Chemotherapy - How It Works
Treatment for breast cancer often involves the use of drugs referred to as chemotherapy. The word chemotherapy comes from two words, "chemo" meaning chemical and "therapy" meaning treatment. A medical oncologist, a physician specializing in the treatment of cancer, prescribes and monitors this treatment.
After carefully reviewing all of your medical records and performing a physical exam, your healthcare providers will recommend a treatment plan, often including chemotherapy. This plan, referred to as a treatment protocol, will consist of one or a combination of the following types of treatment:
• Radiation therapy;
• Hormonal manipulation;
• Stem cell therapy (now recommended to be performed as part of clinical trial);
• Bone marrow transplant (now recommended to be performed as part of clinical trial);
• Observation only.
Treatment protocol decisions are made by your physician(s), decided in consultation with other physicians or through more formal multidisciplinary conferences. Many hospitals or cancer centers conduct multidisciplinary conferences where physicians specializing in different areas of treatment (oncology, radiology, surgery, pathology, primary care, etc.) and other healthcare providers discuss each case and come to an agreement on a treatment protocol. After the most appropriate therapy is selected, the healthcare provider discusses with the patient the reason for the selection and the potential side effects. Regardless of the method used to determine your treatment protocol, it is very important that you understand the plan and have any questions answered. Ask for written information on your disease and the treatment that is deemed appropriate for you.
There are approximately 15 different types of breast cancer and many factors that influence individual treatment decisions. It is imperative that you do not compare your treatment to another patient's treatment. Carefully analyze what friends, family and co-workers say and what you read in newspapers, magazines, the internet or hear on television and radio. Treatment decisions are individually formulated. Rely on your healthcare providers and treatment team for accurate information based on your cancer and treatment.
A combination of chemotherapeutic drugs may be used to fight your cancer. Each drug, however, is used to kill any cancer cells that may be left in the body after your surgery that could continue to grow and divide. The drugs selected have different side effects and work in different ways to kill cancer cells. Chemotherapy drugs work by killing rapidly dividing cells, both cancerous and healthy cells. Other rapidly dividing cells in your body that may also be affected include hair cells which may result in varying amounts of hair loss, gastrointestinal cells causing a sore mouth or throat and blood cells which can produce lower blood counts and fatigue. Most of these cells recover rapidly and the side effects subside quickly. Your treatment team will inform you what side effects to expect from the recommended chemotherapy.
Most chemotherapy drugs used to treat breast cancer are given through an IV (intravenous—needle through a vein), and a few are given orally by mouth. If a patient's veins are hard to locate or some types of chemotherapy drugs that have a potential to damage the skin are to be given, a permanent device may be implanted by a surgeon. This port, called a "life-port" or "port-a-cath," is placed under the skin, usually on the chest wall.
The frequency of treatment will vary according to the type of drugs selected. Treatments are usually started several weeks after surgery and are administered in the physician's office or cancer center. Some drugs may be administered by wearing a battery-operated infusion pump about the size of a cell phone, for around-the-clock administration. Your oncologist will explain how your treatment will be delivered.
Many horror stories about chemotherapy treatment have been told and heard. Fortunately, times have greatly changed with the discovery of new medications and the advancement of technology. A medication for nausea has all but eliminated the nausea and vomiting associated with chemotherapy.
Immunotherapy drugs have been developed that boost the immune system and relieve many of the symptoms resulting from low blood counts. Your treatment team will discuss the treatment protocol and plans for managing possible side effects. Every effort is taken to ensure that side effects are kept to a minimum. Two aggressive means to treat cancer that has spread outside the breast are stem cell therapy and bone marrow transplantation that administer larger doses of chemotherapy. Some insurance companies may still consider these two methods "developmental" or "experimental." It is now recommended that these two treatments, if given, be part of a clinical trial.
Stem cell therapy combines chemotherapy with other drugs to promote the development of stem cells (immature, parent blood cells). Once the cells are developed, they are collected from the blood and stored to later return to the body. The patient is then given large doses of chemotherapy. Several days later the stem cells are returned through and I.V. infusion, much like a blood transfusion. This process rescues the body from the effects of the large doses of chemotherapy. The patient is required to spend several weeks in the hospital or stay near the hospital as an outpatient to monitor the body's response to this treatment.
Bone marrow transplantation, performed in a medical center, removes the bone marrow from large bones in the body such as the hip and stores it to use later. Large doses of chemotherapy are given to the patient and the bone marrow is returned to the body through an I.V. infusion. The patient is required to be hospitalized for several weeks or to stay nearby as an outpatient to monitor the response to the treatment. There are many side effects of bone marrow transplantation. Your oncologist will discuss these treatments with you if you are a candidate for this type of treatment.
Radiation Oncologist and Radiation Therapy
A radiation oncologist is an internal medicine physician who specializes in the treatment of diseases using radiation treatments. After your cancer is evaluated and it is determined that the use of radiation therapy could destroy any remaining cancer cells which may be left in your body, you will be referred to a radiation oncologist. Most patients who have a lump-ectomy or breast-conserving surgery are referred to a radiation oncologist for evaluation prior to their surgery.
Radiation therapy (treatment by high-powered x-rays) is an effective weapon against breast cancer because it damages and prevents cell reproduction. When a cell is about to divide and is radiated, it cannot divide and it dies. Radiation therapy is used to destroy cells in the area of the breast that is radiated. Chemotherapy kills cells that have spread to other parts of your body through the blood or lymphatic system. Often both methods are used to give the best possible chance for eradication of the disease.
On your first visit to a radiation oncologist, the physician will carefully review your pathology report, mammogram records or films, your surgery recommendations or surgical records, results from any diagnostic tests performed and your medical history. A physical exam will be performed and recommendations made for your treatment. If this recommendation includes radiation therapy to your breast area, it will be helpful if you ask the following questions:
• How many radiation treatments will I receive?
• When will these treatments begin?
• How long will each treatment last?
• How will the area to be radiated be marked?
• What kind of soap and bath do you recommend?
• What kind of skin reaction can I expect and how can I best protect my skin?
• Is there anything that I cannot use during my treatments (deodorant, powders, perfumes, etc.)?
• Can I wear my bra or prosthesis during the treatment period?
• Will I be able to perform my normal duties during treatment?
• What side effects may I expect during or after treatment?
• How will the treatments affect my breast after treatment is completed?
• Do you have written information on radiation therapy?
It is important that you understand the benefits and possible side effects of radiation therapy.
Hormonal therapy refers to the different types of cancer treatments, including surgery (removal of ovaries) and medication. Examples of hormonal therapy are estrogens, progestins, androgens (male hormones) and steroids. For most breast cancer patients, the goal of hormonal therapy is to deprive cancer cells of the estrogen hormone. Estrogen can encourage the cancer cell's growth by producing growth factors. Without estrogen, the cancer cell's growth may be controlled.
Hormones naturally circulate in the body through the bloodstream and affect certain organs and cells, such as the breast and prostate. Tumors in these organs often depend on hormones to grow. These hormone dependent breast cancer tumors contain estrogen receptors (ER). When estrogen attaches to these receptors, it can cause the growth of cancer cells. Cancers that have these receptors are known as estrogen receptor positive (ER+). When the action of one hormone is blocked, the growth of the cancer cells is halted. Some patients, however, have tumors that are estrogen receptor negative (ER-) which means that their cancer grows without stimulation from estrogen. Hormonal therapies are not as effective in patients with estrogen receptor negative (ER-) tumors.
Hormonal therapies have been used for more than 100 years. The first type of hormonal therapy was surgically removing the ovaries in premenopausal women with advanced breast cancer. Surgeons removed the ovaries because they make the largest amount of the female estrogen and other female sex hormones in premenopausal women. Without the ovaries, the amount of estrogen in the body is greatly reduced. The ability of the estrogen positive cancer tumors to grow is decreased.
Hormones or hormone suppressants are added to enhance chemotherapy in some treatment plans for cancers that are influenced by their hormonal environment. Hormonal therapy is used to change the hormonal environment of women who have cancers that are stimulated by estrogen or progesterone. Nolvadex® (tamoxifen citrate), an anti-hormonal drug, is used widely to block the stimulation of estrogen on any remaining cancer cells that may be left in the body. The drug, taken by mouth twice a day, enters the bloodstream and attaches to the receptor sites on cancer cells and prevents their growth. Other hormonal drug therapies include Megace® (megestrol acetate), a synthetic form of the hormone progesterone, and Femara®, a drug that blocks the enzyme aromatase.
These drugs do not have the same side effects as chemotherapy. In contrast to the appetite and weight loss associated with most cancer treatments, hormonal therapy can boost the appetite and cause weight gain. In this case, you may be advised not to eat too much high-fat foods to avoid becoming overweight.
Hormonal therapy generally alters sexual functioning in some way. It may directly change the balance of body chemicals necessary to achieve a normal sexual response. Although these hormones are not as sexually damaging as chemotherapy, they can cause some menopausal symptoms, including hot flashes and dry vagina. Because tamoxifen actually acts like a weak form of estrogen on vaginal tissues, in menopausal women it can have the positive benefit of increasing vaginal lubrication.
The hormones themselves can sometimes decrease sexual desire. Women with breast cancer are sometimes treated with androgens (male hormones) when other hormone treatments do not work. Androgen treatments (testosterone) can boost a woman's sexual desire, but in large doses can also deepen her voice, cause acne, and increase facial hair. If a physician prescribes an androgen, the drug dosage will be carefully monitored to prevent these side effects.
Your physician will tell you if you are a candidate for hormonal therapy and which type of treatment. The decision is based on your age and the results of your tumor's hormone receptor study.