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There are a lot of options for chemotherapy regimens in invasive breast cancer.
Chemotherapy drugs kill invasive breast cancer cells by affecting the cells’ ability to divide. The regimens are normally given in a group of two or three drugs, are infused in your vein (also called an IV infusion), and are repeated in cycles every few weeks until treatment is complete.
You may be offered several types of treatment for invasive breast cancer, such as surgery, radiation therapy, chemotherapy, targeted therapy, and hormonal therapy. This article will focus on chemotherapy for invasive breast cancer.
What is Invasive Cancer?
Before we talk about chemotherapy used to treat invasive breast cancer, let’s define some terms to help you understand what invasive breast cancer is.
- Invasive cancer means that the cancer has spread outside the layer of tissue where it started – the cancer is growing into the surrounding, healthy tissue of the same part of the body. You may also hear it described as “infiltrating” cancer.
- Non-invasive cancer is the opposite – the cancer has not invaded into the normal breast tissue.
- Non-metastatic cancer is cancer that has not spread to other parts of the body – the cancer is in the primary site of the body where it started. Non-metastatic cancer is often referred to as early-stage breast cancer and includes Stages I, II, and III.
- Metastatic cancer is cancer that has spread to other parts of the body, such as the bones, lungs, or liver.
What Is Chemotherapy & When Is It Used?
Chemotherapy is a drug treatment that kills cancer cells by stopping them from dividing. It can be used alone or in combination with other drugs, surgery, or radiation.
The National Comprehensive Cancer Network explains chemotherapy options for HER2-negative and HER2-positive breast cancer for preoperative therapy (given before surgery), adjuvant therapy (given after surgery), and recurrent (metastatic) or stage IV disease.
HER2 is a protein called human epidermal growth factor. If cancer cells have this protein, they are described as being HER2-positive, or HER2(+). If cancer cells do not have this protein, they are described as being HER2-negative, or HER2(-).
Chemotherapy can be given as “preoperative” treatment. This means that chemotherapy is used to shrink the size of cancer inside of your body, so it is easier to remove with surgery. Therefore, it is given before surgery. It can also be given after surgical removal of a tumor, to help kill any leftover cells from the surgery.
When chemotherapy is given after surgery to help lower the risk of the cancer coming back, it is called “adjuvant” therapy.
Chemotherapy may also be given for cancer that has returned to or spread to other parts of the body, such as the bone, lung, or liver. This is called metastatic disease. If you have been diagnosed with cancer that has spread to other parts of the body at the time you are diagnosed, you have “M1” disease.
Before You Get Chemotherapy
Before you start chemotherapy, you will be given information about the names of the medications you will receive and side effects that are common, less common, and rare.
You may be given prescriptions for medications that will help prevent side effects once you go home. Fill these before your first day of chemotherapy so that you have them ready for you. Let your medical team know if you need refills for the next chemotherapy cycle.
Some people will get a semi-permanent iv called a “port.” Most people do not need to have a port, but if you have had problems with your veins in the past, a port may be right for you.
Once you are in the treatment center, you will have an iv put in your arm or, if you have one, into your port. You will be given medicines to help reduce or prevent side effects.
Your treatment will go into your vein by either a syringe, a small bag, or a larger bag (depending on which medicines you get).
After the chemotherapy is done, the iv will be removed, and you can go home.
Chemotherapy Drugs
Cyclophosphamide
Cyclophosphamide, also known by its brand name Cytoxan, is an alkylating agent.
Alkylating agents kill cancer cells by interfering with the DNA, or genetic building blocks, of the cancer cells. This causes them to die.
Cyclophosphamide, when combined with other drugs used in the breast cancer, causes hair loss, nausea, diarrhea or constipation, and fatigue.
Carboplatin
Carboplatin is called a platinum-based medication because it contains a platinum compound that helps kill the cancer cell. Carboplatin is used in combination with other medications to treat breast cancer in the preoperative or adjuvant settting.
Carboplatin, when combined with other drugs used in the breast cancer, causes hair loss, nausea, diarrhea or constipation, and fatigue.
Doxorubicin
Doxorubicin is a type of drug called an anthracycline. Anthracyclines kill cancer cells in many ways, including creating substances within the cells to kill them.
These medications may cause nausea and vomiting. hair loss, fatigue, nausea, and diarrhea or constipation. Doxorubicin is a red solution, so it may turn your urine, tears, or sweat a reddish color.
Rarely, doxorubicin can cauase heart problems, specifically a weakening of the heart muscle. The risk of heart problems increases the more doxorubicin you are given. Your oncologist will make sure you do not reach the maximum level of the drug. You may also have a heart test such as an echocardiogram (ultrasound of the heart) or a test that uses an injection (called a MUGA scan).
Epirubicin
Epirubicin is another type of anthracycline, like doxorubicin. One of the ways it kills cancer cells is by creating a substance within the cell, causing it to die. It can cause nausea, diarrhea, or constipation.
Fluorouracil
Fluorouracil is also known as 5-FU. It's called a pyrimidine analog antimetabolite. It kills cancer cells by putting a compound into the cell.
5-FU is used as an injection in invasive breast cancer. A few side effects are diarrhea, mouth/throat sores, and tingling/numbness in your hands and feet.
Capecitabine
Capecitabine is known as it's brand name Xeloda (the X is pronounced as a Z). It is also a pyrimidine analog antimetabolite and kills cancer cells by putting a compound into the cell.
5-FU and Xeloda are similar. Xeloda is taken by mouth because it is basically the pill form of 5-FU. It may cause diarrhea, mouth or throat sores, and tingling or numbers in your hands and feet.
Methotrexate
Methotrexate is a folate antimetabolite. This type of medication kills cancer cells by stopping a process called the folic acid cycle. The main drug in this group used for invasive breast cancer is methotrexate. This drug can come as an infusion, injection, or a tablet taken by mouth.
Since methotrexate interferes with the way folic acid is made in cancer cells, it can also decrease the folic acid in your normal, healthy cells. This causes side effects like diarrhea, mouth sores, and anemia.
Other possible side effects of methotrexate are kidney problems and anemia.
Speak to your doctor before you take any over-the-counter aspirin, pain-relievers, or Pepto-Bismol.
Paclitaxel
Paclitaxel is in a group of medications called taxanes. Taxanes are microtubule inhibitors. They kill cancer cells by stopping the function of the molecule called microtubules.
Paclitaxel may cause hypersensitivity reactions when it is given as an infusion into your body. You will be given medications to prevent a reaction. Some people still may have a reaction. These reactions are a mixture of symptoms that may look like allergies, such as redness, fever, itching, and low blood pressure. If you have a reaction like this, it will happen while you are still at the treatment center, and you will be watched closely.
Taxanes may also cause nerve pain that may feel like pins and needles are in your feet. Speak with your doctor if you are experiencing any form of pain or side effects.
Docetaxel
Docetaxel is also a taxane. Taxanes are microtubule inhibitors, so they kill cancer cells by stopping the function of the molecule called microtubules.
Docetaxel may cause hypersensitivity reactions when it is given as an infusion into your body. You will be given medications to prevent a reaction, but some people still may have a reaction.
Hypersensitivity reactions are a mixture of symptoms that may look like allergies, such as redness, fever, itching, and low blood pressure. If you have a reaction like this, it will happen while you are still at the treatment center, and you will be watched closely.
Taxanes may also cause nerve pain that may feel like pins and needles are in your feet. Speak with your doctor if you are experiencing any form of pain or side effects.
Trastuzumab (Herceptin)
Herceptin is the brand name for trastuzumab. Trastuuzamb is not chemotherapy. They are targeted therapy used in HER2(+) breast cancer. Although these medications are targeted therapy, they are used with chemotherapy in breast cancer.
Example regimens of chemotherapy in combination with Herceptin are in the table below.
Some side effects are nausea, vomiting, and diarrhea, but these side effects are usually due to the chemotherapy instead of the Herceptin. These medications can cause birth defects up to 7 months after getting the drug. Speak with your doctor about birth control. These medications may also have heart side effects, although this is not common. Your doctor may use an echocardiogram or a MUGA scan to test your heart.
Ado-Trastuzumab (Kadcyla)
Kadcyla is the brand name of ado-trastuzumab emtansine. Like Herceptin, it is part of a group of medications called HER2 inhibitors. HER2 inhibitors are targeted therapy used in HER2(+) breast cancer and are often combined with chemotherapy.
Kadcyla is used in early-stage HER2(+) breast cancer when there are still remaining cancer cells after the initial treatment of chemotherapy.
Some side effects are nausea, vomiting, and diarrhea. These medications can cause birth defects up to 7 months after getting the drug. Speak with your doctor about birth control. These medications may also have heart side effects, although this is rare. Your doctor may use an echocardiogram or a MUGA scan to test your heart.
Pertuzumab (Perjeta)
Perjeta is the brand name for pertuzumab. Perjeta is part of a group of medications called HER2 inhibitors. They are targeted therapy used in HER2(+) breast cancer and are combined with chemotherapy in breast cancer.
Example regimens of chemotherapy in combination with Perjeta are in the table below.
Some side effects are nausea, vomiting, and diarrhe. These medications can cause birth defects up to 7 months after getting the drug. Speak with your doctor about birth control. These medications may also have heart side effects, although this is rare. Your doctor may use an echocardiogram or a MUGA scan to test your heart.
Male Breast Cancer
All of these chemotherapy options can be used in men with invasive breast cancer. Your doctor will provide a specific regimen for your individual cancer type and other personal characteristics. Also, genetic testing is recommended for many men with breast cancer.
Fertility, Pregnancy, and Birth Control
If you are still able to become pregnant, speak with your doctor about birth control options. We recommend that people with breast cancer not use hormonal forms of birth control. This includes birth control pills, birth control patches, estrogen rings, estrogen implants, and progesterone IUDs. Condoms are a good option. Copper IUDs and diaphragms with spermicide are also options because they do not have hormones in them. Speak with your medical team for more options to prevent pregnancy.
Chemotherapy Regimens
Your doctor will recommend a combination of chemotherapy medicines, often referred to as a “regimen.” You may receive a combination of drugs from each of the groups mentioned above. We use two or more drugs to help kill the tumor by targeting it in different ways. Giving chemotherapy regimens this way can also help you take lower amounts of each drug, which will decrease your risk of short- and long-term side effects.
The treatment chosen for you will be based on the stage of the cancer, the other features of the tumor (such as the presence or absence of hormone receptor on the tumor), your overall health, how well you tolerate side effects, your age, and other cancer treatments that you are receiving.
For most chemotherapy, the dose is based on your height and weight. Chemotherapy orders are written specifically for you by your cancer doctor. This means that, after you arrive at the treatment center, you will wait while the pharmacist or nurse prepares the chemotherapy for you.
Most of the chemotherapy drugs are given by vein as an IV infusion. Chemotherapy regimens are given as cycles every 7 days, 14 days, 21 days, 28 days, and variations in between. Giving the chemotherapy on specific days followed by at least 1 week of rest allows your body to recover from the side effects of the medications. Most regimens are given as a 21-day or 28-day cycle (every 3 or 4 weeks).
In general, chemotherapy before surgery will be given for approximately 2 to 3 months. Chemotherapy after surgery will be given for 2 to 6 months.
Below are a few examples of chemotherapy regimens that your doctor may prescribe for you. Regimens may be used alone or in combination with targeted therapy, radiation therapy, or surgery.
Underneath each regimen is a more detailed description of each medication.
Chemotherapy Side Effects
Chemotherapy kills cancer cells by stopping them from dividing. Since cancer cells divide rapidly, chemotherapy specifically targets cells that divide rapidly. However, some normal, healthy cells in your body divide rapidly such as cells on your skin, in your mouth, in some parts of your stomach, and on your hair follicles. Chemotherapy cannot tell the difference between your body’s normal, healthy cells and the cancer cells – they simply target cells that divide rapidly. For this reason, chemotherapy can unfortunately cause side effects by affecting those normal, healthy cells in your body that divide rapidly.
Take a look at the graphic below for side effects that chemotherapy may cause. Each chemotherapy drug is different, so discuss with your medical team about which side effects you may experience. Remember to speak with your medical team if you experience any side effects from your treatment.
Summing it up…
Chemotherapy kills cancer cells by stopping them from dividing. Most regimens use two or three different drugs that target cancer cells in different ways. Most drugs are given by vein as repeated cycles every few weeks. Medications given along with chemotherapy will decrease the risk of side effects. Talk with your medical team if you experience any side effects of your chemotherapy.
References
- Gradishar WJ, Anderson BO, Abraham J, et al. National Comprehensive Cancer Network Guidelines Breast Cancer. Version 5.2020 From the National Comprehensive Cancer Network; July 2020. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed August 9, 2020.
- National Cancer Institute Dictionary of Cancer Terms. cancer.gov. https://www.cancer.gov/publications/dictionaries/cancer-terms. Published February 2, 2011. Accessed August 9, 2020.
- National Comprehensive Cancer Network (US). NCCN Guidelines for Patients: Breast Cancer – Invasive. Version 2020. Fort Washington, PA: NCCN; 2020.
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