Chemotherapy

Often, two or more chemotherapy medicines are given together. They work as a team to be as effective as possible against the cancer.

Chemo affects all the quickly dividing cells in your body, even the healthy ones. These can include the quickly dividing cells in the hair follicles, blood cells, skin cells, and cells in the mouth. That’s the reason for some of the side effects that often go along with treatment.

We know that being told you need chemotherapy can trigger anxiety, sadness, and concern about the possible side effects. If you’re experiencing these feelings, you’re not alone. But if chemotherapy is part of your treatment plan, your doctors can help you manage these side effects so you can maintain a good quality of life while you are in treatment. Plus, LBBC is here for you with information, support, and connection.

When is chemotherapy used?

Every person is unique, and so is every cancer situation. Whether you will receive chemotherapy depends on many factors, including:

• Your age and whether you have gone through menopause
• The size of the primary tumor
• Whether there is cancer in your lymph nodes
• Specific characteristics of the cancer cells as explained in your pathology report and sometimes by genomic testing

In early-stage breast cancer, chemotherapy can be given after breast cancer-removing surgery (known as adjuvant chemotherapy) or before surgery (neoadjuvant chemotherapy). So far, research has found these options to be equally effective at lowering the risk of a cancer recurrence and prolonging life.

If you have adjuvant chemotherapy, it will usually begin about a month after your cancer-removing surgery (lumpectomy or mastectomy). This gives you time to heal.

Neoadjuvant chemo — chemotherapy before surgery — can also offer advantages:

• If your tumor is very large and difficult to remove, neoadjuvant chemotherapy can make it easier for surgeons to remove it.
• If you would prefer a lumpectomy to a mastectomy, neoadjuvant chemo can sometimes shrink the cancer enough to make that possible.
• Chemotherapy before surgery also allows your doctors to understand how the cancer is responding to treatment. If one chemotherapy medicine doesn’t shrink the cancer, your doctor will have that information — and can make an informed decision about which medicine to use next.

In metastatic breast cancer, chemotherapy is used differently. While chemotherapy drugs are often used in combination for early-stage breast cancer, in many cases, only one chemotherapy medicine is used at a time to treat metastatic breast cancer. And when metastatic cancer is diagnosed, chemotherapy is often not the kind of treatment given. Instead, it’s given if other treatments, such as hormonal therapy and targeted therapy, stop working against the cancer.

How is chemotherapy given?

Chemotherapy can be given in a few different ways:

• Intravenously (IV) by infusion into a vein
• As an injection (shot) into a muscle
• Orally, as a pill

Often, chemotherapy is most effective when two or more chemotherapy medicines are given together. Intravenous chemotherapy is given in cycles, usually with a day of treatment followed by a period of “off” days. The exact schedule varies depending on the medicines given. Most breast cancer chemotherapy regimens are given every 2 or 3 weeks, though they are sometimes given weekly.

The length of chemotherapy treatment is different for early-stage and metastatic breast cancer:

• For early-stage breast cancer, a full course of chemotherapy for breast cancer usually takes from 3 to 6 months.
• For metastatic breast cancer, how long chemotherapy treatments continue depends on how well it’s working to control the cancer, and whether the side effects are manageable. Your care team may recommend imaging tests, such as CT or PET scans, every few months to see how the cancer is responding to chemotherapy.

Studies have shown that giving cycles of some chemotherapies closer together in time — such as every 2 weeks, instead of every 3 — can be more effective against cancer for some people. This is called dose-dense chemotherapy. However, this plan can increase the chances of low white blood cell counts (neutropenia) and infection. Therefore, it’s not recommended for everyone. If white blood cell counts drop, growth factors such as filgrastim (Neupogen) or pegfilgrastim (Neulasta) can be given to stimulate their recovery.

Common chemotherapy regimens used to treat breast cancer include:

• AC: Adriamycin and cyclophosphamide
• AC-T: doxorubicin and cyclophosphamide, followed by paclitaxel or docetaxel
• ACTH: doxorubicin and cyclophosphamide, followed by paclitaxel and trastuzumab
• CAF: Cytoxan, Adriamycin, and fluorouracil
• CMF: cyclophosphamide, methotrexate, and fluorouracil
• FAC: fluorouracil, Adriamycin, and Cytoxan
• TAC: Taxotere, Adriamycin, and cyclophosphamide
• TC: Taxotere and cyclophosphamide
• TCH: Taxotere, carboplatin, and Herceptin
• TH: paclitaxel and trastuzumab
• THP: docetaxel, trastuzumab, and pertuzumab

For early-stage, triple-negative breast cancer that has a high risk of recurrence, a common regimen includes platinum-based chemotherapy, such as carboplatin (Paraplatin), plus the immunotherapy pembrolizumab (Keytruda) before surgery. Treating the cancer before surgery is called neoadjuvant therapy. After surgery, more cycles of pembrolizumab are given.

Possible side effects

Many people feel frightened of chemotherapy because of the potential for side effects. And chemo can cause many side effects, including hair loss, fatigue, nausea and vomiting, dry skin, mouth sores, weight changes, and even something called chemobrain, which is connected to problems with memory and concentration. Other side effects chemo can bring include low white blood cell counts (neutropenia) and diarrhea. It sounds like a lot, and it is. But not everyone experiences every side effect.

The truth is that while some people have a rough time with chemotherapy, others manage quite well. Many people continue to work while in treatment and report only mild discomfort. Everyone has their own individual response.

Remember that today, there are many ways to manage side effects if they do occur. For instance, very effective anti-nausea medicines are available now, and scalp cooling can reduce the risk of hair loss during treatment. Let your doctors and nurses know about your concerns before your start chemo, and keep them informed if you do need help with feeling better. Your care team will provide ongoing support and strategies to reduce or eliminate side effects.

Common side effects

Some breast cancer chemotherapy side effects are more common than others. Visit the links below to learn more about them, including ways you and your care team can manage them if they do happen.

• Anemia
• Hair loss
• Hand-foot syndrome
• Insomnia and fatigue
• Nail and skin changes
• Neutropenia
• Menopausal symptoms
• Mouth sores
• Nausea and vomiting
• Neuropathy
• Weight loss or weight gain
• Diarrhea

Less common side effects

Some chemotherapy side effects occur less frequently than the ones mentioned above. These include:

• Bone loss. Losing bone means that more of your bone cells are breaking down than are being rebuilt. If chemotherapy causes early menopause or a temporary pause in your menstrual cycle, bone loss can happen. As you’re planning your treatment, ask your care team about the risk of bone loss and ways to protect your bones. Regular weight-bearing exercise can help. You can also ask about nutrition and supplement recommendations, such as vitamin D and calcium. If you do experience bone loss, your doctors can suggest medicine to help maintain and rebuild your bones. Visit Bone loss to learn more.
• Heart damage. A few types of chemotherapy carry an increased risk of heart damage. Your doctor will help to make sure that any chemotherapy-related heart risks don’t outweigh the treatment benefits. Before you begin chemotherapy, your doctor will recommend tests, such as an echocardiogram, to make sure that your heart is in good shape and that you can safely undergo treatment. While not everyone undergoing chemotherapy develops heart problems, always let your doctor right away if you have chest pain, breathing difficulty, or any other potential symptoms of heart trouble during or after your treatments. For more information, visit Heart health.
• Loss of fertility. Chemotherapy can impact fertility because it damages follicles, the egg-containing sacs, in the ovaries. This treatment reduces the number of eggs in the ovaries and shortens the amount of time you’ll be fertile if your periods return after treatment. In some cases, chemotherapy can lead to permanent infertility. But if having children is important to you, let your doctor know, and ask for a referral to a fertility specialist. There are ways to preserve fertility and have a healthy baby even if chemotherapy is part of your treatment plan. Learn more about Breast cancer and fertility.
• Secondary cancers. In rare cases, breast cancer treatments can lead to cancer in another part of the body. For example, some types of chemotherapy raise the risk of blood cancers later on. But keep in mind that this is highly uncommon. Your doctor will work to make sure that the benefit of your chemotherapy regimen outweighs your risk of a secondary cancer. Visit Secondary cancers to learn more.

Preparing for chemotherapy

If you and your care team decide on chemotherapy as part of your treatment plan, there are many ways you can prepare:

• Talk with your care team about any side effects that you might experience with your chemotherapy regimen, and ways you can manage them.
• Ask your doctor if any foods, prescription or over-the-counter drugs, or supplements you are taking interact with the chemotherapy medicines. If there’s an interaction risk, you and your doctor can figure out any temporary adjustments that might need to be made.
• If you work, talk to your employer about your chemotherapy schedule so you can make any necessary adjustments to your work commitments.
• Your care team will likely prescribe medicines, such as anti-nausea drugs, to help with chemotherapy side effects. Be sure to take them according to the recommended schedule.
• Especially for your first chemotherapy session, try to make sure that you don’t have to get home by yourself. You don’t know exactly how you’ll feel immediately afterward, so it’s best if a loved one can help you get home or if you can take a car service.
• You may want to bring a loved one along for company during your chemotherapy sessions. If you choose to go by yourself, having movies to watch or a good book to read will help you pass the time.
• Bring a snack to your sessions in case you get hungry.

Taking care of your overall health will also help you to feel better during chemo. Do your best to stay hydrated, get enough rest, and reduce stress.

At home and at work, you may find that your energy is limited, and on days when you’re receiving chemotherapy, you may be at the hospital for most of the day. Go ahead and accept offers of help from loved ones with cooking, childcare, or household tasks if you need assistance.

Some women who’ve undergone chemotherapy for breast cancer share these suggestions:

• Make a visit in advance to the space where you’ll be receiving treatment so you can have an idea of what it’s like.
• Wear layers to prepare in case the room feels warm or cool to you.
• Bring items that give you comfort.
• Have a trusted loved one take notes when you’re talking with your doctor during treatments.

Visit Preparing for chemotherapy for more tips from women who’ve been there.

Is chemotherapy right for you?

Your doctor will recommend chemotherapy if the cancer has a significant risk of spreading outside your breast or has traveled outside the breast already. Chemotherapy may be given if you have a large tumor, cancer in the lymph nodes, or a tumor with features that make it aggressive.

But sometimes it’s unclear whether you should receive chemotherapy. Your doctor can request something called a genomic test to help you decide. Genomic tests look at groups of genes in breast cancer cells to see whether they are present, absent, or too active. These factors help to predict how likely it is that cancer will come back after treatment.

Each test has a scoring system that works to predict the likelihood of a recurrence for early-stage breast cancer (stage I, stage II, or stage III breast cancer).

Genomic tests available include:

• EndoPredict: This test analyzes 12 genes in hormone receptor-positive breast cancer cells and the cancer cells’ rate of multiplying to predict the likelihood of cancer recurrence within 10 years.
• MammaPrint: This test looks at the activity of 70 genes to predict whether the cancer poses a low or high risk of recurrence at 10 years. MammaPrint can be used to look at hormone receptor-positive breast cancer cells or hormone receptor-negative breast cancer cells.
• Oncotype DX: This test analyzes 21 genes in hormone receptor-positive breast cancer cells to determine if chemotherapy will be of benefit.
• Prosigna: This test looks at 50 genes in hormone receptor-positive breast cancer cells to determine recurrence risk and chemotherapy benefit. This test is for post-menopausal women.

Learn more about breast cancer genomic testing.

Recovery and outlook

While you are receiving chemotherapy, you’ll notice that your energy levels are higher or lower on different days. If you work, pay attention to how you feel while you’re working. Many people are able to continue working during chemotherapy, but there may be days when you need a lighter schedule.

Depending on your treatment plan, chemotherapy may be the last step in your active treatment. For others, chemotherapy may be followed by other treatments such as surgery, radiation, targeted therapy, or hormonal therapy. If you are living with metastatic breast cancer, chemotherapy may be ongoing.

Your doctor may use blood tests or MRIs to monitor your response to chemotherapy. For metastatic breast cancer, CT scans are often used to see if chemotherapy is helping to shrink areas of visible cancer.

If you were diagnosed with early-stage breast cancer, you may have follow-up appointments with your medical oncologist every few months after chemo treatment is finished. If there is still no evidence of cancer after 5 years, you can usually have these appointments once a year.

Some side effects can continue after chemotherapy ends. These can include chemobrain, fatigue, tingling or numbness in your fingers or toes (neuropathy), or weight gain. Your care team can make recommendations to help you if any of these issues persists. It’s also a good idea to ask your doctor about ways to monitor your heart health after chemo ends.

If chemo is the last step of your breast cancer treatment, ask your care team if you can create a survivorship care plan together. This is a written document that can include information about your diagnosis, treatment, ways to manage side effects that may appear months or years later, tests for monitoring your health, insurance resources, nutrition and exercise tips, and more. There are also ways to support your emotional well-being after treatment ends.

Even if chemo isn’t the last treatment you’ll have, many people find the end of chemotherapy to be a great time to look at their health habits overall — and to focus on staying healthy physically and emotionally.