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6. Chemotherapy

Chemotherapy is the use of drugs to kill abnormal cells. In breast cancer, the aim is to use these drugs to poison cells (called cytotoxic drugs) and to destroy any cancer cells that may have spread from the breast to other parts of the body. These cells may not show up in scans or tests, but if you have a type of breast cancer that makes this kind of spread more likely, you could have chemotherapy to make sure your whole body is exposed to these anti-cancer drugs without waiting to see whether or not this will happen in the future.

What’s the difference between chemotherapy and radiotherapy?

Chemotherapy is a systemic treatment which means it treats all the tissues of the body with anti-cancer drugs. Radiotherapy is a local high-energy X-ray treatment, which only acts in the area of the body where it is given.

Why do some people have radiotherapy and others have chemotherapy?

Actually, many people have both. Like all treatments, the one which will be   recommended for you depends on the details of your cancer. Over the years, the progress of people on different treatments is followed up and this research provides cancer specialists with information on when to use chemotherapy and radiotherapy.  This way we learn how useful each treatment is, and how to match people to the right treatment, depending on their risk and on which treatments will work best for them. Chemotherapy may be recommended for people whose breast cancer is large, high grade or has spread to the lymph glands, for example. Radiotherapy may be more suitable for those who have had breast conservation surgery to treat the remaining breast tissue and reduce the chances of the breast cancer coming back there or in some cases to the chest wall after mastectomy, depending on whether the lymph nodes contain cancer cells.

Will I have chemotherapy after my surgery?

It depends on your individual course of treatment, based on the features of your cancer. It is most common to have chemotherapy after surgery as an adjuvant, or additional treatment, and if this is the plan, it might start about three to six weeks after surgery to allow you to get over the operation. Some people have neo-adjuvant treatment to shrink a large tumour before the operation. If you have secondary breast cancer, chemotherapy may be the only treatment to be suggested. You can discuss all this with your doctor or breast care nurse.

I don’t understand how chemotherapy can stop the cancer from growing. What do these drugs do?

Chemotherapy drugs aim to destroy cancer cells by interfering with their ability to grow and divide. Each drug does this in a different way so most people have a combination of two or three (either one at a time or all together) to attack the cancer cells in several ways to increase the chances of killing them.

I am about to start my course of chemotherapy. What will actually happen?

 

The most common way is an injection into a vein using a syringe or through a ‘drip’. This means being in the hospital for about half a day as you need to have blood tests and wait for the results of these before each treatment.

Will I have the same drugs as other people having chemotherapy for breast cancer?

Not necessarily. There are at least six different combinations used to treat people with primary breast cancer: that is a cancer that is only in the breast but may have spread to the lymph nodes. There are also other drugs which are used for secondary breast cancer, which has spread to other parts of the body. Drugs are usually used in combination to increase the chances of killing the most cancer cells. These single drugs and combinations are often used in primary breast cancer:

• FEC (5fluorouracil, epirubicin and cyclophosphamide);

• CMF (cyclophosphamide, methotrexate and 5fluorouracil);

• Epirubicin then CMF;

• FEC then docetaxel (Taxotere®);

• AC: Adriamycin® (doxorubicin), cyclophosphamide.

• TAC: Taxotere® (docetaxel), Adriamycin® (doxorubicin), cyclophosphamide.

These drugs are usually used to treat secondary breast cancer:

• Capecitabine (Xeloda®);

• Vinorelbine (Navelbine®);

• Gemcitabine (Gemzar®).

I need to plan ahead to organize my work, the children and so on. How long does a course of chemotherapy for breast cancer usually take?

It depends on the exact combination you are having but it is usually several months. Normally, you would be given between four and eight doses in total every three or four weeks. Between each treatment your body can rest and recover before the next one – a ‘rest period’. You don’t usually need to visit hospital between treatments (unless you need help with side effects) but you will need a blood test before each treatment to see how your body is coping.

Won’t the cancer cells continue growing between treatments?

It’s unlikely, as the effect of the drugs carries on for quite a few days after the treatment has been given. Cancer cells don’t recover as quickly as normal cells, so repeating the treatments gradually reduces the total number of cancer cells that are, or may be, present in your body.

My doctor says my chemotherapy is an ‘insurance policy’. What does this mean?

It means that chemotherapy is reducing the risk of your cancer spreading. Because tests and scans often can’t detect breast cancer cells that have spread through the body, adjuvant (additional) chemotherapy is given as a precaution in case they have spread. Chemotherapy can reduce the risk of cancer from coming back, and your doctor will know how long chemotherapy needs to be given in order to be most effective.

If my breast cancer comes back, will I be able to have more chemotherapy treatment?

Yes, but you may be given a different combination of drugs, depending on which ones you had before and how long you had them for.

You hear stories about how awful chemotherapy is. Are there lots of side effects?

Not always. Some people experience few side effects during chemotherapy and are able to carry on with daily life more or less as usual. For others, chemotherapy is a miserable experience which has a considerable effect on their lives. It isn’t always helpful to listen to other people’s experiences of chemotherapy as effects can vary so much. It depends not only on which of the many drugs you have, but also on your own individual reaction to the drugs: two people receiving the same combination of drugs may feel completely different during their courses of treatment.

Why do chemotherapy drugs usually cause side effects?

Chemotherapy drugs destroy cells which are constantly and rapidly dividing – which is the way cancer cells behave. But normal, healthy cells grow and divide rapidly to repair body tissues, and so these cells will be damaged too. It is this damage which causes side effects. As chemotherapy is a systemic treatment, this means that side effects are also systemic and so affect body systems such as the digestive system and the immune system. Fortunately, normal cells recover quickly so any side effects of treatment are usually temporary.

Most people have at least some side effects, but it will depend on the drugs you are having. The doctors and nurses will advise you on what to expect, and also on how to cope with any side effects. Some of the more common side effects are dealt with in the following questions.

I’ve been told that once I start treatment I will have to have regular blood tests. Why is this necessary?

The blood tests are to check the amount of red and white blood cells in your blood. Chemotherapy can slow down production of healthy amounts of both red and white blood cells. If this happens, you are more at risk of infections (because of too few white blood cells) and anaemia (too few red blood cells). Regular blood tests will show if the drugs are affecting your blood count. You might need some treatment, such as antibiotics for an infection or a blood transfusion for anaemia. If the blood count is low, the doctors can either adjust the dose of your drugs or lengthen your rest period between treatments.

Although it is worrying and frustrating when this happens, it isn’t unusual. It is much safer to delay treatment by about a week than to give the drugs before your body has recovered.

When they take a blood sample, what are they actually looking for?

Three types of blood cells are each measured:

• White blood cells which help fight infection;

• Platelets which help the blood to clot, preventing bleeding and bruising; and

• Red blood cells which carry oxygen to all the body’s tissues.

 What does it mean if I have a low blood count or if my blood count falls?

Very often you won’t notice anything unusual. Sometimes people say that they feel a bit depressed and tired when their count is at its lowest about 10–14 days after treatment. However, if your count has dropped, or is expected to, you may be told to look out for certain signs or symptoms which should be reported to your doctor.

What kind of things might indicate that my blood count is low?

When your white cells are low, you will be more likely to develop an infection. You should contact your doctor if you have a sore throat or start running a high temperature, or if you notice anything else that might mean you have an infection, such as a burning sensation when you pass urine.

A drop in your platelet count will mean you may bruise more easily.

You might notice that your gums bleed when you brush your teeth, or you might have a nosebleed.

If your red blood cells are affected, you may become anaemic and may feel tired or short of breath, although this is rare. It is very important that you report anything unusual for you to the doctor or your breast care nurse straight away, even if it seems trivial, so that the doctors can check you out and treat you if necessary before it becomes more serious. Everyone having chemotherapy is given a list of emergency contact numbers so you can get in touch with someone from your team if you need to.

Is there anything that can stop my blood count falling too low while I have chemotherapy?

You may have an injection of G-CSF if you are having certain combinations of chemotherapy drugs, or if your blood count is low at each treatment. G-CSF stands for granulocyte-colony stimulating factors, and it helps increase the number of white cells being produced during chemotherapy. This means that you can have your chemotherapy as usual without lengthened rest periods in between.

If I need a blood transfusion, is there a risk of catching AIDS?

Virtually none. All donor blood is tested for the HIV virus, which causes AIDS, and people in known high-risk groups are discouraged from giving blood. In addition, blood products are heat treated to destroy the virus. The risk of transfer of the disease in this way is very small indeed.

Will I feel sick when I am on chemotherapy?

You may feel sick, or occasionally even vomit, after some types of chemotherapy drugs. This can last for one to five days after each treatment, but it may be longer. There are many anti-emetic (antisickness) drugs you can take during your treatment, or straight afterwards, to reduce any nausea or vomiting. It is best to take these regularly as prescribed rather than wait until you feel sick. The staff caring for you may also have other suggestions to reduce sickness, such as changes in eating patterns and learning relaxation techniques.

Part of my chemotherapy is in the form of tablets. Will these make me feel sick?

Possibly – you may find taking the tablets at night will solve this problem. Check with your doctor if you can do this.

If one anti-sickness drug doesn’t work, can I try another?

Yes. Tell the doctor or nurse before your next treatment. There are several drugs which can be prescribed

Will the chemotherapy I’m having make my hair fall out?

It depends on what chemotherapy drugs you are having but most of them cause at least some hair loss. The hair may get thinner or fall out in patches. You may also lose your eyelashes and eyebrows. Treat your hair gently to help keep it in good condition: don’t have it colored or permed and use a cool setting on the hairdryer or heated rollers. Try to avoid anything that can damage your hair, such as brushing it hard or plaiting it. Always ask for advice if you are in any doubt about what to do.

Is there anything I can try to stop the hair loss?

Some people choose to try something called scalp cooling. This involves wearing a very cold hat before, during and after each treatment to try and reduce blood flow to the scalp, so the drugs don’t reach the hair roots and damage them. It doesn’t work for everyone and can be uncomfortable, but you can ask your doctor or breast care nurse about trying it.

Will my hair grow back after my chemotherapy?

Hair loss from chemotherapy is always temporary and the hair grows back in the months after treatment. You may even find your hair starts to re-grow before the end of the course of chemotherapy.

When my hair grows back will it be the same as before?

Not necessarily: sometimes the hair grows back a different colour or texture than before. It may be curly instead of straight. It is not possible to predict whether this will happen to you.

If I’m going to lose my hair, how soon will it happen and what can I do about it?

It could be a few days or a few weeks before your hair begins to fall out. You will probably notice more hair in your brush or comb. There may be hair on your pillow in the morning, which may upset you – wearing a hairnet or turban overnight may help how you feel about this. Some people prefer to cut their hair short or shave their heads as soon as the hair starts coming out. Your hospital can arrange for you to be fitted with a wig before your treatment starts, but if you don’t want to wear a wig, a cap, hat or scarf is an alternative.

You will need to wear something on your head to protect your scalp from the cold, and in the sun you must have a hat and sun block cream. If your scalp becomes dry, use a gentle moisturizer.

Will the chemotherapy make me lose my body hair?

Some drugs do cause temporary loss of all body hair. Ask if this is expected in your case.

Is having chemotherapy painful and does it always have to be given through a ‘drip’ in the hand or arm?

 

Chemotherapy may be no more painful than having an injection or a blood test. However, as the course of treatment goes on the drugs can make your veins at, and above, the injection site more sensitive or sore. You should tell your doctor or nurse if this happens so the sore areas can be avoided. Sometimes the veins are severely affected by the drugs and become hard to find so that injections become very difficult. If this happens you may be offered an intravenous (IV) catheter (tube) which stays in place until the chemotherapy has finished. For example, a central venous catheter (a ‘Hickman line’) is passed underneath the skin of the chest into a large vein just above the heart. Another type, called a peripherally inserted central catheter (PICC), is inserted into one of the large veins in the arm until it also sits in a large vein above the heart. A third alternative is an implanted port (Portcath®) when a catheter is passed under the skin of the chest into a large vein above the heart, but a port remains under the skin and a special needle is used to inject into this when needed.

These kinds of catheter can be left in place for many months. Drugs and fluids can be given through them and blood samples can also be taken from them. To stop them blocking, they need regular weekly flushing with saline (sterile salt water) using a syringe. This can be done by either a district nurse or a friend or partner after training. The dressing covering where they enter the body will need changing regularly to prevent any infection. An implanted port does not need a dressing once the wound has healed.

Why do some people have a Hickman line or PICC and others don’t?

Many people simply don’t need one because their veins remain fine during a course of breast cancer chemotherapy.

Can I eat and drink normally during chemotherapy?

Yes. You may find you lose your appetite for a few days after your treatment but when it returns to normal you can eat your usual foods. Try to drink more while you are having chemotherapy to make sure you are well-hydrated, especially if you are being sick. Generally, it is fine to have alcoholic drinks but some chemotherapy drugs can affect your taste, and for a while you may no longer enjoy certain foods or drinks. If you have any problems with eating tell your doctor or nurse. They may be able to offer some suggestions or ask the hospital dietitian to advise you.

Can chemotherapy affect my chances of having children?

In women, chemotherapy can affect the healthy development of eggs, which in turn can affect fertility. If you have not yet started or completed your family, this can be a major issue, and you will need to think about it carefully. Sometimes periods become irregular or stop during chemotherapy, but this may be temporary and doesn’t mean you cannot conceive. However, in some women periods don’t come back and it is no longer possible to become pregnant. This is more likely the older you are when you start treatment, because you are nearer to the natural age of menopause.

Talk to your doctors and breast care nurses about what you might expect from treatment and tell them if you plan to have children. They can discuss any options with you and may refer you to a specialist fertility doctor to explore these options in more depth before your treatment begins.

It is essential not to become pregnant during or immediately after chemotherapy as the fetus could be affected, so you must use an effective form of contraception throughout treatment, though not the Pill because it contains hormones that could affect your breast cancer.

Can I father a child after I’ve had chemotherapy?

Men with breast cancer can also have problems with fertility, though it is not common. If you plan to father a child in the future discuss this with your doctor before you start your treatment. If your treatment is likely to make you permanently sterile, you should be offered an opportunity to ‘bank’ sperm before starting treatment. Once again, use contraception during and after chemotherapy. My daughter is getting married soon and the date coincides with my chemotherapy.

Can I change the day of my injection?

Usually the doctors are quite willing to change treatment dates by a few days to fit in with special occasions like a wedding, or so you can have a short holiday, so do ask if you can reorganize your dates.

Will I see the doctor regularly during treatment?

Every time you come to hospital for chemotherapy you will usually see a doctor or a nurse who will want to know how you feel and how the chemotherapy is affecting you. Talk about anything unusual you may have experienced, whether it was expected or not. Use this time to discuss any worries you may have and to ask questions. Don’t worry if it’s a physical change or a concern that seems trivial – it’s always best to check. Ask the doctor before taking other medicines and, if you wish to try a complementary therapy, find out if there is any reason why you should not use it at this time.

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