minimize sores. If sores do develop, you may find that frozen juices, ice cream, and watermelon can be very soothing.

Sexual Side Effects—Physical
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. To help prevent infection, 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.

Egg harvesting is a difficult procedure, and may delay chemotherapy. In addition, the hormones used in harvesting and the hormonal changes due to the pregnancy may have undesirable effects on the breast cancer. Discuss these serious issues with your physician.

Sexual Side Effects—Psychological
During cancer treatment, 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.

If you and your partner find it difficult to talk to each other about sex, or cancer, or both, you may want to seek out a counselor who can help you communicate more openly.

Oral Chemotherapy
If you are taking an oral chemotherapy drug, you need to be especially watchful about side effects since you will be taking the medication at home away from the watchful eye of your healthcare providers. If you fail to inform your physician promptly about any side effects that you might be having, the side effects may become worse to the point that you may not be able to take the drug at all. Be sure to find out what side effects to expect, and report them promptly.

Common Chemotherapy Drugs
There are dozens of drugs currently used for breast cancer treatment. Most are used in combinations of two, three, or more. Don't be confused because your doctor, nurse and pharmacist may refer to the drugs by different names. Generic name is the chemical name of the drug. Brand name is the name each manufacturer gives to their specific form of the same chemical. For example, the chemical compound called fluorouracil (its generic name) is marketed as 5-FU by one company, and as Adrucil by another. In pill form, it is known as Xeloda.

 

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