Chemotherapy

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Page last modified on: October 28, 2009

Chemotherapy treatment uses medicine to weaken and destroy cancer cells in the body, including cells at the original cancer site and any cancer cells that may have spread to another part of the body. Chemotherapy, often shortened to just "chemo," is a systemic therapy, which means it affects the whole body by going through the bloodstream. There are quite a few chemotherapy medicines. In many cases, a combination of two or more medicines will be used as chemotherapy treatment for breast cancer. Chemotherapy is used to treat:

early-stage invasive breast cancer to get rid of any cancer cells that may be left behind after surgery and to reduce the risk of the cancer coming back advanced-stage breast cancer to destroy or damage the cancer cells as much as possible

In some cases, chemotherapy is given before surgery to shrink the cancer. In this section, you'll learn more about how chemotherapy works, chemotherapy medicines, and what to expect with chemotherapy. You also can learn about chemotherapy side effects and ways to manage them.

How Chemotherapy Works Who Gets Chemotherapy? Chemotherapy Medicines Choosing a Chemotherapy Combination 1

Talking to Your Doctor About Chemotherapy Chemotherapy: What to Expect Managing Chemotherapy Side Effects Dealing with Chemotherapy Fears Staying on Track with Chemotherapy

The medical experts for Chemotherapy are:

Francene M. Fleegler, M.D., medical oncologist/hematologist, University of Pennsylvania Health System, Philadelphia, PA Jennifer Griggs, M.D., MPH, medical oncologist and breast cancer specialist, University of Michigan, Ann Arbor, MI Blanche Reiner, RN, OCN, University of Pennsylvania Health System, Philadelphia, PA Barbara Reville, M.S., CRNP, oncology nurse practitioner, University of Pennsylvania Health System, Philadelphia, PA Sandra F. Schnall, M.D., medical oncologist/hematologist, Thomas Jefferson University Health System, Philadelphia, PA Marisa C. Weiss, M.D., breast radiation oncologist, Lankenau Hospital, Main Line Health System, Philadelphia, PA Lisa Weissmann, M.D., medical oncologist, Mount Auburn Hospital, Cambridge, MA

How Chemotherapy Works

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Page last modified on: August 6, 2009

Chemotherapy medicines prevent cancer cells from growing and spreading by destroying the cells or stopping them from dividing. Cancer cells tend to grow and divide very quickly with no order or control. Because they're growing so fast, sometimes cancer cells break away from the original tumor and travel to other places in the body. Chemotherapy weakens and destroys cancer cells at the original tumor site AND throughout the body. Most normal cells grow and divide in a precise, orderly way. Still, some normal cells do divide quickly, including cells in hair follicles, nails, the mouth, digestive tract, and bone marrow (bone marrow makes blood cells). Chemotherapy also can unintentionally harm these other types of rapidly dividing cells, possibly causing chemotherapy side effects. Chemotherapy is used to treat:

early-stage invasive breast cancer to get rid of any cancer cells that may be left behind after surgery and to reduce the risk of the cancer coming back advanced-stage breast cancer to destroy or damage the cancer cells as much as possible

When treating early-stage breast cancer, it's fairly common for chemotherapy to be given after surgery, as soon as you recover. Doctors call this "adjuvant" chemotherapy because it's given in addition to surgery, which is considered the primary treatment. In some cases, chemotherapy is given before surgery to shrink the cancer so that less tissue has to be removed. When chemotherapy is given before surgery, it's called "neoadjuvant" chemotherapy. In many cases, chemotherapy medicines are given in combination, which means you get two or three different medicines at the same time. These combinations are known as chemotherapy regimens. In early-stage breast cancer, standard chemotherapy regimens lower the risk of the cancer coming back. In advanced breast cancer, chemotherapy regimens make the cancer shrink or disappear in about 30-60% of people treated. Keep in mind that every cancer responds differently to chemotherapy. Chemotherapy is used to treat all stages of breast cancer, including cancer that has come back in the breast area and breast cancer that has spread to other parts of the body (metastatic disease). Chemotherapy treatments are tailored specifically for each person's unique situation. When deciding on which chemotherapy medicines would be best for you, you and your doctor will take into account the stage and other characteristics of the cancer, such as hormone-receptor status and HER2 status. You'll also consider your menopausal status and any other treatments you've had.

Chemotherapy for early-stage disease

Early-stage breast cancer generally means cancer that is classified as:

stage 0 stage I stages IIA and IIB some stage III

(For more information on the specific characteristics of each cancer stage, visit the Breastcancer.org Stages of Breast Cancer page.) Chemotherapy is used after surgery to remove the breast cancer to get rid of any cancer cells that may be left behind and to reduce the risk of the cancer coming back. In some cases, chemotherapy may be used before surgery to shrink the tumor so less tissue needs to be removed. Each person's treatment plan will be different, but there are some general guidelines about who would benefit from chemotherapy:

Chemotherapy is almost always recommended if there is cancer in the lymph nodes, regardless of tumor size or menopausal status. Doctors recommend more aggressive treatments for premenopausal women diagnosed with invasive breast cancer. Breast cancer in premenopausal women tends to be more aggressive, so chemotherapy is often part of the treatment plan. Chemotherapy may be recommended for some women diagnosed with early-stage breast cancer if the cancer is hormone-receptor-negative and HER2-positive. Both of these characteristics are associated with cancer that is more aggressive. The Oncotype DX test may help some women diagnosed with estrogen-receptorpositive breast cancer and their doctors decide if the cancer is likely to come back and if chemotherapy would offer benefits. Chemotherapy usually is NOT recommended for non-invasive, in situ cancers such as DCIS because they have very little risk of spreading to other parts of the body.

Chemotherapy for advanced-stage/metastatic disease

Advanced-stage breast cancer generally means cancer that is classified as:

some stage III stage IV

Metastatic disease is breast cancer that has spread beyond the breast area and nearby lymph nodes to other parts of the body. Metastatic cancer is considered stage IV. Chemotherapy is used to treat advanced-stage breast cancer by destroying or damaging the cancer cells as much as possible. Because chemotherapy medicines affect the entire body, chemotherapy is commonly used to treat advanced-stage breast cancer. Research has shown that newer chemotherapy medicines, such as:

Taxol (chemical name: paclitaxel) Abraxane (chemical name: albumin-bound paclitaxel) Taxotere (chemical name: docetaxel) Adriamycin (chemical name: doxorubicin) Ellence (chemical name: epirubicin)

are helping women diagnosed with advanced-stage breast cancer live longer. Other chemotherapies used in metastatic breast cancer include Gemzar (chemical name: gemcitabine), Xeloda (chemical name: capecitabine), Navelbine (chemical name: vinorelbine), and Ixempra (chemical name: ixabepilone). Each person's treatment plan will be different, but there are some general guidelines that doctors follow when using chemotherapy to treat advanced-stage breast cancer:

If you've had chemotherapy before, your doctor may recommend using only one chemotherapy medicine at a time to treat advanced-stage disease. This way you get benefits with fewer possible side effects. In general, most chemotherapy medicines can be used until side effects become a problem or the medicine stops being effective. Some chemotherapy medicines seem to work better against cancer tumors when used in combination. So your doctor may recommend a combination of medicines for you because research has shown that combining treatments has contributed to a better overall prognosis for some advanced-stage cancers. If you've had chemotherapy before and the cancer came back or didn't respond, your doctor will likely recommend a different combination of medicines. There are many chemotherapy medicines and if one medicine or combination of medicines doesn't seem to be working, there is almost always something else you can try.

If the cancer is hormone-receptor-positive, your doctor may choose to use hormonal therapy before or after initiating chemotherapy. If you have metastatic breast cancer and chemotherapy is part of your treatment plan, your doctor may use different tests to determine how well the chemotherapy is working and how you're handling the chemotherapy:

Blood cell counts Blood tumor marker tests Bone scans Chest X-rays, or X-rays of other parts of the body MRI CT (CAT) scans PET scans

Stages of Breast Cancer

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Page last modified on: May 12, 2009

Larger Version

Cancer stage is based on the size of the tumor, whether the cancer is invasive or noninvasive, whether lymph nodes are involved, and whether the cancer has spread beyond the breast. The purpose of the staging system is to help organize the different factors and some of the personality features of the cancer into categories, in order to:

best understand your prognosis (the most likely outcome of the disease) guide treatment decisions (together with other parts of your pathology report), since clinical studies of breast cancer treatments that you and your doctor will consider are partly organized by the staging system provide a common way to describe the extent of breast cancer for doctors and nurses all over the world, so that results of your treatment can be compared and understood

Stage 0
Stage 0 is used to describe non-invasive breast cancers, such as DCIS and LCIS. In stage 0, there is no evidence of cancer cells or non-cancerous abnormal cells breaking out of the part of the breast in which they started, or of getting through to or invading neighboring normal tissue.

Stage I
Stage I describes invasive breast cancer (cancer cells are breaking through to or invading neighboring normal tissue) in which:

the tumor measures up to 2 centimeters, AND no lymph nodes are involved

Stage II
Stage II is divided into subcategories known as IIA and IIB. Stage IIA describes invasive breast cancer in which:

no tumor can be found in the breast, but cancer cells are found in the axillary lymph nodes (the lymph nodes under the arm), OR the tumor measures 2 centimeters or less and has spread to the axillary lymph nodes, OR the tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the axillary lymph nodes

Stage IIB describes invasive breast cancer in which:

the tumor is larger than 2 but no larger than 5 centimeters and has spread to the axillary lymph nodes, OR the tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes

Stage III
Stage III is divided into subcategories known as IIIA, IIIB, and IIIC. Stage IIIA describes invasive breast cancer in which either:

no tumor is found in the breast. Cancer is found in axillary lymph nodes that are clumped together or sticking to other structures, or cancer may have spread to lymph nodes near the breastbone, OR the tumor is 5 centimeters or smaller and has spread to axillary lymph nodes that are clumped together or sticking to other structures, OR the tumor is larger than 5 centimeters and has spread to axillary lymph nodes that are clumped together or sticking to other structures

Stage IIIB describes invasive breast cancer in which:

the tumor may be any size and has spread to the chest wall and/or skin of the breast AND 7

may have spread to axillary lymph nodes that are clumped together or sticking to other structures, or cancer may have spread to lymph nodes near the breastbone Inflammatory breast cancer is considered at least stage IIIB.

Stage IIIC describes invasive breast cancer in which:

there may be no sign of cancer in the breast or, if there is a tumor, it may be any size and may have spread to the chest wall and/or the skin of the breast, AND the cancer has spread to lymph nodes above or below the collarbone, AND the cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone

Stage IV
Stage IV describes invasive breast cancer in which:

the cancer has spread to other organs of the body -- usually the lungs, liver, bone, or brain

"Metastatic at presentation" means that the breast cancer has spread beyond the breast and nearby lymph nodes, even though this is the first diagnosis of breast cancer. The reason for this is that the primary breast cancer was not found when it was only inside the breast. Metastatic cancer is considered stage IV.

Additional staging information

You may also hear terms such as "early" or "earlier" stage, "later," or "advanced" stage breast cancer. Although these terms are not medically precise (they may be used differently by different doctors), here is a general idea of how they apply to the official staging system:

Early stage

Stage 0 Stage I Stage II Some stage III

Later or advanced stage

Other stage III Stage IV

Doctors use a staging system to determine how far a cancer has spread. The most common system is the TNM staging system. You may hear the cancer described by three characteristics: 8

size (T stands for tumor) lymph node involvement (N stands for node) whether it has metastasized (M stands for metastasis)

The T (size) category describes the original (primary) tumor:

TX means the tumor can't be measured or found. T0 means there isn't any evidence of the primary tumor. Tis means the cancer is "in situ" (the tumor has not started growing into the breast tissue). The numbers T1-T4 describe the size and/or how much the cancer has grown into the breast tissue. The higher the T number, the larger the tumor and/or the more it may have grown into the breast tissue.

The N (node involvement) category describes whether or not the cancer has reached nearby lymph nodes:

NX means the nearby lymph nodes can't be measured or found. N0 means nearby lymph nodes do not contain cancer. The numbers N1-N3 describe the size, location, and/or the number of lymph nodes involved. The higher the N number, the more the lymph nodes are involved.

The M (metastasis) category tells whether there are distant metastases (whether the cancer has spread to other parts of body):

MX means metastasis can't be measured or found. M0 means there are no distant metastases. M1 means that distant metastases were found.

Once the pathologist knows your T, N, and M characteristics, they are combined in a process called stage grouping, and an overall stage is assigned. For example, a T1, N0, M0 breast cancer would mean that the primary breast tumor:

is less than 2 centimeters across (T1) does not have lymph node involvement (N0) has not spread to distant parts of the body (M0)

This cancer would be grouped as a stage I cancer.

Chemotherapy: What to Expect

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Page last modified on: August 28, 2009

Even after you and your doctor have decided on a chemotherapy regimen, you may still have questions about what to expect and how chemotherapy will affect your daily routine.

Your doctor and oncology nurse can answer your questions. They will give you a lot of information before your chemotherapy starts and will be there for you as your treatment goes on. If you are receiving chemotherapy as an infusion through a thin needle in your hand or arm, an oncology nurse will be with you during the whole procedure. If the chemotherapy is in pill form, you will take it at home. With either form of chemotherapy, you should contact your doctor or nurse by phone if you're experiencing severe side effects such as mouth sores, nausea that doesn't go away after you take the medicine, diarrhea, or fever. Most cancer doctors' offices and treatment centers have a doctor or nurse available 24 hours a day to answer questions. Make sure you know how to contact someone outside of regular office hours in case you have questions or concerns. It's important to remember that each person responds differently to chemotherapy. There are certain general reactions that most people can expect, but don't worry if your reactions -- physically or emotionally -- are different from someone else's. In this section, you can read about what to expect if you're having chemotherapy:

When Do You Get Chemotherapy? How Is Chemotherapy Given? Where Will You Go for Chemotherapy? Before You Begin Chemotherapy Getting a Chemotherapy Infusion Step by Step

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